Dr. Sidney Coupland, in opening the discussion, said: I need hardly say that I have read Dr. Gettings' paper with great interest, and have found it, as other readers must have done, very instructive as well as entertaining. What gives particular interest to his graphic story is the fact that it is based upon the continuous medical records of an institution for nearly a century, and in this respect it must surely be unique. From a remark in the paper, apparently more zeal in clinical note-taking was exhibited in the earlier than in the later period of the history of Wakefield Asylum, but I feel sure that, if this be so, the lapse can only be temporary. As regards dysentery, it is certainly remarkable that a disease, once fairly common in this country, should have almost entirely disappeared from the community at large, a disappearance which seems to have coincided with that of the last serious visitations of cholera in the middle of last century. Even if we accept the usual explanation that these diseases, like typhus, have been banished in consequence of wide-spread improvement in urban and rural sanitation, especially as regards drainage and water supply, we yet cannot ignore the fact that many an insanitary area still exists which à priori might be expected to favour the spread of such disorders. We know, too, how great a scourge dysentery has been to armies in the field, where conditions of fatigue, exposure, imperfect diet, as well as defective sanitation, favour the development of intestinal disorders. My own limited experience confirms the fact of the rarity of dysentery in the general population. During the past thirty or forty years the average number of cases of dysentery admitted into the wards of the Middlesex Hospital has not exceeded one per annum, and in the seven years (1873–9) that I worked in the post-mortem room I only had to examine two subjects of dysentery, one of whom had contracted the disease in India. I was therefore much surprised to find, on joining the Lunacy Commission, that almost daily notifications were received from asylums of deaths from “colitis,” mostly ulcerative in character, and clinically indistinguishable from dysentery, as had been well shown by Dr. Gemmel just about that time. Dr. Gemmel's monograph, published in 1898, was founded on his personal observations at Lancaster Asylum, where for some years “idiopathic ulcerative colitis” had prevailed. It would, therefore, seem as if dysentery, whilst dying out from the population at large, had found a habitat in asylums, whose inmates, owing to their careful segregation, were less liable to most of the zymotic diseases. Regarded as an infective disease, which Dr. Gettings holds to be a sufficient explanation of its persistence in asylums, one can well understand the difficulty in getting rid of it once it has gained a footing, owing to the conditions of asylum life, and the faulty habits of many of the inmates. But it is only of late that it has been so regarded, for it has been customary to ascribe its occurrence to bad sanitation, of which, indeed, colitis was almost considered to be an index. Such a view seemed to be supported by instances like those mentioned by Dr. Gettings in the Wakefield Asylum, of outbreaks of dysentery coinciding with grave sanitary defects, the removal of which was followed by the subsidence of the disease. A classical instance is that of the outbreak at the Cumberland and Westmorland Asylum in 1864, reported on by Dr. (now Sir) Thomas Clouston, then its medical superintendent. The outbreak, which was a severe one, and accompanied with a high mortality, was connected with the irrigation of fields adjoining the asylum with untreated sewage. Col. Kenneth Macleod referred to this epidemic in a discussion at the Epidemiological Society in 1901, and said that when he himself was assistant medical officer at the Durham Asylum in 1864 there was a similar outbreak of dysentery also, and, as at Garlands, it was associated with sewage irrigation. These and similar instances all lent support to the opinion that dysentery resembled enteric fever in being a “filth disease,” meriting as much as the latter the appellation of “pythogenic,” which Murchison applied to typhoid.
Robert Gillies Smith