778 REPORT OF THE EGYPTIAN GOVERNMENT HOSPITAL FOR THE INSANE.

responsible for 2 deaths in 1911 and for 8 invalidings in1910 and 1911.

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The problems in tropical medicine which have during thepast years engaged the attention of the authorities in EastAfrica have been of the utmost importance. I need onlyinstance the decimation of natives by sleeping sickness andthe ravages produced among them by venereal diseases, bothof which have been, and are still being, tackled with energy,but it is also recognised that tropical sanitation has a largepart to play in the prevention of disease. The recent growthof these Protectorates has been coincident with the growthof modern tropical science, and the application of its well-known principles-e.g., the reasonable segregation of

Europeans, the proper laying out of towns and new stations,and the suitable siting and construction of houses, withattention to water-supply and drainage-should ensure thatthe excellent reputation for health which they have enjoyedin the past will be continued and improved upon in thefuture.

’

THE SIXTEENTH ANNUAL REPORT OFTHE EGYPTIAN GOVERNMENT HOS-

PITAL FOR THE INSANE.

THE present report of the well-known lunatic asylumnear Cairo is for the year 1910, and is again written by Dr.J. Warnock, but since it has appeared the second asylumhas been opened at Khanka, under the superintendence ofDr. H. W. Dudgeon, which will gradually relieve theperpetual overcrowding of the original institution.

Statistics: Prevalence and Causation of Insanity.During the last 16 years the number of patients in the

asylum has trebled, but this does not necessarily mean thatlunacy is on the increase in Egypt. On the contrary, it isprobably due to growing civilisation, for public policy nowdemands that more and more potentially dangerous lunaticsshall be detained in the asylum instead of allowing them tobe continually discharged and readmitted. Moreover, thegeneral public is more ready to bring insane relatives whenit is gradually learnt that asylums have become more

humane in their methods. To these causes must be added,as we have pointed out on former occasions, the reductionin the asylum annual death-rate from 33’ 5 per cent. of theresident population to 10’2 per cent. in 1910. The numberof better-class patients is gradually increasing, whichbetokens some public confidence in Dr. Warnock’s manage-ment of the asylum, and S4870 were received for thetreatment of patients in the paying block. Also, 16 patientswere admitted as voluntary boarders on their own writtendemand. The daily average number resident in the asylumwas 1234, while 737 cases were admitted during the year.The greatest number of admissions-were suffering from

mania, and the next chief entry was 109 cases of pellagrousinsanity, besides several others who were afflicted bypellagra. Four-fifths of the pellagrous lunatics came fromUpper Egypt and Cairo, and 14 additional cases were

admitted during the year into the temporary insane wards atthe Tura Convict Prison. The crimes of these 14 were theft,murder of six people, attempt at murder, assault, and destroy-ing cotton plants. Pellagra accounted for 21 deaths at theasylum during the year, being the chief cause of mortality,excepting 40 deaths from general paralysis. The generalrate of mortality in the asylum was 10 - 2 per cent. In viewof the immense importance to Egypt of the problem of theetiology of pellagra, it has been pioposed to the EgyptianGovernment that a holder of a Beit scholarship shoulddevote himself to research upon this subject in Egypt.

It used to be held that general paralysis was exceedinglyrare in Oriental countries, but in Cairo every year cases havebeen admitted into this asylum, varying in number from 15in 1902 to 50 in 1910. Of the 50 paralytics, 39 were-undoubtedly syphilitic and 17 confessed to alcoholic habits.General paralysis accounted for nearly 10 per cent. of theadmissions on the male side, and is apparently becomingmore common among the natives, for 39 of the patients wereOrientals. Alcoholic insanity is also increasing, for theadmissions have risen from 21 cases in 1902 to 45 in 1910.The hasheesh (cannabis indica) habit accounted for 12 per8ent. of the male patients admitted.Deoreased Employment of Mechanical Restraint and Naircotics. _

During the year no less than 851 accidents to patients

were recorded, mostly slight in character, but one lunaticin a single room succeeded in hanging himself from a highwindow bar by making a rope of his strong clothing.And there were ten instances of fractured bones, not dueto ill-usage by attendants, but caused by falls or bypatients quarrelling together. The report says : ’’ Withoutdoubt a more alert staff would prevent many of theseaccidents." "

Only one patient was treated by wet packs, and five otherswere subjected to camisole restraint to prevent their re-

moving bandages applied for fractures and wounds. Thestomach tube was used for artificial feeding 5247 times,which gives some idea of the large number of acutely insanepatients who without this measure would have died ofstarvation. The average seclusion was 238 hours per day,or, in other words, 30 patients were secluded for eight hoursa day all the year round. In addition to a great reductionin the use of mechanical restraint and seclusion, the doses ofnarcotics, mostly paraldehyde, were diminished from 6758in 1909 to 4966 during the year, in spite of the increasednumber of patients. This drug reduction is due, accordingto Dr. Dudgeon, to the increase of single rooms, because ina dormitory one noisy, restless individual used to necessitatehalf a dozen sleeping draughts being adminstered to his

neighbours.Suggested Reforms.

Dr. Warnock, in addition to other reforms, has been

trying for five years to get the Egyptian Government toraise the pay of the nurses and attendants, so as to make iteasier to find and retain a respectable class of employees.In order to show the necessity for this he states that 136new employees were engaged during the year ; 48 resignedtheir appointments, while 28 left without giving notice.

Sixty were dismissed for the following reasons : 10 becauseinformation was received in disproof of their alleged goodcharacters, 16 for repeated acts of neglect and irregularity,6 for disobedience of orders, 8 for being repeatedly detectedasleep on duty, 8 for striking patients, 3 for stealingpatients’ food or tobacco, 3 for ill-health, and 6 for generalincompetence."

" He urges that asylum attendants should bepaid at least as well as police constables. Another reform

suggested is that the provincial medical officers should keepa register of all lunatics examined by them, and should sendnotes of the previous history to the asylum with the patient.The custom in Egypt of repeatedly petitioning for the

discharge of lunatics, however dangerous or demented, showsthat the relatives have often no adequate knowledge of theuses of an asylum. Even after an inmate has murderedseveral people his relatives still urge his release. Forinstance, a fanatical barber addicted to hashish had a

violent outbreak one day and tried to cut the throats ofthose of his clients who did not belong to his religion ; oneclient was severely injured, but the relatives of the barberare now busy petitioning for his discharge, though they areaware that he is not fit to be trusted at home. It is notsurprising to learn that when a convalescent is discharged,and when the promises of a responsible relative have beenrecorded, those promises are seldom kept. By the officialreturns it appears that- during the year 13 persons weremurdered in Egypt by lunatics, while attempts to murder 15other persons were made; it is extremely improbable thatthese figures are complete. Dr. Warnock has done much toeducate the Government and public opinion, but it is obviousthat he has not yet. completed his labours.

LEEDS GENERAL INFIRMARY: THESCHEME OF EXTENSION.

IN THE LANCET of June 15th, 1912, our Leeds corre-

spondent briefly outlined the scheme of enlargement andreconstruction of the Leeds General Infirmary which is to becarried out as a memorial to King Edward in that city.The proposed extensions and improvements are so muchneeded and of such importance that some further referenceto them is desirable. They will not only add greatly to thescope and efficiency of the institution itself, but will involvethe rearrangement of neighbouring streets and the clearingof a ’’ slum" area adjoining the present infirmary site.The King Edward Memorial Fund was started in 1911,

and of the £150,000 needed for the reconstruction of theinfirmary over £110,000 have already been subscribed;The requirements of the infirmary, as stated in a pamphlet

779

780 ANNUAL REPORT OF THE REGISTRAR-GENERAL FOR 1910.

issued in 1911, were : (1) Modernising- the existing wards andbringing their sanitary arrangements up to date; (2) buildingfour new operating theatres ; (3) providing additional accom-modation for nurses; (4) building two additional wards ;(5) making additions to the pathological department ;(6) building additional rooms for the use of the casualty and<out-patient departments ; (7) providing new boilers andboiler house ; and (8) making the alterations required to

safeguard the patients and the buildings against fire.After considering fully the question of removing the

.hospital to another locality it was determined that, if thenecessary funds were forthcoming, the extensions should’be carried out on the present site. Considerable progresshas already been made towards satisfying the above require-ments-thus, eight of the 13 existing large wards have been.moderised, accommodation for five additional nurses and30 additional patients has been provided, and the wardblock which was burned down has been rebuilt on lineswhich render it practically fireproof, and other means havebeen taken to reduce the danger of fire. But it was

impossible to cope with the other requirements withoutacquiring additional land, on which the new buildings couldbe erected.

The present scheme, as our correspondent pointed out,depends for its complete success upon cooperation betweenthe city council and the hospital authorities, whereby themaximum of space may be acquired with the greatest advan-tage both to the institution and to the city. The infirmaryboard, adopting a bold policy, have already purchased over’6000 square yards of land adjoining their present site, andit is estimated that nearly the same amount of land will haveto be acquired by the corporation in order to carry out theirportion of the complete scheme. The plan now advocatedby the infirmary board will enable them to build four newoperating theatres, an addition to the existing nurses’ home,.a block of three large wards and additional rooms for thecasualty and out-patient departments, and a new boilerhouse and laundry, in positions which are most convenientfor the working of the institution and which will also affordopportunities for making great additions to the ward accom-modation in the future without interfering with existingbuildings, all this to be done with the minimum of expense.Our illustration, kindly lent by Mr. F.. J. Bray, generalmanager of the infirmary, gives a view of the infirmary as itis now and shows the buildings which will be done awaywith. The lines across it show the course of the new roadwhich it is proposed that the corporation should construct.

ANNUAL REPORT OF THE REGISTRAR-GENERAL FOR 1910.

(Concluded from page 712.)

FURTHER examination of the vital statistics of recent

years leads us inevitably to the conclusion that a mainfactor in the continued reduction of the general mortality isthe unprecedentedly low death-rate within the first five

years of life. In the year 1910 the mortality at every agegroup in both sexes was below that of 1909, itself a year of

- remarkably low death-rates.Causes of Death.

Commenting on the causes of death in 1910 Dr. Stevensonemphasises the fact that a laige share of the whole numberof deaths is contributed by fo-ir of the more importantdiseases-viz., tuberculosis, pneumonia, bronchitis, and

cancer, which together account for one-third of the total.The proportions in which the different diseases contribute tothe death roll are shown by a special diagram, in which thewhole area of the circle represents the deaths from allcauses, whilst the various segments represent deaths fromparticular causes or groups of causes. The statement

already made that the mortality from all causes was lowerin 1910 than in any previous year applies equally to themortality from tuberculosis in all its forms, as well as toenteric fever and to scarlet fever.

s Diphtheria and Antitoxin.If the deaths ascribed to diphtheria and croup are con-

sidered together, as most nearly representing the true fatality.of the former disease, the mortality therefrom was the lowestrecorded since 1880. Inquiries addressed to the practitioners

certifying deaths as’ from "croup" " elicited further infor-mation which resulted in the transfer of 123 of them to

laryngitis, 42 to diphtheria, and 18 to laryngismus stridulus,reducing the number finally classed as croup to 73. Thenumber so returned as recently as 1891 had been no less than2638. In the year 1910 the death-rate from diphtheria andcroup-viz., 122 per 1, 000, 000-is much the lowest since 1855,in which year diphtheria was first shown separately fromscarlet fever in the official tables; and in this connexionit must be borne in mind that the effect of increasingaccuracy in diagnosis is probably to minimise the fall in

mortality.From a recent report of the Metropolitan Asylums Board

it appears that the London mortality from diphtheria reachedits maximum in 1893, since which year the rate has fallengreatly, and this fall has been coincident with the introduc-tion and increasing use of the treatment of diphtheria byantitoxic serum.

Enteric Fever.The mortality from enteric fever in 1910 was the lowest

on record : it was equal to a rate of 53 per 1,000,000 living,and was below the average for the quinquennium ended1909 by 24 per 1,000,000. In the year 1869 enteric feveraccounted for a mortality equal to 390 per 1,000,000 ;within the 42 years since elapsed it has fallen from thatfigure to 53 per 1,000,000, the rate of the year under notice.It is interesting to note that the arrest in the decline ofenteric fever mortality during the last years of the nine-teenth century is comparable to that which occurred atabout the same period in the mortality from all causes.

This period was one of increasing infantile mortality.On the other hand, the period of decline of enteric fevermortality which set in about 1900 corresponds nearly to thesimilar period of recent improvement in infantile mortality.Further pursuing this point, Dr. Stevenson remarks thatthe experience of this country in regard to infantile mortalityhas been paralleled by that of most other European countriesin this respect, but there is no such parallelism in the caseof enteric fever.

Tuberculosis.

In this report, as in several of its predecessors, consider-able prominence is given to the behaviour of tuberculosis.It. is beyond question that the diseases of the tuberculousgroup are in the aggregate more destructive to health andlife than any others in the list. They are certainly in anexceptional degree amenable to control by the well-knownmeasures, the due enforcement of which constitutes one ofthe foremost duties of our sanitary authorities.

In an instructive diagram the incidence of mortality fromvarious forms of tuberculosis is shown for each quin-quennium since the middle year of last century. From thiswe learn that although there has been in both sexes a steadydecrease in the loss of life from tuberculosis, the decrease hasbeen much greater among females than among males. Inthe quinquennium ended 1855 the rates were the same inboth sexes-namely, 3637 per 1,000,000 ; but in the quin-quennium ended 1910 the female rate had fallen to 1350per 1,000,000, or 25 per cent. below the rate for males,which was 1798 per 1,000,000. Very remarkable is the factthat in the case of phthisis the mortality among females didnot fall below that of males until the quinquennium 1866-70, but that since that period the excess in decrease offemale mortality has been most marked in the case of generaltuberculosis, the mortality from tuberculous phthisis amongfemales in the last quinquennium being lower than thatamong males by 29 per cent.

In the Registrar-General’s recent reports the deaths fromtuberculous phthisis include those from tuberculous laryngitis.Taken together the deaths so classed in 1910 were equal to71 per cent. of the total deaths from tuberculosis, and to arate of 1015 per 1,000,000 of the population. This rate isthe lowest on record, and is below the average for the

quinquennium immediately preceding by 10 per cent. Dis-

regarding variations in methods of death classification, itis possible to make a rough comparison among severalcountries as regards their mortality from phthisis. InPrussia, Scotland, the Netherlands, Belgium, and Englanda marked diminution in mortality has taken place in recentyears. In three countries in the list the rates are in excessof those of England and Wales., The mortality from meningeal tuberculosis is steadilydecreasing, the deaths attributed thereto in the year under