and his shamefaced, sheepish admission of the various recorded facts brought to his attention are doubtless the reaction to a great deal of teasing on this subject, and to its treatment as a bad habit rather than as a matter to understand and explain. One feels that if it were possible to get him to talk frankly, he would be able to tell us much about the fears and impulses which are at the bottom of his washing performances. His sensitiveness and tendency to quarrel with those about him are probably more or less a product of his deafness, by virtue of which he hears only snatches of talk, and builds suspicions and misinterpretations upon these fragments. The deafness and washing obsession contribute equally and unconsciously to setting him apart from the other boys; of this isolation, self-inflicted though it is in part, he is doubtless very conscious and perhaps resentful.

In considering the psychopathological findings described above, one is struck at once by the variety of reactions which these patients display. This fact is particularly impressive if one has been accustomed to think of patients with constitutional mental defect as having to belong in one of two air-tight compartments: either in that of feeble-mindedness, which contains the idiot, the imbecile and the moron with set behavioristic capabilities and stereotyped adaptive mechanisms somewhat arbitrarily standardized; or in the compartment of "feeble-mindedness plus insanity" which contains any and all aberrations from the behavior typical of the patients in the first compartment. One cannot but infer from even these few recorded observations that in this branch of psychiatry also, in spite of the sound and tangible help to individualistic study offered by the Binet-Simon test, we have spent more time in consideration of feeble-mindedness as a disease in general than in a study of the facts presented by each individual patient. Obviously, the existence of temperamental idiosyncracies showing so many links in common with the ordinary variations in behavior found in the child who is not mentally defective, necessitates some attention to the individual personality if we are really to do justice to our feeble-minded patients. Inquiries along such lines are not merely of etiological interest as matters for research, but can also be made of practical help to teachers and all others wrestling with the problem of the care and training of

the mentally defective. Physicians dealing with these cases should certainly have psychopathological experience and training.

I should like to express my indebtedness to Dr. Adolf Meyer of The Johns Hopkins Hospital for his kindly oversight and helpful suggestions in the course of this work.

I would also thank Prof. E. R. Johnstone, Superintendent of The Training School at Vineland, N. J., for permission to use the case material presented above.

REFERENCES.

1. Goddard, Henry H.: Feeble-mindedness, Its Causes and Consequences. The Macmillan Co., 1914, p. 505.

2. Kraepelin: Psychiatrie, 1913, Vol. 3, p. 911.

3. Meyer, Adolf: An Attempt at Analysis of the Neurotic Constitution American Journal of Psychology, Vol. 14, pp. 90-103.

THE PROBLEM OF PULMONARY TUBERCULOSIS IN

A PSYCHIATRIC HOSPITAL.

BY S. A. SILK, PH. G., M. D., WASHINGTON, D. C.,

Senior Assistant Physician, Saint Elizabeth's Hospital, Washington, D. C.* Formerly: Resident Physician, Philadelphia General Hospital; Assistant Physician, Pennsylvania State Sanatorium for Tuberculosis, Mont Alto, Pennsylvania; and Medical Superintendent, J. C. R. A. Sanatorium, Los Angeles, California.

1

Whatever our opinion may be regarding the relationship of pulmonary tuberculosis to the various psychoses, whether we believe that pulmonary tuberculosis in some instances is the cause or the result, either entirely or in part, of the psychosis, or that it is an entirely independent condition-whether, as White 1 suggests, "tuberculosis might be defined as a failure in the sublimation of respiratory libido," the causes of which could only be determined if the unconscious mind of the patient were known, we all agree that pulmonary tuberculosis is and will remain quite a problem in every hospital for the mentally ill.

Tuberculosis does not confer any immunity against the development of a psychosis, nor does the presence of a psychosis confer immunity against tuberculosis. Of the vast number of humanity afflicted with pulmonary tuberculosis, some will develop a psychosis, and of the equally great number of the mentally ill, some will develop pulmonary tuberculosis. The hospital for the mentally ill will, therefore, be called upon to admit patients in whom pulmonary tuberculosis is present upon their admission to the hospital, and, also, to care for those who develop the disease after a greater or lesser period of stay in the institution, but who were apparently free from it upon admission. While it is quite evident that it is the duty of every hospital to cure as many cases of either class as possible, using all the modern means known to the medical world in combating this disease, the far greater problem is the prevention of the spread of the disease

*This hospital was known until fecent years as the Government Hospital for the Insane.

among the non-tubercular population, and the discussion of the problem in this paper therefore will be mainly with that object in view. On superficial consideration of this problem, it may lend itself to an apparently simple solution. It would seem as though all that would be necessary is that every psychiatric hospital should have a proper building, specially adapted for the purpose, where all patients known to be tubercular could be segregated. Practically, however, because of the special nature of the disease, the problem presented is by no means a simple one.

Pulmonary tuberculosis is a rather chronic disease, extending often for a period of 15, 20, or more years. The original affection usually takes place during childhood, and the disease as seen in the adult is generally the reactivated process of childhood days. Though due to a specific micro-organism, the actual development of the disease and its progress depend upon so many other factors, as heredity, susceptibility, state of general resistance of the body, environment, and mental state of the individual, that the germ itself takes a place of secondary importance in the etiology and progress of the disease. The human body shows a great resistance to the disease, and even after definite infection takes place the body is able to check the progress and arrest the pathological process begun. However, while one lung or a portion thereof may successfully arrest the disease process, the other lung, or another portion of the same lung, may eventually succumb thereto.

The balance may, at times, be a very fine one. At times, it may require very little effort to raise the general resistance of the body in order to successfully arrest even a quite extensive disease process; while, at other times, the general resistance may be so low that, once the disease took root, no extraneous efforts could save the body from disintegration. The lowering of the bodily resistance does not depend upon any one specific factor, but anything that causes a rapid drain upon the energy of the individual may lead to the same result. It matters not, apparently, whether it be overwork or dissipation, impure air or mental strain, such as worry or fear.

In treating tuberculosis, we therefore must consider the individual as a whole, and his various reactions to internal and external stimuli.