- Email: [email protected]
Tuberculosis in mental hospital patients
July 1952
TUBERCLE
because the series is comparatively very large, and the vast majority of workers in this field hold the contrary view. Far from the problem remaining insoluble, it is being solved. Such patients are faring well. The majority of the men are earning a living and meeting familial responsibilities. The women are, in many cases, rearing a family. With regard to the comparative value of collapse measures, artificial pneumothorax is the most successful in apical segment cavities. Phrenic nerve interruption is also of value. We have seen that these measures are readily interchangeable. When one has set the process of cavity closure in motion, the other can be used to complete the task. Pneumoperitoneum has a useful but minor" role in treatment. It is of value in showing the response of the cavity to elevation of the diaphragm, and exerts a greater influence on basal lesions than on apical lesions.
201
There is no evidence that primary resection should take priority in the treatment of these cases. The value of persistence with collapse measures has been proven. When these fail, however, and only then, resection will deal successfully with a certain proportion of this minority. I wish to express thanks to Dr L. E. Houghton, Dr J. C. Roberts and Dr K. R. Stokes for kind permission to study their cases, and for advice with the original work. I am indebted to Dr J. Sumner for criticism of the original work and to Dr K. R. Stokes for much helpful criticism of this article. References
Annotation (1949) British Medical Journal, u, z I63. Clifford-Jones, E., and Macdonald, N. 0943) Tubercle, xxw, 97Crofton, J. (1949) Thorax, xv, 96, Gordon, B. L., Charr, R., and Sokoloff, M. J. (x944) Amer. Rev. Tubere., XLIX, 43 ~. Price Thomas, (3. (194~) Brit..7. Tuberc., xxxvl, 4Rothsteln, E. (I945) Amer. Rev. Tubere., u x , 39. Rozenblat, B. (1949) Brit..7. Tuberc., xr.m, 47-
Tuberculosis in Mental Hospital Patients* By FRIEDA R. HENDELES
Shenley Hospital, Herts Until as recently as five years ago, many physicians in mental hospitals were unaware of any danger in the neglect of detection and treatment of tuberculosis in their patients. They considered such treatment to be a waste of public money, which would be far better spent on the treatment of sane patients in sanatoria. The mentally sick were regarded as a dead loss; indeed, any suggestion that tuberculosis should be routed out and that patients were entitled to treatment of their tuberculous condition was regarded as little more than the latest 'witch hunt'. Until two years ago, the prevalence of the disease in mental hospitals of England and Wales was in the region of I3- 5 cases per thousand, with fresh notifications per year, ranging from 9 per thousand in I944 to 7"4 per thousand in I949 (Board of Control). Here, then, lay a reservoir of infection which
should have engaged the attention of all concerned with public health. The important contributing factors have been overcrowding, poor nutrition, poor ventilation, non-detection of the disease, and neglect of the elements of hygiene by the patients. Six years ago, on joining the staff of Shenley Hospital, the author organized a tuberculosis unit to serve the mental hospital population. Tile aims of such an organization were three: first as a public health measure which had bccn long overdue, second for the protection of nursing staff and auxiliaries, and third, for the satisfactory integration of treatment for the patients. Perhaps these aims require further elucidation: (I) Contrary to popular belief, there is today considerable patient movement from mental hospitals in tile way of admissions,
*Read to the North-West Metropolitan Regional Tuberculosis Society - FebTua W 1952
202
July
TUBERCLE
escapes, parole, periods of leave and extramural care. A certain number of patients ~ire now allowed to live in the hospital and go out to work daily whilst some of our very young patients go to a neighbouring school. Unsuspected cases of tuberculosis in any of these groups present a hazard to the general public. (2) Nursing staff and auxiliaries are more vulnerable to infection by reason of prolonged and close contact with patients whose habits are often unhygienic and deteriorated. (3) Mental treatment has of late advanced to the extent that the prospect of resuming a useful life in the outside world has become a reality for a good proportion of patients. The discharge rate of mental hospitals is now 75"5 per cent of acute admissions (Board of Control). The advantage of treating the tuberculous condition concurrently with the mental state will obviate the necessity of more prolonged sanatorium treatment at a later stage, and, at least, prevent it from becoming intractable or even hopeless. It is noteworthy that many neurotics are treated in mental hospitals as voluntary patients, consequently the provision of tuberculosis treatment for all is doubly desirable. In all patients, the first aim is the conversion of an 'open' case to a 'closed' one, even where the mental prognosis is poor. Certain interesting facts have emerged ti-om the researches of Waldo Oechsli, et al., in America, and Donal Early in England. First, that the incidence of tuberculosis in mental hospitals is higher in men than in women. Secondly, that the incidence of the disease is highest in long-term cases. In the past, the relationship between tuberculosis and schizophrenia used to be regarded as a direct and simple one, but the belief is now growing, in the light of clinical evidence, that it is a complex one with the interplay of environmental and constitutional factors involved." 'Statistically significant' evidence submitted by American authors indicates that the mental state is a factor, hut only a minor one.
1952
In states of delirium and confusion accompanied by pulmonary tuberculosis, it has been observed that the mental condition sometimes clears dramatically when the pulmonary condition is brought under control. Whether this is coincidental or is a significant fact is, as yet, undetermined. Wassersug and McLaughlin of America give an interesting illustration in the case of a 24-year-old negress with a puerperal psychosis. On admission, she had tuberculous infiltration of the L. lung, with positive sputum. L.A.P. was induced, and the delirium and confusion cleared dramatically. She was then sent on for thoracoplasty as the sputum was still positive. T h e y state that had A.P. not been available, the mental illness would have been prolonged, thus rendering the ultimate prognosis for both mental and physical disease poor. The detection of tuberculosis in mental patients by clinical means is very different from that in the normal individual, and in many cases the disease is in an advanced state before it comes to the notice of the doctor. This is because our patients rarely produce a pyrexia in the toxic phase, rarely cough, and almost always swallow their sputum, except when profuse. Such symptoms as loss of weight, tachycardia and apathy towards food are sometimes erroneously attributed to the mental state, these being common accompaniments of certain mental conditions.
Organization In organizing a tuberculosis unit and control service in a mental hospital one must bear in mind two importaht considerations. First, a fair proportion of patients are unable to co-operate to the same degree as ordinary patients in matters of personal hygiene and observation of general precautions. A deteriorated and impulsive patient m a y spit on his bed, into his food, into the nurse's face, or smear sputum and faeces over everything. The increased risks involved in the nursing of such patients impose on those in charge the highest possible standards. Protective measures and control must there-
July
1952
203
TUBERCLE
fore be far more rigid than in an ordinary sanatorium. Hence, a set of staff changing rooms features specially in such a unit. Secondly, m a n y persons engaged in mental nursing are without general nursing training; at the same time, it should be stressed that a general training alone would be of little value in this work. Size of Unit The most economical is a central unit serving sever,51 hospitals; it should comprise 2-} per cent of the total number of beds to be served, in the proportion of two male to one female since the incidence of tuberculosis is higher in our male patients. The unit at Shenley contains 6o beds for male patients while female patients receive treatment in a similar unit at Napsbury Hospital. Our unit serves three mental hospitals, takes admissions direct from tuberculosis sanatoria, chest clinics and out-patient clinics in the catchment area of the hospital. Siting and Ward Plan The building is separate from the other wards yet within easy access of the x-ray Department and Pathology Laboratory. There are two villas, each containing two wards leading on to glass-roofed verandahs fitted with an observation cabin for night nurses. The unit has its own sterilizing room, screening room, separate staff quarters, and day rooms for ambulant patients. Amongst the special equipment available are viewing screens, an x-ray screen, Maxwell Apparatus, and E.C.T. machine with Lucas Respirator for administration of specially modified electro-convulsion therapy. Medical Staffing The medical staff consists of a Consultant Chest Physician, and a Psychiatrist with a special interest in tuberculosis. Ideally, the Psychiatrist in charge of the tuberculosis unit should combine his duties with those of Tuberculosis Control Officer for the entire hospital population. If the doctor who is to be responsible for the unit has had no previous experience of tuberculosis, he should
receive instruction from the Consultant Chest Physician, and, if possible, should also spend a three-month training period at a sanatorium, preferably as a resident or alternatively by attendance several times a week. Nursing Staff and Training Our nursing staff consists of a Charge Nurse, Staff Nurse and two junior nurses, for every 3 ° patients. The Charge Nurses are attached permanently to the unit and have received practical sanatorium training supplementary to that given at Shenley by the author who has trained them to run the unit with minimal demands on the doctor's time. They are trained to take blood for E.S.R., and to do laryngeal swabbing; the reason that they are encouraged to undertake these functions being that the nurse-patient relationship in a well-run mental hospital is inevitably a close and important one. Nurses so trained are likely to obtain far better co-operation than the doctor himself. Prospective Sisters and Charge Nurses for the unit should, if possible, receive three months' practical nursing experience in a tuberculosis sanatorium in addition to special training given by the unit doctor.
Auxiliary Staff An Occupational Therapist is attached to the sanatorium wards. This specific kind of auxiliary worker should be given one lecture on tuberculosis underlining the hazards the disease presents in the mentally sick, as well as a practical demonstration of the precautionary measures taken on the wards. Protection of Staff Protection of nursing and auxiliary staffs is rigidly controlled but those who fear working with tuberculosis are excluded from the unit. All nursing and auxiliary staff, on joining the hospital, have an x-ray of chest and a Mantoux test, whilst the negative reactors are precluded from contact with the sanatorium wards and are offered vaccination with BCG as soon as possible after joining. After the first examination, skiagrams are
204
TUBERCLE
repeated twice more at six-monthly intervals and thereafter at yearly intervals. The sanatorium staff are x-rayed at threemonthly intervals up to six months after leaving the unit. Protective Precautions It is essential for nursing and auxiliary staffs to wear protective clothing at all times on duty in view of the added risks of working with impulsive and deteriorated patients. Gowns are of ankle-length operating-theatre type. Masks of ample proportions (lined with cellophane) are worn at all times and changed at least every two to three hours. Gloves are worn for the performance of all dressings and for the collection of sputum. The latter is collected in mono-containers which can be incinerated readily. Since mental hospital laundries arc sometimes staffed by patients, to a large extent bed linen and clothing are given preliminary treatment by the sanatorium staff. Articles grossly contaminated by sputum and faecal matter are soaked in a 2 per cent phenol solution for four hours, before transfer to the laundry for boiling in open baths for twenty minutes. Other articles are collected into linen bags, sealed, and sent for steam sterilization at 220 ° F. Waste food from these wards is sterilized after collection. Detection and T r e a t m e n t of Tuberculous Patients
Every patient, on admission to hospital, undergoes investigation for contact with or family history of tuberculosis. Routine chest radiography is done within a week of admission, with subsequent yearly repetition. In tile unit itself, every effort is made to segregate patients according to their mental as well as physical condition. Patients are nursed on verandas at all times unless the temperature falls below freezing point. It is found that'acclimatization takes place very quickly and that. superadded respiratory infections are infrequent. The exceptions to this routine, of course, are the acutely ill or
July
1952
toxic patients. Rest is given with graded exercise within the limits of the patient's co-operation and happiness. Special investigations and recording of clinical information are carried out exactly as in ordinary sanatoria. All forms of therapy available to sane tuberculous" patients are also available to our patients, who, contrary to the conventional belief, rapidly become amenable and co-operative to all clinical procedures. Any chest surgery indicated is carried out at Clare Hall Hospital. Though less frequently applicable than in the mentally healthy person, chest surgery is considered to hold a definite place in the care of the tuberculous mental patient, who falls into routine procedures with little difficulty and becomes surprisingly co-operative during major surgical thoracic treatment. This is confirmed by the work of Weiner of the American Veterans Administration, whilst Sarot of Seaview Hospital even recommends lung resection for the met/tally ill. Mental treatment is given concurrently with physical treatments and includes modified electro-convulsion therapy, psychotherapy, prolonged narcosis, and in some instances lcucotomy. Insulin therapy is contra-indicated as is ordinary electroconvulsion therapy. Entertainments for the patients are provided on the wards in the form of cinema shows, individual radio sets, pianos and a library. Occupational therapy takes a variety of forms, similar to that found in an ordinary sanatorium. Visiting and Parole Only adults are allowed on the sanatorium wards and patients' visitors are strongly discouragcd from close contact and kissing. The only patients allowed out on parole, or home on leave, are those in whom the disease is quiescent or under control, namely those with negative sputum. All cases on discharge are referred to timir local chest clinics in the usual way.
July
1952
TUBERCLE
' Quiescent' Our use of this term is applied where there has been an absence of clinical or radiological signs of activity for eighteen months, together with negative laryngeal swabs or sputum for the same period. Such patients may be ti-ansferred to other wards in the hospital, but remain under modified supervision, as long as their mental condition keeps them in hospital. This modified supervision consists in yearly x-ray, laryngeal swabs, and six-monthly E.S.R. Results Our imit thus corresponds closely in many ways with the ordinary sanatorium and provides a gratifying measure of success in the trdatment of mental patients, as well as in keeping the general wards free of tuberculous patients.
Over a five-year period, we have treated xo9 patients in the unit. O f these 32 per cent have become 'quiescent' or 'arrested', whilst a fi~rther I I per cent have been discharged mentally well with their tuberculosis quiescent or arrested. Two thoracoplasties have been performed in the latter group. 17"4 per cent died of pulmonary tuberculosis, of whom z 1.9 per cent had advanced disease on admission. Quotation of a few cases will serve to illustrate the kind of patient we are called upon to treat: 37-year-old Canadian nurse with longstanding bilat, pulmonary tuberculosis. Treated m Canada with subsequent breakdown of lesions on several occasions after periods of a year's inactivity. Admitted to us in a state of mania, with positive sputum. L. phrenic crush and pneumoperitoneum performed. Mental condition gradually returned to normal, hmg lesions became quiescent. Discharged four and a half years ago, returned to Canada and remains well in every respect. A male schizophrenic, aged 3 x, was transferred to us after a ten-year sojourn in another mental hospital where no facilities were available for Tb. treatment. A L. apical lesion was present, but sputum negative. General tr. given, lesions became quiescent and mental condition gradually became normal. Dis-
205
charged one and a half years ago. Now working and IMng in lodgings. Remains well. A boy, aged 19, suffering from hysterical fugues was discharged from military service because of his mental state. On admission routine x-ray revealed recent bilat, soft lesions in mid-zones. Laryngeal Swab positive. Tr. with chemotherapy, pneumoperitoneum, followed by L.A.P. Mental condition became normal, pulmonary lesions controlled. Discharged ten months ago. Remains well. Summary (z) Mental hospitals are a reservoir of tuberculous infection and a potential danger to the public through the medium of inr creased patient-movement.
(2) Nursing staffs in these hospitals are exposed to greater hazards than general nurses in cases of undetected tuberculosis. (3) Results of modern research into tuberculosis in the mentally sick are revealed. (4) The organization of a tuberculosis unit and tuberculosis control service is described. (5) Concurrent tuberculosis treatment and mental treatment is advocated. (6) A five-year test period for the tuberculosis unit has given encouraging results. Acknowledgments The author expresses a debt of gratitude to Dr O. Fitzgerald, Medical Superintendent of Shenley Hospital, and Dr F. Simmonds, Medical Superintendent of Clare Hall Hospital, without whose support and cooperation the unit would never havc been established. Bibliography Early, D. (I95o) .7. Ment. Sc., CDII, 199. Lamblotte, L. O., Washington, E. L., and Bozalis, G. S. (1919) Amer. Re~'. Tuberc., ux, 289. Oectasli, W. 0949) U.S. Public Health Repts.,Jan. 7, I. Memo, Supervision of Nurses' ttealth: King Edward's Hospital Fund for London (i95o). Pollak, 0949-195o) Amer. fl. Ment. Def., LXV,333" Prendergast and King 095o)January21, 78. .lied. flour., Australia. Ruskin, 09t5) 248. ..lm..r. Rev. Tubere., 248. Wassersug, J., and McLaughlin, W. (1951) flour. Nerr'. & 3Ieat. Dis., cxm, I x5. Weiner, A. (195o) Dis. Chest. Abs., 388.
TUBERCLE
because the series is comparatively very large, and the vast majority of workers in this field hold the contrary view. Far from the problem remaining insoluble, it is being solved. Such patients are faring well. The majority of the men are earning a living and meeting familial responsibilities. The women are, in many cases, rearing a family. With regard to the comparative value of collapse measures, artificial pneumothorax is the most successful in apical segment cavities. Phrenic nerve interruption is also of value. We have seen that these measures are readily interchangeable. When one has set the process of cavity closure in motion, the other can be used to complete the task. Pneumoperitoneum has a useful but minor" role in treatment. It is of value in showing the response of the cavity to elevation of the diaphragm, and exerts a greater influence on basal lesions than on apical lesions.
201
There is no evidence that primary resection should take priority in the treatment of these cases. The value of persistence with collapse measures has been proven. When these fail, however, and only then, resection will deal successfully with a certain proportion of this minority. I wish to express thanks to Dr L. E. Houghton, Dr J. C. Roberts and Dr K. R. Stokes for kind permission to study their cases, and for advice with the original work. I am indebted to Dr J. Sumner for criticism of the original work and to Dr K. R. Stokes for much helpful criticism of this article. References
Annotation (1949) British Medical Journal, u, z I63. Clifford-Jones, E., and Macdonald, N. 0943) Tubercle, xxw, 97Crofton, J. (1949) Thorax, xv, 96, Gordon, B. L., Charr, R., and Sokoloff, M. J. (x944) Amer. Rev. Tubere., XLIX, 43 ~. Price Thomas, (3. (194~) Brit..7. Tuberc., xxxvl, 4Rothsteln, E. (I945) Amer. Rev. Tubere., u x , 39. Rozenblat, B. (1949) Brit..7. Tuberc., xr.m, 47-
Tuberculosis in Mental Hospital Patients* By FRIEDA R. HENDELES
Shenley Hospital, Herts Until as recently as five years ago, many physicians in mental hospitals were unaware of any danger in the neglect of detection and treatment of tuberculosis in their patients. They considered such treatment to be a waste of public money, which would be far better spent on the treatment of sane patients in sanatoria. The mentally sick were regarded as a dead loss; indeed, any suggestion that tuberculosis should be routed out and that patients were entitled to treatment of their tuberculous condition was regarded as little more than the latest 'witch hunt'. Until two years ago, the prevalence of the disease in mental hospitals of England and Wales was in the region of I3- 5 cases per thousand, with fresh notifications per year, ranging from 9 per thousand in I944 to 7"4 per thousand in I949 (Board of Control). Here, then, lay a reservoir of infection which
should have engaged the attention of all concerned with public health. The important contributing factors have been overcrowding, poor nutrition, poor ventilation, non-detection of the disease, and neglect of the elements of hygiene by the patients. Six years ago, on joining the staff of Shenley Hospital, the author organized a tuberculosis unit to serve the mental hospital population. Tile aims of such an organization were three: first as a public health measure which had bccn long overdue, second for the protection of nursing staff and auxiliaries, and third, for the satisfactory integration of treatment for the patients. Perhaps these aims require further elucidation: (I) Contrary to popular belief, there is today considerable patient movement from mental hospitals in tile way of admissions,
*Read to the North-West Metropolitan Regional Tuberculosis Society - FebTua W 1952
202
July
TUBERCLE
escapes, parole, periods of leave and extramural care. A certain number of patients ~ire now allowed to live in the hospital and go out to work daily whilst some of our very young patients go to a neighbouring school. Unsuspected cases of tuberculosis in any of these groups present a hazard to the general public. (2) Nursing staff and auxiliaries are more vulnerable to infection by reason of prolonged and close contact with patients whose habits are often unhygienic and deteriorated. (3) Mental treatment has of late advanced to the extent that the prospect of resuming a useful life in the outside world has become a reality for a good proportion of patients. The discharge rate of mental hospitals is now 75"5 per cent of acute admissions (Board of Control). The advantage of treating the tuberculous condition concurrently with the mental state will obviate the necessity of more prolonged sanatorium treatment at a later stage, and, at least, prevent it from becoming intractable or even hopeless. It is noteworthy that many neurotics are treated in mental hospitals as voluntary patients, consequently the provision of tuberculosis treatment for all is doubly desirable. In all patients, the first aim is the conversion of an 'open' case to a 'closed' one, even where the mental prognosis is poor. Certain interesting facts have emerged ti-om the researches of Waldo Oechsli, et al., in America, and Donal Early in England. First, that the incidence of tuberculosis in mental hospitals is higher in men than in women. Secondly, that the incidence of the disease is highest in long-term cases. In the past, the relationship between tuberculosis and schizophrenia used to be regarded as a direct and simple one, but the belief is now growing, in the light of clinical evidence, that it is a complex one with the interplay of environmental and constitutional factors involved." 'Statistically significant' evidence submitted by American authors indicates that the mental state is a factor, hut only a minor one.
1952
In states of delirium and confusion accompanied by pulmonary tuberculosis, it has been observed that the mental condition sometimes clears dramatically when the pulmonary condition is brought under control. Whether this is coincidental or is a significant fact is, as yet, undetermined. Wassersug and McLaughlin of America give an interesting illustration in the case of a 24-year-old negress with a puerperal psychosis. On admission, she had tuberculous infiltration of the L. lung, with positive sputum. L.A.P. was induced, and the delirium and confusion cleared dramatically. She was then sent on for thoracoplasty as the sputum was still positive. T h e y state that had A.P. not been available, the mental illness would have been prolonged, thus rendering the ultimate prognosis for both mental and physical disease poor. The detection of tuberculosis in mental patients by clinical means is very different from that in the normal individual, and in many cases the disease is in an advanced state before it comes to the notice of the doctor. This is because our patients rarely produce a pyrexia in the toxic phase, rarely cough, and almost always swallow their sputum, except when profuse. Such symptoms as loss of weight, tachycardia and apathy towards food are sometimes erroneously attributed to the mental state, these being common accompaniments of certain mental conditions.
Organization In organizing a tuberculosis unit and control service in a mental hospital one must bear in mind two importaht considerations. First, a fair proportion of patients are unable to co-operate to the same degree as ordinary patients in matters of personal hygiene and observation of general precautions. A deteriorated and impulsive patient m a y spit on his bed, into his food, into the nurse's face, or smear sputum and faeces over everything. The increased risks involved in the nursing of such patients impose on those in charge the highest possible standards. Protective measures and control must there-
July
1952
203
TUBERCLE
fore be far more rigid than in an ordinary sanatorium. Hence, a set of staff changing rooms features specially in such a unit. Secondly, m a n y persons engaged in mental nursing are without general nursing training; at the same time, it should be stressed that a general training alone would be of little value in this work. Size of Unit The most economical is a central unit serving sever,51 hospitals; it should comprise 2-} per cent of the total number of beds to be served, in the proportion of two male to one female since the incidence of tuberculosis is higher in our male patients. The unit at Shenley contains 6o beds for male patients while female patients receive treatment in a similar unit at Napsbury Hospital. Our unit serves three mental hospitals, takes admissions direct from tuberculosis sanatoria, chest clinics and out-patient clinics in the catchment area of the hospital. Siting and Ward Plan The building is separate from the other wards yet within easy access of the x-ray Department and Pathology Laboratory. There are two villas, each containing two wards leading on to glass-roofed verandahs fitted with an observation cabin for night nurses. The unit has its own sterilizing room, screening room, separate staff quarters, and day rooms for ambulant patients. Amongst the special equipment available are viewing screens, an x-ray screen, Maxwell Apparatus, and E.C.T. machine with Lucas Respirator for administration of specially modified electro-convulsion therapy. Medical Staffing The medical staff consists of a Consultant Chest Physician, and a Psychiatrist with a special interest in tuberculosis. Ideally, the Psychiatrist in charge of the tuberculosis unit should combine his duties with those of Tuberculosis Control Officer for the entire hospital population. If the doctor who is to be responsible for the unit has had no previous experience of tuberculosis, he should
receive instruction from the Consultant Chest Physician, and, if possible, should also spend a three-month training period at a sanatorium, preferably as a resident or alternatively by attendance several times a week. Nursing Staff and Training Our nursing staff consists of a Charge Nurse, Staff Nurse and two junior nurses, for every 3 ° patients. The Charge Nurses are attached permanently to the unit and have received practical sanatorium training supplementary to that given at Shenley by the author who has trained them to run the unit with minimal demands on the doctor's time. They are trained to take blood for E.S.R., and to do laryngeal swabbing; the reason that they are encouraged to undertake these functions being that the nurse-patient relationship in a well-run mental hospital is inevitably a close and important one. Nurses so trained are likely to obtain far better co-operation than the doctor himself. Prospective Sisters and Charge Nurses for the unit should, if possible, receive three months' practical nursing experience in a tuberculosis sanatorium in addition to special training given by the unit doctor.
Auxiliary Staff An Occupational Therapist is attached to the sanatorium wards. This specific kind of auxiliary worker should be given one lecture on tuberculosis underlining the hazards the disease presents in the mentally sick, as well as a practical demonstration of the precautionary measures taken on the wards. Protection of Staff Protection of nursing and auxiliary staffs is rigidly controlled but those who fear working with tuberculosis are excluded from the unit. All nursing and auxiliary staff, on joining the hospital, have an x-ray of chest and a Mantoux test, whilst the negative reactors are precluded from contact with the sanatorium wards and are offered vaccination with BCG as soon as possible after joining. After the first examination, skiagrams are
204
TUBERCLE
repeated twice more at six-monthly intervals and thereafter at yearly intervals. The sanatorium staff are x-rayed at threemonthly intervals up to six months after leaving the unit. Protective Precautions It is essential for nursing and auxiliary staffs to wear protective clothing at all times on duty in view of the added risks of working with impulsive and deteriorated patients. Gowns are of ankle-length operating-theatre type. Masks of ample proportions (lined with cellophane) are worn at all times and changed at least every two to three hours. Gloves are worn for the performance of all dressings and for the collection of sputum. The latter is collected in mono-containers which can be incinerated readily. Since mental hospital laundries arc sometimes staffed by patients, to a large extent bed linen and clothing are given preliminary treatment by the sanatorium staff. Articles grossly contaminated by sputum and faecal matter are soaked in a 2 per cent phenol solution for four hours, before transfer to the laundry for boiling in open baths for twenty minutes. Other articles are collected into linen bags, sealed, and sent for steam sterilization at 220 ° F. Waste food from these wards is sterilized after collection. Detection and T r e a t m e n t of Tuberculous Patients
Every patient, on admission to hospital, undergoes investigation for contact with or family history of tuberculosis. Routine chest radiography is done within a week of admission, with subsequent yearly repetition. In tile unit itself, every effort is made to segregate patients according to their mental as well as physical condition. Patients are nursed on verandas at all times unless the temperature falls below freezing point. It is found that'acclimatization takes place very quickly and that. superadded respiratory infections are infrequent. The exceptions to this routine, of course, are the acutely ill or
July
1952
toxic patients. Rest is given with graded exercise within the limits of the patient's co-operation and happiness. Special investigations and recording of clinical information are carried out exactly as in ordinary sanatoria. All forms of therapy available to sane tuberculous" patients are also available to our patients, who, contrary to the conventional belief, rapidly become amenable and co-operative to all clinical procedures. Any chest surgery indicated is carried out at Clare Hall Hospital. Though less frequently applicable than in the mentally healthy person, chest surgery is considered to hold a definite place in the care of the tuberculous mental patient, who falls into routine procedures with little difficulty and becomes surprisingly co-operative during major surgical thoracic treatment. This is confirmed by the work of Weiner of the American Veterans Administration, whilst Sarot of Seaview Hospital even recommends lung resection for the met/tally ill. Mental treatment is given concurrently with physical treatments and includes modified electro-convulsion therapy, psychotherapy, prolonged narcosis, and in some instances lcucotomy. Insulin therapy is contra-indicated as is ordinary electroconvulsion therapy. Entertainments for the patients are provided on the wards in the form of cinema shows, individual radio sets, pianos and a library. Occupational therapy takes a variety of forms, similar to that found in an ordinary sanatorium. Visiting and Parole Only adults are allowed on the sanatorium wards and patients' visitors are strongly discouragcd from close contact and kissing. The only patients allowed out on parole, or home on leave, are those in whom the disease is quiescent or under control, namely those with negative sputum. All cases on discharge are referred to timir local chest clinics in the usual way.
July
1952
TUBERCLE
' Quiescent' Our use of this term is applied where there has been an absence of clinical or radiological signs of activity for eighteen months, together with negative laryngeal swabs or sputum for the same period. Such patients may be ti-ansferred to other wards in the hospital, but remain under modified supervision, as long as their mental condition keeps them in hospital. This modified supervision consists in yearly x-ray, laryngeal swabs, and six-monthly E.S.R. Results Our imit thus corresponds closely in many ways with the ordinary sanatorium and provides a gratifying measure of success in the trdatment of mental patients, as well as in keeping the general wards free of tuberculous patients.
Over a five-year period, we have treated xo9 patients in the unit. O f these 32 per cent have become 'quiescent' or 'arrested', whilst a fi~rther I I per cent have been discharged mentally well with their tuberculosis quiescent or arrested. Two thoracoplasties have been performed in the latter group. 17"4 per cent died of pulmonary tuberculosis, of whom z 1.9 per cent had advanced disease on admission. Quotation of a few cases will serve to illustrate the kind of patient we are called upon to treat: 37-year-old Canadian nurse with longstanding bilat, pulmonary tuberculosis. Treated m Canada with subsequent breakdown of lesions on several occasions after periods of a year's inactivity. Admitted to us in a state of mania, with positive sputum. L. phrenic crush and pneumoperitoneum performed. Mental condition gradually returned to normal, hmg lesions became quiescent. Discharged four and a half years ago, returned to Canada and remains well in every respect. A male schizophrenic, aged 3 x, was transferred to us after a ten-year sojourn in another mental hospital where no facilities were available for Tb. treatment. A L. apical lesion was present, but sputum negative. General tr. given, lesions became quiescent and mental condition gradually became normal. Dis-
205
charged one and a half years ago. Now working and IMng in lodgings. Remains well. A boy, aged 19, suffering from hysterical fugues was discharged from military service because of his mental state. On admission routine x-ray revealed recent bilat, soft lesions in mid-zones. Laryngeal Swab positive. Tr. with chemotherapy, pneumoperitoneum, followed by L.A.P. Mental condition became normal, pulmonary lesions controlled. Discharged ten months ago. Remains well. Summary (z) Mental hospitals are a reservoir of tuberculous infection and a potential danger to the public through the medium of inr creased patient-movement.
(2) Nursing staffs in these hospitals are exposed to greater hazards than general nurses in cases of undetected tuberculosis. (3) Results of modern research into tuberculosis in the mentally sick are revealed. (4) The organization of a tuberculosis unit and tuberculosis control service is described. (5) Concurrent tuberculosis treatment and mental treatment is advocated. (6) A five-year test period for the tuberculosis unit has given encouraging results. Acknowledgments The author expresses a debt of gratitude to Dr O. Fitzgerald, Medical Superintendent of Shenley Hospital, and Dr F. Simmonds, Medical Superintendent of Clare Hall Hospital, without whose support and cooperation the unit would never havc been established. Bibliography Early, D. (I95o) .7. Ment. Sc., CDII, 199. Lamblotte, L. O., Washington, E. L., and Bozalis, G. S. (1919) Amer. Re~'. Tuberc., ux, 289. Oectasli, W. 0949) U.S. Public Health Repts.,Jan. 7, I. Memo, Supervision of Nurses' ttealth: King Edward's Hospital Fund for London (i95o). Pollak, 0949-195o) Amer. fl. Ment. Def., LXV,333" Prendergast and King 095o)January21, 78. .lied. flour., Australia. Ruskin, 09t5) 248. ..lm..r. Rev. Tubere., 248. Wassersug, J., and McLaughlin, W. (1951) flour. Nerr'. & 3Ieat. Dis., cxm, I x5. Weiner, A. (195o) Dis. Chest. Abs., 388.