534 
Tuberculosis and Segregation 
Dr Newsholme's figure appears to be quoted from the 56th Annual Report of the 
Commissioners in Lunacy, and in this case it should read 15*8 per 1000 aud not 
per 100, and although Dr Newsholme appears to have made a similar slip in 
dealing with the deathrate in the general population, he seems to be comparing 
deatlis from all forms of tuberculosis among the insane — some of which have 
possibly a direct relation to their insanity — with deaths from phthisis alone in the 
general population. Further he has made no allowance for the very marked 
difference between the age distributions of the two groups he is comparing. 
The difFerence is so great that a phthisis deathrate of 1'46 per 1000 in the 
general male population is equivalent to one of 2"41 per 1000 among the insane 
population of males. Even if the corrected deathrate among the insane for 
phthisis were ten times its magnitude among the sane, we fail to understand 
what Dr Newsholme means when he asserts that : " the segregation of each 
tuberculous lunatic has been equivalent to the withdrawal of ten ordinary tuber- 
culous persons " (p. 274). Because tuberculosis among lunatics is ten times as 
frequent — judging by deaths, and accepting for the purpose of argument Dr News- 
holme's figures — why should the isolation of one tuberculous lunatic be equivalent 
to the withdrawal of ten sane tuberculous persons ? That must suppose a tuber- 
culous lunatic capable of spreading ten times the infection of a tuberculous but 
sane individual. All Dr Newsholme could say would be that from the standpoint 
of segregation it is ten times more desirable to segregate any lunatic, than 
any sane person, for the former is ten times as likely to die of tuberculosis. 
Dr Newsholme brings no evidence to show that the individual tuberculous 
lunatic is ten times as dangerous as the individual tuberculous sane person. 
As a matter of fact we still need very careful investigation of the relation of 
lunacy to tuberculosis, not only having regard to some forms of tuberculosis as 
possible sources of feeble-mindedness, if not of insanity, but also having regard 
to whether the old idea of asylum segregation as a possible cause of the spread 
of tuberculosis among lunatics is wholly erroneous, and we might further examine 
whether the new idea that the majority of tuberculous lunatics were tuberculous 
on admission is in its turn wholly sound*. In the present state of our know- 
ledge we think the assertion that the increased segregation of lunatics has 
substantial relation to the decrease in the phthisis deathrate is quite unproven. 
(4) Dr Newsholme's third approximation to the segregation ratio is the 
index lOOj^j/p^ Avhere is the number of paupers in institutions and is 
the total number of paupers, indoor and outdoor. Unfortunately Dr Newsholme's 
usage does not agree with his definition. The index he appears to use is generally 
lOOprjpi, and the values of this are given in the last column of Table LXV 
(p. 277) and Table LXVII (p. 279). In Table LXVI (on p. 277), however, the 
100 factor is dropped and pijpr again used in the heading to the central column, 
* Many lunatics enter and re-enter asylums, it does not follow because they died of tuberculosis 
and were tuberculous on last admission that their tuberculosis was there on first admission. 
