Some Lessons of the War.
Are we, as a nation, doing all that we should for the mentally
afflicted? This is the question—no less urgent and important now than
it was a century ago—to which we call the serious attention of the
reader.
It is no new discovery to recognise the immediate importance of its
proper consideration, of the honest facing of the present conditions,
and of the urgency for such reform as shall lead to an affirmative
answer to our question. Already it has been the subject of considerable
discussion in recent medical literature, and in the medical press
numerous efforts have been made to bring it to the attention of the
general public. In July, 1914, the Medico-Psychological Association
of Great Britain and Ireland, a body composed chiefly of the medical
officers of our asylums, issued the report of a special committee
which had been appointed, in November, 1911, to consider the “status
of Psychiatry as a profession in Great Britain and Ireland, and the
reforms necessary in the education and conditions of service of
assistant medical officers.” Unfortunately, within a few weeks of its
publication, the outbreak of war prevented that discussion of the
question which would otherwise assuredly have followed the publication
of so momentous a statement. For in the report stress was laid on the
“absence of proper provision for the early treatment of incipient
and undeveloped cases of mental disorder,” on the lack of adequate
“facilities for the study of psychiatry and for research” and upon
“the unsatisfactory position of assistant medical officers” in the
asylum service. Clearly the stressing of such points by a committee,
thoroughly competent to form a judgment in such matters, compels a
negative answer to our leading question. The report makes it perfectly
clear that this country has grievously lagged behind most of the
civilised nations in the treatment of mental disease.
Yet all attempts in the way of important and far-reaching reform have
been frustrated, at least during times of peace, by a strange state
of indifference and inertia and by lack of knowledge. Thus, even so
recently as January 15th, 1916, the _British Medical Journal_ was
responsible for the statement “The only hope that our present knowledge
of insanity permits us to entertain of appreciably diminishing the
number of ‘first attacks’ lies in diminishing habitual and long
enduring drunkenness and in diminishing the incidence of syphilis.”[74]
This statement would have been sufficiently amazing if it had been made
three years ago; but when the hospitals of Europe contain thousands of
“first attacks” of insanity, which are definitely _not_ due either to
alcohol or syphilis, the only conclusion to be drawn is that its author
must have been asleep since July, 1914, or have become so obsessed
by a fixed idea as to be unable to see the plain lessons of the war.
Syphilis, no doubt, is responsible for a considerable number of cases
of insanity, and drink perhaps for some more[75]; but the incipient
forms of mental disturbance which the anxieties and worries of warfare
are causing ought to impress even the least thoughtful members of the
community with the fact that similar causes are operative in peace
as well as in war, and are responsible for a very large proportion
of the cases of insanity. But—and this is still more important—it is
precisely these cases which can be cured if diagnosed in their early
stages, and treated properly. The chief hope of reducing the number
of patients in the asylums for the insane lies in the recognition of
this fact, and in acting on it by providing institutions where such
incipient cases of mental disturbance can be treated rationally, and
so saved from the fate of being sent into an asylum. We may refer the
reader to p. 82 _et seq._, on which was given a short account of the
success of these reforms. We reiterate some of the advantages of the
clinic system—treatment of the patient without the necessity of the
ordinary asylum associations and the consequent social stigma; and the
considerable reduction in the number of patients requiring internment
in asylums which has followed upon the establishment of the psychiatric
clinic.
In this country insuperable obstacles in the way of this urgent reform
have been raised by our distinctive national obstinacy, and our blind
devotion to such catch-phrases as “the liberty of the subject,”—even
when this involves the eventual incarceration of the patient whose
liberty to escape treatment and to become insane, is the issue
jealously defended. Now, however, the stress of war has compelled
us to see matters in another light. The present war, which has been
responsible for destroying so many illusions, has worked many wonders
in the domain of medicine.
The rational and humane treatment of early cases of mental disturbance
has now been inaugurated on precisely those lines which have been so
long urged, with such little success, by the more far-seeing members of
the medical profession.[76]
A good example of this reform is the splendid work now being
carried out, at the Maghull Military Hospitals, near Liverpool, for
officers and men, organised and superintended by Major R. G. Rows.
The institutions are specially devoted to the treatment of soldiers
suffering from “shock” and other psychoses. The success already
achieved there is sufficient evidence of the great value of these
special hospitals for the treatment of nervous and mental disorders in
their early stages.
But if the lessons of the war are to be truly beneficial, much more
extensive application must be made of these methods, _not only for our
soldiers now, but also for our civilian population for all time_. We
have before us the practical experience of those countries which have
undertaken this great experiment in preventive medicine, yet apart
from the encouraging results of its treatment practised in our special
military hospitals, its present position in this country is only too
accurately described in the report to which we have referred. With
few exceptions[77] “the subject (of mental disease) is left severely
alone.”[78] Our arm-chair writers direct their attention to safer
subjects, such as eugenics, for example, and here they can be happy in
feeling they are on secure ground, because they are aware that their
neighbour knows little more about it than they do. Or they inspire
reports, and I quote a sentence from a recent report as a contrast to
the encouraging sound of the word ‘recovering.’[79]
In the _Standard_ newspaper a few days ago, (_i.e._, in 1914) there
was a reference to a report issued by the London County Council in
which one paragraph began with the statement, ‘Once a lunatic, always
a lunatic.’ This is the message sent in this country to our sufferers,
a message as brutal as it is unjustifiable. Again, in the _Standard_
of February 11th in the year of grace 1913, there appeared the
statement that ‘the Camberwell Guardians have issued instructions that
the use of “anklets” on violent lunatics in their institutions is to
be discontinued.’
With reference to the dictum “Once a lunatic always a lunatic” we
should like to call attention to another statement in this report. “The
fact that, _even under the present conditions of delayed treatment,
about 33 per cent. of those admitted to the asylums of England and
Wales are discharged recovered_, demonstrates that the feelings of
helplessness and hopelessness, with which such illnesses are usually
regarded, are by no means justified. The evidence of many authorities
who have had practical experience of the value of treatment during
the incipient stages of the illness, shows conclusively that the
exercise of scientific care during the early phases of mental disorder
would save many from such a complete breakdown as would necessitate
certification and removal to an asylum. In all other branches of
medicine facilities for dealing with disease in its initial stages are
recognised as indispensable and therefore the Committee regard it as
essential that, in the large centres of population at any rate, means
should be provided to obviate the delay that now exists in providing
adequate treatment for mental disorders. It is, therefore, recommended
that psychiatric clinics should be established.”[80]
Again, at the International Congress of Medicine in London, in August,
1913, an important discussion of these problems was introduced by
an account of the Henry Phipps Psychiatric Clinic which has been
established in Baltimore for the treatment of mental disorders, and
for teaching and research in this subject. In the course of the
discussion special emphasis was laid upon “the necessity for _teaching
the medical profession and the public_ that many mental disorders are
absolutely recoverable, that good hospital and scientific treatment
save many, that the mere economy of our monster institutions represents
a sham economy paid for by the patients and their families, and that
psychiatry must extend beyond the asylums.”[81]
Emphasis was also laid upon the importance of making these hospitals,
for the care and cure of those suffering from mental illness, centres
for scientific education and research and for the development of
prophylactic measures. For, unless medical students are provided with
facilities for the study of these early cases the present deplorable
condition of affairs will be perpetuated. All honest medical work is
essentially research; for every individual patient presents problems
which need investigation; and facilities should be provided for making
such enquiries under the most favourable conditions. As Dr. Flexner has
well said,[82] it is impossible “to develop two types of physician,
one to find things out, the other to apply what has been ascertained.
For the same kind of intelligence, the same sorts of observation,
knowledge and reasoning power are needed for the application as for the
discovery of effective therapeutic procedure.”
This last consideration leads us to the examination of another potent
factor in the present situation, _viz._:—
_The Attitude of the Medical Profession._ When it is remembered that
mental factors play an important rôle in the causation and continuance
not only of obviously mental disorder but also of bodily troubles,
and that therefore successful diagnosis and treatment must inevitably
take these factors into account, it may seem remarkable that the
medical profession as a whole should take so little interest in, and
know so little of psychology. Even when the psychological aspect
of their problems becomes the outstanding element in diagnosis and
treatment, the vast majority of medical practitioners show little or no
inclination to satisfy their scientific curiosity and to endeavour to
understand the condition of their patients.
But this attitude becomes more comprehensible, and in a certain measure
more excusable, when we look into the courses of instruction provided
for students in our medical schools. What training in psychiatry—to say
nothing of psychology and psychopathology—have they received in the
schools? How many hours have been spent in lectures or demonstrations
upon mental diseases? And how has this modicum of time been spent? How
many hours are devoted to actual _personal investigation_ of patients
suffering from early mental disorder? All the instruction in such
matters that our students get at present in most of the medical schools
is given in a few hours during one term, when they visit an asylum
where demonstrations are given of _advanced_ cases of mental disease:
“melancholia,” “mania,” “dementia,” etc.
Lest we may be accused of wild statements, let us quote again from the
Medico-Psychological Association’s report. (The italics are ours.):—
“... the attention given to mental diseases before qualification
is much less than that given in many other countries. Owing to the
absence of clinics, the medical student _has no opportunity of
observing borderland or undeveloped cases_.” (p. 6.)
“To this absence of teaching facilities is due the lack of knowledge
of the general practitioner, who should be competent to recognise, and
possibly to deal with, some of the earliest symptoms; _to this we owe
the lack of real equipment in those who enter the lunacy service_.”
(p. 21.)
In this connection it is interesting to quote from a comparatively
recent report on medical education. Four years ago the Carnegie
Foundation for the Advancement of Teaching published a report on
“Medical Education in Europe.” This work was remarkable both for its
perspicacity and thoroughness and for the frankness and detachment with
which its author, Dr. Abraham Flexner, expressed the opinions he had
formed after a detailed study of the medical schools of this country
and on the Continent. This valuable and important document was barely
noticed by the medical press in this country. But this is not the place
for a discussion of the psychology of this conspiracy of silence. For
it certainly does not imply any reflection upon the impartiality or the
thoroughness of Dr. Flexner’s research; on the contrary, it is a silent
tribute to the seriousness of the exposure of the weaknesses of our
medical schools. But the report is also a most valuable appreciation of
the strength of our methods of medical education. It provides a minute
analysis and comparison of the methods of teaching clinical medicine
in Great Britain and on the Continent. The summary clearly defines the
distinctive merits of the British system, and has such an important
bearing upon the questions we are considering in this book that we
will quote its most essential paragraph.
“The limitations by which medical education in Great Britain is
hampered have now been candidly exposed. It is nevertheless true that
in respect to the student, nowhere else in the world are conditions
so favourable. In our discussion of Germany we pointed out that its
clinical instruction was overwhelmingly demonstrative; that the
student _saw_ and _heard_ but almost never _did_. Clinical education
in England has completely avoided this wasteful error. It is primarily
practical. It makes, indeed, the huge mistake of assuming that a more
scientific attitude towards the problems of disease is in some occult
way hostile to practicality; for it protests against the adoption of
modern methods of investigation, as though practical teaching would
be in some inexplicable fashion endangered thereby. However, that
may be, the English are indubitably correct in holding that sound
medical training requires free contact of the student with the actual
manifestations of disease. It is the merit of English and, as we shall
also perceive, of French medical education that the student learns
the principles of medicine concurrently with the upbuilding of a
veritable sense-experience in the wards, and that he acquires the art
of medicine by increasingly intimate and responsible participation in
the ministrations of physician and surgeon. The great contribution
of England and France to medical education is their unanswerable
demonstration of the entire feasibility of the method of instruction
which the end sought itself imposes.”[83]
We have quoted at length this vivid and accurate portrayal of the
distinctive feature of British methods of clinical instruction in order
to emphasise the fact that in the teaching of psychological medicine
the British utterly neglect this excellent method of instruction which
Dr. Flexner considered so admirable a feature of our medical schools.
The British method of teaching psychological medicine, so far as the
subject is taught at all,[84] is that of class-demonstration, but, as
we have seen, the avoidance of exclusive reliance upon this method is
the feature on which Dr. Flexner congratulates the British schools. On
the other hand, while the Germans are criticised for their adherence
to the class-demonstration, it should be remembered that, although
this source of weakness appears in their undergraduate classes, it
is they and not we who provide facilities, in their clinics, to the
post-graduate student for free contact with patients in incipient
stages of mental illness.
Therefore we have neglected to apply, in the case of mental diseases,
the very methods which in all other branches of medicine have been so
conspicuously successful as to be selected by an impartial critic as
the distinctive merit of British medical training.
We have indicated briefly the type of instruction in psychiatry
obtaining in our medical schools at present. Its educational value
is certainly very slight; and—what is worse—it serves to give the
future doctor a hopeless outlook on insanity. For the instruction of
students in the nature and treatment of tuberculosis we do not send
them to some sanatorium to gaze upon patients dying from the disease.
They personally examine patients in the early stages and learn to
recognise the subtler manifestations of the onset of the tubercular
attack, when there is some hope of giving useful advice and saving the
sufferer. Why cannot mental disease be dealt with in the same way? Why
cannot our students be afforded, in general hospitals, the opportunity
of personally examining patients in the incipient stages of mental
disturbance? They would then not only acquire a knowledge of the real
nature of insanity, but would also learn, in the school of experience,
the individual differences which are exhibited in the working of the
normal mind, a lesson which would be of the utmost value to them in
dealing with _all_ their patients, whether their ailments be bodily or
mental. But in addition such a training would impress on them, in a
way that nothing else could do, the vitally important fact that mental
disease is curable, and is not the hopeless trouble which is likely
to be suggested by the spectacle of a few asylum patients in advanced
stages of lunacy.
Even, however, if the asylums afforded better facilities for the
proper study of mental disease than unfortunately is the case in
most institutions in this country, they are usually not sufficiently
near the medical schools to permit the student properly to acquire
his knowledge, as he does of other diseases, by frequent and regular
attendance for a considerable period of time. Nor, as yet, have many
of the medical officers in our asylums sufficient up-to-date knowledge
of psychiatry to enable them usefully to co-operate with the medical
schools and the teaching staffs of the general hospitals in achieving
the desired aim. We know that there are some exceptions to this general
statement, and fortunately they are becoming more numerous. But viewing
the condition of affairs in the country as a whole, in respect of this
important matter, one can only accurately describe it as deplorable.
These are hard words, and we are well aware that their use may
expose us to the charge of superficial, uninformed and even spiteful
criticism. Let us, therefore, turn to the gratifyingly frank and honest
statements of the asylum workers themselves, embodied in the report
from which we have quoted.
“_The tendency of routine to kill enthusiasm and destroy medical
interests._
The promotion or advancement of a medical officer depends so little
upon his knowledge of psychiatry that he has no inducement for
that reason to devote himself to an earnest study of the subject.
His work is apt to begin and end with the discharge of essential
routine duties to the exclusion of careful clinical and scientific
investigation.
The work assigned to junior medical officers is, in the majority of
cases, monotonous, uninteresting and without adequate responsibility.
For those whose personal enthusiasm keeps alive in them the desire
to extend their knowledge, such opportunities as that of study-leave
are rarely afforded them. The existing system, therefore, leads to
the stunting of ambition and a gradual loss of interest in scientific
medicine. It tends, therefore, to produce a deteriorating effect upon
those who remain long in the service.”[85] (pp. 8 and 9.)
_Methods of Making Appointments._
“Appointments are made by lay committees, which, though they are
generally wishful to appoint the best candidate, are in most cases
without expert advice, and without adequate knowledge of the factors
involved. The results are, therefore, generally haphazard in
character, often dependent upon influence or personal consideration,
as they frequently bear out little relation to the actual claims and
qualifications of the candidate.” (p. 7.)
We submit then, that our expression of opinion is but a paraphrase of
the authorised report. The study of this publication as a whole will
only deepen this impression in the reader.
In the foregoing paragraphs we have pointed out the vital importance of
research in relation to mental disease. All properly conducted clinical
work is of the nature of original investigation; and in the examination
of patients suffering from mental disturbance this is particularly
the case. But a vast amount of research work must be carried out in
properly equipped hospitals and laboratories if we are to deal with the
problems of lunacy in the same efficient manner as we have learnt to
treat tuberculosis. In this connection it is important to emphasise the
lack of an adequate knowledge of normal psychology among many of the
medical officers and the absence of psycho-pathological research in so
many of our asylums.
It must not, however, be inferred that the only reform needed is an
increase and improvement of the _mental_ treatment of mental disease.
It is not merely the psychological side that is neglected. The most
depressing aspect of the present state of affairs _is the comparative
absence of all research_. Investigations into the material basis of
mental disease, while certainly more numerous than psychological
investigations, are at present few in number. Hosts of problems
concerned with the nervous system are awaiting investigation, and the
admirable results obtained by the small band of energetic workers in
our country serve to show how sadly our nation is neglecting its golden
opportunities for accomplishing much more in this respect. Important
problems in connection with the normal and morbid anatomy of the
nervous system, its pathology and its bio-chemistry, suggest themselves
to the worker at every step. The physiological and psychological
effects of different diets, of drugs like the hypnotics, _et cetera_,
how little we know of them! Are we to rest content in leaving this vast
unknown land to be charted by other nations?
Original research is thus urgently needed in all those departments
which should be included in asylum work. But it is also necessary for
the researches to be co-ordinated. Not a few individual doctors in
our asylums, usually members of the junior staffs, are endeavouring
to carry on original investigations; but in the majority of cases the
absence of any prospect of direct or indirect personal benefit from
this work damps their enthusiasm, if it does not make such work wholly
impossible. And, of course, without the willing co-operation of the
asylum authorities co-ordinated researches cannot be carried out.
We shall again quote from the report of the Medico-Psychological
Association in justification of our statement:—
“Research is largely dependent on individual enthusiasm, but can
certainly be stimulated and maintained by the co-operation of the
senior medical staff. There is reason to fear that such work is
undertaken in some quarters without any guidance or encouragement
from seniors, and laborious original investigations have received
little or no recognition from those in authority.... Although there
is no uniformity of practice, report is made that in many asylums
junior medical officers are placed in charge of chronic cases only,
and have no duties in reference to the treatment of newly-admitted
cases. This appears to be most undesirable. Junior medical officers,
in addition to their statutory routine duties, should be given the
opportunity of co-operation with their senior colleagues in clinical
work. Consultation between the various members of the medical staff in
doubtful and interesting cases is very desirable....” (p. 30.)
If the reader will pause for a moment, and in imagination put himself
in the position of a junior medical officer, “_placed in charge of
chronic cases only_,” he will not only come to understand the “stunting
of ambition and the gradual loss of interest in scientific medicine” of
which he has read, but may admire the self-restraint of a report which
can speak in temperate language of such a state of affairs.
Another difficulty that stands in the way of this urgently needed
reform in medical education is the inadequacy of the text-books
available for the student. In many of these text-books the introductory
chapters contain some, often irrelevant,[86] morbid anatomy, and the
remainder deals with “psychology.” The latter frequently consists
largely of anecdotes, often “funny” and sometimes more appropriate
to the “after-dinner” hour than the text-book, and enumerations of
the mental _symptoms_ of the cases. In practically every available
English text-book the latter are depicted only as they appear after
they have become fixed, habitual, hardened and rationalised. Such
“units” of terminology as “delusions,” or “delusions of persecution,”
“hallucinations,” etc., are freely used. In other departments of
clinical medicine the text-book writer does not describe a patient as
suffering from a cough, and leave it at that; yet the phrase “suffering
from delusions” is the veriest commonplace in the text-books. Yet
just as a cough may be due to tuberculosis of the lung, pharyngeal
irritation, hysteria, or a variety of utterly different causes, each
class of case requiring a different treatment, so the causes of
delusions are even more infinitely varied.
But the gravest defects of these text-books is that few of them make
any attempt whatever, except in the case of such forms of disease as
have an organic cause, to explain the _development_ of the trouble, the
precise nature of the primary cause or causes and the way in which the
disturbance of the patient’s personality has been gradually effected.
Unfortunately there are serious defects in many of the works upon
general psychology which render them almost useless to the student of
psychological medicine. This may explain, if it does not excuse, the
quaint selection of subjects, often wholly irrelevant or inappropriate,
which form the contents of the psychological section of many English
books on mental disorders. But this deficiency is not a sufficient
excuse for the neglect of the kind of instruction that is of vital
importance for the proper understanding of such disorders. When books
such as those written by McDougall, Stout, Hart, Shand, and Déjerine
and Gauckler, are available, it is possible to use the facts of normal
psychology as the natural, rational and necessary means of explaining
and interpreting departures from the normal state.
We may summarise here some of the chief defects of our national system
of treating mental disorder. First and foremost is the serious waste
of time which almost invariably occurs before the mental sufferer
comes under medical care. This is due to a variety of causes—all of
them preventable. The chief is that, lying in the path of patients who
would _voluntarily_ seek help, there is the insurmountable obstacle of
the asylum system and its restrictions. The men in the asylum service,
who have the opportunity of acquiring an intimate knowledge of mental
diseases, are _forbidden_ to carry that knowledge into the outside
world for the benefit of the mental sufferer. If a patient, suffering
from a mental disorder in its earliest and easily curable stage, should
voluntarily go to an asylum and ask for advice, all that can be done
for him is to suggest that he should consult a medical man outside, or
to recommend him to call and see the relieving officer. Now, unless
the patient has considerable means, it is practically certain that he
will be able to consult no medical man who is conversant with—much
less expert in—the treatment of early mental disorder. And, though
the relieving officer’s intentions may be of the best, it is just his
‘help’ and all that it means, that the unfortunate is so desperately
striving to avoid. In short, all that the officials under our present
system can say to such a man is, “Go away and get very much worse, and
then we shall be allowed to look after you!” Can stupidity go farther
than this?
Even, however, if the doctor were allowed to help such a person in the
asylum, this would be far from an ideal solution of the difficulty.
Entry into such an institution, even if voluntary, would entail the
serious social stigma which has been so often mentioned. Furthermore,
the asylum, with its associations and implications, particularly the
assumption of the irresponsibility of the patients interned in it,
would destroy one of the chief therapeutic agents in the treatment
of such cases. We mean the conviction of the patient that he is
still responsible for his actions, and that he is still able, under
direction, to cure himself.
The place to which such a patient should be able to go is obviously
one which is exempt from any stigma; one in which of his own free will
he may stay for a time under care, or if this be unnecessary, as is
very frequently the case, which he may visit at frequent intervals
for advice and treatment. It should be staffed by skilled specialists
who are familiar with the diagnosis and treatment of _early_ and
_incipient_ mental disorder, not only with that of advanced insanity.
For years such institutions have existed in other countries and form an
important part of their contribution towards the alleviation of human
suffering.
The chief functions of such a psychiatric clinic would be:—
(1) Attendance on the mentally sick.
(2) The provision of opportunities for personal intercourse between
patients and the psychiatrists in training.
(3) The theoretical and practical instruction of students.
(4) Advising general practitioners and others who are faced with
difficult problems arising in their daily work.
(5) To serve as a connecting link between investigation in the large
asylums and that in the anatomical, pathological, bacteriological,
bio-chemical, psychological and other laboratories of the universities.
(6) The scientific investigation of the mental and bodily factors
concerned in mental disease.
(7) The furtherance of international exchange of scientific knowledge
concerning mental disorder, by the welcome accorded to visitors from
other countries.
(8) The dissemination of medical views on certain important social
questions and the correction of existing prejudices concerning insanity.
(9) When necessary, the after-care of the discharged patient.
We have already given some details of the activities of a few of the
clinics abroad[87] and have pointed out their valuable function in
saving a high percentage of patients from the fate of an asylum, while
at the same time relieving the community of the serious expense of
keeping these patients for life as pauper lunatics.
We may quote from an article by Dr. R. G. Rows[88] describing the
psychiatric clinics at Munich and Giessen:
“They are carried on upon the lines of ‘freely come, freely go,’ as
far as is consistent with the safety of the patient and of the public.
In neither of these clinics is any legal document necessary for the
admission or discharge of patients. But where the character and
severity of the mental disturbance require the longer detention of the
patient in the clinic or in an asylum, such detention can be exercised
only under a legal procedure which carefully safeguards the rights of
the patients.
In this way it is possible to avoid the stigma which is attached to
certification and seclusion in an asylum. That this is appreciated
by the general public is demonstrated by the number of people who
make use of the opportunities offered them. To the clinic at Giessen,
with its seventy beds, between three and four hundred patients were
admitted in 1907. From the report of the clinic at Munich for the
years 1906-7 we learn that there were 1,600 admissions in 1905 (the
first complete year after it was opened), 1,832 admissions in 1906,
and 1,914 admissions in 1907. At the present time admissions go on
at the rate of ten or twelve per day. It should be mentioned that
at Munich the clinic is open night and day for the reception of
patients, so that they can be brought under the care of an expert at
the earliest possible moment, and the painful impressions produced
often by detention and restraint by unskilled persons and unsuitable
surroundings are reduced to a minimum. This immediate treatment at
the hands of men experienced in insanity is a matter of the greatest
importance, from the point of view of a favourable termination of many
of these cases.
Let us now consider the actual treatment of those admitted into these
institutions. What most strongly impressed us in these clinics was the
absence of noise and excitement amongst the patients; it was certainly
an ample demonstration of the value of the means of treatment adopted.
It is recognised in the first place that patients must not be crowded
together: none of the wards contain more than ten beds.... For the
patient who is too excited to be kept in bed or who disturbs the
others too much, experience has shown that prolonged warm baths
provide the best means of quieting him and bringing him into such a
condition as will allow of his being kept in the ward. The extent to
which the bath treatment is employed may be judged from the fact that
besides the baths used for ordinary purposes of cleanliness there
are in the clinic at Munich eighteen baths for prolonged treatment,
five movable baths, one electric, and one douche bath. The wet pack
is occasionally used. The baths are so arranged that the patient can
remain in the bath for days or weeks as the case demands, sleep there
and take his food there. The result of the treatment is that hypnotic
drugs and confinement to a single room have come to be regarded as
evils to be used only on rare occasions; in fact, the single rooms are
occupied by convalescent and quite quiet patients and not by recent
and acute cases.
Treatment on these lines will of course necessitate the employment
of a large medical and nursing staff. At Giessen, with 70 beds and
between three and four hundred admissions a year, there are five
medical officers including the director. At Munich, with one hundred
and twenty beds and three or four thousand admissions, there are
fifteen medical officers to carry on the work of examination and
supervision of the patients. The nursing staff must be provided in the
proportion of at least one to five. This is of course a high figure,
but there are two conditions to be remembered: first, the very large
number of admissions dealt with, and secondly, that these clinics are
established not for the housing of the insane, but for the care and
cure of those suffering from incipient mental disturbances—a most
important distinction, and one not yet fully appreciated in this
country.
Besides the patients admitted into the clinics for treatment, a large
number obtain advice and help from the out-patients’ department.”
It should be mentioned that in Germany there is a psychiatric clinic
attached to every university.
Among the most important functions of a clinic are instruction and
research. Each assistant in the Munich clinic carries on some chosen
line of study. In order that he may have better facilities for
becoming acquainted with the literature on the subject and finishing
his selected work, he is given, besides his annual month’s leave,
two months of each year for this purpose. Frequent evenings are set
apart for discussions of original work carried on in the clinic and
elsewhere. Besides this, numerous short courses in special subjects are
provided, so that it is possible to enter the clinic for instruction
in matters requiring a special knowledge of delicate technique and
diagnosis.
Of very special importance in the Munich clinic is the course for
qualified medical men. In 1907 this was attended by _sixty men, of
whom one third were foreigners_. What can we, in Great Britain, show
in comparison with this? Our physical, chemical, physiological, and
pathological laboratories attract distinguished foreigners from the
universities of other countries, though twenty would be a number on
which even our most celebrated laboratories would pride themselves. But
how many foreigners come to us to study insanity? Very few indeed, and
the reason is not far to seek.
In the Munich clinic, again, we find well equipped rooms for
clinical examination, for the deeper investigation of mental life
by experimental psychology, for the study of morbid anatomy and
pathology and for the finer examination of the blood and other fluids
of the body. Furthermore, these laboratories are not only spacious and
well-equipped, but are occupied by busy, keen and skilled workers.
Testimony to their activity is afforded in abundance by their frequent
publications.
We submit, then, that the clinic system is a decided advance in the
treatment of mental disorder which other countries have adopted while
for years we have stood by with folded hands.[89] From the humanitarian
and the scientific point of view there is everything to be said in
favour of the clinic. The practical Englishman will, however, ask “What
about the financial aspect? Are not these institutions, with their
heavy proportion of doctors and nurses to patients, prohibitively
expensive?”
The answer to this question is that certainly the clinic is relatively
more expensive than the asylum. But since the function of the clinic
is to save as many patients as possible from entering the asylum, it
is obvious that its expense must be judged from a special standpoint.
The maintenance of a repair shop is always comparatively costly,
whether the material to be mended be human or not. The cost per day
of repairing a motor car is usually distinctly higher than the daily
charge for garaging it in its broken-down state. Yet we gladly pay the
higher charge for the simple reasons that a motor car in its garage is
of no use to us, and that the daily charge for housing the car would
amount to a colossal figure if paid for many years. Cannot we apply the
same reasoning to the case of the mentally disordered human being?
This is to take the very lowest view of the value of the individual to
the community. Yet it would seem that the British public, so far, has
been impervious even to this financial consideration.
But, it may still be asked, cannot the doctors in the asylums carry
out the work suggested? The answer to this is, that apart from the
undesirability of allowing a patient suffering from a mild mental
disorder to be associated with an institution housing the definitely
insane, it is a physical impossibility for the asylum doctors to do
this work so long as the present proportion of doctors to patients
remains unchanged. How many members of the British public realise the
fact that it is quite usual for an asylum doctor to be in charge of
at least 400 patients, and that this number sometimes rises to 600?
When it is remembered that insane patients are even more prone than
the average person to suffer from physical ailments, and that their
mental disorders are infinitely complicated by the delay incurred
before they come under medical care, it becomes clear that the doctor
who would succeed in treating such patients individually would require
titanic energy and the addition of at least twenty-four more hours to
each of his working days. We cannot therefore compare the staff of a
clinic with that of a British asylum, for the staff of the latter is
lamentably and obviously too small.
Regarding the financial aspect of the question we may quote again from
Dr. Rows’ article:—
“... we shall no doubt be met with the objection that the provision
of such institutions will involve the expenditure of such an immense
sum of money. I believe we spend in Great Britain about £3,000,000
a year on those suffering from various forms of mental affliction.
That, certainly, is an immense sum to spend while getting so little in
return. A large proportion of this money is spent in housing, feeding,
clothing, and taking care of the 97,000 inmates of the county and
borough asylums of England and Wales. We learn from the commissioners’
report, published in 1910, that 20,000 patients were admitted into
these asylums during the previous year, and of these, over 30 per
cent. were discharged after a longer or shorter detention. Now it may
safely be said that very few of these 20,000 fresh admissions did
obtain, or could have obtained, any advice for their mental illness
at the hands of anyone who had had experience of mental disorders,
before they reached the stage when certification and seclusion in an
asylum became necessary. When we visited Giessen we were informed by
Professor Sommer that in the province of Hesse, by reason of suitable
treatment during the early stages of mental illness they had been
enabled to postpone for some years the erection of a new asylum in
the province. Is it not therefore fair to assume that, if facilities
were provided whereby expert advice and treatment in a well-organised
psychiatric clinic could be obtained by those threatened with a mental
breakdown, we should save enough of the £3,000,000 to justify the
expenditure involved in the establishment of such clinics? Further
benefits would be derived from them in that we should be able to avoid
the breaking-up of the home, which now, in so many instances, follows
the removal of the bread-winner of the family to an asylum and his
long detention there.”
And
“... it may be suggested that we should attempt to demonstrate the
possibility of saving money in order to carry the public with us in
the matter. I do not think that is necessary. The value of treatment
of the early stages of mental disorder cannot be expressed in pounds,
shillings and pence. Moreover, I submit that our duty as medical
men is to guarantee the satisfactory treatment of the patient, and
we have no right to allow our action to be dominated by monetary
considerations. I feel sure that the more this question is placed
before the public in an intelligent manner, the more we insist upon
the necessity for early treatment and for scientific knowledge as
a basis of any treatment, the less will the public grumble about
expense. We have ourselves to thank if the public refers so constantly
to money matters. Do we ever encourage the public to regard the
question from any other point of view? Do we point out that insanity
is a product of civilisation? Do we encourage people to regard
insanity as an illness for which something can be done and which
should be treated with intelligent and humane consideration? Do we
not rather say with the public, “Lock him up, put him where he can
neither harm himself nor his neighbour?” Do we not talk of sterilising
the unfortunate sufferers and preventing marriage and procreation
before we have made an honest effort to investigate what insanity
really is, what is the mechanism of its production, and how we can
teach those so afflicted to help themselves? How then can we expect
the public to do anything but grumble at the expense? The public
has not objected to spend money in other branches of medicine when
the necessity has been demonstrated, and there is no reason, if the
members of the lunacy service in this country will develop confidence
in themselves, why they should not be able to instil confidence into
those outside the profession.”
_Suggested Reforms._ After the depressing picture of the present state
of affairs in this country it will be asked, “What should be done to
remedy it?” The answer to this question is clear and definite.
For the relief of the mentally afflicted amongst us, and especially
for the prevention of insanity, it is our bounden duty as a nation
to take measures such as most civilised countries have adopted some
time ago. For this purpose it is necessary that there should be
hospitals to which patients in the early stages of mental disturbance
can go, without any legal formalities, and receive proper treatment
from physicians competent to diagnose their troubles and to give them
appropriate advice. It is important that such special hospitals should
be attached to general hospitals, so that sensitive patients may not
be deterred from resorting to them by the fear of the stigma which in
this country, unfortunately, is so inseparably linked with the idea of
a “lunatic asylum.” It is also important that such institutions should
be affiliated to medical schools, not merely to ensure the adequate
education of the coming generations of medical practitioners, but
also to afford the staffs of such hospitals the proper opportunities
for carrying on the work of investigation which is essential for the
success of the scheme we have sketched out.
No less important and urgent a reform than the foregoing, however,
is another consideration—the _legal_ aspect of the treatment of the
mentally deranged.
The glaring defects of the present system have been well and briefly
pointed out by Dr. Bedford Pierce in his article from which we have
quoted, published in the _British Medical Journal_ of January 8th, 1916.
Again, Sir George Savage, writing in Allbutt’s _System of Medicine_
(Vol. VIII, p. 429) states:—
“The lunacy legislation of this country, despite the Acts of 1890 and
1891, remains in an unsettled state; and the care and treatment of the
insane are burdened with vexations and unnecessary restrictions. Not
only are the steps required for the placing of a person of unsound
mind under legal care complicated and clumsy, but they result in many
cases in a delay of that early treatment which is so important in
cases of mental disease.”
Dr. F. W. Mott writes:—
“There is yet one point which it is desirable to mention, as the
result of both hospital and asylum experience, and that is the
necessity of some earnest attempt being made to establish a means
of intercepting, for hospital treatment, such cases of incipient
and acute insanity as are not yet certifiable. It is probable that
many would not come into the asylums, and a certain number of cases
thus come under observation willingly, and in time to retard the
progress of the disease. Practitioners could send doubtful cases for
observation and treatment to such hospitals, where, moreover, the
opportunity would be afforded of improving their own knowledge as to
the early signs of insanity.”[90]
He urges the desirability of the establishment of special wards in
connection with general hospitals, pointing out that a mental case
coming from such a ward would not thereby be stigmatised as insane. He
quotes from ‘an American writer on psychiatry’:—“Fortunate would be
the community in which there was a fully equipped and well-organised
psychiatrical clinic under the control of a university and dedicated
to the solution of such problems. The mere existence of such an
institution would indicate that people were as much interested in
endeavouring to increase the public sanity as they are in the results
of exploration in the uttermost parts of the earth, or in the discovery
of a new star.”[91]
The Medico-Psychological Association’s report says:—
“The lunacy law does not permit of the establishment of clinics on
the lines which have been recommended, nor does it provide for the
admission of uncertified cases to the public asylums. This, for the
present at any rate, renders nugatory the suggested schemes for
affording treatment for incipient and non-confirmed cases of mental
disorder, and with that, to a large extent, fail the opportunities for
study on which stress has been laid for adding to the knowledge and
increasing the efficiency of asylum medical officers.” (p. 10.)
Such weighty opinions as these serve to emphasise a further factor in
the urgently needed reform—the necessity for a thorough overhauling of
the law of lunacy, so that, while guarding the liberty of the subject,
every obstacle should be removed that obstructs patients threatened
with the dire calamity of insanity from securing preventive treatment
at the earliest possible moment.
In the _Lancet_ of August 5th, 1916, Dr. L. A. Weatherley writes:—
“The great fact that must be continually brought forward in all these
discussions is that, according to the reports of the Commissioners
in Lunacy, the _recovery-rate of mental diseases is to-day no higher
than it was in the ‘seventies’ of last century_. The ever-increasing
difficulty in getting mental cases with small means quickly under
skilled care must, I feel sure, account to a great extent for this
lamentable fact.”
“Marking time” since the seventies of the last century—how does this
condition compare with that of most of the other branches of medical
science? Heart disease, diphtheria, tuberculosis, tetanus, sepsis of
all kinds, all these troubles and many others have shown unmistakable
signs of yielding to the incessant and many-sided assaults of medical
research. And, of insanity, all we have to report in this country is
“little or no progress for fifty years.” Verily we have buried our
talent deep in the ground.
Finally, we may quote from an article the opening sentences of which
might have been written yesterday, yet it was published in 1849! It
was the fourth report of the visiting committee of Hanwell Asylum. The
committee say:—
“In the constitution of the Hanwell Asylum we are also struck by the
paucity of the medical officers attached to it. There appear in round
numbers to be about 500 patients on the male and 500 on the female
side, yet there is only one resident medical officer attached to each
department, and one visiting physician for the whole establishment.
The inefficiency of so small a medical staff is obvious. If we
look across the Channel we find in Paris that the Salpêtrière,
with its thousand patients, has four times the number of visiting
physicians and ten times the number of resident medical officers. The
disproportion between the sane and the insane is here so great that it
is impossible under such a system to bring any moral influence to bear
upon the afflicted multitude.”
“... There ought to be a more numerous medical staff _and a
permanent clinic_ attached to such an institution.... The County
Asylum of Hanwell, supported largely as it is by county rates and
parish assessments, is as much a hospital as St. George’s or St.
Bartholomew’s, and ought to have a medical staff as numerous and
efficient as those of any other metropolitan hospitals. While charity
might thus be administered upon the highest principles of Christian
benevolence, something ought to be done to advance our knowledge of
science and thereby enable us to relieve the afflictions of suffering
humanity.”
The dust lies thick upon this volume, published a short time before the
_Crimean_, not the present war. And to-day, like this early Victorian
committee, we still ask for clinics, we still ask for scientific work
to be carried out by a more numerous and better equipped staff, we
still look across the Channel with admiration—in short, approving the
better, we follow the worse. We have dawdled away half-a-century and
more in comparative idleness. Now the war has taught us our lesson. Are
we to forget it again?
Excuses for inertia, brought forward before August, 1914, can be
accepted no longer. The thousands of cases of shell-shock which have
been seen in our hospitals since that time have proved, beyond any
possibility of doubt, that the early treatment of mental disorder is
successful from the humanitarian, medical and financial standpoints.
It is for us, not for our children, to act in the light of this great
lesson.
FOOTNOTES:
[74] p. 105.
[75] It should not be forgotten, however, that resort is often made to
alcohol as an easy means of drowning the worry of an incessant mental
conflict. In other words, it is clear that in treating alcoholism,
as in treating insanity, we are not absolved from the plain duty of
seeking its mental cause or causes. “Drink” then, in many cases,
appears rather as a secondary complication than as a primary factor.
[76] _Cf._ W. Aldren Turner, _op. cit._
[77] One of the most gratifying of these is the generous gift of
a clinic to London by Dr. Henry Maudsley. Up to the present this
institution has been rendering valuable service to the country as part
of the 4th London General Military Hospital.
[78] _Appendix to Medico-Psychological Association Report_, p. 18.
[79] “One thing which impressed ... [us] ... when going through ...
the Giessen clinic with Professor Sommer, was the frequency with which
we heard him utter the word ‘recovering’ as we passed the patients.”
_Ibid._, p. 17.
[80] _Op. cit._, p. 2.
[81] _Op. cit._, pp. 15-16.
[82] _Vide infra._
[83] p. 202.
[84] “... at present we have few facilities for teaching the subject,
and the subject is not taught.” (_Medico-Psychological Association’s
Report_, p. 20.)
[85] Concerning this sentence the _British Medical Journal_ wrote, on
Nov. 29th, 1914, “A more severe indictment of the existing system than
is contained in this report it would be difficult to frame.... We can
add nothing to this strongly worded condemnation except an expression
of agreement with the opinion that the statement of the facts submitted
demands the earnest attention of public authorities and all interested
in the welfare of the insane.”
[86] Irrelevant because such books give an account of the morbid
anatomy of the nervous system only as it presents itself after disease
of very long duration.
[87] pp. 82 _et seq._
[88] “The Development of Psychiatric Science as a Branch of Public
Health,” _Journal of Mental Science_, January, 1912.
[89] The gratifying establishment of the Maudsley clinic and the
provision of facilities for out-patient treatment at a few hospitals
in England and Scotland are signs that matters are at last improving.
But we are sure that the physicians in charge of such out-patient
departments would be the first to admit their inadequacy and to urge
the desirability of the psychiatrical clinic of the kind described in
this book.
[90] _Archives of Neurology_, 1903, Vol. II, p. 1.
[91] _Archives of Neurology_, 1907, Vol. III, p. 28.
Index.
_Page_
Agoraphobia, 92
Alcohol and insanity, 106
Allbutt, Sir Clifford, 27, 34
Amendment of Lunacy Law, need for, 130
Appointments in asylums, 116
Asylums, lunatic, 105 _et seq._
Attitude of medical profession to psychology, 102, 106, 111
Attitude of public towards insanity, 78
Analysis, comparison of chemical and psychological, 54
Bacon, Francis, 9
Baltimore Psychiatric Clinic, 110
Bernardin de St. Pierre, 45
Blässig’s case of loss of speech, 43
Boston Psychopathic Hospital, 82
British attitude towards insanity, 79, 120
British medical training, 114
_British Medical Journal_, 4, 5, 18, 106, 116, 129
Burt, C., 3, 17
Butler’s, Samuel, _Erewhon_, 103
Cannon on bodily effects of emotion, 8
Carnegie Foundation’s report, 112
La Charité Hospital, 83
Chloroform, use of in cases of loss of speech, 12
Clinics for treating mental disorders, 84, 107, 121
Clinics, cost of, 125
” functions of, 83, 121
” efficacy of, 82-85, 123
Common sense not infallible, 58
Conflict, mental and moral, 98
Déjerine and Gauckler, 6, 34, 35, 42, 44, 45, 46, 90, 120
Defects of British methods, 120
_Derfflinger_, sailor from German battle-cruiser, 43
Diagnosis, importance of exact, 47 _et seq._
Dreams, 22, 61-63
Emotion of fear, 92
Emotions, 3, 9
Emotional factor as cause of mental disturbance, 71
Evils resulting from delay in treatment, 81
Fear, 92, 95
Financial aspect of reform, 125 _et seq._
Firmness, 28, 31
Flexner’s report on medical education, 110-113
Forgetfulness, 49
Forsyth, D., 4, 8
Freud, S., 63, 73
Gaupp on hysteria, 22, 23
German attitude towards mental disorder, 84
Giessen clinic, 84, 122
Hanwell asylum, 131
Hart, Bernard, 57, 119
Heredity, the influence of, 78, 86, 88, 89
Hesse, experience in, 82
Hypnotism, 36 _et seq._
” usefulness in recent cases, 38
Hypnotism, objections to use of, 39-44
Hysteria, 22, 30, 94
Instincts, 3, 91
International Congress of Medicine, 110
Isolation, treatment by, 32 _et seq._
Isolation, limits to usefulness of, 34, 35
Jung, C. G., 71, 74, 86
Kindness, therapeutic value of, 45
Kraepelin, E., 91
_Lancet_, 4, 5, 14, 37, 130
Law relating to Lunacy, need for amendment, 130
Loss of memory, 43
” sight, 11
” sleep, 7
” speech, 11, 43
Lunacy, need for amendment of law relating to, 130
Lunatic Asylums, 78
Maghull Military Hospitals, 108
_Manchester Guardian_, 24
Maudsley Clinic, 125
Medical education, inadequate teaching in psychology, 100
Medico Psychological Society’s report, 80, 105, 108, 112, 118
Mott, F. W., on clinics, 129
Möhr, on theory of isolation, 32
Munich clinic, work of, 122 _et seq._
Myers, C. S., on hypnotism, 5, 30, 37, 38
Neurotic parents, influence of, 89
Pear, T. H., on effects of loss of sleep, 7
Persuasion, psychotherapy by, 44
Physical basis of disease, 96, 99
Pierce, Bedford, on need for reform, 18, 79, 83, 129
Proportion of cases cured in asylums, 82, 109
Proportion of cases not needing asylum treatment, 82
Psychoanalysis, 73-75
Psychological analysis, 53 _et seq._
Rational treatment, 46
Re-education, 53, 72
Régis, on significance of word “neuropathic”, 94
Reform of methods for dealing with mental disturbance, 128
Research, the importance of, 117
Rows, R. G., 82, 108, 122, 126
Savage, Sir George, 27, 129
Shaw, G. Bernard, 93
_Sherlock Holmes_, 63
Smith, May, on effects of loss of sleep, 7
Sommer, R., 109
Stewart, Purves, 95
Subjective disturbances, 12
Suggestion, 36
Suppression of emotions, 9
Syphilis, 106
Sympathy, 28, 29
Stigma of insanity, 84
Text-books on psychological medicine, inadequacy of, 118
Treatment, 27
Tuberculosis, comparisons with, 77, 85, 114
Turner’s, W. Aldren, report, 14, 108
Unconscious factors, influence of, 57 _et seq._
Understaffing, medical, of asylums for the insane, 81
Weatherley, L. A., 130
Wiltshire, H., 10
Work, therapeutic value of, 50
Worry, relief of, 67, 68
Ziehen, T., 83
Zürich University Psychiatric Clinic, 86