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.