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 matter, 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." 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 (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) 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 causes 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 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.

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 the subject (of mental disease) is left severely alone. 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 know 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.

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 unjustifiable. Again, in the Standard of February 11^th 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 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, show 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 he established".

 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".

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, "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, vis.:-

The Attitude 0f the Medical Profession. When it is remembered that mental factors play an important role 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 Medica-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."

 " 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."

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 bearingupon 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."

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, 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 clef 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 saying the sufferer. Why cannot mental disease he dealt with in the same way? Why cannot our students be afforded, in general hospitals, the opportunity of personally examin- ing 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 thern 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."

 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 but little relation to the actual claims and qualifications of the candidate." 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 con- nection with the normal and morbid anatomy of the nervous system, its pathology and its biochemistry, suggest themselves to the worker at every step. The physiological and psychological effects of different diets, of drugs like the hypnotics, etc et cetara, 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 im- possible. And, of course, without the willing co-operation of the asylum authorities coordinated researches cannot he 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 . . ."

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 textbooks available for the student. In many of these text-books the introductory chapters contain some, often irrelevant, morbid anatomy, and the remainder deals with "psychology." The latter frequently consists largely of anecdotes, often "funny and some- times 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 MeDougall, Stout, Hart, Shand and Dejerine 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 casts. 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, biochemical, 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 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 describing the psychiatric clinics at Munich and Giessen:

"They are carried on upon the lines of 'freely come, freely go' as far as the safety of the patient and of the public. In neither of the 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 were1600 admissions in 1905 (the first complete year after it was opened), 1832 admissions in 1906, and 1914 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 tue 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. 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 thy 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 pounds 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 20,00 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 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 -rumble 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 "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 he 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 complicates 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."

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.

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 ancertified 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".

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. Weatherly 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 Salpetriere, 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 staft 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.

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