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MENTAL HEALTH 1928.

THE LANCET.

LONDON : SATURDAY, OCTOBER 5, 1929.

" Insanity is ... only a disease 3r diseases...and a mind diseased can be minister less effectivelythan a body diseased. But the old

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n of insanitydies hard, and its traces are still persistenu. l’he modernconception calls for the eradication of olu.-establishedprejudices and a complete revision of the attitude of society."Tms quotation from the Report of the Royal

Commission remains the text of the Fifteenth AnnualReport of the Board of Control, Part I. of which hasjust been published.1 The sentence would provokeno dissent if the single-lettered word" a" were

omitted. Insanity is disease like other diseases, butto call it " a " disease is to overlook the fact that it isnothing specific but due to a multitude of disordersof body and mind. Hospitalisation of all institutionsfor the mentally afflicted is the Board’s great aim,although homes will still be needed for the chronicand infirm cases. Much has been accomplished;much remains to be done. Many institutions still fallshort in greater or lesser degree of the standard set bythe best, and the best could be still better. Manylocal authorities take a conservative position towardsmodern developments; while recognising the reason-ableness of a cautious attitude towards new " cures,"the Board feels strongly that in treating mentaldisease experiments should be made freely. Even ifstatistical results are disappointing, the patient andhis relatives obtain an incalculable psychologicalbenefit from the feeling that everything possible isbeing done, and that there is always hope. The onlydirection at present in which there is definite thera-peutic advance is the malarial treatment of generalparalysis, to which we referred in a recent issue2

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It is a regrettable and rather surprising fact that in allother departments of mental disease the average-recovery -rate-30 - 84 per cent. for last year-hasremained practically constant over a long period ofyears. This may be partly due to a higher standard ofrecovery nowadays, but whatever its cause, it mustcombine with the greater longevity of chronic cases,and the increase in general population, to produce asteady increase in the number of persons under care.The average annual increase of such persons is, in

fact, just over 2000, and the total number on Jan. 1st,1929, was 141,080. The Board points out that thisincrease by no means indicates an alarming increasein mental disorder, but it does mean a disquietingshortage of accommodation. To increase the numberof beds in an existing institution, or to build a new one,may cost 1500 per bed, and makes a heavy demand onthe finances of the local authority. For this reasonit is a true economy to spend money on the varioushospitalisation schemes which make for the mostintensive use of beds already available.

On this ground the Board strongly deprecates-understaffing on either the medical or the nursing.side, and welcomes the progress made during the yearin the provision of restful and comfortable accommo-dation for nurses. It regrets the unsettled conditions oftraining in mental nursing and the difficulty ofsecuring women nurses of good type and anxious toseek a qualification. It notes, however, the paradox

1 H.M. Stationery Office. 1929. Pp. 93. 1s. 9d.2THE LANCET, August 24th, p. 402.

that hospitals which set a high standard have theleast difficulty in obtaining probationers. It urgesthe appointment, wherever possible, of a specialoccupation officer, citing the experience of the Dutchhospitals, Gantpoort and Maasoord, which emphasisesafresh that there are many patients, includingviolent types, who benefit considerably and becomefar more amenable if trouble is taken to find theoccupation best suited to the individual. This taskdemands experience, skill, and time, which an over-worked medical and nursing staff cannot be expected todevote. Another measure which can be confidentlyexpected to reduce the need for beds is a well-staffedout-patient centre. To overcome the foolish tendencyto postpone treatment until concealment is impossible,the Board invokes the cooperation of the press.Adequate advance in new methods cannot be madewithout coordination, and the Report urges localauthorities to encourage scientific research in suchtherapeutic reinforcements as ultra-violet and otherlight treatment, electrotherapy and hydrotherapy.Much of the work which is already being done wouldhave its value greatly enhanced if the results wererecorded under a uniform and approved schedule. Acommittee of the Medical Research Council is takingsteps to associate certain mental hospitals in a

scheme of this kind. The Board notes with pleasurean increase in the number of mental hospitals thatare linked up with medical schools, for it feels thatnothing could be worse for psychological medicinethan any tendency to divorce it from other branches ofmedical study. Another development worthy of everyencouragement is the organisation by the RoyalMedico-Psychological Association of study tours of

foreign hospitals. The Board suggests that a reportof these tours by the Association would be of greatvalue to those who are unable to participate in them.One suggestion coming from abroad is the appoint-ment of a skilled psychiatrist as after-care officer.This experiment has been made with great successat Maasoord, Rotterdam, which has a markedly lowerreadmission-rate than other Dutch hospitals whichhave no such official. Another valuable appointmentwould be that of a social worker as almoner, to

supplement the admirable work which is now done bythe Mental After-care Association in tempering forthe discharged patient the shock of return to a stressfuland often temperamentally difficult workaday world.But when all is said and done it is the accumulationof the chronic insane, especially cases of dementiaprsecox, which constitutes one of the urgent socialproblems of the day. The cost and the wastage isterrific. Concentrated effort is needed-and willjustify large expenditure of public money in research;research, that is to say, into causes, into a group oftherapeutic methods, intensive experiment withoccupation therapy, and any other kind of therapy,so long as conducted in a limited field and on linesthat render it possible to estimate results. It would,we think, be worth while to offer valuable prizes foressays outlining details for research ; not for theresearch itself, but for grounds for expecting usefulresults from further study. The public wants awaken-ing to the gravity of this problem.The outstanding events of the year in the field of

mental defect were the passing of the Local Government Act and the publication of the Report of the MentalDeficiency Committee. The Board’s Report reviewsthe relevant sections of the Act and points out thebenefits which may be expected to result fromuniform control. It is hoped that both ascertainmentand classification will be greatly impioved. Thefigures. given;- in the Wood Report make it; highly

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probable that the increased accommodation madeavailable by the Act will still be inadequate. Theolder type of poor-law institution is only suitable forthe untrainable and unemployable classes, buta great many defectives of this type are still occupyingspace in mental hospitals, and their transfer to a poor-law institution would release beds urgently required forcurable cases of mental disease. For the educabledefective new colonies are still badly needed, andlittle was done during 1928 to meet the shortage;Hampshire and West Riding County Councils openednew colonies, and three other new institutions alsobecame available. Several designs for big schemes arenow, however, well advanced, and the Board is of ’,the opinion that every local authority ought to have acentral colony or a share in a colony where there is li,enough land for workshop and field employments and recreation. Although the actual amount of newaccommodation-625 beds-falls so short of urgentrequirements, yet it is nearly double that of 1927, anda large number of local authorities are taking steps inthe face of many difficulties to fulfil their statutoryobligations. While taking a guarded attitude towardssterilisation, the Board definitely recommends theprohibition of marriage of defectives. Shortage ofaccommodation, therefore, the key-note of the reportson mental deficiency for many years past, is still theprincipal trouble to-day, and has extended to mentalhospitals also. Most of the hospitals are overcrowdedand many have already been expanded to the utter-most limit. The position is serious ; a modern mentalhospital takes time to design and construct, and nolocal authority can afford to postpone serious effortsto meet the problem until the strain on their existinghospital has become acute.

CURES AND PREVENTION.THE author of a new American handbook on " The

Common Head Cold and its Complications "1 explainsthat if the information he has to offer is not altogethersatisfactory " it is because our scientific knowledge isnot in all respects final." As Regius Professor ofMedicine at Oxford Sir FARQUHAR BUzzARD woulddoubtless agree with this statement, but in theaddress published on p. 695 he suggests that weknow enough about colds to feel hopeless about them.The common cold is not curable, he said ; and as forprevention, the necessary measures would be so

troublesome and onerous that the public would neverput up with them. He advised his audience (in themanner of Mr. BELLOC) to answer, as they took theirfees, there is no cure for this disease, Henry willvery soon be well.

While it is quite true that the symptoms of infec-tious diseases are mostly the signs of a battle betweenparasite and tissues, we cannot agree either with hisstatement that " all the material facts about " thecommon cold are already known, or with his pessi-mistic outlook that no cure for that complaint willbe found as relatively effective, for example, as anti-toxin in diphtheria. It seems evident that there issome " material fact" about these infections ofmucous surfaces which has not yet been ascertained.No one so far has hit upon any theory or any empiricalprocedure which will enable us to kill the microbesor prevent their injurious action on the tissues. Butno cheerful believer in the intelligence of man can

1 By Walter A. Wells, A.M., M.D., F.A.C.S., Professor of Oto-laryngology, Georgetown University, Washington, D.C., with anintroduction by Hugh S. Gumming, M.D., Surgeon-GeneralUnited States Public Health Service. New York (obtainable inEngland from Messrs. Macmillan & Co., Ltd.). Pp. 225. 10s. 6d.

seriously doubt that there is a solution somewhere.Bacteriology is only just getting into its stride and

immunology has hardly begun to totter on its first

steps’; the golden age of catarrhs is surely only justround the corner.Meanwhile what is to be done ? Sir FARQUHAR

BUZZARD urges very truly that if we cannot cure a.

disease we should give our minds to prevention, andthat we should frankly recognise that some conditions,.such as the paralyses of poliomyelitis, are in effectincurable. With such doctrine no one can possiblyquarrel. Medicine has always put prevention in thefront of its programme, its main triumphs are hygienicrather than therapeutic, and it is along these lines.that it will progress. But it remains true, and pro-bably will always remain true, that the daily work ofthe medical man will be chiefly therapeutic. Preven-tion will sometimes fail, and the diseases of old ageare, as far as we know, unpreventable ; with ourageing population they will become relatively morefrequent. One has, too, to recognise that a man orwoman who is incurably diseased is by no means as.good as dead. From their own point of view, andoften enough from the world’s point of view, they areas much alive as anyone else, and much of the kindlyart of medicine will, we hope, always be devoted tomaking the rest of their pilgrimage as easy andeffective as it may be. It is questionable whethermedical men ever do anything more really useful,though the theory and practice of helping those who’are irretrievably maimed does not perhaps play anylarge part in our curriculum. Medicine is not whollymaterialistic : it would discharge its functions sadlyif it had nothing in view but a healthy body. Let ushave that by all means if we may, but if we cannotlet us bear in mind that comfort and cheerfulness do-

many people good besides the sick man. Whenprevention and cure have failed, there is much leftto do which is worth doing.

WORLD HEALTH ORGANISATION.COMPETENT observers of the Tenth Assembly of

the League of Nations have detected in its proceedings.an unusual insistence on active progress and increasedachievement. The note was heard in all directions,not only on the promotion of peace and disarmament,but in the discussions of such diverse matters as tariffbarriers, international communications, child life

protection, control of drugs of addiction, and eventhe internal organisation of the secretariat. Amongthem the Health Organisation of the League-a termwhich includes the medical director and his staff, thehealth committee, and advisory health council-cameunder review in its place. If we may judge from thediscussion of its work in the Second Committee,reported in the Assembly Journal of Sept. 18th, andby the subsequent approval by the Assembly of thereport submitted to it by the Czecho-Slovakiandelegate, Mr. FIERLINGER, it emerged not only withcredit, but with as much enthusiasm as the Assemblycan be expected to show over an undertaking whichhas so far gone its way without producing politicalrepercussions or national controversies. The outputof the Organisation in terms of its publications-continues to grow, while the steady increase in the-variety of subjects with which it deals is made evidentwhen the last annual report of the medical director is-contrasted with those which he presented only a fewyears ago. The compilation and issue of returns aboutnotified infectious diseases and similar data from thedifferent countries of the world continue both at