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OCTOBER 14, 1922.

An AddressON

MENTAL HYGIENE IN RELATION TOINSANITY AND ITS TREATMENT.

Delivered on Oct. 10th to the Students’ Medical Society,Charing Cross Hospital, London,

BY SIR FREDERICK W. MOTT, K.B.E., M.D.,F.R.C.P. LOND., LL.D. EDIN., F.R.S.,

CONSULTING PHYSICIAN TO CHARING CROSS HOSPITAL; DIRECTOROF PATHOLOGICAL LABORATORY OF L.C.C. MENTAL HOSPITALS.

PRIOR to the war there was a considerably prevalentbelief that mental hygiene meant only the treatment offeeble-mindedness and insanity, which are the moststriking examples of mental ill-health. They are

striking because individuals so afflicted are anti-social ;the State consequently assumed the responsibility ofproviding for the care of the feeble-minded and theinsane by detention, but hitherto little has been donein the way of prevention, and not enough in the wayof cure. Public opinion was aroused against thesending of soldiers, said to have become insane owingto the terrors, stress, and strain of war, to lunaticasylums without a period of probation. Questionswere asked in Parliament, and it was enacted that nosoldier should be discharged and sent to an asylumunless it could be shown that he was suffering from anincurable mental disease-e.g., general paralysis ofthe insane, or epileptic insanity. The same regulationapplied to ex-Service men under treatment by theMinistry of Pensions.

THE TREATMENT OF EARLY MENTAL CASES WITHOUTCERTIFICATION.

It has long been recognised that there is a greatneed of neurological and psychiatrical clinics attachedto general hospitals, or of special clinics with hospitalsfor the treatment of mental disorder in borderlandcases-in cases of psychoneuroses and psychoses in theremedial or curable stage-such as existed for soldiersand ex-soldiers who were receiving a pension. Thepublic, not cognisant of all the facts, naturally wish toknow why this principle, which worked well with thearmy and pensions, cannot be applied to the civilianpopulation. But the conditions are different ; whilea man was in the army he was as safely under controlas if he were certified, and if he ran away he could betreated as a deserter. The Ministry of Pensions hadnot so much control, although the pension could bewithheld if suitable treatment were refused. Thedifficulty with the voluntary boarder is, that howeverdangerous he may be to himself or others, he cannot bekept under restraint in a mental hospital against hiswish at present for more than 24 hours. Either theState must provide legal machinery whereby certifiablecases can be detained for a period of probation withthe consent of the friends-notification having beenmade to the Board of Control or to some otherproperly constituted authority, to prevent wrongfuldetention-or such patients must be discharged tofriends, who must be told that the patient will have tobe certified. If legal objection is raised to detentionagainst the patient’s wish, at any rate a minor might,with the consent and expressed wish of parents orguardians, be detained under such conditions. Sucha provision is especially desirable in that a largenumber of early cases in the remedial stage occur atpuberty and in early adolescence. If the patient hasto be discharged in a condition in which it was deemedthat his mental stage necessitated certification, thiscould either be done in the customary way through therelieving officer, or a medical man from the outsidecould be called to certify the patient under an urgencyorder for removal to an asylum for certified lunatics.If the patient had no friends a visiting justice mightsuffice; the patient would then be handed over to therelieving officer and taken to the infirmary and there

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certified and sent to an asylum. The former methoclis much more likely to succeed in getting the patientin the early curable stage.

EXISTING MENTAL HOSPITALS AND THE TREATMENTOF EARLY CASES.

All cases not definitely diagnosable as incurableshould, if sent to a county or borough asylum, bereceived in a hospital, apart from the main building,and treated on lines indicative, as far as possible, ofcure. Economic difficulties will arise, as there arefew asylums in which suitable buildings exist. Everymental hospital should have an out-patients’ clinicattached—or, better, affiliated with a clinic outsidethe asylum grounds, and especially adapted andequipped for the treatment of early mental cases.

Great advantages from both an economic and curativepoint of view might be expected from these out-patients’ clinics. Patients could be discharged ontrial from mental hospitals earlier and their progresswatched. It would be desirable to have separate daysfor these patients to attend, so that they did not mixwith cases that had never been in an asylum. Thetreatment could be continued and prophylacticmeasures by social workers carried out. Practitionerswould be induced to send cases earlier, and therewould be far less objection on the part of friends andthe patients themselves, than of their being sent to theinfirmaries. It would be better if they were desig-nated " neurological and psychiatric clinics," as

experience shows much less objection would arisein getting borderland and early cases of mentaldisorder to attend if the word "mental" was omitted.

ASYLUMS CALLED MENTAL HOSPITALS.

It will not suffice to call asylums mental hospitals,in spite of the fact that in the past alienist physiciansand commissioners in lunacy protested against theimplication that these institutions (with few excep-tions) did not practise hospital methods of treatment.

It is now generally recognised that it is unwise as itis unjust to treat early curable cases in the sameinstitutions as chronic incurables. It is unwise toput any patient in whom there is a hope of recoveryin an atmosphere where despair of recovery exists.Mental depression is not likely to be removed in anew patient by the information of a chronic patientthat he has been in an asylum, 5, 10, 15, or 20 years,and the feeling " All hope abandon, ye who enterhere " may thereby be installed in his mind andbecome firmly fixed. In a few asylums it is pleasingto note that there is a villa for acute cases andanother for convalescent cases, so that a patient maynever be herded with the chronic incurable cases.Such a provision should be compulsory in everyasylum which receives acute and therefore curablecases. It is desirable that the nurses should have hada general hospital training. It would be a greatadvantage if such female nurses were employed inthe care of male patients. It would be necessaryfor a small staff of male attendants to be available,but they should be under the control and directionof a trained hospital sister. These institutions maybe rightly designated, then, mental hospitals. Suchprovisions would be a satisfaction to a large sectionof the public and tend to allay a widespread feel-ing of distrust regarding the present treatment’ ofearly cases of mental disease.

DIFFICULTIES OF REFORM.

It may be urged that however necessary are thesereforms in provision of separate hospitals for thetreatment of acute curable cases, the ratepayer willexclaim against the cost ; in this respect propagandistwork is necessary to explain to the overburdenedtaxpayer, for whom I have the greatest sympathy,that the cost of maintenance need not be increased,but that the rates should be more wisely spent, onthe principle that the first duty of the authorities is toprevent disease, failing that to cure disease, andfailing that to prolong life and relieve suffering. Thiscan be done as follows.

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1. By endeavouring to prevent disease-that is,by mental hygiene on the lines adopted by the NationalCommittee of Mental Hygiene of the United States ofAmerica. This was founded in 1916 ; its secretary isMr. Clifford Beers, who wrote a remarkable book," A Mind that Found Itself." In this he describes hisown treatment, and shows how almost everythingwas done except the right thing to restore him tomental health. The National Committee Executiveconsists of a number of well-known men, andColonel T. W. Salmon is the medical director.Since 1917 it has issued a quarterly journal termed- M6M<< Hygiene, which contains valuable articlesand investigations upon the lines set forth in thefollowing statement of the general purposes of theSociety :-The National Committee for Mental Hygiene and its

affiliated state societies and committees are organised towork for the conservation of mental health; to help preventnervous and mental disorders and mental defect; to helpraise the standards of care and treatment for those sufferingfrom any of these disorders or mental defect; to secure anddisseminate reliable information on these subjects andalso on mental factors involved in problems related toindustry, education, delinquency, dependency, and the like ;to aid ex-service men disabled in the war; to cooperatewith federal, state, and local agencies, and with officialsand with public and private agencies whose work is in anyway related to that of a society or committee for mentalhygiene. Though methods vary, these organisations seekto accomplish their purposes by means of education, inencouraging psychiatric social service, conducting surveys,promoting legislation, and through cooperation with themany agencies whose work touches at one point or anotherthe field of mental hygiene.When one considers the large groups of people who

may be benefited by organised .work in mentalhygiene, the importance of the general purposes of theabove-described movement at once becomes apparent.Such work is not only for the mentally disorderedand those suffering from mental defects, but also forall those, who, through mental causes, are unable so toadjust themselves to their environments as to livehappy and efficient lives.

2. By adequate provision of separate properlyequipped buildings for the treatment on modernhospital and scientific lines of early curable andborderland cases, uncertified for a period of time, withlegal provision against their improper detention, thusavoiding the stigma of asylum detention. Havingregard to the financial difficulties, it might be urgedthat so far as possible, where a group of asylumsexists under one authority, endeavours should bemade to send acute recoverable cases to those asylumsmore suitably constructed and more adequatelyequipped for their treatment.

3. All incurable and chronic cases segregated, butclassified in such a way that adequate and propertreatment can be afforded them. Prior to the war itwas calculated that 5000 of the 20,000 lunatics in theLondon County Council Mental Hospitals had beenresident 20 years or more, and 10,000 ten yearsor more.

A large proportion of the 21 8s. 7d. per week whichsuch patients now cost in the London County MentalHospitals is expended on maintenance and pay ofthe staff and its three eight-hour shift system. Thisdoes not include the cost of buildings and theirupkeep, which is heavy. When will the public realisethat it is brains, not bricks, that are wanted ?

RESEARCH.

Expenditure upon intensive scientifically conductedresearch in hospitals and laboratories into the causes,prevention, and treatment of insanity by skilled,properly-paid medical officers and social workers, islikely to be of more use and more economical in theend than expenditure on magnificent and costlybuildings. For 20 years I was endeavouring toawaken the authorities to the necessity of combatingvenereal disease, for it was overwhelmingly provedthat syphilis, besides being the sole cause of generalparalysis of the insane, is also a very frequent causeof mental deficiency and organic dementia, yet

nothing was done until the Royal Commission onVenereal Disease in 1914.

EDUCATIONAL.The war has shown the great need of systematic

teaching of psychological medicine as part of themedical curriculum. In 19071 I strongly advocatedthis teaching for post-graduates, and suggested thata diploma of psychological medicine should beinstituted, for I felt sure that it would raise the tone ofmedical men employed in the care of the insane andlead to better diagnosis and treatment of mentaldisease in the early curable stage. I also advocatedthe establishment of a psychiatrical clinic in London.where incipient and borderland cases could be seenand treated. I was convinced in 1907 that theinstitution of a diploma in psychological medicinewould prove as valuable as the diploma of publichealth, and I called upon the President of the RoyalCollege of Physicians to try to induce the RoyalColleges to give such a diploma, but I was quiteunsuccessful. Just prior to the war CambridgeUniversity led the way and instituted such a diploma,and now many universities and the Royal Collegesgive diplomas of psychological medicine. The

systematic teaching of psychological medicine hasbeen in operation now for two years at the MaudsleyHospital. Four courses have been completed, andthe fifth course commenced to-day (Oct. 10th).These classes have been well attended, and a largenumber of graduates and medical officers haveobtained diplomas in psychological medicine. Thishas produced a new spirit among the medical officersof the London County Mental Hospitals-a spiritfostered, I am pleased to say, by the Mental HospitalsCommittee of the London County Council; moreover,the possession of the diploma is becoming indis-pensable for senior appointments, and it is more andmore being recognised that administrative capacityis not the only qualification necessary for the post ofsuperintendent or of senior medical officer.

NEGLECT OF MEDICAL PSYCHOLOGY IN THE PAST.Sir G-eorge Newman, in an admirable report on

medical education in 1920, stated : " It is deplorablethat the English student of medicine should have noopportunity of learning modern methods of psychiatryor of diagnosing incipient and undeveloped cases ofmental disease." And yet, in 1913, Parliamentimposed statutory duties upon the medical practi-tioner, among them being, " He must be competent todiagnose all forms of mental disease " (MentalDeficiency Act, 1913). The public might ask whythe authorities did not previously insist upon propertraining in this important branch of medical education,involving the liberty of the subject. The effects ofneglect of training in this important branch ofmedicine was shown in conscripting for the war. Thedifficulty regarding the treatment by the Ministry ofPensions of ex-service men in asylums has arisen fromthe fact that a large number of potential lunatics wereadmitted into the army, and this might to a greatextent have been avoided had medical men knownmore about incipient mental disease.

DIAGNOSIS AND TREATMENT.Successful diagnosis is the first step to efficient

treatment. To effect this, a well-paid, skilled medicalofficer of experience, who has recently had a trainingin psychological medicine, should investigate the caseupon admission. To do this efficiently requires time.knowledge, and patience. The examination shouldcommence with a careful inquiry of the friendsregarding family history, disposition of patient, andconduct from early childhood onward. An inbornpredisposition will often be revealed, and the onset ofmental disorder may be shown to have commencedlong before the friends, or even the family doctor,knew of it. The patient’s mental and bodily con-dition should be carefully examined. Importantindications for treatment by psychotherapy or

1 Archives of Neurology and Psychiatry, 1907, vol. iii.. Preface.p. vii.

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medical therapy may be discovered. A carefulexamination of the bodily condition necessitates a

clinical equipment on hospital lines, including a darkroom for ophthalmoscopic examination, also a smalllaboratory with the necessary equipment on modernlines for the complete investigation of the excreta,discharges, blood, secretions, and fluids of the body,such as exists in a general hospital. A certain amountof valuable clinical research could be carried out ifthese conditions were provided.

CENTRAL RESEARCH LABORATORY.A central research laboratory should be provided for

a group of mental hospitals. This laboratory shouldhave a director and an efficient, adequately paidstaff which should collaborate with the asylums of thegroup, and undertake such skilled routine laboratoryinvestigations as might be needed. The directorshould promote and advise research in the asylums ofthe group, and afford help where necessary. Thedirector and his staff should undertake systematicresearches in collaboration with the medical superin-tendents and medical officers, but should retain anindependent position. The central laboratory shouldbe equipped with the necessary rooms and appliancesfor histological, bacterio-biological, chemical, andpsycho-physical investigations.

DIET.

Among the other measures of treatment that callfor urgent reform is a more liberal diet. The armyregulations gave soldiers suffering with nervous andmental disease 3250 calories and extra meat ration ;the asylum dietary, even after the armistice, wasonly 2250 calories, and was deficient in animal fat.A more liberal diet, with a sufficiency of both water-soluble and fat-soluble vitamins, is necessary. Itmay be urged that patients put on weight when theyhave resided in asylums for a short time, and they donot suffer with any of the bodily diseases due tovitamin deficiency-viz., scurvy and beri-beri. Anacid test of diet in relation to deficiency is the death-rate, especially of those chronic diseases in whichdeficient vital resistance plays a predominant role-e.g., tuberculosis. Another point in connexion withdietary is monotony. People do not realise what animportant part the pleasures of the palate play instimulating the flow of the gastric and digestivejuices, and thereby facilitating digestion and assimi-lation, which, reacting on the whole body, help to .1.remove mental depression.

OCCUPATION IN ASYLUMS.

During the war, in the treatment of war psycho-neuroses and psychoses, I found occupation of greatvalue in treatment, but the occupation must bedesired by the patient, and he must be interested in it ;otherwise it will have no therapeutic value as a

means of mental diversion and self-criticism. I tookrisks, and allowed men who were not always free fromthe suspicion of suicidal tendencies to work in thecarpenter’s shop. The success of the carpenter’s shopdepended upon conditions which were made possibleby the generosity and sympathy of Lady HenryBentinck, who provided a carpenter’s shop, fullyequipped with all the necessary appliances and acapable instructor. It was not therefore trammelledby army regulations ; the men who worked there wereinterested, because they made what they felt theycould make well, and because it became their own tosell if they wished, the only charge made being thecost of the material. Revived self-respect, pride ofwork, and emulation are necessary if occupation is tobe of any therapeutic value in mind-healing. Patientsin the asylums who work on the farms have bread andcheese extra, other workers in the laundry, kitchen,workshops, and farm have a little tobacco daily.Almost daily, when the laboratory was at ClayburyAsylum, I saw a gang of from 20 to 30 inmates pro-ceeding to work on the farm ; many were draggingon a slack rope attached to a very small cart, otherscarried agricultural implements over their shoulders ;the party was preceded by one playing a whistle pipe.

l I venture to say that one navvy would do more work; than the whole party. In the reports these numbers: are recorded as so many working on the farm-it

just depends on what is meant by work-as a thera-peutic measure. If those who were able were encouragedto work by reward, if they were permitted to growfruit, flowers, and vegetables which would be of someprofit to them, it would be mental hygiene in theproper sense of the word. I know the extremedifficulties attending occupational treatment, butwhat is wanted in the asylum administration is moreindividuality, and less camouflage and stereotypingin the management and treatment of the insane, witha view to cure and making their lives less dreary andmonotonous. I have a great belief in the value ofsong and music as mind healers, and since manypatients possess these artistic faculties, it is a properthing to encourage them in the exercise of it. Bandsshould play daily in the grounds or building ; if thatis not possible, gramophones with good cheerful anduplifting records might be used. It is a depressingsight to see these poor creatures seated in a day-roomor taking exercise in an airing court, exhibitingbrooding, melancholy, or a demential ineptitude,occasionally enlivened by maniacal excitement onthe part of one or more of the inmates. Such is theprevailing atmosphere in the chronic wards of anasylum. It must be acknowledged that to someextent this is necessarily unavoidable, owing tothe state of mind of the patients. The wardsthemselves generally are well furnished and bright,and the attendants, having regard to the difficulttasks they have to perform, as a general rulecarry out their duties with efficiency and con-

sideration, but there is a stereotyped systemwithout variation, extending even to the air in thewards of some asylums, which can easily be detectedby the nose, for there is, generally speaking, a charac-teristic " omnium gatherUID" odour of beeswax,turpentine, stale tobacco, exhalations of humanbodies, and soiled clothes ; this also to some extent isunavoidable owing to the dislike of open-windowventilation and the large numbers collected in thewards. Variety is the spice of life, but that is justwhat this institutional life does not provide. Efforts,therefore, should be made to effect changes in thetraditional systems prevailing in these great institu-tions for the care and detention of the mentallyafflicted.

In conclusion, I would call attention to the desira-bil.ity of taking all precautions necessary to avoid theintroduction into new asylums of carriers of typhoid,paratyphoid, and dysentery; we should then notwitness what has so frequently happened in the past-viz., outbreaks of these infective bowel diseases andtheir installation in the institution to the continuousdanger of patients admitted for the care of theirmental affliction. Once introduced, owing to the.habits of the patients and the difficulties attendingthe discovery of these carriers, it is almost impossibleto eradicate the infection.Many of the suggestions and reforms which I have

indicated were proposed by Dr. Hubert Bond, aCommissioner in Lunacy, in his presidential addressto the Medico-Psychological Association, 1921.

LIGUE D’HYGIENB MENTALE.A Ligue d’Hygiene Mentale was formed on Dec. 8th,

1920, under the patronage of the French Minister ofHealth. It is subsidised by the General Council ofthe Department of the Seine, and by the MunicipalCouncil of Paris. The objects of this league are onvery much the same lines as the National Committeeof Mental Hygiene. Dr. Colin recognises the greatimportance of prophylaxis, and he points out thatinsanity is, in a great number of cases, curable andavoidable, and that it is so much the more curable theearlier it is treated.

It is hoped that the recently appointed Committeeof Mental Hygiene, of which Sir Courtauld Thompsonis president, will receive support in carrying out a.

programme of mental hygiene for this country onsomewhat similar lines to that of the United States.