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Special Articles.MENTAL DISORDER AND DEFICIENCY

IN 1927.THE SHORTAGE OF ACCOMMODATION.

THE Board of Control, in their Report for 1927, laystress on several problems of increasing urgency.Everyone in any way connected with lunacy adminis-tration will share their great regret that no legislationhas yet been introduced to give effect to the recom-mendations of the Royal Commission of 1926. The

passage of the Mental Deficiency Act, 1927, was,

however, an event of far-reaching importance. Notonly have various difficulties been removed whichwere inherent in the Act of 1913, but the new Actdefines mental defect and, by the changes which itintroduces into the definition of the four categories of- defectives, enables provision to be made for post-encephalitic and other similar cases.The shortage of accommodation for mentally

diseased patients and mental defectives alike isincreasingly serious, but whereas the large majorityof the counties and county boroughs have eitherprovided a mental hospital of their own or possessa share in one, not a single local authority has itselfprovided sufficient institutional accommodation tomeet the needs of its own defectives, and scarcely 18 percent. have provided any accommodation whatever.Of all persons annually sent for treatment under theLunacy Acts, 93-5 per cent. are received into countyor county borough mental hospitals, but upon thelowest calculation the number of defectives whorequire institutional care and cannot have it is notfar short of 20,000. The Board, however, opposestrongly the suggestion, at first sight reasonable, toconcentrate for the time upon the provision of accom-modation for defectives and to relax efforts toaccommodate mental patients. "No such policyought to be countenanced for a moment," they say," nor ought any rivalry to be admitted between

the two components of this dual need." The twoproblems are complementary, and one cannot beconsidered without the other. The Board regret thatadvantage has not been more often taken of Section 28of the Mental Deficiency Act of 1913, which permitsone committee to be constituted for the purposes ofboth Acts. The ruling factor, of course, as theypoint out, is public opinion. The community nowfully realises that provision for the requirements ofcertified patients is an absolutely unquestionableduty. What it has yet to realise is that a large numberof these patients would never have become certifiableif they had had proper treatment at an early stage,and that a large proportion of the poor-law expendi-ture and of the cost of the prison service is traceableto neglect in caring for mental defectives.

The Mental Hospitals.On the first day of 1928 the number of notified

insane persons under care in England and Waleswas 138,293, an increase over the figure for 1926of 1667. The number of direct admissions was21,893, 31 less than in the previous year. The ratioof admissions per 10,000 of the populations aged 16and over is now 7-66, and the table given in theReport shows a steady decline in the last seven years.The general recovery-rate is 31-43 per cent. of directadmissions, and the general death-rate is 7-94 percent. of the average daily number registered, against7-30 per cent. for 1926 ; this is the first rise in thedeath-rate since 1922. The number of patientsresident in county and borough mental hospitalsincreases on an average by 2529 every year. Thenumber of vacancies, on the other hand, in spite ofthe reopening of Ewell Colony, Epsom, has decreased

1 Fourteenth Annual Report of the Board of Control. Part I. H.M. Stationery Office. Pp. 87. 1s. 9d.

from 2319 in 1926 to 1570 at the beginning of thisyear. Moreover, whereas on Jan. lst, 1927, therewere vacancies for 148 women, there was in Januaryof this year a deficiency of recognised bed spacefor 34. The position, in the words of the Board,has become critical. As a temporary measure EwellColony, originally a hospital for male epileptics, wasreopened last year as a mental hospital with beds for100 men and 329 women, and it is estimated thatby the end of this year various small additions andrearrangements will have provided accommodationfor another 1250 patients-barely half the averageannual increase. " It is evident that such makeshiftswill do very little to ease the general situation, andunless energetic measures are promptly taken seriousovercrowding of these hospitals is inevitable." Atthe moment only two authorities, Middlesex andSwansea-Merthyr Tydfil, are building new institu-tions. The situation is complicated by the fact that15 local authorities, responsible for nearly 2500patients, have no mental hospital of their own butcontract with neighbours to receive their patients.Now that very few mental hospitals have anyvacancies, the larger of the authorities with no insti-tution of their own are finding it extremely difficult tosecure accommodation. As a rule they have notsufficient patients to make the erection of a hospitaleconomical, and the solution suggested by the Boardis that they should arrange with neighbouringauthorities who own institutions to extend themsufficiently to accommodate their patients for a

number of years.Meratcal Deficiency.

Serious as is the shortage of accommodation for" lunatics," the position of the constantly growingarmy of defectives who require institutional treat-ment is much more so, and the Board report that,unless a great effort is made in the immediate future,it will become difficult and even impossible toadminister the most important sections of the MentalDeficiency Act. Urgent cases needing prompt actionfrequently come to the notice of the Board, and novacancies can be found. On the first day of 1928the number of defectives in institutions was 20,429 ;at the most moderate estimate-I per 1000 of thewhole population-the number requiring treatment is39,067. During the last six years the number ofdefectives of whom local authorities have obtainedknowledge has increased from 25,470 to 61,522 ;many of these are reported to local authorities becausethey have got into trouble of some kind and needprotection in institutions. The figures for the lasttew years of detectives recommended by educationauthorities show a progressive increase, which willbecome more rapid as education authorities awakento the necessity of further care for defectives leavingschool. Although most of these authorities have notcompleted their ascertainment and some have hardlybegun it, the Januarv returns show that 1479 casesare " awaiting removal to an institution." Moreover,on Jan. lst there were 265 defectives in " places ofsafety," that is, detained. This measure was clearlyintended merely to ensure the safe custody of a defec-tive during the fortnight or three weeks before apetition is presented, and detention for considerableperiods without training or proper classification isobviously very unsatisfactory. Of equal importance,in the Board’s opinion, is the great and increasingdifficulty in finding accommodation for cases reportedfrom prisons, who otherwise have to remain wherethey are under admittedly undesirable conditions.The Board do not mention, but certainly do notoverlook, the deplorable handicap that rests uponthe infant but highly beneficial enterprise of thosebenches of magistrates who employ trained psycho-logists to help them to keep defectives out of prison.Finally, the lack of accommodation in proper insti-tutions results in the certification of a very largenumber of mental defectives under the Lunacy Acts,especially of low-grade and troublesome patients, forwhom managers of small institutions and boards ofguardians are naturally unwilling to shoulder the

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responsibility. Mental hospitals would be shortenough of beds even if they were not obliged to shelterdefectives, whom they cannot benefit and who hinderthe recovery of other patients. The Board considerthe need to be so urgent that they devote much spacein their Report to an eloquent restatement of thenumerous irrefutable arguments in favour of an

immediate and adequate effort by all local authoritiesto found sufficient colonies to house all the defectiveswho in the interest of the community should be caredfor in special institutions. The present shortage is, intheir opinion, not entirely due to difficult financialconditions, but is sometimes the result of a failure bythe local authority to realise the importance andgravity of the situation. Mental defectives are

very prolific and always beget defectives ; defectiveparents inevitably create centres of degeneracy,disease, inebriety, pauperism, and crime, for whichlocal authorities cannot escape responsibility. Thegreater number of defectives who are given training Iearly in life can be rendered harmless and amenable,cured of obnoxious habits, and under favourableconditions and proper supervision made self-supporting. The duty of all whose words’ carryweight with those responsible is obvious : to pressand to continue pressing for the full and adequaterecognition of the vital importance of this problemto the nation’s health.

- The New Mentctl Deficiency Act.The most important alteration of the law governing

defectives is made by the section which replacesSection 1 of the old Act; instead of limiting mentaldefect to conditions dating from birth or from anearly age," it defines it as a condition of arrestedor incomplete development of mind existing beforethe age of 18 years, whether arising from inherentcauses or induced by disease or injury." The newAct thus includes defect resulting from encephalitislethargica, epilepsy, and other diseases. The Boarddo not summarise the Act in detail, but point outcertain other important amendments. The class ofpatients " subject to be dealt with " now includesany patient of whom his parent or guardian hasrepresented to the local authority that he needs careor training that cannot be provided in his home.The parent’s consent may now be dispensed withwhen he is abroad and the attempt to obtain itwould mean undue delay. When a court has ordereda certificate and it has been found impracticable topresent one, or the court has dismissed it and the caseis left unsettled, the temporary detention may beextended. The local authority is charged withproviding suitable training or occupation for defec-tives under supervision or guardianship or in certifiedinstitutions, and authorities which exercise dualpowers under the Mental Deficiency and EducationActs may provide ordinary certified schools whichcan be at the same time certified institutions fordefectives.The Board reprint much of what they wrote last

year on the marriage of defectives, and state that inthe light of fresh experience and resolutions theyhave received from a number of local authorities,their opinion is that the time has come when definitelegislative steps should be taken to prevent themarriage of those under Order. They have not,however, seen any reason to modify their attitudetowards sterilisation, which they do not thinkpromises any substantial help towards solving theproblem of accommodation. They comment againon the wide variation in the returns sent in by thevarious local authorities of defectives ascertainedduring the year. The figures vary between 4-66 and0-03 per 1000 of the population, a discrepancy greaterthan can be accounted for by any possible differenceof local incidence. The Board state that the methodsof local authorities returning low figures call forimprovement, and recommend the employment of aspecially trained officer or the use of the services ofa specially trained secretary of a voluntary association.The number of defectives under guardianship has

increased by 252, but 49 authorities have not a single

case under guardianship, and 29 others have only-one or, at the most, two. The Board reiterate theirwarning of last year urging care in the selection bothof guardians and of cases for guardianship ; in thisfield their experience has been closely parallel withthat of the Scottish Board.2 The search for suitableguardians should, they say, be organised and not leftuntil urgency arises. A list may be submitted bythe ascertainment and supervision officer, or aguardianship society can be formed ; some such planshould be set on foot in every district, to prevent thesending of defectives far from their own countiesand their own local authority. The northern countieshave so far no organisation of this kind.

Mental Nursing and Other Matters.The Board commend the progress made in providing

detached nurses’ homes, which not only set free verynecessary accommodation but tend to raise thestatus of mental nurses and the standard of theirwork. They promise a fuller discussion of the subjectin a future report. Meanwhile, they notice with greatpleasure the opening in June, 1927, of the newnurses’ home and training school at the CountyMental Hospital, Maidstone. By far the largest ofits kind, this home accommodates 136 sisters andnurses ; it is separate from the hospital, cost ;1346,000,and set free space for 160 beds.The commemoration of the Pinel Centenary called

for a historical article on mechanical restraint at theend of Part 1. of the Report, and the work of thevoluntary associations is warmly commended. Thereis a note on the mental after-effects of encephalitislethargica. Part II. of the Report contains, inaddition to statistical tables, entries by commissionsat institutions and other matter, a supplementsetting out or mentioning 65 contributions submittedto the Board on clinical and pathological research androutine laboratory work carried out in institutions-visited by them. Five of the papers deal with bio-chemical problems, five with encephalitis lethargica(including two dealing with its treatment by malaria),ten with general paralysis, and four with treatment ingeneral. Only two deal with histology, a subjectwhich the Board consider does not nowadays receivesufficient attention. The Board commend the workhighly, exhort every medical officer to contribute hisshare to it, and encourage the record of negativeequally with positive findings.

THE LONDON MEDICAL EXHIBITION.(Continued from p. 729.)

II! BOOTS PURE DRUG Co., LTD. (Nottingham),.displayed photographs of their analytical, research,and manufacturing laboratories as a background toa representative selection of their standard products,among them being Stabilarsan, Sulphostab, Thiostab,Bismostab, and Vaccines (St. Thomas’s). In additionthere was an interesting display of the syntheticantiseptic Acriflavine, and prominence was given toa series of pharmaceutical products of this non-irritantbactericide ; pessaries, gauzes, solution tablets,bougies, an emulsion as a surgical dressing, and an,oral tablet as a urinary antiseptic. Capsules andtablets of Hexyl-Resorcinol were also on exhibit anda solution in glycerin with " low surface tension advan--tages " when used as a surgical dressing. LiverExtract " Boots " (M.R.C. approved process) invarious forms was exhibited and also Cholumbrinfor cholecystography, and Viules, a series of sterileampouled products. Insulin and Ephedrine were alsoshown.-E. H. SPICER AND Co., LTD. (Watford, Herts,and 72, Wigmore-street, London, W.). One of the-prominent exhibits on this stand was Calsoma, the-tribasic phosphates of calcium and magnesium, sodiumbiphosphate, and magnesium citrate in effervescentform. This has proved a useful gastric antacid,.

2 THE LANCET, August 18th, p. 339.