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MENTAL HYGIENE REUNION

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conditions for the operative treatment of the com-plicating factor. The tragedy of the missing testicle,following operation for hernia in infancy, must beavoided. The chance of natural descent in patientswho have had an operation for hernia seems to beless good than in the uncomplicated canal testis.Where there is no evidence of hernia or hydrocele

the outlook is far more favourable, and naturaldescent and development of the testicle may be

expected in most cases up to the age of 16 years.A hopeful prognosis can therefore be given, observa-tion being required at intervals after the age of9 years. Parents can be advised that active therapyby injection will be undertaken if no sign of descentis present after pubertal changes are well established.At this period the increasing mass of the testicle willin itself be an important factor in encouraging itsdescent to its normal habitat.Too early hormone treatment may induce pre-

cocious sex maturity without the balancing andsocially essential inhibitions. Dorff has recordeda case in which a boy of 8 years after prolonged

treatment became an exhibitionist. E. T. Engle (1932)has also issued a word of warning and suggests9 years as the earliest age at which to commence

injections, whilst it is not desirable to wait untilafter 14 years. To an older boy the reason and needfor treatment can be explained and his cooperation-obtained. In the younger child weekly injectionand measurement of the genitals combined withthe heightened sex appetite is likely to have a

subversive influence.

SummaryIn summing up our present knowledge, we can say

that whilst the outlook for the undescended testiclehas always been brighter than has been generallybelieved, in that four out of five will probably descendnaturally, the future outlook is even more favourable.Descent may be accelerated when advisable and

surgical treatment will be required only for selectedcases.

PEARSE WILLIAMS, M.D., M.R.C.P.Physician to the Children’s Hospital, PaddingtonGreen, and to the Willesden General Hospital.

SPECIAL ARTICLES

MENTAL HYGIENE REUNION

THE fourth European Mental Hygiene Reunionwas held under the auspices of the National Councilof Mental Hygiene in the conference room of theMinistry of Health on Oct. 5th and 6th. The official

opening was performed by the DUKE OF KENT aspresident of the Council on Monday afternoon.

Mental Hygiene and the NurseThe EARL OF FEVERSHAM, presiding on Tuesday

morning, pointed out that this age of competitionplaced a heavy strain on the individual, which ledto fear and so to many psychological problems,which were intensified as civilisation progressed.An encouraging factor on the other side was the

holding of an international conference to find outand remedy the causes of these problems. Nursesdeserved praise for the great qualities which theybrought to their task, and it was most importantthat they should be rightly directed and their oppor-tunities of furthering the mental health of their

patients, and of spreading the doctrines of mentalhygiene, should be used to the full.

Dr. HANS ROEMER, of Illenau (secretary of theGerman Council for Mental Hygiene), said that thecare of the sick had led to the recognition of thepsychological changes which were part of the physicalillness. The hospital must provide a healing atmo-sphere of encouragement and protection to build upresistance against disease, and when the patientmended, his will to health must be reinforced. Thenurse played the chief part in influencing the patient.She must be armed with sympathy and real under-standing to protect his abnormally keen senses andmeet his fears and complaints, so as to win his con-fidence. She must fit his returning strength to suit-able tasks, and must fight against boredom andidleness. She must meet the relatives with tact andfirmness. In the treatment of neurotics her psycho-logical cooperation was especially important. In

Germany welfare work in the patients’ homes wasbeing more and more carried on by institution nursesunder the direction of the hospital physician. Thisnew work had been started since the war, and the

intelligence of the staff nurses had enabled them tomeet its demands without special training. Itallowed the convalescent to be discharged earlier,unified specialist treatment, and provided for thereoall of the patient if his health again gave trouble.Candidates for such work must be physically andmentally sound and free of hereditary taint, psycho-pathic tendency, and tuberculosis. Social class hadlittle importance compared with intellectual abilityand independence of mind. The candidates who

sought work as mental nurses because of a latentpsychic affinity to the patients should be weededout, since they might later prove to be psychopathic.Schizoid or latent schizophrenic personalities mustbe rejected. The medical staff must care for themental hygiene of the nurses, who should be paidproperly, given free time each week, and insured

against accident, illness, and old age. Each nurseshould be allotted to the post most suited to her

capacity, and posts should be regularly changed.The nurse should have a hygienic room of her own,remote from the atmosphere of disease. Nurses’" casinos " with common refectory and recreationrooms had been in use for a long time ; in manyGerman, Dutch, and Swiss hospitals they included acommunal bathing establishment, music rooms, andfacilities for sport and games.

Dr. VIKTOR WIGERT (professor of psychiatry atthe Caroline Institute, Stockholm) declared that thenursing staff of mental hospitals in most countrieshad a considerably lower standard of general andmedical training than the staff of general hospitals.The nurses had often attended lower-grade schools,and were trained only in mental hospitals. In manycountries, however, including Scandinavia, successfulefforts had been made to obtain fully trained nursesfor the care of mental patients. The fully trainednurse had a tradition and spirit which the mentalhospital lacked, and also wide experience of thesick, and a practical psychological insight. She wastrained in a strict and elaborate technique whichwas more and more necessary with the increase ofpurely physical treatment in mental hospitals.Scandinavian mental hospitals had made highlysuccessful use of women assistants in male wardsAt first the schools of nursing had looked down uponthe care of the insane, but they now recognised it

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as a great and humane task. On the other side, atheoretical and practical training in the care of mentalpatients was most valuable to the general nurse,who was always dealing with patients who were

nervous and mental in all but name. This knowledgeintroduced her to the service of mental hygiene, tospeak and act in its favour, and to be its pioneerin all the branches of her work. The best socialworkers were those who had been trained as nurses.Psychiatry was a compulsory subject at nearly allScandinavian nursing schools.

Dr. HEINRICH KOGERER (lecturer in psychiatryand neurology at Vienna University) spoke of theimportance of choosing nurses with the rightpersonality. A woman, and especially a maternalwoman, made the best nurse; she created thematernal environment which a patient needed, sincehis illness represented a regression to childhood.The infantile type of woman was at a disadvantagebecause of her dependence on the male and herreluctance to part with her patients when they werecured. He barred out from the nursing professionwomen with any grade of mental defect, but notmild psychasthenics with strong ethical compensa-tion. Hysterics he regarded with horror, for their

busy zeal, he said, covered irresponsibility, cruelty,and dishonesty. Compulsion types created a mis-

leading impression of great conscientiousness, andtheir natural egoism kept them from any true socialdevotion. Some healthy schizothymic persons madesuccessful nurses through their strong sense of dutyand their reserve. Kretschmer’s mimosa-like typeswere often disturbing to their colleagues because oftheir touchiness, but this characteristic rarely inter-fered with their faithful handling of a patient. Thework of cyclothymics varied in quality with theirfeeling phases, but they were often persons of highmental and ethical endowment. The nurse was a

go-between for patient and physician, and her taskwas to gain the patient’s confidence. She was an

organ of contact, a means of accomplishing the

physician’s intention, and a line of communicationfor the patient’s mental changes.

Miss E. L. MACAULAY (matron of the Kent CountyMental Hospital) pointed out that a mental nursewho desired to take general training must undergothe full three years’ course. This was a regrettablehandicap, and she hoped that continental practicewould eventually be followed in this matter. Homesfor nurses entirely separate from the hospital werevery desirable ; one of the most important provisionsfor a nurse’s comfort and efficiency was that sheshould be allowed to have her breakfast brought toher in bed. Nursing in the Kent County MentalHospital followed the lines of a general hospital,and achieved the best results in the shortest time.The employment of female nurses in male wards had _been an unqualified success, and the nurses of bothsexes cooperated satisfactorily. More use shouldbe made of the mental nurse in social work, whereshe could bring her psychological training to bear onethical problems.Dr. A. SOININEN (Finland) said that in the mental

hospital of which he was director 35 per cent. of thenurses had been trained in general nursing and 30 percent. of the probationers had had two years’ generaltraining. The greater expense was justified by theincreased turnover of patients. Social work shouldbe in the hands of nurses trained in psychiatry.The population of Finland was sparse and the insanewere poorly provided for : only 2 per cent. were inmental hospitals. It was hoped to solve the problem

by employing general nurses trained in psychiatryto do out-patient and preventive mental work amongthe people as well as the usual work of visitingnurses.

Prof. R. SOMMER (founder of the German Asso-ciation for Mental Hygiene) warned mental hospitaldirectors that the administrative side of an insti-tution was apt to be cut off from the medical side.It was essential, in the choice and training of nurses,that a psychological physician should assist in theselection and advise constantly during the course ofthe training, so that unsuitable probationers mightbe eliminated as soon as possible.

Dr. W. MORGENTHALER (Switzerland) said that astart had been made in his country for the carefulinstruction and efficient supervision of the privatenurse.

Dr. HANS EVENSEN (Norway) spoke of the work ofmental hospital nurses in supervising outside casesin their districts.

Mental Hygiene and the School

On Tuesday afternoon Sir LAURENCE BROCK,chairman of the Board of Control, presided over adiscussion on mental hygiene among older school-children (11-18 years of age).

Prof. K. H. BOUMAN (Amsterdam) said he regardedthe final phase of adolescence as quite as importantas infancy and childhood, which were much morepopular with students of mental hygiene. Those

qualities that were important for a full and fruitfulsocial life must now be developed and completed.More emphasis should be laid on the school than onany other phase of spiritual development. Personalbravado rebelling against the levelling influence ofauthority especially characterised this period, andmany cases of neurosis began in an unsuccessfulresult of this battle. Boarding-schools and collegesoffered peculiar advantages because they withdrewthe adolescent from the home and parental authorityand made him adapt himself to the requirements ofa group. Schools paid too little attention to sexualenlightenment and guidance. Parental educationusually failed to provide this instruction and theschool teacher should be the one to take the matterin hand, provided he were sufficiently qualified.Criminality was a great danger of this age, and

fortunately more and more people were holding theview that adolescents should be separately tried byexpert judges and be subjected to other punishmentsthan those fixed for adults. Alcoholism among youngpersons was increasing and caused an increase in

regressive delinquency, so that the fighting of alco-holism was still one of the most important problemsof the mental hygienist. To prevent the excessiveuse of liquor by young people was to attack the evilat its root, before the worst results had shown them-selves. Precautions should be taken in workshopsand factories, and on public highways, to preventaccidents in which young people might suffer headinjuries. A number of grave mental diseases appearedfor the first time towards the end of puberty : theywere rarely acute psychoses and the transition fromthe normal to the abnormal could only be discoveredby the expert. The incidence of schizophrenia wasgreatest at about the age of twenty. The importantcases for the schoolmaster were those which were" cured " with more or less defect. They were nottreated in institutions because they were not recog-nised or were not sufficiently disturbing. The symp-toms were often interpreted as psychopathy, neurosis,or criminality-as symptoms of aberrations of

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character-and were therefore treated’ by punish-ment. A relatively large number of highly giftedpupils at secondary schools and universities wereaffiicted by it. Manic-depressive psychosis also

usually showed itself for the first time in adolescence.It became the task of the teacher to suspect itsmild forms early. The symptoms of the neurosesusually appeared now for the first time, though thereal cause lay much earlier. The last phase of pubertywas an age of many conflicts and when adaptationfailed the neurotic state manifested itself. Many ofthe immediate causes of neurosis and sexual per-version must be looked for in the structure and

management of schools. As the influence of the homeon education receded and society could not yet makeits influence fully felt, the school was the obviousinstitution to guide these young people. Mutual

understanding was necessary between the school-master and the psychopathologist. This cooperationwould have to be organised : the training of theschoolmaster must include the normal and some ofthe abnormal psychology of the child and the adoles-cent ; the psychological physician must learn some-thing of the principal problems of education. Schoolmedical inspection would have to be extended toinclude the psychiatrist, and every school shouldhave its psychopathologist to examine the pupilsregularly in close cooperation with the teachingauthorities and to give advice.

Dr. J. R. REES (medical director, Institute ofMedical Psychology) pointed out that secondaryeducation was the privilege of only 7 per cent. ofthe under-18 group in England and Wales. Mostof the scholars in this group therefore had superiorintelligence. Many leaders would be drawn from itin the future, and the intelligence of its membersmade them especially liable to emotional problemsand difficult situations. The examination systemprovided many real problems for the psychiatristand the teacher through making too great demandson some children. It roused stimulating feelings ofsuperiority and inferiority, whereas the real require-ment of every individual was that he should do hisbest. The superiority-inferiority conflicts were mostimportant at this period, when the competitive spiritwas rife and there was every opportunity for develop-ing an abnormal outlook. Most of the difficultieswere expressions of earlier conflicts. The " too

good " child, whose defect appeared a valuable

quality in earlier days, often became an obvious

problem when initiative was demanded of him.The rebel would remain a rebel until someone could

give him wise assistance. The spoilt child would bemiserable because he would be unable to fit into aschool community. Sexual problems were often

merely manifestations of the struggle for emotionaland spiritual growth. The teaching of religion wasa difficult problem, and there was much to be saidfor the British system which, through communitylife, games, and the much-ridiculed sportsmanshipand service, aimed to produce a sense of social respon-sibility and a capacity to think in non-rigid fashionabout the deeper problems of life. Psychotic break-down was rare at this period, though schizophrenicand manic-depressive children were occasionallyfound. Nevertheless, the psychoneurotic disabilitieswhich were so frequent in adults must all be presentin embryo, and it was the responsibility of the physi-cian to see that they were recognised and, if possible,dealt with. Delinquencies, sexual or otherwise, usedin the past to be dealt with as antisocial manifesta-tions which demanded expulsion. Nowadays schoolswere recognising much more that these conditions

could be dealt with by hospitalisation, like infectiousdiseases. The offenders were sent away for suitabletreatment, and received back when their difficultieshad been adjusted. This plan was the more valuablebecause these delinquencies were so readily curableat that age, often by simple psychotherapy.

Children of indifferent intelligence must be recog-nised and eliminated from higher education. Theycould be helped and trained in other ways. Schoolsmust make more use of scientific methods of voca-tional guidance, and admirable work was being donein London by the National Institute of Industrial

Psychology. It was now little short of a social crimeto let any child become a vocational misfit withouta struggle. In the school life of every child thereshould from time to time be an individual stock-

taking, and for this much better cooperation wasneeded by parents, teachers, and doctors. If teachersand parents believed in possibilities of sound mentaladjustment there could no longer be any place forfeelings of superiority or animosity. The parents’societies which many schools encouraged did enor-mously valuable work. Through them, and throughthe enlightenment of teachers and school doctors,there was great hope for the future.

Dr. GEORGES HEUYER (Paris) praised the coöpera-tion between psychiatrists and educationists whichhe had found in this country, and announced that aconference on child psychiatry would be held inParis on July 24th-28th, 1937, immediately afterthe International Congress of Mental Hygiene. Hecordially invited all British mental hygienists toattend.The CHAIRMAN remarked that, while the elementary

teacher was accustomed to call on the psychiatristto help him, there was great scope for missionariesin public schools. When the authorities in one ofthe older British public schools had recently dealtwith two obviously pathological cases of delinquency,the only method they could think of had been asevere beating, and they had then been greatly sur-prised to find that no moral reformation took place.It was peculiarly the business of the house-masterand house-monitor to ascertain cases in which the

psychiatrist should be called in.Prof. KOGERER emphasised that confidence was

essential to effective progress in education and wasthe first requisite for a proper relationship betweenteacher and pupil. Early childhood and pubertywere two periods in which there was extreme lackof confidence. The onset of menstruation broughta girl suddenly face to face with reproduction andall that it implied, a very frightening experience ;the boy was often carried away by a sudden uprushof aggressive tendencies which his parents andteachers met with barriers and restraint. Theteacher must by every means make friends with hispupils and win their confidence, and the first stepto mental health in the school was to re-educate theeducators.The meeting passed unanimously the following

motion by Dr. HEUYER:-" The Congress recommends that in each nation the

administrative body charged with settling the methodsof selecting abnormal school-children and devising thetime-tables and curricula for normal scholars should includea psychiatrist duly elected by the mental hygiene associa-tion of that nation."

Prof. VERMEYLEN (Brussels) declared that if mentalhygiene was not started until eleven years of age itwas often too late and the harm was already done..It should be started in the nursery school, and the

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doctrine that effort was more important than achieve-ment should be taught at that age. Maladaptationwas by no means restricted to abnormal children.Children with supernormal and normal intelligencefell into a great variety of types, and particularaspects of intelligence were developed at different

ages. A perfectly normal child might suffer fromfailure of adaptation through not assimilating theinstruction it was receiving. When one capacitywas precociously developed the child might rely onit to the exclusion of its other faculties, which mightbecome almost lost. Some children found a gravedifficulty in going forward from the home to theschool-precisely the same difficulty as when a childrefused to be weaned. In Belgium the teacherswere constantly crying out for skilled medical assist-ance in all these difficulties ; the trouble was thatthere were not enough medical psychologists to goround.- He would have liked to add to the Congress’sresolution the statement that the medical schools

ought to give further opportunities to those whowished to be specially trained in psychiatry, andshould teach the refinements of child psychology atall ages.

MEDICINE AND THE LAW

Obstruction of Order to Send Child to HospitalTHERE is occasionally a clash between the require-

ments of public health and the traditional principlethat an Englishman’s home is his castle. A father,living at Parkstone near Bournemouth, was sum-

moned a fortnight ago on a charge of havingobstructed the execution of an order for the removalof his child to hospital. The little girl, two yearsold, was suffering from the typhoid epidemic whichlately attacked the district. Her parents isolatedher by placing her in a first-floor bedroom where hermother had practically lived with her during theillness. No other member of the family was allowedin the room and the father claimed to have followedmedical advice in the treatment of the case and inmeasures of disinfection. The medical officer ofhealth certified the case as one where proper accom-modation was not being provided in the child’s home,and the local authority obtained a magistrate’sorder authorising the corporation, through a policesergeant, to remove the child to hospital. The policeofficer went to the house next day with an ambulance,accompanied by the sanitary inspector and necessarystaff. The father refused to let the child go ; heinsisted that she was being treated quite satisfactorilyat home. The warrant was read to him and he saidhe fully realised the consequences of preventing itsenforcement. He put his hand on the policeman’sshoulder, pushed him away, stood in his path, anddeclared that the child should not be taken away.This was undeniably obstruction and the father’sprotests at the police-court that the medical officerof health had never been near the house and could notsay whether the accommodation was proper or notavailed him nothing. The magistrates announcedthat the case was proved but, as it was the first ofits kind, the defendant would be discharged underthe Probation of Offenders Act.The local authority was presumably acting under

Section 124 of the Public Health Act, 1875, as

extended by Section 65 of the 1907 Act. Restatedin the new Public Health Act which will come intoforce next April, the law requires a justice of thepeace to be satisfied of three things : (a) that the

circumstances of the patient are such that properprecautions to prevent the spread of infection cannotbe taken or that such precautions are not in factbeing taken ; (b) that serious risk of infection is

thereby caused to other persons ; and (c) that accom-modation is available in a suitable hospital. If so

satisfied, the justice may order removal and main-tenance at the local authority’s cost. If it be truethat the medical officer of health presses for theorder without prior inspection of the circumstancesin the patient’s home and merely on the ground thatthere are (a) an epidemic, (b) an infected patient,and (c) a suitable hospital, it would seem to beassumed that treatment in a private house is initself a sufficient ground for holding that precautionsagainst infection are not being taken. The parentin the Parkstone case was evidently protesting againstthe suggestion that he was not looking after hischild properly. It was not, however, open to himto obstruct the policeman on the ground that theorder was made on insufficient reasons. In Bookerv. Taylor (1882) a mother resisted an order forremoval of her child under Section 124. She wassummoned and the magistrates declined to convictbecause they thought the order invalid. The HighCourt held that the magistrates had no right to gobehind the order and examine its validity ; theywere bound to convict if there had been obstruction.Thus the parent’s trouble begins when the local

authority finds a magistrate who will make the order.The new version of the law, contained in Section 169of the Public Health Act, 1936, emphasises the factthat the magistrate may, if he deems it necessary,act ex parte. Thus the parent may have no chanceto oppose the making of the order.The reluctance of fathers and mothers to let their

children go to hospital is as common an experienceas the reluctance to let them undergo particularforms of treatment. Bearing in mind these parentaltendencies, our courts of summary jurisdiction areusually lenient. Early this year an American caseindicated a more vigorous attitude. A father inNew Jersey was prosecuted under a Child WelfareAct (evidently corresponding to Section 1 of ourChildren and Young Persons Act, 1933) for neglect-namely, the failure to permit an act necessary to achild’s physical welfare. He had refused to sign aform consenting to the child’s immunisation againstdiphtheria ; he said he knew of children who sufferedill effects from the serum. The New Jersey tribunalfined him 50 dollars and sentenced him to 30 days’imprisonment, but suspended sentence for a brief

period to give him an opportunity either of appealingor of changing his mind. No further report of hisdecision is available. The tribunal was apparentlya juvenile court, which may be expected to exactmore progressive standards of parental behaviourthan the ordinary bench.

NATIONAL HOSPITAL, QUEEN-SQUARE.-The Hol-born Chamber of Commerce has undertaken to raise12,000 towards the rebuilding of this hospital. Thissum will provide two new operating theatres with anadjoining X ray department. The Rockefeller trustees’offer of 60,000 towards the cost of rebuilding the researchdepartment and surgical unit is dependent on the hospitalraising the remaining money for buildings and equipmentby December, 1937. If this is accomplished, the trusteeswill give a further f60,000 towards the endowment ofresearch. The total cost of the rebuilding scheme is180,000. Before the Chamber of Commerce launched itseffort the building fund stood at 98,500, leaving 81,600to be raised.


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