343

THE LANCET.

LONDON: SATURDAY, AUGUST 12, 1922.

Mental Hospital Administration.

MENTAL HOSPITAL ADMINISTRATION.

IT is difficult to convince those whose idea of reformis uncompromising, radical, and destructive, that thesemethods have their own serious dangers. A publicprejudice against mental hospital administration hasbeen fostered, and a growing fear as to the fate offriends incarcerated therein has been excited by thepublication last year of what has now been proved anexaggerated or, at any rate, an atypical picture ofasylum conditions. The report 1 of the committeeappointed by the Ministry of Health to investigate thecharges made in Dr. MONTAGU LOMAX’s book has nowbeen issued, and its main conclusion is that, in theopinion of the committee, the present provision forthe care and treatment of the insane in this country isJmmane and efficient, and that the personal care ofthe individual patient compares favourably with thatin any other country.

Dr. LOMAX has drawn attention to disadvantages,long known to exist and remediable, but at a costwhich few local authorities are prepared to pay. Criticsof our mental hospitals must remember that it is thecommunity itself which imposes limitations on theextent to which the efficiency of these institutions canbe developed. In practically every aspect of asylumadministration criticised by Dr. LoMAX the abuse,where it exists, is dependent on the need for economyin staff or general working expenses. Diet is anobvious example, since though it may be suggestedthat variation costs no more than monotony, this isonly true if the catering department is actively super-vised by experts. The committee found meals betterserved and the general atmosphere more attractive ininstitutions which provided separate ward dining-- rooms in place of a central dining-hall. Again, theemployment of patients in the kitchens, the laundries,and the wards is an economy which will not lightly beset aside by local authorities in favour of open-airand congenial occupations ; the additional cost of

imported skilled domestic labour would be consideredprohibitive. We have no wish to condone an undueuse of sedatives for patients. Routine prescription ofsedatives for restless and excited patients amounts toa confession of failure. In one institution (not named).as many as one-fifth of the patients appear to receivea dose of a sedative every night ; but it would not

surprise us to hear that the hospital in question hasdropped into this deplorable practice on account of thedifficulties of obtaining and keeping an adequate staff.

’This brings us back to the dangers of a ruthless cam-paign such as the present one against mental hospitals.Clearly, Dr. Loax’s book has been widely read inasylums and has created a prejudice among patientswhich reacts upon the staff. Even supposing study-leave, improved conditions for married men, an in-creased and better paid medical staff were universallydecided on, the attractions of this branch of the medicalprofession would hardly be great enough to draw thefirst-rate graduates it needs while the service is beingso generally abused. This factor applies with evenmore force to better-class male and female nurses,who may well be discouraged from entering an

unpopular profession or even induced by their friends1 Cmd. 1730. H.M. Stat. Office. 3s.

to leave it. It is not that criticism can or should bestifled. Rightly directed it may lead to provision inthe future of more money for reconstruction, for betterbuildings, and a larger, more specialised staff ; but

discouragement of the men and women at presenttrying to make the best of existing conditions bytelling them it is impossible to do so can only lead todisaster in the future.

Upon the special points that have emerged fromthe report there is little to add to previous commentson the subject. The Ministry of Health Committeecrystallise their views of improved administration in aseries of recommendations which we print on p. 352.The importance of selecting a suitable medical

superintendent, who, it is again acknowledged, mustremain responsible for the administrative as well as themedical efficiency of the institution, is manifest. Anunfortunate appointment may damage the welfare ofpatients for a whole generation under present condi-tions, since the assistant medical officers are naturallychosen on the recommendation of the superintendent.The efficiency of the nursing service is at once thepivot of the whole system of administration and theindex of its success. Besides taking steps to attracta better class of probationer, the report suggests thatdistinction should be made between the two dutiesof the staff, nursing proper and social duties. If, inthe attempt to attract a better type of nurse, thepolicy is adopted of further shortening hours of work,continuity of treatment may suffer and the sociallife of the institution may decline. As to the Board ofControl, it is recognised that supervision from a strongcentral authority is needed to prevent abuses. TheBoard should not be abolished, as some would suggest,but strengthened. Men of sufficient standing andcharacter should be selected as additional membersto carry weight when interviewing medical superin-tendents. But quite apart from staff and centralcontrol there is one direction, luckily not a costlyone, in which advances may immediately be made.There is no definite evidence that the visiting com-mittees actually visit the mental hospitals in thesense of providing for every patient free access tosomeone outside the doctor, the clergyman, or theofficial. The cooption to the visiting committees ofmembers of the local council with some leisure whowill frequently visit patients, make friends with them,and patiently hear their grievances, real or imaginary,will be welcomed by the medical and nursing staff,who have little time themselves to devote to the

sociological aspects of their work. It will be seen thatwithout amendment of the Lunacy Acts, expresslyruled out of the committee’s purview, there is amplescope within their recommendations for salutarychange in the whole atmosphere of our public mentalhospitals. Stimulus has been given to initiate thischange, but an outside atmosphere of hostility andrecrimination will only produce the same atmospherewithin. What is now needed is constructive effort.

Residential Treatment of OphthalmiaNeonatorum in the Metropolis.

Two facts came to light at the conference which webriefly reported last week (see p. 291) on the treatmentof ophthalmia neonatorum in the metropolis, whenrepresentatives of the Metropolitan Asylums Boardmet delegates from other public bodies interested inthe question, in order to discuss the steps that couldbe taken to ensure fuller utilisation of the facilitiesfor treatment provided by the Board. Each of thetwo facts brought to light must prejudicially affect

344 RESIDENTIAL TREATMENT OF OPHTHALMIA NEONATORUM.

the success of St. Margaret’s Hospital, the institutionestablished by the Board for the treatment of thiscondition, both as a centre for clinical work and forprevention. The majority of the cases of ophthalmiareceived at the hospital-over 60 per cent. in fact-aregonococcal in origin, and for success early treatmentis essential. It is most unfortunate that so many ofthe children are not brought before serious mischief hasdeveloped. Once ulceration of the cornea is present theprospect of even partial success, much less of completecure, is materially reduced, so rapid are the destructivechanges in’ cases of the more virulent type. The

average day of disease on which the children comeunder hospital treatment at St. Margaret’s is the

ninth, as against the fifth at Liverpool and certainother large towns. That this should be the case inthe provincial towns is, perhaps, not unnatural, seeingthat the entire health organisation is under the

jurisdiction of one authority, and in effect controlledby a single individual, the medical officer of health ;whereas, in London, the cases are drawn from a

number of different sanitary areas, each of which isadministered by a separate health officer. Uniformityof procedure could, therefore, hardly be expected tothe same degree in the metropolis.

Midwives do not seem to be responsible for thedelay, their duty being, in cases they attend, at onceto call in a medical practitioner at the earliest sign ofophthalmia ; that they fulfil their obligations in thisrespect was attested by the medical inspector attachedto the London County Council, and by the representa-tives of the Central Midwives Board. In many casesthe result of investigation showed that the delayin securing hospital treatment was to be laid at thedoor of the medical practitioner to whom the case hadbeen reported by the midwife. That the doctorin the circumstances should feel that it was his dutyto treat the case to the best of his ability is onlynatural, and in the milder cases such treatment is aptto be followed by results which may quite fairly beregarded as satisfactory. In virulent cases, however,in which destructive changes in the cornea developwith great rapidity, the only chance of saving thesight lies in the application of intensive methods oftreatment from the outset. This is practicallyimpossible to secure except the patient be residentin a hospital. Failure to discriminate in the earlystage of the disease is largely responsible for thefailures. To remedy this unfortunate state of things iseminently desirable, and an attempt to educate theprofession at large as to the paramount importanceof early hospital treatment in the severer cases wouldseem to be worth a trial. Some degree of successmight be achieved by the medical officers of healthcircularising the local practitioners in their district.The second disability, mentioned at the conference,

which militates against full use being made of thefacilities offered at St. Margaret’s is the impressionwhich has, rightly or wrongly, got about, that theinstitution is one for the treatment of venerealdiseases. Primarily, in the interests of the babies,the mothers are strongly advised to enter the hospitalthemselves for the purpose of suckling them, and acertain number do so. Many, however, are deterredfrom going in themselves by reason of the supposedvenereal stigma. Although the majority of themothers are infected with gonorrhoea, a good manyare not, and a certain number of the infected casesare quite ignorant of their condition. Although theofficers of the hospital exercise the greatest discretionin not referring to the venereal aspect of their patients,in circumstances where a number of women havelittle else to do but sit together and. gossip, it is only

to be expected that they should discuss the situationand form erroneous impressions. Ideas such as thesedie hard and are difficult of eradication, St.Margaret’s Hospital has only been established aboutthree and a half years, and it is possible that time maybring about a truer understanding. The difficultposition cannot be attributed to anyone’s fault.

THE VOLUNTARY PRINCIPLE AND THESTAFF FUND.

ALMOST simultaneously with the annual meetingof the Representatives of the British Medical Asso-ciation, who were arriving at a definition of thevoluntary hospital system and discussing the ethics ofpayment being made to the staffs of such institutions,a conference was being held in London betweenrepresentatives of the medical staffs of ten of theleading London teaching hospitals, having for itsobject to register an opinion on the propriety of thefoundation of a staff fund.! The second of theresolutions arrived at at this conference, which wasadopted by seven of the ten hospitals, ran as follows,a substantial dissent in opinion being thus recorded :-That when the State, a municipal or other public body

pays towards the accommodation, maintenance, and treat-ment of a patient, or group of patients, in a voluntary hospital,a percentage of such moneys should be allocated to a stafffund.

This resolution should be compared with the followingresolution arrived at by the Representative Meetingof the British Medical Association, but not reacheduntil after considerable debate :-When the board of management of a voluntary hospital

enters into a financial arrangement with a public authority,an employer of labour, approved society, insurance company,or under a contributory scheme or otherwise for the receptionof patients, such arrangement should be taken to cover thecost of maintenance and treatment, and a percentage of allsuch receipts should be passed into a fund which is at thedisposal of the honorary medical staff of that hospital.The strong difference of opinion which was known toexist in staffs of the London hospitals on the subjectof the payment of honorary physicians and surgeonswas thus reflected at a conference of speakers who werecharged to register the views of medical men workingat voluntary hospitals in various parts of the kingdom.It is impossible not to feel sympathy with the minoritywho are clinging to worthy ideals, and whose attitudeis entirely for the public good. At the back of theiraction is the principle that as long as medical servicesare voluntary those who offer them have a positionfrom which to advise the lay management of hospitalsas to what class of case is suitable for admissionnot only on medical but also on financial grounds.But certainly in many parts of England the principleof a staff fund has already been accepted.

1 See THE LANCET, July 29th, 1922, p. 244.

SOUTH AFRICAN COUNCIL OF PUBLIC HEALTH.-The following have been appointed by the Governor-Generalof the Union of South Africa as members of the Council ofPublic Health, under Section 4 of the Public Health Act of1919, for a period of three years commencing July 1st,1922 : Dr. Charles Porter, Dr. Servase Meyer de Kock,Dr. Ernest Hill, Dr. David Pieter Marais, Dr. Paul D.Cluver, Mr. Joseph Henry Nicolson, O.B.E., J.P., and MissMabel Elliott.

INTERNATIONAL CONFERENCE OF MEDICAL WOMEN.A Conference of medical women of various nationalitieswill be held at Geneva during the first week of September.This is the second occasion on which medical women fromvarious parts of the world will have met together, the firstmeeting having been held in New York in 1919. Theauthorities of the University of Geneva have promisedaccommodation for the meetings of the Conference, whereatmany subjects of international medical importance willbe considered. The members of the Conference will beinvited to place the constitution of the International MedicalWomen’s Association on a permanent basis. The pro-ceedings will begin with an inaugural banquet on Sept. 4thand will last for four or five days. -