The Essential Unity of the Mental Problem.* By
W. F.
Menzies, M.D., B.Sc.,
F.R.C.P.
I must thank most cordially the Committee of the Staffordshire Association for Mental Welfare for their kindness in inviting me to fulfil this year the pleasingduty of delivering- the Annual Address, and I hope what I have to say will be neither too boring nor too far divorced from problems connected with the daily " work of the Association. The Essential Unity of I have chosen as my subject the Mental Problem " because the treatment of the mentally affected is considerably handicapped by well-meant, but, as I think, misdirected efforts to confine the problems of mental illness within water-tight compartments?that is, on the one hand Mental Defect, on the other hand Mental Disorder. The Brain.?I am not going to waste your time over a long discourse on brain physiology, but in order to begin at the beginning, or as near that point as justifiable, I must ask you to bear with me for a few minutes while I give a very sketchy demonstration of the growth of mind by means of a few diagrams. Here we have a rough outline drawing of the brain of a shark, a crocodile, a kangaroo, and a human being. I have chosen these vertebrate animals as being roughly of equal body weight. This is the brain stem or medulla, which governs the three vital functions of respiration, circulation and digestion. You see that the brain stem is much the same size in each. The brain masses below are called the basal ganglia These lower and cerebellum, which the reflex movements and postures.
organise mechanisms, which have nothing to do with reason, the fish, is a thin layer of brain cortex containing
are
coloured grey.
few
cells,
Above,
in
connected practically with one sense, that of smell. In the reptile the cortical layer is thicker, but still nearly all reasoning is done by the sense of smell. Even in the kangaroo this is largely so, but great advances have been made. Here you see an area of brain cortex devoted to sight, another to hearing, another to body sensation, a fourth to movement. Each of these functions is connected with the basal ganglia. But in man, what a difference? Round each of the four special *
a
nerve
The Annual Address to the Staffordshire Association for Mental Welfare, delivered at on 30th April, 1927, illustrated by wall diagrams.
Stafford
66
MENTAL WELFARE.
there is a supplemental area, called an association area, where the These association areas are connected, not only functions are elaborated. with the basal ganglia and with the organs of sense and the voluntary body muscles, but also with one another, each to every other one. How is this done? In the lower mammals, guinea pigs, rabbits, etc., there are layers of brain cells, These neurons, as they are called, whose long fibres run out from brain to body. or 20 deep according to the activity of the various senses. three or four be may But in man, and to some extent in the higher mammals?dog, cat, elephant?the telephone exchange system, as it might be called, is infinitely more complicated. Above the first layer is another, composed of small cells, granular cells they are called, which are the jack plugs in the switch board, and above them an association layer, called the supragranular layer, 20, 40, 60 cells deep, sending fibres to every other part of the cortex. The infragranular layers are linked up through the basal ganglia to nerves running to and from the internal organs, the sympaIt is the nerve currents in these sympathetic nerves, constantly thetic nerves. reaching the brain second by second, sleeping and waking, from conception to dissolution, ever stimulated or controlled by the great system of endocrine glands, which are the basis of what we call emotion, that wonderful mainspring of energy, interest and endeavour, of joy and sorrow, of hope and despair. But this is not all. As we rise in the scale of intelligence the brain cells themselves become more complicated. Here is a human brain cell; note the bushy network of fine fibrils, stretching out to embrace similar fibrils of a neighbouring cell, like the rootlets of a plant. Here is a less bushy cell, with fewer rootlets; this might serve for a sheep, a congenital imbecile, or a demented person; under I want to make it the microscope you might not be able to tell which it was. quite clear that the complications in the human cortex are to those of the fish as many millions to one, and that all the attributes of human mentality can be accounted for on a strictly mathematical basis of anatomical structure, namely, the power of storing up associated memories, hereditary and instinctive on the one hand, acquired by education and observation on the other. Most of us " presume other and more metaphysical characters, collectively called the mind," but we need not do so unless we like, for the permutations and combinations of nerve paths in the brain are mathematically sufficient. If you travel from Lichfield to Stoke by rail you may go by Colwich, or Stafford, or Birmingham, or Crewe, or Uttoxeter and Leek. But if you chose to walk and utilised every footpath, a few yards on one, a few yards on another, you could pursue many millions of paths, and could not use them up in 10 generations. Such is the difference between the brain of the lowest and highest vertebrate animal. When we raise the arm the supragranular cortex does not concern itself with the details of the movement. These are all arranged by the infragranular layers, basal ganglia, spinal cord, and elsewhere, according to patterns worked out through millions of years of trial and What the supraerror, and now become automatic, instinctive, even unconscious. granular layer cares for is the purpose of the movement, and here again patterns have been worked out by thousands of years of habits, beliefs, manners, and ways of thought acquired throughout each successive culture phase in human history. This is why the higher mammals alone have the power of learning by experience, and of varying almost infinitely the thousands of millions of alternative pattern paths of nerve force. The conflicting emotional stimuli involved in the choice of these paths are a well recognised basis of worry, or even of mental breakdown. Just one other law of evolution :?The oldest acquired structure or function is the most stable, the newest is the most vulnerable to disease or accident. The brain stem is the oldest part of the brain ; it has varied very little since backbones were first evolved in the fishes of the Silurian geological series countless ages ago. The supragranular layers of the brain cortex are the newest developments ; they perish easily under embryonic or environmental stress, more especially in the sense
special
areas
Mental welfare.
67
prefrontal, or extreme front portion of the brain, the part where ideas and problems highly complicated movements, which we call thought, are worked out, that part of the brain possessed by the human race only. When this goes man might of
as
well have
no
forehead;
his behaviour is
on
the level of that of
a
monkey.
heredity affects things. As soon as a fertilised vegetable or animal germ begins to develop it divides into two portions, the bodyplasm and the germ-plasm. The body-plasm grows on to form the individual, the germ-plasm, which constitutes the sex glands, remains embryonic, but in possession of all the family qualities, until it is called upon to form the basis of a new generation. So environmental stresses may affect both body-plasm and germto the former comes to light in the individual, injury to the latter plasm; injury not until some I believe, although many do not, that succeeding generation. is a Mendelian recessive quality, of the brain as above, cells, explained instability and appears only when an undue stress affects a brain whose cells in a former Next
a
few words about how
generation (where,
of course,
they
were
only germ-plasm,
not
body-plasm),
were
If this be true it follows that sterilisation of the unfit can remove from a population at the most 25 per cent, of mental deficiency. But as in practice mental deficients are not responsible for anything like their proportionate percentage of births, probably a nation would be lucky who succeeded in removing even 10 per cent, of mental deficiency by such means; for it must be remembered that in the present culture phase of civilised society sterility necessarily accompanies the graver forms of mental defect. Nor does sterilisation save the cost of segregation, most defectives being asocial.
similarly subjected
to undue
environmental
stress.
We have now arrived at the position that, as regards heredity in mental what is inherited is not a tendency to mania, or melancholia, or mental deficiency, or epilepsy, or neurasthenia, but is an inherited weakness of constitution of the brain cells, more especially the newest acquired cells of the supragranular layers of the prefrontal cortex. Some of the hereditary causes of neuronic failure are plain and self-evident, such as alcohol, lead poisoning, or syphilis, or other physical disease in the parent, but many are at present beyond our knowledge and belong to the accumulation of adverse "environments of former generations; these we class under the general term neuropathic If the injury to the body-plasm and germ-plasm be severe, the diathesis." individual may perish at a very early embryonic stage, but in proportion as it is less urgent or less continuous, development goes on longer and longer until At birth the brain cortex has the individual may be born apparently normal. attained about three-fifths of its adult depth, but the supragranular layers are much behind-hand. Most defective brains have gone on growing until the seventh or eighth month, or else their owners would not have been born alive at all. If the supragranular layers of the cortex are partly formed, the child is educable in greater or less degree, but we find that if a child cannot be taught to talk, there is some defect even in the infragranular layers._ A great deal of discussion is at present centred round the disease encephalitis lethargica, or sleepy sickness. At what age does a person whose brain is permanently injured by this disease cease to become a case of mental deficiency and become one of acquired mental disorder? Whatever view is taken, it is clear that the decision is not on physiological so much as on social grounds. Certain acquired mental disorders begin early in life, at the stress periods, puberty or adolescence, when not only are sexual functions beginning to exercise an enormous influence on the character of the child, but the increasing brain power is creating all sorts If the brain cells fail under of new social difficulties which call for adjustment. the strain, we get precocious dementia, dementia praecox, a most unfavourable type of mental illness, and one all too common under the increasing worries of competition. But who can say that this is wholly an evil? To the individual
weakness,
68
Mental welfare.
a calamity, but to the race a blessing-, for these cases rarely marry, and Nature is ever careless of the individual, but ever the neurosis cures itself. careful of the race. The brains of many idiots are grossly malformed, and those of many advanced dements much changed by chronic inflammatory conditions, but there is a large class of cases in which it is almost impossible to tell after death whether the brain was that of an imbecile or a dementia piEecox or a manic-depressive. And so during life; often the history alone will give us a clue as to the age at which the brain became affected; by no direct medical examination can we tell whether the illness was congenital or acquired. This is especially true of young acute maniacs and epileptics. There are always the two classes of causes at work?there is the predisposing cause, an inherited want of vitality in the brain cells, and there is the exciting cause, generally a tissue poison generated within the body of the individual as the result of inharmonious environThese two great classes of determinants are like the rope and the weight ment. The strong-er the rope the longer it will carry a given weight, it has to carry. But whether the heavier the weight the sooner will it wear out a given rope. mental failure is pre-natal, or infantile, or adult, or senile, becomes merely an equation of accumulated severity of causes versus the resistance of the individual. Ascertainment.?Having dealt with continuity of causation, I now come There are a good many social services already to the question of ascertainment. in existence which are or might be utilised for the early detection of mental illness. It is highly desirable to adapt existing means to present needs rather than create entirely new agencies. We have the ante-natal clinics, the infant welfare centres, health visiting, the school medical service, the industrial welfare movement, venereal and tuberculosis clinics, the Central Association for Mental Welfare and its affiliated branches, the National After-Care Association, Ex-Service Men's Associations, the Industrial Approved Benefit Societies, various religious and temperance Social Welfare Associations, and an unclassified list of local groups of voluntary workers making praiseworthy efforts in various directions to ameliorate society in general and further their own pet schemes in particular. But there is an almost total lack of co-ordination, there is no attempt at continuity, and there are important gaps in the age periods. In a large percentage of our mental patients careful records have been kept of their early days, at Infant Welfare Centres or by school medical officers, if only these were not pigeon-holed in locked compartments by the various authorities responsible. After leaving school they are lost sight of, for it is precisely persons with congenital or acquired mental weakness who tend to gravitate into the unemployed and unemployable classes, being unable to compete with the more able members of society. Most of the organisations, voluntary or rate-supported, are at present concerned with bodily illness and its prevention, but with very slight extension they could gather data which would be of great value should their patients later on require mental attention; for the origins of bodily and mental illnesses are common and indivisible, and one never knows what information as to bodily conditions may not in the future indicate the special direction to be followed in mental treatment. Let us consider the work of some of these agencies. Probably the most useful of all is the ante-natal clinic, not only because it holds the earliest inquiry in the child's existence, but also because at it the parent is examined, and the large field of disease which in later life displays a mental side is adequately explored and dealt with. Thus a careful history of insanity, neuroses, epilepsy, alcohol and temperamental peculiarities in father and mother is taken, and the mother is especially examined for signs of syphilis, heart disease, tuberculosis and Bright's disease, the first of which notoriously affects the grovvth of the infant's brain almost more than its body, accounting for one-fifth to one-fourth of mental cases, congenital or acquired. If a history of still-births or miscarriages is elicited, or signs of active disease noted in
it is so
MENTAL WELFARE.
the mother
69
or her elder children, absolutely specific and sure treatment can be given unborn child saved from all taint. Things are not quite so hopeful in Bright's disease, but if convulsive seizures in the mother can be prevented, Next in order of importance the child's brain is generally preserved from injury. comes pelvic defects in the mother, which, if severe, may necessitate Caesarian section or premature induction of labour, thus saving the child's skull from undue pressure or fracture, both of which may at times result, the former in primary dementia, the latter in birth paralysis and mental defect. Lastly, the nutrition of the mother is attended to, especially cases of semi-starvation or dietary defects, which, would, if neglected, inevitably lead to rickets, deformities, or mental defect in the infant. From the age of a fortnight up to 2 years or older, children are brought to Infant Welfare Centres. Sometimes, if attached to hospitals or instituted by the local authority, these centres carry on the work progressively from the ante-natal clinics, but often they are independent, and the medical men and nurses have not then the advantage of the record cards, and so have to begin de novo. A doctor will examine the baby at the first visit and note whether the child notices things, looks round and smiles, or is abnormally placid, or whether it A great attraction is the tea and social gathering of seems unhappy and cross. mothers, and when a tactful and enterprising lady visitor is in charge of this part of the job the centres become very popular, and much useful knowledge of maternity and child management is spread by the discussions. If necessary, histories of the family are taken. Weight charts are kept, dietary arranged, and the proper management of the bowels inculcated. Deformities, stigmata of degeneration and signs of the usual infantile ailments are looked for, and the growth of the teeth noted according to the age. If older, what progress is being made with weaning and training in cleanliness, and whether the child is progressing normally with walking and talking. The medical officer looks for early signs of rickets, eczema, cretinism, mongolism, hydrocephalus, dysthyroidism, flaccid or spastic paralysis, tetany, chorea, etc. All these and many others are important as regards subsequent mental defect or illness. Cod liver oil and ultraviolet ray treatment are often provided. From 3 years onwards the child begins to come under the Education Authorities, and thenceforwards up to 14 he is under a most carefully devised The play schools for and skilfully organised scheme of progressive training. infants of 3 to 5 are a most useful preliminary to education in the crowded slum districts of the great towns, and the nurses have an unique opportunity for observing physical and mental defects, and drawing the medical officer's attention to the necessity for treatment. Incidentally these play classes are ideal disseminators of children's diseases, but there is something to be said for the argument that, if the child gets these infectious fevers over early, his education is less interfered with later on. In rural districts the child is far better playing near his home until he begins school at 5, but it certainly leaves a gap of 2 years in observation, unless the district nurse is an observant person not overwhelmed with specific duties. Like all high-grade machines, the school system has its defects, and from the medical point of view the greatest is the result of rushed work and the inevitable fall into a groove. I do not know about the conditions in Staffordshire, but in many places the school medical officers are far too few to give adequate consideration to individual cases, or to conduct a full examination sufficiently often. I understand they aim at three examinations in the nine years of school life?clearly not enough. But the teachers are wonderful in spotting mental and character anomalies in the pupils; and if the school nurses spend enough time over the teeth and adenoids, the worst shortcomings are avoided. The shy and reticent child, often inclined to be delicate, the one, as we say, with an "inferiority complex," is too apt to be left severely alone in a large class
and
the
70
MENTAL WELFARE.
These until repeated failures to reach the required standard compel attention. the children often slightly defective congenitally, made worse by the deafness of adenoids and mouth-breathing, who recruit the ranks of the mental defectives, And the terrible results or later on enter the hopeless alley of dementia praecox. of encephalitis lethargica make it most important for teachers to be on the look out for those slight and undiagnosed cases which result in quite as formidable sequelae as those whose original illness assumed the more acute and unmistakable In fact, my experience seems to show that many of the worst of the moral type. " " or type passed unnoticed at first, and only a year or two or three Apache years later the teacher can recall when questioned that the child seemed dull or out of sorts for a day or two, but that this was put down to a dietary indiscreThis problem of the encephalitic is going to tax the ingenuity of tion at home. I have had some the country in a few years, when these children grow up. under observation for over 3 years, who, although the disease has not progressed, have become more and more unmanageable as they grow bigger and stronger. Previously quiet, diligent and well-behaved children now lie, steal and assault others; reproofs, arguments, punishments and rewards are alike " I'm sorry, I know I was wrong, but useless, the answer is always the same, Five minutes later another small outrage I couldn't help it; I won't do it again." is committed. Now imagine these no longer little children, but powerful adults. What will become, say, in a murder case, of the McNaughten dictum as to knowledge of the nature and quality of the wrongful act? I have several of both sexes who have passed puberty, and they are now adding sexual misbehaviour to their childish peccadilloes; and with it all these patients preserve their devilish monkey ingenuity and cleverness, never at a loss for an explanation or an excuse. What modern system of detention will control these people in the future, certainly not a criminal lunatic asylum as at present constituted ? Luckily, this type seems rarely to occur when the original infection appears in an adult, but only in those whose brains are yet far off full development. The Industrial Welfare Clinics deserve a few words. The working of the Industrial Research Board on the physical and psychical sides of employment will lead to the diagnosis of the mental waverers. Transference to more suitable employment, together with advice as to more hygienic living and the treatment of dental and rheumatic affections, should ultimately diminish the cost of institutional treatment and remove part of the heavy burden of unemployment through chronic invalidism. The hospitals of the country are filled with those who have through ignorance and unhealthy surroundings been pushed to the wall or fallen by the way. One hopes that when the cost of industrial clinics is shared fairly between sick benefit societies, or still better, the trade unions, on the one hand, and the employers, on the other, a reasonable Government grant in aid will come to far less than the present cost of poor relief, unemployment, mental deficiency and insanity. The casuals and unemployables will still need to be provided for, but it is not beyond the wit of man, although it may seem beyond the pecuniary capacity of successive governments, to devise remedies for roping them in before their cases have become hopeless. Administration.?I have tried to show that the same sets of causes, hereditary and environmental, are at work in producing mental defect and mental illness, and that, beyond certain fairly-defined limits, it seems to our present knowledge almost fortuitous which, if either, will emerge in a given individual. And we see constantly in our hospitals mental defectives who have regular relapses into active insanity, in no way distinguished from other persons who between their attacks are normal members of society. The rest of my address will be devoted to administrative recommendations for unifying treatment. There are two societies devoted to the amelioration of the mental problem. The older is the Mental After-Care Association, founded in 1886 for the are
purpose
MENTAL WELFARE.
of
71
There are many local branches, but from asylums. men and women, all of them assistance its many poor, By some friendless, yet capable with a modicum of assistance of earning- their own living, have been sent temporarily to homes, convalescent or otherwise, for a change of air and scene, or have been found employment, or received small monetary grants towards fresh clothing or tools, or have been cheered by Like other charitable organisations, the occasional visits of voluntary workers. I he other is the this association is chronically hampered by lack of funds. Central Association for Mental Welfare. It would greatly lighten the mental problem if these two Associations amalgamated. Nor are we free from trouble in Staffordshire. After a good many years of striving we have obtained the Staffordshire Mental Hospitals Board, and one would have thought that the obvious step of extending its aegis to cover mental deficiency would have commended itself to every authority in the geographical area. Yet we know that some stand out. To anyone like myself, whose official life is drawing to an end, it seems inexplicable that the public should be willing to see their money wasted in overlapping, and still worse, see the education and control of the mental defective suffer; and those who know anything worth while about the subject realise that this is exactly what will happen if each local authority sets out to manage its own defectives. People who deny this assertion are not those who have given their working lives to the solution of the problem, so that all I can The Board of Control suggested that the willing do is to plead for the wide view. authorities form a voluntary board for mental deficiency, but what good would this be? They could not raise money by precept, and every trifling expenditure, structural alteration, and so on, would have to be submitted seriatim to each authority. If one dissented, that expenditure could not be incurred, and at best I do not suggest the negotiations and correspondence would be interminable. that local mental deficiency committees should lose their identity, but that each authority should appoint one or more members of the board from their own mental
supervising- discharges
none in this
district.
deficiency committee, if indeed they have not already one common committee for mental work. But this alone would not satisfy those of us who are idealists. We say that there should be no divorce between education and mental treatment, or between mental treatment and public health. Accordingly, we should like it made possible to have members of these committees of each authority upon what would then, we hope, bear the name of the Staffordshire Board of Mental Health. Following the precedent of the Education Acts, we should like other special interests co-opted, although of persons not responsible to the ratepayers; I can instance voluntary societies, the Police Court Mission, the Staffordshire Nursing
Infant Welfare Committees, Local One member of each of these, and there may be others, would act as liaison officers without having sufficient voting power to interfere with the ratepayers' wishes. Next we would like to see more team work among the medical officers. Too often at present the specialist medical service is overwhelmed by routine. It arrangements could be made so that these officers and medical officers of social service committees and institutions should confidentially refer all mental cases in their early and unconfirmed stages to the Board of Mental Health, much as cases of infectious disorders are reported, no publicity would be entailed, and in many cases preventive measures, physical or psychological, could be taken without loss of time. But it must be acknowledged that such suggestions are Utopian, and could only be brought about gradually after an Early Mental Treatment Act and amendments to the Mental Deficiency Acts had paved the way for the education of the public in these matters. There would then be in the offices of the Board of Mental Health a complete card index record of the salient features from the ante-natal clinics onwards through life of all who might presumably require medical advice
Association,
the Health
Visiting Committee,
War Pensions Committees and Orthopaedic Associations.
11
Mental welfare.
their mental health. The Board of Mental Health would have one senior medical the Medical Officer of Mental Health, who would be responsible to the Board for the classification of all cases reported to them, and who, after a personal visit and examination in whatever part of the geographical area, would advise as to disposal, whether for home treatment, or guardianship, or at a local clinic, or in a mental defective colony, or a mental hospital. The Board's executive officers would be people analogous to the present relieving officers, possibly, when the Board had taken over from Boards of Guardians the responsibility for all mental cases, the same individuals, or some of them. Officials of other bodies co-ordinating would act for the Board on a part-time basis. The Medical Officer of Mental Health should be an official of long experience, co-ordinate to, but independent of, the Medical Officer of Health. I am aware that the British Medical Association and many of the higher Ministry of Health officials would have him as an Assistant Medical Officer of Health, but both the Board of Control and the Royal Medico-Psychological Association are opposed to this on many grounds; one of these is sufficient, viz., that he would have to consult with the M.O. H. of many local authorities, and should not, therefore, be under any one of them, but only under the combined Board of Mental Health. Another reason is that, unless the post were independent and of senior standing, no man of life-long experience of mental cases could be found to fill it. He would have nothing whatever to do with the internal administration of the Board's institutions, but he would be consultant to the local psychological clinics in the various smaller towns, which he would have to visit regularly. He would also be expected to give advice on mental cases if asked for by the school or other medical officer of The local any of the local authorities constituting the Board of Mental Health. clinics would be held on one day a fortnight or month, conveniently in the same room used on other days for health clinics, children's welfare centres, and so The medical officer of mental health would probably refer cases requiring on. prolonged psychotherapy to the psychological and psychiatric clinics attached to the general hospitals in one of the larger county boroughs; for under our model scheme there would be reciprocity between general and mental hospitals, and one or more medical officers of the latter would be appointed honorary psychiatrist to the neighbouring general hospital. With these out-patient or in-patient clinics, set up by the local authority in alliance with the hospital managers, the medical officer of mental health would be connected in a consultant capacity alone. Voluntary and uncertified early cases, as suggested under the Early Mental Treatment Bill, would in a few years comprise quite half the admissions to the It is so in Scotland, where voluntary boarders are more mental hospitals. numerous and where early cases may be received for 6 months without a justice's order. The Scots are reputed to be as fond of liberty as the English, yet there is no case on record of an action for illegal detention. The reason is that there the medical officer of a mental institution has power to discharge, and does discharge, a recovered patient or one whose friends accept responsibility for his welfare. Patients get out of Scottish asylums so easily that they are less anxious to leave, which is perhaps human nature. Scotland is half a century ahead of England in questions of mental health. A common fallacy is that this somewhat elaborate scheme for covering the whole geographical area would result in roping into institutions large numbers of mental cases who need never go there. We aim at quite the opposite goal, the idea is to keep as many out as possible, but to have these under such supervision that the best could be got out of them. For instance, we receive into mental hospitals many middle-aged defectives with the history that they worked as unskilled labourers under father, brother or friend for many years, and got along all right, earning a small wage, until the relative died or gave up work; then they were helpless. A case like this would no longer require to spend the rest of his life in a hospital or colony; a on
official,
MENTAL WELFARE.
73
suitable place of work, perhaps on the land or away from the former city factory, would be found for him, and if necessary the guardian would be allowed a small weekly grant if the patient's wage-earning capacity were very low. But at present city is separated from country, and there is no list of suitable country guardians available in the town. Before concluding I should say a few words about mental defective colonies. I estimate that there may be 1,500 deficients in the Staffordshire geographical area who would benefit by institution treatment, at least in their earlier years. 1 fear it is too late to hope for one institution for the county, the next best hope is one for the north of, say, 750 beds. This is too small to get the best value out of the money spent, but makes the best of a bad job. Many of the
trade outfits would be unduly costly per head in a small colony where expensive machinery had to be installed, such as power joinery, fitting and metal welding, bookbinding and printing. On the other hand, in a small institution too many people would be trained for jobs in which they could never make a living, such as tin smith, basket making, weaving, and luxury trades much taught to the blind. Even tailoring and shoemaking do not offer much inducement at present, and yet the resources of each shop would have to be fully utilised to pay for its upkeep. The bulk of deficients should learn a staple trade in a colony, farming, a building operation, or in this district potting. It must ever be borne in mind that 9 out of 10 have not brain to compete in the open market, and must at best need supervision for life, so there is little use in troubling them with a literary education further than trying to teach them to read simple stories as a means of relaxation and to keep them out of mischief in the evenings. Further, they can learn only one process in any trade, and can then perform it mechanically. The larger the institution the more grading can be done. Large classes are a serious handicap in a normal school; in a defective colony they are anathema. There must be individual attention if successful results are to be attained, and the children must be caught young. I suppose at Cheddleton we have the lowest grade school in the country. The paralysed idiots, utterly helpless, with less sense than a fish, first have orthopaedic treatment to reduce their deformities. Then they have to be taught cleanliness, grasping and walking. Needless to say, little can be expected if we get them at 11 or 12?we must have them at 2 or 3. The greatest difficulty is talking; for often the speech centres in the brain are undeveloped. But if these children can be taught to use fairly intelligible signs and sounds, they can get along. That the lowest and grossest idiots can be so greatly benefited, idiots so extreme that no ordinary colony will have them, holds out quite a bright hope that many belonging to the higher grades may ultimately become useful members of their own limited social sphere, and save the money spent on their keep, while a few may even earn a moderate competence in the world outside. A small colony cannot grade its cases sufficiently. With 90 children at Cheddleton we require 5 grades, and if we had double the number of cases we would have 9. Extend this detailed classification through all the range of mental deficiency, and you would require at least 40 grades. I once heard an officer at Darenth, with over 2,000 patients, complain that they could not sub-divide their people as they would like. Catch the children young, grade them minutely, educate them individually, and when they grow up find guardians for them, and you will in the end get 15 to 20 per cent, of them But catch them late, immure them in removed from being a burden on the rates. small homes or colonies, treat them more or less in bulk, and there they will remain for the rest of their lives.
W. F.
Menzies, M.D., B.Sc.,
F.R.C.P.
I must thank most cordially the Committee of the Staffordshire Association for Mental Welfare for their kindness in inviting me to fulfil this year the pleasingduty of delivering- the Annual Address, and I hope what I have to say will be neither too boring nor too far divorced from problems connected with the daily " work of the Association. The Essential Unity of I have chosen as my subject the Mental Problem " because the treatment of the mentally affected is considerably handicapped by well-meant, but, as I think, misdirected efforts to confine the problems of mental illness within water-tight compartments?that is, on the one hand Mental Defect, on the other hand Mental Disorder. The Brain.?I am not going to waste your time over a long discourse on brain physiology, but in order to begin at the beginning, or as near that point as justifiable, I must ask you to bear with me for a few minutes while I give a very sketchy demonstration of the growth of mind by means of a few diagrams. Here we have a rough outline drawing of the brain of a shark, a crocodile, a kangaroo, and a human being. I have chosen these vertebrate animals as being roughly of equal body weight. This is the brain stem or medulla, which governs the three vital functions of respiration, circulation and digestion. You see that the brain stem is much the same size in each. The brain masses below are called the basal ganglia These lower and cerebellum, which the reflex movements and postures.
organise mechanisms, which have nothing to do with reason, the fish, is a thin layer of brain cortex containing
are
coloured grey.
few
cells,
Above,
in
connected practically with one sense, that of smell. In the reptile the cortical layer is thicker, but still nearly all reasoning is done by the sense of smell. Even in the kangaroo this is largely so, but great advances have been made. Here you see an area of brain cortex devoted to sight, another to hearing, another to body sensation, a fourth to movement. Each of these functions is connected with the basal ganglia. But in man, what a difference? Round each of the four special *
a
nerve
The Annual Address to the Staffordshire Association for Mental Welfare, delivered at on 30th April, 1927, illustrated by wall diagrams.
Stafford
66
MENTAL WELFARE.
there is a supplemental area, called an association area, where the These association areas are connected, not only functions are elaborated. with the basal ganglia and with the organs of sense and the voluntary body muscles, but also with one another, each to every other one. How is this done? In the lower mammals, guinea pigs, rabbits, etc., there are layers of brain cells, These neurons, as they are called, whose long fibres run out from brain to body. or 20 deep according to the activity of the various senses. three or four be may But in man, and to some extent in the higher mammals?dog, cat, elephant?the telephone exchange system, as it might be called, is infinitely more complicated. Above the first layer is another, composed of small cells, granular cells they are called, which are the jack plugs in the switch board, and above them an association layer, called the supragranular layer, 20, 40, 60 cells deep, sending fibres to every other part of the cortex. The infragranular layers are linked up through the basal ganglia to nerves running to and from the internal organs, the sympaIt is the nerve currents in these sympathetic nerves, constantly thetic nerves. reaching the brain second by second, sleeping and waking, from conception to dissolution, ever stimulated or controlled by the great system of endocrine glands, which are the basis of what we call emotion, that wonderful mainspring of energy, interest and endeavour, of joy and sorrow, of hope and despair. But this is not all. As we rise in the scale of intelligence the brain cells themselves become more complicated. Here is a human brain cell; note the bushy network of fine fibrils, stretching out to embrace similar fibrils of a neighbouring cell, like the rootlets of a plant. Here is a less bushy cell, with fewer rootlets; this might serve for a sheep, a congenital imbecile, or a demented person; under I want to make it the microscope you might not be able to tell which it was. quite clear that the complications in the human cortex are to those of the fish as many millions to one, and that all the attributes of human mentality can be accounted for on a strictly mathematical basis of anatomical structure, namely, the power of storing up associated memories, hereditary and instinctive on the one hand, acquired by education and observation on the other. Most of us " presume other and more metaphysical characters, collectively called the mind," but we need not do so unless we like, for the permutations and combinations of nerve paths in the brain are mathematically sufficient. If you travel from Lichfield to Stoke by rail you may go by Colwich, or Stafford, or Birmingham, or Crewe, or Uttoxeter and Leek. But if you chose to walk and utilised every footpath, a few yards on one, a few yards on another, you could pursue many millions of paths, and could not use them up in 10 generations. Such is the difference between the brain of the lowest and highest vertebrate animal. When we raise the arm the supragranular cortex does not concern itself with the details of the movement. These are all arranged by the infragranular layers, basal ganglia, spinal cord, and elsewhere, according to patterns worked out through millions of years of trial and What the supraerror, and now become automatic, instinctive, even unconscious. granular layer cares for is the purpose of the movement, and here again patterns have been worked out by thousands of years of habits, beliefs, manners, and ways of thought acquired throughout each successive culture phase in human history. This is why the higher mammals alone have the power of learning by experience, and of varying almost infinitely the thousands of millions of alternative pattern paths of nerve force. The conflicting emotional stimuli involved in the choice of these paths are a well recognised basis of worry, or even of mental breakdown. Just one other law of evolution :?The oldest acquired structure or function is the most stable, the newest is the most vulnerable to disease or accident. The brain stem is the oldest part of the brain ; it has varied very little since backbones were first evolved in the fishes of the Silurian geological series countless ages ago. The supragranular layers of the brain cortex are the newest developments ; they perish easily under embryonic or environmental stress, more especially in the sense
special
areas
Mental welfare.
67
prefrontal, or extreme front portion of the brain, the part where ideas and problems highly complicated movements, which we call thought, are worked out, that part of the brain possessed by the human race only. When this goes man might of
as
well have
no
forehead;
his behaviour is
on
the level of that of
a
monkey.
heredity affects things. As soon as a fertilised vegetable or animal germ begins to develop it divides into two portions, the bodyplasm and the germ-plasm. The body-plasm grows on to form the individual, the germ-plasm, which constitutes the sex glands, remains embryonic, but in possession of all the family qualities, until it is called upon to form the basis of a new generation. So environmental stresses may affect both body-plasm and germto the former comes to light in the individual, injury to the latter plasm; injury not until some I believe, although many do not, that succeeding generation. is a Mendelian recessive quality, of the brain as above, cells, explained instability and appears only when an undue stress affects a brain whose cells in a former Next
a
few words about how
generation (where,
of course,
they
were
only germ-plasm,
not
body-plasm),
were
If this be true it follows that sterilisation of the unfit can remove from a population at the most 25 per cent, of mental deficiency. But as in practice mental deficients are not responsible for anything like their proportionate percentage of births, probably a nation would be lucky who succeeded in removing even 10 per cent, of mental deficiency by such means; for it must be remembered that in the present culture phase of civilised society sterility necessarily accompanies the graver forms of mental defect. Nor does sterilisation save the cost of segregation, most defectives being asocial.
similarly subjected
to undue
environmental
stress.
We have now arrived at the position that, as regards heredity in mental what is inherited is not a tendency to mania, or melancholia, or mental deficiency, or epilepsy, or neurasthenia, but is an inherited weakness of constitution of the brain cells, more especially the newest acquired cells of the supragranular layers of the prefrontal cortex. Some of the hereditary causes of neuronic failure are plain and self-evident, such as alcohol, lead poisoning, or syphilis, or other physical disease in the parent, but many are at present beyond our knowledge and belong to the accumulation of adverse "environments of former generations; these we class under the general term neuropathic If the injury to the body-plasm and germ-plasm be severe, the diathesis." individual may perish at a very early embryonic stage, but in proportion as it is less urgent or less continuous, development goes on longer and longer until At birth the brain cortex has the individual may be born apparently normal. attained about three-fifths of its adult depth, but the supragranular layers are much behind-hand. Most defective brains have gone on growing until the seventh or eighth month, or else their owners would not have been born alive at all. If the supragranular layers of the cortex are partly formed, the child is educable in greater or less degree, but we find that if a child cannot be taught to talk, there is some defect even in the infragranular layers._ A great deal of discussion is at present centred round the disease encephalitis lethargica, or sleepy sickness. At what age does a person whose brain is permanently injured by this disease cease to become a case of mental deficiency and become one of acquired mental disorder? Whatever view is taken, it is clear that the decision is not on physiological so much as on social grounds. Certain acquired mental disorders begin early in life, at the stress periods, puberty or adolescence, when not only are sexual functions beginning to exercise an enormous influence on the character of the child, but the increasing brain power is creating all sorts If the brain cells fail under of new social difficulties which call for adjustment. the strain, we get precocious dementia, dementia praecox, a most unfavourable type of mental illness, and one all too common under the increasing worries of competition. But who can say that this is wholly an evil? To the individual
weakness,
68
Mental welfare.
a calamity, but to the race a blessing-, for these cases rarely marry, and Nature is ever careless of the individual, but ever the neurosis cures itself. careful of the race. The brains of many idiots are grossly malformed, and those of many advanced dements much changed by chronic inflammatory conditions, but there is a large class of cases in which it is almost impossible to tell after death whether the brain was that of an imbecile or a dementia piEecox or a manic-depressive. And so during life; often the history alone will give us a clue as to the age at which the brain became affected; by no direct medical examination can we tell whether the illness was congenital or acquired. This is especially true of young acute maniacs and epileptics. There are always the two classes of causes at work?there is the predisposing cause, an inherited want of vitality in the brain cells, and there is the exciting cause, generally a tissue poison generated within the body of the individual as the result of inharmonious environThese two great classes of determinants are like the rope and the weight ment. The strong-er the rope the longer it will carry a given weight, it has to carry. But whether the heavier the weight the sooner will it wear out a given rope. mental failure is pre-natal, or infantile, or adult, or senile, becomes merely an equation of accumulated severity of causes versus the resistance of the individual. Ascertainment.?Having dealt with continuity of causation, I now come There are a good many social services already to the question of ascertainment. in existence which are or might be utilised for the early detection of mental illness. It is highly desirable to adapt existing means to present needs rather than create entirely new agencies. We have the ante-natal clinics, the infant welfare centres, health visiting, the school medical service, the industrial welfare movement, venereal and tuberculosis clinics, the Central Association for Mental Welfare and its affiliated branches, the National After-Care Association, Ex-Service Men's Associations, the Industrial Approved Benefit Societies, various religious and temperance Social Welfare Associations, and an unclassified list of local groups of voluntary workers making praiseworthy efforts in various directions to ameliorate society in general and further their own pet schemes in particular. But there is an almost total lack of co-ordination, there is no attempt at continuity, and there are important gaps in the age periods. In a large percentage of our mental patients careful records have been kept of their early days, at Infant Welfare Centres or by school medical officers, if only these were not pigeon-holed in locked compartments by the various authorities responsible. After leaving school they are lost sight of, for it is precisely persons with congenital or acquired mental weakness who tend to gravitate into the unemployed and unemployable classes, being unable to compete with the more able members of society. Most of the organisations, voluntary or rate-supported, are at present concerned with bodily illness and its prevention, but with very slight extension they could gather data which would be of great value should their patients later on require mental attention; for the origins of bodily and mental illnesses are common and indivisible, and one never knows what information as to bodily conditions may not in the future indicate the special direction to be followed in mental treatment. Let us consider the work of some of these agencies. Probably the most useful of all is the ante-natal clinic, not only because it holds the earliest inquiry in the child's existence, but also because at it the parent is examined, and the large field of disease which in later life displays a mental side is adequately explored and dealt with. Thus a careful history of insanity, neuroses, epilepsy, alcohol and temperamental peculiarities in father and mother is taken, and the mother is especially examined for signs of syphilis, heart disease, tuberculosis and Bright's disease, the first of which notoriously affects the grovvth of the infant's brain almost more than its body, accounting for one-fifth to one-fourth of mental cases, congenital or acquired. If a history of still-births or miscarriages is elicited, or signs of active disease noted in
it is so
MENTAL WELFARE.
the mother
69
or her elder children, absolutely specific and sure treatment can be given unborn child saved from all taint. Things are not quite so hopeful in Bright's disease, but if convulsive seizures in the mother can be prevented, Next in order of importance the child's brain is generally preserved from injury. comes pelvic defects in the mother, which, if severe, may necessitate Caesarian section or premature induction of labour, thus saving the child's skull from undue pressure or fracture, both of which may at times result, the former in primary dementia, the latter in birth paralysis and mental defect. Lastly, the nutrition of the mother is attended to, especially cases of semi-starvation or dietary defects, which, would, if neglected, inevitably lead to rickets, deformities, or mental defect in the infant. From the age of a fortnight up to 2 years or older, children are brought to Infant Welfare Centres. Sometimes, if attached to hospitals or instituted by the local authority, these centres carry on the work progressively from the ante-natal clinics, but often they are independent, and the medical men and nurses have not then the advantage of the record cards, and so have to begin de novo. A doctor will examine the baby at the first visit and note whether the child notices things, looks round and smiles, or is abnormally placid, or whether it A great attraction is the tea and social gathering of seems unhappy and cross. mothers, and when a tactful and enterprising lady visitor is in charge of this part of the job the centres become very popular, and much useful knowledge of maternity and child management is spread by the discussions. If necessary, histories of the family are taken. Weight charts are kept, dietary arranged, and the proper management of the bowels inculcated. Deformities, stigmata of degeneration and signs of the usual infantile ailments are looked for, and the growth of the teeth noted according to the age. If older, what progress is being made with weaning and training in cleanliness, and whether the child is progressing normally with walking and talking. The medical officer looks for early signs of rickets, eczema, cretinism, mongolism, hydrocephalus, dysthyroidism, flaccid or spastic paralysis, tetany, chorea, etc. All these and many others are important as regards subsequent mental defect or illness. Cod liver oil and ultraviolet ray treatment are often provided. From 3 years onwards the child begins to come under the Education Authorities, and thenceforwards up to 14 he is under a most carefully devised The play schools for and skilfully organised scheme of progressive training. infants of 3 to 5 are a most useful preliminary to education in the crowded slum districts of the great towns, and the nurses have an unique opportunity for observing physical and mental defects, and drawing the medical officer's attention to the necessity for treatment. Incidentally these play classes are ideal disseminators of children's diseases, but there is something to be said for the argument that, if the child gets these infectious fevers over early, his education is less interfered with later on. In rural districts the child is far better playing near his home until he begins school at 5, but it certainly leaves a gap of 2 years in observation, unless the district nurse is an observant person not overwhelmed with specific duties. Like all high-grade machines, the school system has its defects, and from the medical point of view the greatest is the result of rushed work and the inevitable fall into a groove. I do not know about the conditions in Staffordshire, but in many places the school medical officers are far too few to give adequate consideration to individual cases, or to conduct a full examination sufficiently often. I understand they aim at three examinations in the nine years of school life?clearly not enough. But the teachers are wonderful in spotting mental and character anomalies in the pupils; and if the school nurses spend enough time over the teeth and adenoids, the worst shortcomings are avoided. The shy and reticent child, often inclined to be delicate, the one, as we say, with an "inferiority complex," is too apt to be left severely alone in a large class
and
the
70
MENTAL WELFARE.
These until repeated failures to reach the required standard compel attention. the children often slightly defective congenitally, made worse by the deafness of adenoids and mouth-breathing, who recruit the ranks of the mental defectives, And the terrible results or later on enter the hopeless alley of dementia praecox. of encephalitis lethargica make it most important for teachers to be on the look out for those slight and undiagnosed cases which result in quite as formidable sequelae as those whose original illness assumed the more acute and unmistakable In fact, my experience seems to show that many of the worst of the moral type. " " or type passed unnoticed at first, and only a year or two or three Apache years later the teacher can recall when questioned that the child seemed dull or out of sorts for a day or two, but that this was put down to a dietary indiscreThis problem of the encephalitic is going to tax the ingenuity of tion at home. I have had some the country in a few years, when these children grow up. under observation for over 3 years, who, although the disease has not progressed, have become more and more unmanageable as they grow bigger and stronger. Previously quiet, diligent and well-behaved children now lie, steal and assault others; reproofs, arguments, punishments and rewards are alike " I'm sorry, I know I was wrong, but useless, the answer is always the same, Five minutes later another small outrage I couldn't help it; I won't do it again." is committed. Now imagine these no longer little children, but powerful adults. What will become, say, in a murder case, of the McNaughten dictum as to knowledge of the nature and quality of the wrongful act? I have several of both sexes who have passed puberty, and they are now adding sexual misbehaviour to their childish peccadilloes; and with it all these patients preserve their devilish monkey ingenuity and cleverness, never at a loss for an explanation or an excuse. What modern system of detention will control these people in the future, certainly not a criminal lunatic asylum as at present constituted ? Luckily, this type seems rarely to occur when the original infection appears in an adult, but only in those whose brains are yet far off full development. The Industrial Welfare Clinics deserve a few words. The working of the Industrial Research Board on the physical and psychical sides of employment will lead to the diagnosis of the mental waverers. Transference to more suitable employment, together with advice as to more hygienic living and the treatment of dental and rheumatic affections, should ultimately diminish the cost of institutional treatment and remove part of the heavy burden of unemployment through chronic invalidism. The hospitals of the country are filled with those who have through ignorance and unhealthy surroundings been pushed to the wall or fallen by the way. One hopes that when the cost of industrial clinics is shared fairly between sick benefit societies, or still better, the trade unions, on the one hand, and the employers, on the other, a reasonable Government grant in aid will come to far less than the present cost of poor relief, unemployment, mental deficiency and insanity. The casuals and unemployables will still need to be provided for, but it is not beyond the wit of man, although it may seem beyond the pecuniary capacity of successive governments, to devise remedies for roping them in before their cases have become hopeless. Administration.?I have tried to show that the same sets of causes, hereditary and environmental, are at work in producing mental defect and mental illness, and that, beyond certain fairly-defined limits, it seems to our present knowledge almost fortuitous which, if either, will emerge in a given individual. And we see constantly in our hospitals mental defectives who have regular relapses into active insanity, in no way distinguished from other persons who between their attacks are normal members of society. The rest of my address will be devoted to administrative recommendations for unifying treatment. There are two societies devoted to the amelioration of the mental problem. The older is the Mental After-Care Association, founded in 1886 for the are
purpose
MENTAL WELFARE.
of
71
There are many local branches, but from asylums. men and women, all of them assistance its many poor, By some friendless, yet capable with a modicum of assistance of earning- their own living, have been sent temporarily to homes, convalescent or otherwise, for a change of air and scene, or have been found employment, or received small monetary grants towards fresh clothing or tools, or have been cheered by Like other charitable organisations, the occasional visits of voluntary workers. I he other is the this association is chronically hampered by lack of funds. Central Association for Mental Welfare. It would greatly lighten the mental problem if these two Associations amalgamated. Nor are we free from trouble in Staffordshire. After a good many years of striving we have obtained the Staffordshire Mental Hospitals Board, and one would have thought that the obvious step of extending its aegis to cover mental deficiency would have commended itself to every authority in the geographical area. Yet we know that some stand out. To anyone like myself, whose official life is drawing to an end, it seems inexplicable that the public should be willing to see their money wasted in overlapping, and still worse, see the education and control of the mental defective suffer; and those who know anything worth while about the subject realise that this is exactly what will happen if each local authority sets out to manage its own defectives. People who deny this assertion are not those who have given their working lives to the solution of the problem, so that all I can The Board of Control suggested that the willing do is to plead for the wide view. authorities form a voluntary board for mental deficiency, but what good would this be? They could not raise money by precept, and every trifling expenditure, structural alteration, and so on, would have to be submitted seriatim to each authority. If one dissented, that expenditure could not be incurred, and at best I do not suggest the negotiations and correspondence would be interminable. that local mental deficiency committees should lose their identity, but that each authority should appoint one or more members of the board from their own mental
supervising- discharges
none in this
district.
deficiency committee, if indeed they have not already one common committee for mental work. But this alone would not satisfy those of us who are idealists. We say that there should be no divorce between education and mental treatment, or between mental treatment and public health. Accordingly, we should like it made possible to have members of these committees of each authority upon what would then, we hope, bear the name of the Staffordshire Board of Mental Health. Following the precedent of the Education Acts, we should like other special interests co-opted, although of persons not responsible to the ratepayers; I can instance voluntary societies, the Police Court Mission, the Staffordshire Nursing
Infant Welfare Committees, Local One member of each of these, and there may be others, would act as liaison officers without having sufficient voting power to interfere with the ratepayers' wishes. Next we would like to see more team work among the medical officers. Too often at present the specialist medical service is overwhelmed by routine. It arrangements could be made so that these officers and medical officers of social service committees and institutions should confidentially refer all mental cases in their early and unconfirmed stages to the Board of Mental Health, much as cases of infectious disorders are reported, no publicity would be entailed, and in many cases preventive measures, physical or psychological, could be taken without loss of time. But it must be acknowledged that such suggestions are Utopian, and could only be brought about gradually after an Early Mental Treatment Act and amendments to the Mental Deficiency Acts had paved the way for the education of the public in these matters. There would then be in the offices of the Board of Mental Health a complete card index record of the salient features from the ante-natal clinics onwards through life of all who might presumably require medical advice
Association,
the Health
Visiting Committee,
War Pensions Committees and Orthopaedic Associations.
11
Mental welfare.
their mental health. The Board of Mental Health would have one senior medical the Medical Officer of Mental Health, who would be responsible to the Board for the classification of all cases reported to them, and who, after a personal visit and examination in whatever part of the geographical area, would advise as to disposal, whether for home treatment, or guardianship, or at a local clinic, or in a mental defective colony, or a mental hospital. The Board's executive officers would be people analogous to the present relieving officers, possibly, when the Board had taken over from Boards of Guardians the responsibility for all mental cases, the same individuals, or some of them. Officials of other bodies co-ordinating would act for the Board on a part-time basis. The Medical Officer of Mental Health should be an official of long experience, co-ordinate to, but independent of, the Medical Officer of Health. I am aware that the British Medical Association and many of the higher Ministry of Health officials would have him as an Assistant Medical Officer of Health, but both the Board of Control and the Royal Medico-Psychological Association are opposed to this on many grounds; one of these is sufficient, viz., that he would have to consult with the M.O. H. of many local authorities, and should not, therefore, be under any one of them, but only under the combined Board of Mental Health. Another reason is that, unless the post were independent and of senior standing, no man of life-long experience of mental cases could be found to fill it. He would have nothing whatever to do with the internal administration of the Board's institutions, but he would be consultant to the local psychological clinics in the various smaller towns, which he would have to visit regularly. He would also be expected to give advice on mental cases if asked for by the school or other medical officer of The local any of the local authorities constituting the Board of Mental Health. clinics would be held on one day a fortnight or month, conveniently in the same room used on other days for health clinics, children's welfare centres, and so The medical officer of mental health would probably refer cases requiring on. prolonged psychotherapy to the psychological and psychiatric clinics attached to the general hospitals in one of the larger county boroughs; for under our model scheme there would be reciprocity between general and mental hospitals, and one or more medical officers of the latter would be appointed honorary psychiatrist to the neighbouring general hospital. With these out-patient or in-patient clinics, set up by the local authority in alliance with the hospital managers, the medical officer of mental health would be connected in a consultant capacity alone. Voluntary and uncertified early cases, as suggested under the Early Mental Treatment Bill, would in a few years comprise quite half the admissions to the It is so in Scotland, where voluntary boarders are more mental hospitals. numerous and where early cases may be received for 6 months without a justice's order. The Scots are reputed to be as fond of liberty as the English, yet there is no case on record of an action for illegal detention. The reason is that there the medical officer of a mental institution has power to discharge, and does discharge, a recovered patient or one whose friends accept responsibility for his welfare. Patients get out of Scottish asylums so easily that they are less anxious to leave, which is perhaps human nature. Scotland is half a century ahead of England in questions of mental health. A common fallacy is that this somewhat elaborate scheme for covering the whole geographical area would result in roping into institutions large numbers of mental cases who need never go there. We aim at quite the opposite goal, the idea is to keep as many out as possible, but to have these under such supervision that the best could be got out of them. For instance, we receive into mental hospitals many middle-aged defectives with the history that they worked as unskilled labourers under father, brother or friend for many years, and got along all right, earning a small wage, until the relative died or gave up work; then they were helpless. A case like this would no longer require to spend the rest of his life in a hospital or colony; a on
official,
MENTAL WELFARE.
73
suitable place of work, perhaps on the land or away from the former city factory, would be found for him, and if necessary the guardian would be allowed a small weekly grant if the patient's wage-earning capacity were very low. But at present city is separated from country, and there is no list of suitable country guardians available in the town. Before concluding I should say a few words about mental defective colonies. I estimate that there may be 1,500 deficients in the Staffordshire geographical area who would benefit by institution treatment, at least in their earlier years. 1 fear it is too late to hope for one institution for the county, the next best hope is one for the north of, say, 750 beds. This is too small to get the best value out of the money spent, but makes the best of a bad job. Many of the
trade outfits would be unduly costly per head in a small colony where expensive machinery had to be installed, such as power joinery, fitting and metal welding, bookbinding and printing. On the other hand, in a small institution too many people would be trained for jobs in which they could never make a living, such as tin smith, basket making, weaving, and luxury trades much taught to the blind. Even tailoring and shoemaking do not offer much inducement at present, and yet the resources of each shop would have to be fully utilised to pay for its upkeep. The bulk of deficients should learn a staple trade in a colony, farming, a building operation, or in this district potting. It must ever be borne in mind that 9 out of 10 have not brain to compete in the open market, and must at best need supervision for life, so there is little use in troubling them with a literary education further than trying to teach them to read simple stories as a means of relaxation and to keep them out of mischief in the evenings. Further, they can learn only one process in any trade, and can then perform it mechanically. The larger the institution the more grading can be done. Large classes are a serious handicap in a normal school; in a defective colony they are anathema. There must be individual attention if successful results are to be attained, and the children must be caught young. I suppose at Cheddleton we have the lowest grade school in the country. The paralysed idiots, utterly helpless, with less sense than a fish, first have orthopaedic treatment to reduce their deformities. Then they have to be taught cleanliness, grasping and walking. Needless to say, little can be expected if we get them at 11 or 12?we must have them at 2 or 3. The greatest difficulty is talking; for often the speech centres in the brain are undeveloped. But if these children can be taught to use fairly intelligible signs and sounds, they can get along. That the lowest and grossest idiots can be so greatly benefited, idiots so extreme that no ordinary colony will have them, holds out quite a bright hope that many belonging to the higher grades may ultimately become useful members of their own limited social sphere, and save the money spent on their keep, while a few may even earn a moderate competence in the world outside. A small colony cannot grade its cases sufficiently. With 90 children at Cheddleton we require 5 grades, and if we had double the number of cases we would have 9. Extend this detailed classification through all the range of mental deficiency, and you would require at least 40 grades. I once heard an officer at Darenth, with over 2,000 patients, complain that they could not sub-divide their people as they would like. Catch the children young, grade them minutely, educate them individually, and when they grow up find guardians for them, and you will in the end get 15 to 20 per cent, of them But catch them late, immure them in removed from being a burden on the rates. small homes or colonies, treat them more or less in bulk, and there they will remain for the rest of their lives.
