[To the Editor of the SPECTATOR.] Sra, — A popular Highland pulpit
orator of the last generation, while preaching to a crowded congregation in Inverness,. feeling the heat oppressive, raised his arm, and, pointing a finger to a gallery door, said, without any modulation of his voice and without any obvious interruption in the flow of his discourse, " Will someone please open that door ? " and, turning to the opposite gallery, he repeated his request in similar .manner. As the congregation dispersed two serious- minded women were overheard commenting upon the sermon : " Ah ! " said one to the other, " it was a heart-searching sermon ; and, eh, -woman, wasn't he beautiful on the-doors ? "
Now, it is all very well to be beautiful on the doors, but it is irrelevant, and no amount of clamorous utterance can make it anything else. Those who make the clamour may think that they are arresting public attention, but they are only creating a diversion. Nevertheless, it is true that the public
are showing some anxiety as to whether all is well with lunacy administration, and I think the Spectator has rightly divined the trend of public opinion and provided suitable opportunity for its expression.
Lunacy. reform is not a subject for contention ; but it is desirable that the public should get guidance in matters of essential importance for its adequate consideration.
It is a curious fact that, while the better care of the insane was one of the first objects towards which the humanitarian movement of the early part of the nineteenth century was directed, yet the influence of the idea of legal control, borrowed from the custom of regarding an insane person as akin to a guilty person, has dogged the footsteps of medical opinion and the ideals of those entrusted by law with the care of the insane down to the present day. Notwithstanding that adverse influence, it is one of the proud achievements of medical practice that more than forty years ago it was possible for the late Sir William T. Gairdner to describe the activities of a modern asylum in these terms : " No more brilliant application of medical science than this has ever been known in any age of the world's history."
It would be wrong to suggest that conflict exists between medicine and law ; but it is right to recognize that experience has shown that, within certain necessary limitations, the legal atmosphere may now be replaced by the purely medical view of insanity and of the appropriate arrangements for the care and treatment of patients who suffer from mental unsoundness. That, in itself, is a very large reform. Let me ask attention to some of its implications.
1. Your correspondent, Mr. Ray Muir, rightly draws attention to the importance of treatment on a voluntary basis, but I fear he is somewhat out in his statement of the number of voluntary boarders in Scottish asylums. The 75 per cent of such boarders in the Crichton Royal Institution at Dumfries applies only to private patients—neither in Scot- land nor in England are rate-aided patients allowed the privi- lege of voluntary admission. This restriction ought to be removed. It may possibly raise a smile to suggest the idea of popularizing asylums, but when one reflects how great was the popular initial prejudice against entering a fever hospital the hope may be entertained that, were the legal necessity for certification removed, many patients would voluntarily place themselves under care and treatment, and that, too, at an earlier and more curable stage than is the current usage when tests and methods, more repugnant than residence in an asylum, are imposed as necessary preliminaries to skilled treatment. I shall refer to this aspect of the question later. Meantime, it is useless to talk of adding a few more lectures on insanity to the already overburdened medical course- of studies, while the highly-trained medical officers of asylums cannot get patients with the same freedom of access to their wards as the Physicians of General. Hospitals.
2. The Maudsley Hospital has been hailed as the dawn of a new epoch in the treatment of patients suffering from mental unsoundness. Let us not forget that we owe it to men whose devotion to the care of the insane led them to rejoice in what had been accomplished by their predecessors and contem- poraries and to promote ideals derived therefrom. But it is a pathetic reflection that .this new effort is beset with sug- gestions calculated to raise false hopes, which have done more than all the clamour raised by Dr. Lomax and his friends to unsettle the public mind in relation to asylums. A cult has arisen who teach that, if patients can be got early enough, their minds can be psycho-analysed, their repressions " got up," their complexes resolved and their reason restored. At present I am only concerned with the fact that this kind of teaching has raised false hopes as to the value of early treat- ment, and created by contrast a pernicious prejudice against asylums. Perhaps I may, without impropriety, refer to the successful efforts made in Glasgow, where a hospital was established twenty years ago on the same lines as the Maudsley. But in advocating this advance I was in spirit and in method doing nothing more than my colleagues, the Physicians of Asylums, only I was in the happy position of being free from the handicap of having to get my patients certified before they could be admitted to my wards. In short, neither new methods in the treatment of insanity nor reflections upon the treatment and nursing of patients in asylums are implied by the new movement represented by the establishment of the Maudsley and other hospitals. 3. I have already referred to the unsatisfactory procedure adopted in arranging for the admission of patients to public asylums in England. It is too long and complicated a story to recite fully. But, in my opinion, it is a scandal, of which discovery I make a free gift to the Press. Decent citizens who become afflicted in their minds are removed by the Relieving Officer to the workhouse, there detained, ostensibly for pur- pose of observation, and a citizen magistrate is called upon to decide whether the patient requires asylum treatment. The part played by the medical man who grants a certificate is really that of a witness, and the magistrate grants his order only if he is satisfied that the patient is insane. Meanwhile the patient, during the most critical stage of his illness, is not getting the skilled medical attention and nursing which he requires. He is not neglected, but his condition is not diagnosed, or rarely so. All this should be changed. From the moment that mental disorder becomes apparent, access to appropriate treatment should be available.
I hope I have made some headway in showing that lunacy reform is well understood by everybody engaged in practice in that branch of medicine, and that many of us whose work can testify to our sympathy with the afflicted are prepared, in discharge of their obligations to the public, to take some pains to put the case in its true perspective, though they may regard themselves as under no obligation to answer pointless
inquiries.—I am, Sir, &c., J. CARSWELL. 96 Heath Street, Hampstead, N.W. 3.
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