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CARE OF THE MENTALLY DEFECTIVE.
403
being used when it should be, or, if it is used, it is not used properly. Of these, he believes the latter to be the more important factor. CARE OF THE MENTALLY DEFECTIVE. THE Mental Deficiency Act,- which was passed without opposition at the end of the last Parliamentary session, is a small one of only 11 sections ; it is nevertheless of considerable importance to local authorities as well as to all medical practitioners who may be called upon to deal with mental defectives. We therefore welcome the explanatory circular No. 702 which has just been issued by the Board of Control. The Act is an amending one, its main purpose being to remove certain difficulties which have been experienced in the practical working of the principal Act since this was passed in 1913. Many of these difficulties centred round the definition of mental defect, and undoubtedly the alterations of chief importance to the medical profession are those which relate to such definition. It will be recalled that in the original Act it was required that, before a person could be dealt with as a mental defective, the defect must have been present " from birth or from an early age." We believe the intention of these words was to ensure that other forms of abnormality, such as those arising from disorder or deterioration, should not be dealt with as mental defect. In many quarters, however, this purpose has not been appreciated, and the words have been interpreted literally and as meaning the first few years of life. This restricted interpretation has been found to result in the exclusion from the Act of many persons who are unquestionably mental defectives, and for whom its provisions were intended. For instance, all with practical experience of defectives are aware that while the lower grades of idiocy and imbecility are usually recognised without difficulty in the early years of life, it is far otherwise with those suffering from the milder grades of feeble-mindedness. In many of these the deficiency may not reveal itself until towards the end of the first decade, or even not until adolescence. Again, it is by no means uncommon for mental defect to be brought about at these later Common ages by injury or disease of the brain. examples of this occur in the various forms of meningitis and encephalitis, as well as the arrest of mental development induced by epilepsy. During the past few years some hundreds of children have been rendered mentally defective by encephalitis lethargica ; but, as the original definition stood, it was found impossible in many cases to deal with these as defectives and to secure their admission to institutions under the Act, although such institutions might afford the most suitable form of treatment. In the Act of 1927 the words " from birth or from an early age " are deleted, and there is given for the first time a definition of mental defectiveness-viz., " a condition of arrested or incomplete development of mind existing before the age of 18 years, whether arising from inherent causes or induced by disease or injury." This definition must, of course, be read in conjunction with those of the four classes of defectives which precede it ; but there is no doubt that the changes will go a long way towards remedying the difficulties we have alluded to, as well as towards making clear who are, and who are not, defectives. As the circular points out, the essential criterion of mental defect is not a defect of intellectual capacity, as this term is usually understood ; for mental defect may exist in persons of considerable intellectual capacity. It is an incapacity for efficient social
adaptation of such kind and degree as to render the person in need of care, supervision, and control. A person who suffers from any defect of mind, arising before the age of 18 years, which is sufficient to necessitate external care is a mental defective within the meaning of the Act. It may be pointed out that the designation of the fourth class has been changed from moral imbeciles to moral defectives, and that the words " on which punishment has had little or no deterrent effect " have been deleted from the definition of this class. No doubt this change will be an advantage ; indeed, we are inclined to regard it as somewhat unfortunate that the opportunity was not also taken to redraft the definition of ordinary imbeciles. They are still defined as " incapable of managing themselves or their affairs "-a perfectly true definition, but one which conveys a somewhat misleading view of the marked incapacity of this class. The remaining sections of the Act to which the circular draws attention are either drafting amendments or administrative changes. The most important of these may be briefly referred to. Although the principal Act permitted parents in a position to pay fees to place their defective children in suitable institutions, it made no provision for such as were unable to pay fees to do this, unless it could be showed that these children were " neglected, abandoned, or without visible means of support, or cruelly treated." This was found to be a hardship, and it is now remedied by allowing such children to be dealt with on the representation of their parents or guardians to the local authority that they are in need of care or training which cannot be provided in their homes. Another disadvantage existed in the case of children about to be discharged from special schools. These pass out of the jurisdiction of the local education authority at the age of 16 years, and, if their supervision is to be continued, they must be notified to the local (control) authority. But the education authority has hitherto only been empowered to do this in the case of children needing to be sent to institutions or placed under guardianship. In many cases neither of these courses is necessary ; all that is needed is supervision, and Section 2 of the Act now enables the child to be notified for this purpose. The circular draws attention to the difficulty which has sometimes been experienced in the case of mental defectives coming before the courts. The court is empowered to direct that a be petition presented to have the defective sent to an institution ; but where it has been impracticable to do this, or where the petition has been dismissed, there has hitherto been no provision for the detention of the person until the case could be suitably disposed of by the court. Section 5 provides the machinery necessary for this purpose. Section 7 of the Act imposes a new obligation upon local authorities. Hitherto they have only been required to provide suitable training for defectives in institutions ; they now have the duty of providing this for defectives who are under guardianship or supervision. They may, however, be relieved of this obligation if they satisfy the Board of Control that there are adequate reasons for exemption. Hitherto local authorities have only been able to receive into their own certified institution patients from their own area ; the Act now enables them to receive those from any other local authority, and this is a provision which may be of decided advantage to small authorities, who will thereby be enabled to board out their cases until such time as they caii provide their own accommodation. While the amendments and additions to the Act, to which this circular directs attention, will be of especial concern to local authorities and to medical men holding
404
official posts,
of the changes, particularly those of importance to the medical profession as a whole. The time has arrived when few general practitioners can afford to be without an adequate working knowledge of mental defect in its relation to education, conduct, and citizenship. It is quite certain that more general use might be made of the course of instruction arranged by the London University Extension Board in cooperation with the Central Association for Mental Welfare, and intended primarily for medical men holding official positions. The course is based on the requirements of the syllabus for the University diploma in psychological medicine. Series of lectures will be given by Dr. A. F. TREDGOLD, Dr. F. C SHRUBSALL, Prof. CYRIL BURT, and Dr. NORWOOD EAST, and the clinical work will include visits to special schools and residential institutions. A certifidate of attendance is granted. The next course will be held from May 14th-19th at the University, Imperial Institute-road, South Kensington, and communications in regard to it should be addressed to Miss EVELYN Fox, University Extension Department, at that address.
definition,
some
are
of
Annotations. "
Ne quid nimis."
TESTIMONIAL TO SIR DAWSON WILLIAMS. ALLUSION was made recently in these columns to an admirable intention to present a testimonial to Sir Dawson Williams, who lately retired from the Editorship of the British Aledical Journal, after 30 years in that position and nearly 50 years close connexion with the editorial work of the paper. There is a widespread feeling that the occasion should not pass without some recognition, from the profession as a whole, of his long and distinguished services to the science and practice of medicine. We understand that it is accordingly proposed to issue a general appeal and to send to the medical press a first list of supporters for publication on March 10th. Those wishing to be included in this list are invited to send their contributions, not later than March 3rd, to Sir StClair Thomson, who has been asked by the provisional Executive Committee to act as honorary treasurer. Though the Committee does not wish to limit the amount of individual donations, it hopes that the sum eventually received will include a large number of contributions of two guineas or less and so represent the profession generally. Cheques should be made payable to Sir StClair Thomson and sent to 64, Wimpole-street, London, W. 1, and the envelopes marked " Dawson
Williams Testimonial."
again the importance of a contaminated water-supply in the spread of this disease. Among the 8000 inhabitants supplied with filtered water there were only eight cases of cholera, whereas among the remainder, numbering 22,000, whose water-supply was not filtered, there were 273 cases. According to a short note addressed to the Office International by Dr. Djavad Asthiany, the epidemic was suppressed by Oct. 25th, thanks to the provision of sanitary cordons and vaccination. More than 40 per cent. of the inhabitants in the infected towns and the adjoining areas were vaccinated, a supply of vaccine sufficient for 700,000 doses having been provided. Dr. Thomson notes that, although much importance was attached to vaccination, sanitary cordons were found to be necessary, and the movements of nonvaccinated persons on the principal lines of communication were strictly regulated. The total number of cases notified up to Nov. 5th in Iraq was 1038, among which there were 756 deaths. Two new lines of communication have now to be considered in connexion with any outbreak of cholera in Iraq. The first is the air route from Cairo to Basra by Palestine and Baghdad. The weekly aeroplane takes 12 hours from Cairo to Baghdad and 27 hours from Cairo to Basra, for it does not fly by night. When this route has been extended to Karachi, a traveller from an infected centre in India may, in three and a half days, find himself on board ship at Port Said. The other new line of communication is the motor-car route between Baghdad and Beirut, via Damascus. The journey takes only 29 hours, and the traffic on this route is increasing continuously. About 200 travellers pass this way every week, and in 1926 about 2000 pilgrims made use of it to reach Jeddah. These two new routes and the discovery of oil in Iraq give point to the remark recently made that Iraq has ceased to be oriental and has come to be part of Europe. It is fortunate that with these extended facilities for the transmission of disease there should be an effective quarantine network at points of landing. The medical authorities in Syria control the motor traffic, of which Damascus is a centre, and the aerial traffic is under strict medical supervision in Palestine and Egypt. In order not to hamper the development of these new lines of communications, the medical authorities in Egypt intend to make sanitary restriction as light as possible compatible with safety. Travellers coming from infected regions, reaching Egypt by aeroplane, and wishing to catch boats bound for European ports, may continue their journey without observation or quarantine at the aerodrome, provided they can show that they have received two injections of a cholera vaccine, the second of which was given at least six days earlier, and provided also that they look quite well. The medical officer of the ship by which they travel from Egypt must be told where they came from. ____
GAIT, NORMAL AND ABNORMAL. CHOLERA IN IRAQ. EVER since the days of the brothers Weber, whose THE epidemic of cholera which broke out in Iraq in the summer of 1927 gave an opportunity to test book on the human mechanism was published more the efficiency of prophylactic inoculation, of measures than 90 years ago, physiologists and surgeons have for the purification of the drinking-water, and of from time to time made attempts to analyse and the working of quarantine restrictions. Happily full record the movements of the body and limbs in locomotion. Some of these attempts havebeen fairly use was made of this opportunity, as may be seen from the report1 of Dr. C. P. Thomson, president successful, especially since instantaneous photography of the Egyptian Conseil Sanitaire. On July 20th has come to the observer’s aid, but the practical value the medical officer of health of Basra observed of the records] has been small. During the war a elaborate and efficient cinematographic apparatus two suspicious cases, and several were found at the was constructed in the experimental workshop of the same time at Abbadan, but it was not till July 23rd that a bacteriological diagnosis was made. It says Ministry of Pensions and excellent photographic charts much for th3 promptness of the medical officers were obtained of normal gait and also of the gait of a concerned that travellers who had left the infected area man wearing an artificial limb. These records were on the morning of the 23rd were received on the morning described and commented on by Mr. R. C. Elmslie in of the following day at the aerodrome in Cairo with a paper published in the St. Bartholomew’s Hospital unusual attention by its quarantine medical officers. J ournal,I and the charts and photographs were reproThe epidemic in Abbadan served to demonstrate once duced by Mr. Muirhead Little in his book on Artificial Limbs. Excellent as these photographs and tracings 1 Office International d’Hygiène Publique, Bulletin, vol. xix., 1 2 1922 (H. K. Lewis). September, 1920. No. 11.
very
being used when it should be, or, if it is used, it is not used properly. Of these, he believes the latter to be the more important factor. CARE OF THE MENTALLY DEFECTIVE. THE Mental Deficiency Act,- which was passed without opposition at the end of the last Parliamentary session, is a small one of only 11 sections ; it is nevertheless of considerable importance to local authorities as well as to all medical practitioners who may be called upon to deal with mental defectives. We therefore welcome the explanatory circular No. 702 which has just been issued by the Board of Control. The Act is an amending one, its main purpose being to remove certain difficulties which have been experienced in the practical working of the principal Act since this was passed in 1913. Many of these difficulties centred round the definition of mental defect, and undoubtedly the alterations of chief importance to the medical profession are those which relate to such definition. It will be recalled that in the original Act it was required that, before a person could be dealt with as a mental defective, the defect must have been present " from birth or from an early age." We believe the intention of these words was to ensure that other forms of abnormality, such as those arising from disorder or deterioration, should not be dealt with as mental defect. In many quarters, however, this purpose has not been appreciated, and the words have been interpreted literally and as meaning the first few years of life. This restricted interpretation has been found to result in the exclusion from the Act of many persons who are unquestionably mental defectives, and for whom its provisions were intended. For instance, all with practical experience of defectives are aware that while the lower grades of idiocy and imbecility are usually recognised without difficulty in the early years of life, it is far otherwise with those suffering from the milder grades of feeble-mindedness. In many of these the deficiency may not reveal itself until towards the end of the first decade, or even not until adolescence. Again, it is by no means uncommon for mental defect to be brought about at these later Common ages by injury or disease of the brain. examples of this occur in the various forms of meningitis and encephalitis, as well as the arrest of mental development induced by epilepsy. During the past few years some hundreds of children have been rendered mentally defective by encephalitis lethargica ; but, as the original definition stood, it was found impossible in many cases to deal with these as defectives and to secure their admission to institutions under the Act, although such institutions might afford the most suitable form of treatment. In the Act of 1927 the words " from birth or from an early age " are deleted, and there is given for the first time a definition of mental defectiveness-viz., " a condition of arrested or incomplete development of mind existing before the age of 18 years, whether arising from inherent causes or induced by disease or injury." This definition must, of course, be read in conjunction with those of the four classes of defectives which precede it ; but there is no doubt that the changes will go a long way towards remedying the difficulties we have alluded to, as well as towards making clear who are, and who are not, defectives. As the circular points out, the essential criterion of mental defect is not a defect of intellectual capacity, as this term is usually understood ; for mental defect may exist in persons of considerable intellectual capacity. It is an incapacity for efficient social
adaptation of such kind and degree as to render the person in need of care, supervision, and control. A person who suffers from any defect of mind, arising before the age of 18 years, which is sufficient to necessitate external care is a mental defective within the meaning of the Act. It may be pointed out that the designation of the fourth class has been changed from moral imbeciles to moral defectives, and that the words " on which punishment has had little or no deterrent effect " have been deleted from the definition of this class. No doubt this change will be an advantage ; indeed, we are inclined to regard it as somewhat unfortunate that the opportunity was not also taken to redraft the definition of ordinary imbeciles. They are still defined as " incapable of managing themselves or their affairs "-a perfectly true definition, but one which conveys a somewhat misleading view of the marked incapacity of this class. The remaining sections of the Act to which the circular draws attention are either drafting amendments or administrative changes. The most important of these may be briefly referred to. Although the principal Act permitted parents in a position to pay fees to place their defective children in suitable institutions, it made no provision for such as were unable to pay fees to do this, unless it could be showed that these children were " neglected, abandoned, or without visible means of support, or cruelly treated." This was found to be a hardship, and it is now remedied by allowing such children to be dealt with on the representation of their parents or guardians to the local authority that they are in need of care or training which cannot be provided in their homes. Another disadvantage existed in the case of children about to be discharged from special schools. These pass out of the jurisdiction of the local education authority at the age of 16 years, and, if their supervision is to be continued, they must be notified to the local (control) authority. But the education authority has hitherto only been empowered to do this in the case of children needing to be sent to institutions or placed under guardianship. In many cases neither of these courses is necessary ; all that is needed is supervision, and Section 2 of the Act now enables the child to be notified for this purpose. The circular draws attention to the difficulty which has sometimes been experienced in the case of mental defectives coming before the courts. The court is empowered to direct that a be petition presented to have the defective sent to an institution ; but where it has been impracticable to do this, or where the petition has been dismissed, there has hitherto been no provision for the detention of the person until the case could be suitably disposed of by the court. Section 5 provides the machinery necessary for this purpose. Section 7 of the Act imposes a new obligation upon local authorities. Hitherto they have only been required to provide suitable training for defectives in institutions ; they now have the duty of providing this for defectives who are under guardianship or supervision. They may, however, be relieved of this obligation if they satisfy the Board of Control that there are adequate reasons for exemption. Hitherto local authorities have only been able to receive into their own certified institution patients from their own area ; the Act now enables them to receive those from any other local authority, and this is a provision which may be of decided advantage to small authorities, who will thereby be enabled to board out their cases until such time as they caii provide their own accommodation. While the amendments and additions to the Act, to which this circular directs attention, will be of especial concern to local authorities and to medical men holding
404
official posts,
of the changes, particularly those of importance to the medical profession as a whole. The time has arrived when few general practitioners can afford to be without an adequate working knowledge of mental defect in its relation to education, conduct, and citizenship. It is quite certain that more general use might be made of the course of instruction arranged by the London University Extension Board in cooperation with the Central Association for Mental Welfare, and intended primarily for medical men holding official positions. The course is based on the requirements of the syllabus for the University diploma in psychological medicine. Series of lectures will be given by Dr. A. F. TREDGOLD, Dr. F. C SHRUBSALL, Prof. CYRIL BURT, and Dr. NORWOOD EAST, and the clinical work will include visits to special schools and residential institutions. A certifidate of attendance is granted. The next course will be held from May 14th-19th at the University, Imperial Institute-road, South Kensington, and communications in regard to it should be addressed to Miss EVELYN Fox, University Extension Department, at that address.
definition,
some
are
of
Annotations. "
Ne quid nimis."
TESTIMONIAL TO SIR DAWSON WILLIAMS. ALLUSION was made recently in these columns to an admirable intention to present a testimonial to Sir Dawson Williams, who lately retired from the Editorship of the British Aledical Journal, after 30 years in that position and nearly 50 years close connexion with the editorial work of the paper. There is a widespread feeling that the occasion should not pass without some recognition, from the profession as a whole, of his long and distinguished services to the science and practice of medicine. We understand that it is accordingly proposed to issue a general appeal and to send to the medical press a first list of supporters for publication on March 10th. Those wishing to be included in this list are invited to send their contributions, not later than March 3rd, to Sir StClair Thomson, who has been asked by the provisional Executive Committee to act as honorary treasurer. Though the Committee does not wish to limit the amount of individual donations, it hopes that the sum eventually received will include a large number of contributions of two guineas or less and so represent the profession generally. Cheques should be made payable to Sir StClair Thomson and sent to 64, Wimpole-street, London, W. 1, and the envelopes marked " Dawson
Williams Testimonial."
again the importance of a contaminated water-supply in the spread of this disease. Among the 8000 inhabitants supplied with filtered water there were only eight cases of cholera, whereas among the remainder, numbering 22,000, whose water-supply was not filtered, there were 273 cases. According to a short note addressed to the Office International by Dr. Djavad Asthiany, the epidemic was suppressed by Oct. 25th, thanks to the provision of sanitary cordons and vaccination. More than 40 per cent. of the inhabitants in the infected towns and the adjoining areas were vaccinated, a supply of vaccine sufficient for 700,000 doses having been provided. Dr. Thomson notes that, although much importance was attached to vaccination, sanitary cordons were found to be necessary, and the movements of nonvaccinated persons on the principal lines of communication were strictly regulated. The total number of cases notified up to Nov. 5th in Iraq was 1038, among which there were 756 deaths. Two new lines of communication have now to be considered in connexion with any outbreak of cholera in Iraq. The first is the air route from Cairo to Basra by Palestine and Baghdad. The weekly aeroplane takes 12 hours from Cairo to Baghdad and 27 hours from Cairo to Basra, for it does not fly by night. When this route has been extended to Karachi, a traveller from an infected centre in India may, in three and a half days, find himself on board ship at Port Said. The other new line of communication is the motor-car route between Baghdad and Beirut, via Damascus. The journey takes only 29 hours, and the traffic on this route is increasing continuously. About 200 travellers pass this way every week, and in 1926 about 2000 pilgrims made use of it to reach Jeddah. These two new routes and the discovery of oil in Iraq give point to the remark recently made that Iraq has ceased to be oriental and has come to be part of Europe. It is fortunate that with these extended facilities for the transmission of disease there should be an effective quarantine network at points of landing. The medical authorities in Syria control the motor traffic, of which Damascus is a centre, and the aerial traffic is under strict medical supervision in Palestine and Egypt. In order not to hamper the development of these new lines of communications, the medical authorities in Egypt intend to make sanitary restriction as light as possible compatible with safety. Travellers coming from infected regions, reaching Egypt by aeroplane, and wishing to catch boats bound for European ports, may continue their journey without observation or quarantine at the aerodrome, provided they can show that they have received two injections of a cholera vaccine, the second of which was given at least six days earlier, and provided also that they look quite well. The medical officer of the ship by which they travel from Egypt must be told where they came from. ____
GAIT, NORMAL AND ABNORMAL. CHOLERA IN IRAQ. EVER since the days of the brothers Weber, whose THE epidemic of cholera which broke out in Iraq in the summer of 1927 gave an opportunity to test book on the human mechanism was published more the efficiency of prophylactic inoculation, of measures than 90 years ago, physiologists and surgeons have for the purification of the drinking-water, and of from time to time made attempts to analyse and the working of quarantine restrictions. Happily full record the movements of the body and limbs in locomotion. Some of these attempts havebeen fairly use was made of this opportunity, as may be seen from the report1 of Dr. C. P. Thomson, president successful, especially since instantaneous photography of the Egyptian Conseil Sanitaire. On July 20th has come to the observer’s aid, but the practical value the medical officer of health of Basra observed of the records] has been small. During the war a elaborate and efficient cinematographic apparatus two suspicious cases, and several were found at the was constructed in the experimental workshop of the same time at Abbadan, but it was not till July 23rd that a bacteriological diagnosis was made. It says Ministry of Pensions and excellent photographic charts much for th3 promptness of the medical officers were obtained of normal gait and also of the gait of a concerned that travellers who had left the infected area man wearing an artificial limb. These records were on the morning of the 23rd were received on the morning described and commented on by Mr. R. C. Elmslie in of the following day at the aerodrome in Cairo with a paper published in the St. Bartholomew’s Hospital unusual attention by its quarantine medical officers. J ournal,I and the charts and photographs were reproThe epidemic in Abbadan served to demonstrate once duced by Mr. Muirhead Little in his book on Artificial Limbs. Excellent as these photographs and tracings 1 Office International d’Hygiène Publique, Bulletin, vol. xix., 1 2 1922 (H. K. Lewis). September, 1920. No. 11.
very