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English Mental Care through American Eyes
309
physical restraint (he saw leather cuffs, such as are used in Americatoday, exhibited with chains and manacles as relics of an archaic age) ; by the general use of occupational therapy ; and by the fact that our mentally sick are looked after by nurses, trained or in and not by attendants. On the last he have fully realised the difference not point may LONDON:SATURDAY, FEB. 19, 1949 between State registration and the certificate of the Royal Medico-Psychological Association. Since the certificate was withdrawn, the mental section of the State register has offered the only qualification American Eyes Mental Care open to mental nurses ; and it may be that fewer RECENT books by former patients have given a mental nurses will take this than were wont to take discouraging account of life in public mental hos- the R.M.P.A. examination. In the coming years pitals,l and we publish this week the rather unhappy this may result in a fall in the number of " trained " experiences of a doctor who entered a private hospital mental nurses, and a rise in the proportion of assistant as a voluntary patient. But if there is much room for and part-time nurses-without any change whatever improvement here, it seems that conditions are, in the type of men and women undertaking the work. to say the least, no better in -many of the State Dr. PRATT also approved the continuous superin America. An article in in vision of our mental hospitals by the Board of Control, Life, early hospitals 1946, carried photographs of patients in such hospitals their small size compared with American hospitals, who appeared much neglected : and the story told the low two-story buildings, the self-contained by a former attendant in two State mental hospitals2 admission units, the high proportion (54-2% of is a painful description of the humiliations and hardadmissions in 1946) of voluntary patients, the ship which patients often suffer, and the inhumanity adequacy of linen and bedding, the individual look of engendered in those employed to care for them. patients’ clothing, the widespread use of physical Dr. DALLAS PRATT, who in 1947, on behalf of the therapies, and the many outpatient clinics attached American National Mental Health Foundation, made to mental hospitals. No less than 15 of the J6 were a survey 3 of 16 English public mental hospitals, running their own outpatient clinics, staffed by the thought our standards, on the whole, much better hospital psychiatrists. Some of these clinics were than those in the United States--despite the high held in the mental hospitals -themselves, but more level of care in such famous American hospitals as were-held in the general hospital of the area. Some the Phipps Clinic and the Institute of Living. hospitals were running several clinics-thus Mapperley Since Dr. PRATT’s aim was to indicate practices has nine, Warlingham Park three, and Netheme that backward State hospitals might usefully follow, reported 4000 - outpatient sessions during - the year. he dwells more freely on our highlights than our In 1943, when Dr. C. P. BLACKER made his neurosis black spots ; but it is encouraging to learn there are survey, there were 216 psychiatric clinics in England enough of these to strike a stranger’s eye. His and Wales, all but 66 of them being based on mental experience was not confined to our best hospitals hospitals. This gave 1 clinic to every 170,000 (though these formed a large proportion of the 16);. people, which Dr. PRATT compares with 688 clinics he deliberately visited 4 of " less progressive type," in the United States, in 1946, or 1 clinic to every of which 2 were definitely backward. From informa204,000 people. Such clinics, he notes, benefit the tion given him, he graded the 101 mental hospitals mental hospitals themselves, since they bring the in England and Wales as: " progressive," less than staff face to face with the community’s need for a quarter; backa better mental-health service, and stimulate them "average," more than half; ward," a quarter. Judged by the same standard, to provide it. he thinks that half to three-quarters of American Against these compliments must be set some State hospitals could be classed as backward, and that adverse findings. One of the 16 superintendents was most of the rest are average ; " very few indeed can " opposed in principle " to occupational therapy, be considered progressive." It would be interesting saying that enough occupation was provided iri his to know the information on which this grading was hospital by the " clipping of hedges, the carting away made. We cannot call to mind any official report of rubbish, and the digging of holes." This habit of giving the necessary data, and it seems likely that it regarding the patient as a form of cheap labour for was founded on impressions of members of the Board the use of the hospital is most undesirable., In the of Control, or on material available to them. If so, better hospitals it is recognised that if occupation our own medical profession would welcome the is to be used as a remedv it must serve the needs of to the needs of the hospital opportunity to share the information given to the patient, in Dr. PRATT. administrator. Dr. PRATT also found that some He was particularly impressed by the fine grounds, county councils are inefficient and unduly hampered freely used by patients, which surround many of our by red tape, and that some poor areas have mainmental hospitals;boy the curtains, flowers, and tenance-rates which are too low-though even the unbarred windows which give a pleasant atmosphere lowest, he says, are more than double the lowest to wards and day-rooms, regardless of whether they rates in the U.S.A., and the average is about half as house quiet or disturbed patients ; by the absence of much again as the American average. He was writing before the National Health Service was 1. Lancet, 1947, ii, 880. 2. Orlansky, H. Politics, 1948, no. 3, p. 162, launched ; under it, these economic differences 3. Published by the Foundation, 1520, Race Street, Philadelphia 2, can surely be adjusted. It might even be possible, on U.S.A. 1948. Pp. 28. $.50.
THE LANCET
English
training,
through
0"
preference
310 some grant-giving plan, to encourage backward of the total haemoglobin which is formed by oxyhospitals to bring their standards up to those of the hsemoglobin can easily be calculated when these The same method is best. This is the system applied to general hospitals pigments are in solution. for Fund and with less Edward’s London, by King Hospital applicable, though accuracy, to whole blood, it has been singularly effective, over a period of years, and SQUIRE2 applied the device to transilluminated in persuading the laggards to modernise their kitchens, This device was further developed by living tissues. 3 nurses’ increase the MILLIKAN GOLDIE and their quarters, improve staffing 4 during the late war, when it of their almoner’s departments, or take other welcome found a special place in the study of the reactions of steps towards perfection. Mental hospitals work so airmen exposed to low oxygen pressures. The impetus much in isolation, each a little cosmos under a senior of these technical advances is now being felt in officer whose word is law, that they have few chances ordinary clinical investigation. The oximeter, as the of emulating one another. A grant-giving body apparatus is called, is being increasingly used in the such as the King’s Fund could help them -to develop United States...It consists of an ear unit fitting over a spirit of healthy rivalry. the pinna, with an electric bulb in front and a photoDr. PRATT was also disappointed with some of our electric cell behind. The heat generated by the bulb mental hospital equipment, notably the X-ray plant, dilates the vessels of the ear and increases the bloodand The last flow accommodation. laboratories, lavatory sufficiently to make the ear blood equal in he found to be inadequate Jn some mental hospitals oxygen content to the arterial blood. Galvanometers surely a serious indictment at a time when the wards connected. to the instrument indicate the amount of He also finds us more light transmitted by the ear, and hence the oxygen are notoriously overcrowded. saturation of arterial blood can be estimated. prone to give physical than psychiatric treatment to the mentally ill, and was a little dubious of the The method, however, is not yet completely accurate use made of sedation in one of the hospitals he visited. when used in this way, as Beer’s law relating to will the patients who have be remembered that (It optical density of translucent solutions cannot apply written books on life inside our mental hospitals exactly to whole blood in tissues. Thick ears and agree in thinking that sedation is often used for the thin ears add to the variables. The method has an convenience of the nurses rather than the benefit .error of 3-7% in absolute readings. But it reveals of the patients.) Finally, Dr. PRATT observed that the changes in a patient’s oxygen saturation much more psychiatrists, nurses, occupational therapists, and exactly. In a normal person the arterial blood is social workers attached to our mental hospitals are 95% saturated with oxygen. - If he is given oxygen too few, as we well know. Thus the picture is in to breathe the oximeter reading will rise about 5% some respects imperfect even to the eye of the kindly as the haemoglobin becomes fully saturated. This visitor. But the number of mental hospitals in the forms the basis of an informative test. whole country is so small that it should not be beyond By observing these oximeter responses GODFREY us to make them an absolute credit to the great and his colleagues5 have obtained some useful clinical data. A rise of more than 5% in the arterial oxygen pioneers of humane treatment for the mentally sick. saturation indicates previous subnormal saturation. The Oximeter In patients with congestive heart-failure the oximeter THE theoretical basis of cyanosis is now well response to oxygen breathing was usually about understood. Oxyhaemoglobin is bright red, while 10-15%, showing a definite but moderate degree of reduced haemoglobin is darker and bluer. It is the The arterial unsaturation (85-90% saturated). undue preponderance of reduced haemoglobin in the response of patients with primary pulmonary disease skin capillaries that makes some people look purple was mixed. Sometimes there was a remarkable or blue. The blueness may result from imperfect in arterial saturation on breathing oxygen improvement oxygenation of the blood leaving the left heart. oxygen=in one case + 27 %-but sometimes the This, in turn, is consequent on defective oxygenation response was relatively small, possibly because the in the lungs or even partial bypassing of the blood was continuing to flow through completely lungs, as in congenital heart disease, and is called unaerated parts of the lungs, so that even oxygen cyanosis of central origin. In peripheral cyanosis, on inhalation could not correct the deficiency. Similarly the other hand, the blueness results entirely from a poor responses would be expected in the blue forms local disturbance of the circulation, with sluggish of congenital heart disease, where blood is shunted blood-flow and excessive removal of oxygen by the from the right to the left side without going through tissues from the relatively stagnant blood. Hitherto the lungs at all. A further report by GROOM et a1.6 the clinical differentiation of the two types has been shows how the oximeter can be adapted for use with based simply on appreciation of their existence cardiac catheter studies in obscure congenital heart combined with shrewd guess-work. Examination of disorders. The exploration of such hearts by this a sample of arterial blood will often decide, but many technique is no easy matter, and an immediate clinicians hesitate to adopt this procedure, and in approximation to the oxygen saturation of blood drawn from various positions within the heart is of any case the prompt analysis of samples for their immense value to the investigator. The Mayo Clinic gas content requires laboratory facilities which are not found in every hospital. investigators simply draw blood back through a The possibility of using optical methods for transilluminated polythene tube, the light falling on estimating the degree of oxygen saturation of arterial an oximeter cell. This permits immediate recognition blood has been recognised for at least fifteen years.l 2. Squire, J. R. Clin. Sci. 1940, 4, 331. Goldie, E. A. J. sci. Instrum. 1942, 19, 23. Oxyhaemoglobin transmits red light more readily 4.3. Millikan, G. A. Rev. sci. Instrum. 1942, 13, 434. than reduced haemoglobin does, and, by using a photo5. Godfrey, L., Pond, H. S., Wood, F. C. Amer. J. med. Sci. 1948, 216, 605. electric cell with appropriate filters the percentage 6. Groom, D., Wood, E. H., Burchell, H. B., Parker, R. L. Proc. ,
1.
Kramer, K.
Z. Biol. 1934, 95, 126.
Mayo Clin. 1948, 23, 601.
physical restraint (he saw leather cuffs, such as are used in Americatoday, exhibited with chains and manacles as relics of an archaic age) ; by the general use of occupational therapy ; and by the fact that our mentally sick are looked after by nurses, trained or in and not by attendants. On the last he have fully realised the difference not point may LONDON:SATURDAY, FEB. 19, 1949 between State registration and the certificate of the Royal Medico-Psychological Association. Since the certificate was withdrawn, the mental section of the State register has offered the only qualification American Eyes Mental Care open to mental nurses ; and it may be that fewer RECENT books by former patients have given a mental nurses will take this than were wont to take discouraging account of life in public mental hos- the R.M.P.A. examination. In the coming years pitals,l and we publish this week the rather unhappy this may result in a fall in the number of " trained " experiences of a doctor who entered a private hospital mental nurses, and a rise in the proportion of assistant as a voluntary patient. But if there is much room for and part-time nurses-without any change whatever improvement here, it seems that conditions are, in the type of men and women undertaking the work. to say the least, no better in -many of the State Dr. PRATT also approved the continuous superin America. An article in in vision of our mental hospitals by the Board of Control, Life, early hospitals 1946, carried photographs of patients in such hospitals their small size compared with American hospitals, who appeared much neglected : and the story told the low two-story buildings, the self-contained by a former attendant in two State mental hospitals2 admission units, the high proportion (54-2% of is a painful description of the humiliations and hardadmissions in 1946) of voluntary patients, the ship which patients often suffer, and the inhumanity adequacy of linen and bedding, the individual look of engendered in those employed to care for them. patients’ clothing, the widespread use of physical Dr. DALLAS PRATT, who in 1947, on behalf of the therapies, and the many outpatient clinics attached American National Mental Health Foundation, made to mental hospitals. No less than 15 of the J6 were a survey 3 of 16 English public mental hospitals, running their own outpatient clinics, staffed by the thought our standards, on the whole, much better hospital psychiatrists. Some of these clinics were than those in the United States--despite the high held in the mental hospitals -themselves, but more level of care in such famous American hospitals as were-held in the general hospital of the area. Some the Phipps Clinic and the Institute of Living. hospitals were running several clinics-thus Mapperley Since Dr. PRATT’s aim was to indicate practices has nine, Warlingham Park three, and Netheme that backward State hospitals might usefully follow, reported 4000 - outpatient sessions during - the year. he dwells more freely on our highlights than our In 1943, when Dr. C. P. BLACKER made his neurosis black spots ; but it is encouraging to learn there are survey, there were 216 psychiatric clinics in England enough of these to strike a stranger’s eye. His and Wales, all but 66 of them being based on mental experience was not confined to our best hospitals hospitals. This gave 1 clinic to every 170,000 (though these formed a large proportion of the 16);. people, which Dr. PRATT compares with 688 clinics he deliberately visited 4 of " less progressive type," in the United States, in 1946, or 1 clinic to every of which 2 were definitely backward. From informa204,000 people. Such clinics, he notes, benefit the tion given him, he graded the 101 mental hospitals mental hospitals themselves, since they bring the in England and Wales as: " progressive," less than staff face to face with the community’s need for a quarter; backa better mental-health service, and stimulate them "average," more than half; ward," a quarter. Judged by the same standard, to provide it. he thinks that half to three-quarters of American Against these compliments must be set some State hospitals could be classed as backward, and that adverse findings. One of the 16 superintendents was most of the rest are average ; " very few indeed can " opposed in principle " to occupational therapy, be considered progressive." It would be interesting saying that enough occupation was provided iri his to know the information on which this grading was hospital by the " clipping of hedges, the carting away made. We cannot call to mind any official report of rubbish, and the digging of holes." This habit of giving the necessary data, and it seems likely that it regarding the patient as a form of cheap labour for was founded on impressions of members of the Board the use of the hospital is most undesirable., In the of Control, or on material available to them. If so, better hospitals it is recognised that if occupation our own medical profession would welcome the is to be used as a remedv it must serve the needs of to the needs of the hospital opportunity to share the information given to the patient, in Dr. PRATT. administrator. Dr. PRATT also found that some He was particularly impressed by the fine grounds, county councils are inefficient and unduly hampered freely used by patients, which surround many of our by red tape, and that some poor areas have mainmental hospitals;boy the curtains, flowers, and tenance-rates which are too low-though even the unbarred windows which give a pleasant atmosphere lowest, he says, are more than double the lowest to wards and day-rooms, regardless of whether they rates in the U.S.A., and the average is about half as house quiet or disturbed patients ; by the absence of much again as the American average. He was writing before the National Health Service was 1. Lancet, 1947, ii, 880. 2. Orlansky, H. Politics, 1948, no. 3, p. 162, launched ; under it, these economic differences 3. Published by the Foundation, 1520, Race Street, Philadelphia 2, can surely be adjusted. It might even be possible, on U.S.A. 1948. Pp. 28. $.50.
THE LANCET
English
training,
through
0"
preference
310 some grant-giving plan, to encourage backward of the total haemoglobin which is formed by oxyhospitals to bring their standards up to those of the hsemoglobin can easily be calculated when these The same method is best. This is the system applied to general hospitals pigments are in solution. for Fund and with less Edward’s London, by King Hospital applicable, though accuracy, to whole blood, it has been singularly effective, over a period of years, and SQUIRE2 applied the device to transilluminated in persuading the laggards to modernise their kitchens, This device was further developed by living tissues. 3 nurses’ increase the MILLIKAN GOLDIE and their quarters, improve staffing 4 during the late war, when it of their almoner’s departments, or take other welcome found a special place in the study of the reactions of steps towards perfection. Mental hospitals work so airmen exposed to low oxygen pressures. The impetus much in isolation, each a little cosmos under a senior of these technical advances is now being felt in officer whose word is law, that they have few chances ordinary clinical investigation. The oximeter, as the of emulating one another. A grant-giving body apparatus is called, is being increasingly used in the such as the King’s Fund could help them -to develop United States...It consists of an ear unit fitting over a spirit of healthy rivalry. the pinna, with an electric bulb in front and a photoDr. PRATT was also disappointed with some of our electric cell behind. The heat generated by the bulb mental hospital equipment, notably the X-ray plant, dilates the vessels of the ear and increases the bloodand The last flow accommodation. laboratories, lavatory sufficiently to make the ear blood equal in he found to be inadequate Jn some mental hospitals oxygen content to the arterial blood. Galvanometers surely a serious indictment at a time when the wards connected. to the instrument indicate the amount of He also finds us more light transmitted by the ear, and hence the oxygen are notoriously overcrowded. saturation of arterial blood can be estimated. prone to give physical than psychiatric treatment to the mentally ill, and was a little dubious of the The method, however, is not yet completely accurate use made of sedation in one of the hospitals he visited. when used in this way, as Beer’s law relating to will the patients who have be remembered that (It optical density of translucent solutions cannot apply written books on life inside our mental hospitals exactly to whole blood in tissues. Thick ears and agree in thinking that sedation is often used for the thin ears add to the variables. The method has an convenience of the nurses rather than the benefit .error of 3-7% in absolute readings. But it reveals of the patients.) Finally, Dr. PRATT observed that the changes in a patient’s oxygen saturation much more psychiatrists, nurses, occupational therapists, and exactly. In a normal person the arterial blood is social workers attached to our mental hospitals are 95% saturated with oxygen. - If he is given oxygen too few, as we well know. Thus the picture is in to breathe the oximeter reading will rise about 5% some respects imperfect even to the eye of the kindly as the haemoglobin becomes fully saturated. This visitor. But the number of mental hospitals in the forms the basis of an informative test. whole country is so small that it should not be beyond By observing these oximeter responses GODFREY us to make them an absolute credit to the great and his colleagues5 have obtained some useful clinical data. A rise of more than 5% in the arterial oxygen pioneers of humane treatment for the mentally sick. saturation indicates previous subnormal saturation. The Oximeter In patients with congestive heart-failure the oximeter THE theoretical basis of cyanosis is now well response to oxygen breathing was usually about understood. Oxyhaemoglobin is bright red, while 10-15%, showing a definite but moderate degree of reduced haemoglobin is darker and bluer. It is the The arterial unsaturation (85-90% saturated). undue preponderance of reduced haemoglobin in the response of patients with primary pulmonary disease skin capillaries that makes some people look purple was mixed. Sometimes there was a remarkable or blue. The blueness may result from imperfect in arterial saturation on breathing oxygen improvement oxygenation of the blood leaving the left heart. oxygen=in one case + 27 %-but sometimes the This, in turn, is consequent on defective oxygenation response was relatively small, possibly because the in the lungs or even partial bypassing of the blood was continuing to flow through completely lungs, as in congenital heart disease, and is called unaerated parts of the lungs, so that even oxygen cyanosis of central origin. In peripheral cyanosis, on inhalation could not correct the deficiency. Similarly the other hand, the blueness results entirely from a poor responses would be expected in the blue forms local disturbance of the circulation, with sluggish of congenital heart disease, where blood is shunted blood-flow and excessive removal of oxygen by the from the right to the left side without going through tissues from the relatively stagnant blood. Hitherto the lungs at all. A further report by GROOM et a1.6 the clinical differentiation of the two types has been shows how the oximeter can be adapted for use with based simply on appreciation of their existence cardiac catheter studies in obscure congenital heart combined with shrewd guess-work. Examination of disorders. The exploration of such hearts by this a sample of arterial blood will often decide, but many technique is no easy matter, and an immediate clinicians hesitate to adopt this procedure, and in approximation to the oxygen saturation of blood drawn from various positions within the heart is of any case the prompt analysis of samples for their immense value to the investigator. The Mayo Clinic gas content requires laboratory facilities which are not found in every hospital. investigators simply draw blood back through a The possibility of using optical methods for transilluminated polythene tube, the light falling on estimating the degree of oxygen saturation of arterial an oximeter cell. This permits immediate recognition blood has been recognised for at least fifteen years.l 2. Squire, J. R. Clin. Sci. 1940, 4, 331. Goldie, E. A. J. sci. Instrum. 1942, 19, 23. Oxyhaemoglobin transmits red light more readily 4.3. Millikan, G. A. Rev. sci. Instrum. 1942, 13, 434. than reduced haemoglobin does, and, by using a photo5. Godfrey, L., Pond, H. S., Wood, F. C. Amer. J. med. Sci. 1948, 216, 605. electric cell with appropriate filters the percentage 6. Groom, D., Wood, E. H., Burchell, H. B., Parker, R. L. Proc. ,
1.
Kramer, K.
Z. Biol. 1934, 95, 126.
Mayo Clin. 1948, 23, 601.