HOSPITAL TREATMENT V. LUNACY TREATMENT.

569

HOSPITAL TREATMENT V. LUNACY TREATMENT.

Correspondence. "Audi alteram

To the Editor of THE LANCET.

partem."

SIR,-The difficulty of getting alienists to address COMBATANT themselves to the real problem of the hospital treatment of preventable cases in mental disorder is well COMMISSIONS. illustrated by the correspondence upon the subject the Editor of THE LANCET.

STUDENTS AND

MEDICAL

To

appearing

in your issue of

July 31st. The question

SIR,-The following are extracts from a letter I of treatment is not at issue. It is one of policyhave just received from a medical student on the viz., the classification of mental cases into two above subject :great divisions, preventable on the one hand, and "II am writing on behalf cf my fellow-students to thank confirmed or dangerous on the other. To the you for all the trouble you have taken. We feel somewhat alienist the ideal is to bring within his scope surprised at the reply you have received from the War Office ; the whole field of mental disorder. Early and for there is

demand

for medical

both

men, greater cases inspire him. He is conscious military and civil, than there has ever been before, and unless preventable the usual supply of students is kept up I fail to see how they of his service and power when such cases are He ignores the will be obtained, for the longer the war lasts and the larger brought to him for treatment. a

now

army becomes the more urgent will be the call for medical men. One has to bear in mind that a doctor cannot be trained under five years, so that when those who are now in their final years are qualified there will be a scarcity for some years to come unless the supply of students is

our

kept up." The hospitals are now urgently in want of senior students to fill the posts of those who have just become qualified." In the army we deal with men by the million, so surely the few hundred men who are now engaged studying in different parts of the country for the medical profession would be far more useful if they continued with their own work rather than waste two or three years of their training, for the doctor is quite as essential for the welfare of this country as the soldier or sailor, and, like the latter, the medical profession must have recruits." "

"

The foregoing appears to me to put the case very clearly and logically. The Government have admitted the mistake they made in the early days of the war in allowing munition workers to proceed to the front. To-day’s papers announce that they are taking measures to prevent a repetition of this mistake in the case of skilled agricultural labourers. Surely the same applies with equal, or even greater, force to those who are to fill the ranks of the medical profession. In your leading article this week you point out the increasingly numerous ways in which medical men be of service to the State and to the fact that their numbers are already disquietingly low.

can

I am,

Sir,

yours

faithfully, W. D. HALLIBURTON.

King’s College, London, August 27th, 1915.

THE

REGISTRATION OF CANADIAN MEDICAL PRACTITIONERS. To the Editor of THE LANCET.

directed to state that Part II. of the SIR,-I Medical Act, 1886, has by an Order of His Majesty in Council, dated August 12th, been extended to the Province of Ontario. I am, therefore, in a position am

to inform you of the terms of the resolution by the Executive Committee as follows :-

passed

’’ That any person who holds the Licence or Membership of the College of Physicians and Surgeons of Ontario, granted after examination in medicine, surgery, and midwifery, together with the licence to practise in the Province, shall be entitled to be registered in the Colonial List of the Medical Register," provided he satisfies the Registrar regarding the other particulars set forth in Part II. of the Medical Act, 1886. Degrees in medicine granted by the Queen’s University, the Western University, and the University of Toronto may also be registered as additional titles provided they are registered in Ontario. I am, Sir, yours faithfully, NORMAN C. KING, Registrar. General Council of Medical Education and Registration of the United Kingdom, Oxford-street, W., August 27th, 1915.

very essential fact that to every case, whether

early or late, which he treats in an asylum he adds the stigma of insanity. If it were not for this there would be no problem to face. The ’question is, How can early and preventable cases be dealt with without branding the patient and saddling him with a disability that must remain with him for life, and even be handed down to his posterity ? The popular test of insanity is commitment to an asylum. " He has been in an asylum," " His mother was in an asylum," " His father was in an asylum," are the popular phrases by which the stigma is expressed, and to this comment upon an inmate, however brief his detention may have been or trivial his mental disorder, there is no possible reply or explanation to satisfy the popular mind. It is already a notorious fact that a far larger proportion of our soldiers in the field are suffering from nerve-wrack and mental shock than in any preceding war. It is equally notorious, happily, that these symptoms are generally temporary and capable of complete removal by appropriate treatment. It would be a cruel wrong to brand any recoverable case with the stigma to which I have referred, and, in addition, to weaken his chance of employment in the future. Now the problem before the War Office is how to treat these soldiers without contact, either in appearance or in reality, with any institution associated with lunacy or even with mental experts whose treatment of the case, or whose management of the institutions to which these soldiers are sent, may justify in the popular mind the painful association that an asylum entails. I have said that the ideal of the alienist to bring all classes of mental disorder within his purview. The ideal for which a large number of Members of the House of Commons. and many outside the House who are associated with them, stand is entirely opposed to this. It involves little or no change of treatment. It is a question of administrative policy. In this ideal two domains are recognised in the field of mental disorder, the Hospital domain and the Asylum domain. The characteristics of the former are the characteristics of any special department in general

is

hospital practice-voluntary admission, voluntary residence, early and preventive treatment by medical specialists, absence of repugnance to patient or friends, and freedom from all suspicion of stigma. The characteristics of the asylum domain are: the strictest safeguards against unnecessary internment such as are implied in legal certification, compulsory incarceration and detention, and the inevitable and ineradicable stigma associated with the painful of compulsory detention and loss of liberty.

facts

570 Now between t]4ese two domains, according to this artificial circulation the blood-vessels (without view, there is a great gulf fixed. They should be distinguishing between the arteries and veins) kept separate and distinct; and rarely, if ever, contract when the blood is well arterialised and should an alleged lunatic be committed to an dilate when it is venous. In some experiments asylum until he has passed through, and not which I made on the circulation of the blood through profited by, preventive treatment in the hospital the liver I was able to confirm these statements. domain. As I there said,1 "Sometimes the blood would flow A very grave difficulty at present exists in the very easily through the liver, would, indeed, pour absence of such a hospital alternative. At present, out from the hepatic vein in a full stream, as if no when a person suspected of mental disorder is obstacle whatever had been presented to its flow being examined, the examining physician must through the hepatic capillaries. At other times, either certify insanity or freedom from insanity. however, the flow would be slow and scanty, the If he certifies insanity and the patient is com- blood evidently meeting with great resistance in mitted, the doctor accepts the grave responsibility the capillaries. These two conditions were someof adding to that person and even to his posterity times found in the same liver at different periods of the stigma of insanity. If, on the other hand, he the experiment, and they appeared to depend to a certifies freedom from insanity, he accepts perhaps considerable extent upon the quality of the blood which was circulating." That the veins have a a graver responsibility-that of giving a person his who It commit suicide or homicide. very considerable contractile power is at once might liberty is not uncommon for the doctor to accept the lesser evident if one looks at one’s own hands, for responsibility and certify a doubtful or difficult sometimes they are small, contracted, and almost If a third alternative existed, and a patient disappear, while at others they are full and case. could be received into a preventive hospital for turgid. It is when there is backward pressure diagnostic observation and treatment there is not on the venules from such conditions as mitral conthe slightest doubt that a large number now certified striction or mitral regurgitation, that the veins become most swollen and cyanosis appears, though as insane would be given the advantages which such a scheme would provide. If hospital provision both the cyanosis and bulbar condition of the such as I have described existed, the area of certi- fingers are more marked in congenital than in fiability wopld be immediately diminished, and a acquired heart disease. The relaxation of veins large number would escape detention and escape must not be dismissed, because the vena cava and also the stigma attached to it. Asylums would pulmonary veins have both an independent power then be relegated to their proper function of of rhythmical contraction, and it is complete relaxaproviding for confirmed or dangerous cases, and tion of the walls of the vena cava and its tributaries which cause the complete failure of circulation our best alienists would come into the hospital domain, enjoy the status, and do the very excellent and consequent death in Goltz’s well-known experikind of work that is now done by the specialists in ments on shock. The subject is, however, so important and so For this our other great hospital departments. that both I and others will be very glad difficult the of detachment hospital sphere complete from the asylum sphere in the treatment of indeed if Dr. Harry Campbell will bring forward those suffering from mental disorder many his arguments in favour of venular spasm. I am, Sir, yours faithfully, Members in the House of Commons have been LAUDER BRUNTON. and for some alienists can at time, contending New Cavendish-street, W., August 19th, 1915. this opportune moment serve the purpose of a great and much needed reform if they lend their aid to a scheme that will protect the most afflicted THE STERILISATION OF ALBUMINOUS of our people, and at the same time promote their CULTURE MEDIA BY ETHER. own status and usefulness. To the Editor of THE LANCET. I am, Sir, yours faithfully, SIR,-In THE LANCET of June 12th last, under W. A. CHAPPLE. House of Commons, August Hth, 1915. this heading, we published a short note upon a method we had employed for sterilising serum for FUNCTIONAL DISEASES OF THE VEINS. culture purposes by means of ether. In your issue of July 31st Captain T. G. M. Hine, R.A.M.C., To the Editor of THE LANCET. as a at Millbank, expressed SiR,—Dr. Harry Campbell’s excellent work on himself as bacteriologist and incon" greatly disappointed blushing has given him a high place amongst the venienced " as a result of "trusting to the very authors who have studied vaso-motor phenomena. statements " in our paper. So highly do I esteem this book that I bought a positive We must confess to have read his long letter copy of it to have it constantly by me when writing with some surprise, not only because of the severity my paper on Functional Diseases of the Arteries. of the criticism which he bases a very short Any opinion that he puts forward is deserving of experience, but also because hisupon practical results the most careful consideration, and it is with much have been so different from ours. We have now used hesitation that I venture to differ from him in this method for some ten and have prepared regard to the causation of cyanosis, either localised by it many litres of sterilemonths, serum which we have used or general. and are using in large quantities for various culture I quite agree with him in believing that the whiteDuring the past few weeks we have purposes. ness of the skin, either from exposure to cold or in also made inquiries among others who have used Raynaud’s disease, is due to combined contraction the method, and we have been informed of one of the arterioles and venules, but the blueness in which sterility was not complete. instance is, I think, due to distension and not to spasm It would only appear, therefore, that Captain Hine has of the venules. I believe that the distension been unfortunate and has hastily concluded that probably depends upon a localised asphyxia of our publication was premature or ill considered. the venules. My old master, Professor Ludwig, 1 Disorders of used to say that in making experiments, with Digestion, p. 25. y

working