Mental health in relation to the family

PUBLIC HEALTH, April, 1948 work of the health department make this report easy to read and give full scope for Dr. Williams' lively style ; this is, in fact, a report with personality, and achieves, a direct contact with the local reader by speaking o f " y o u r " services, etc. Why is it that in so many areas the Annual Report is still printed in a format reminiscent of 1875 and repellent to the modem reader ? Even a large city's annual report, with its greater mass of solid statistics to present, can make its contents more palatable by good printing and layout; bu~ generally the interior text is so cluttered up with statistical tables, many of which could be relegated to appendices, as in the Barking Report, that a study of the material, however well written, is heavy going. We suspect that anything savouring of " trumpet blowing " is still repugnant to the average M.O.H., whereas this should be regarded as part of his educational function. T h e forthcoming shedding of the detailed clinical returns of cases admitted to municipal ,hospitals and sanatoria may well prove an opportunity for the M.O.H. to refurbish his pen and to return to his true task of educating public opinion by drawing attention to the successes of preventive medicine and to social factors which obstruct the attainment of health. Bronchial Carcinoma

Radio appeals, press notices, and a stream of quasi-scientific articles in the columns of the syndicated journals have focused public attention on cancer. Some colleagues must have felt the need for some additional up-to-the-minute epidemiological information on this question, and the General Register Office's Studies on Medic'al and Population Subjects No. 1--Regional and Local Differences in Cancer Death Rates, by Dr. Percy Stocks (1947)--wii1 supply the answer. It is perhaps hardly widely enough realised that the death-rate due to cancer of all sites has more than doubled in recent years. Just how far a more intelligent population, associated with highly improved diagnostic aids, is responsible for this altering picture is difficult to assess. But the remarkable feature has been that the returns from other countries, e.g., Switzerland, tell the same story, and perhaps even more astonishing is that whereas the mortality for carcinoma of the stomach and oesophagus has diminished, that for lung cancer has continued to mount. Closer examination discloses that this increase is almost wholly confined to the male sex, and in this country it would appear that the county areas of the West Riding of Yorkshire and Lancashire are among the most severely affected regions. T h e aetiology of cancer remains as perplexing as ever, apart from the accepted occupational diseases noted among chimney sweeps, mule spinners and briquette and shale workers; though to these could be added the Erzgebirge miners of Saxony, where radioactivity and arsenic appear to be implicated. Moreover, there is no evidence to suggest that bronchial carcinoma has a pronounced relation " with such social indices as low wages and overcrowding." Others have endeavoured to correlate the presence of smoky atmospheric and sunshine conditions with the increase or diminution in pulmonary carcinoma, b u t the evidence, though detailed, is not wholly convincing. Another interesting field of speculation is the degree to which chain cigarette smoking might be implicated as a predisposing factor. Whatever the aetiological and exciting causes, g r e a t e r attention must clearly .be paid to the alarming increase in the incidence of bronchial carcinoma which has risen from 29.6 to 40.7 per 100,000 between 1941 and 1945. It would appear that among the principal causes responsible for the high mortality of this condition is tardy diagnosis and an unawareness by general practitioners and public of the early inanifestations of bronchial carcinoma. As regards the former, the existing tuberculosis officers provide a cadre of available investigators. Unfortunately, in the past some tuberculosis physicians have failed to make use of ancillary diagnostic methods ~such as bronchography and bronchoscopy. There would appear to be a clear cut case for an extension of the existing Diagnostic Chest Service offered by local authorities to relieve the already grossly overtaxed resources of Thoracic Surgical Units. Early diagnosis means operability and possibly " life " ; delay makes death a certainty.

123 MENTAL HEALTH IN RELATION

TO T H E F A M I L Y

With some referenee to the National Health Service Act, 1946 ~

By C. O. STALLYBRASS,M.D., D.P.H., Deputy Medical OJficer of Health, City of Liverpool " Divinitds du Styx, Ministres de la mort, Je n'invoquerai point votre piti6 cruelle." So spoke Orpheus in the Underworld. By mental health is meant, literally, wholeness of mind. Mind and body form one individual, that is, again literally, something which cannot be divided. You may anatomise man into several pieces, but the living brain and body are but parts of a whole, each acting in accord, the body portraying the mind, and ~the mind bespeaking the body. Man may analyse the psycho but Nature's work is one of synthesis. Sir Charles Sherrington says in the preface to the latest edition of his " T h e Integrative Action of the Nervous System," that brain and m i n d are integrated together " the last and final integration." May I i n t e r p o l a t e t h a t it was within the Physiology Department of Liverpool University that he carried out those experiments which led up to that great w o r k . But whilst Sherrington's statement is physiologically true, from the standpoint of mental health there are two fktrther integrations to be performed by the individual, integration into family life and then again the individual and the family must be integrated into the larger community of the world. It is the lesson of the Peckham Health Centre that unless this final integration is carried out, mental and physical health will be imperfect. Every individual is unique alike in his inheritance and in his environment. Out of these ingredients the child, says Adler, builds u p like an artist his unique personality and style of life. Let me remind you of the physical basis of the integration of the mind and the body. T h e control of the viscera is concentrated in the floor of the raid-brain, especially in the hypothalamus. Here, or nearby, are concentrated the centres controlling the heart and vascular system, respiration and renal function--diabetes insipidus or meltitus may arise from local lesions here--and the vagus centre controlling that nerve with all its ramifications in the viscera. Hard by is the pituitary which has been termed the conductor of the endocrine orchestra. I n encephalitis lethargica, of which I have seen over 500 cases, lesions occur in the thalamus, which are accompanied by profound physical and mental disturbances. I n children the control of the higher centres of the brain over the emotions is gravely upset and the child becomes a changeling unrecognisable when comparison is made with its behaviour before the illness. I have described these children as " rudderless barques." For them, " Reason, the steersman, has forsaken the wheel and the human barque, a pitiful thing to see, goes unsteered, blown hither and thither b y every gust of emotion that arises." I have only met one of these changelings who made an adequate recovery. In the terse language of the R.A.F., they have no future. I n greater or less degree psychosomatic disease, of which I may have more to say later, is due to psychological disturbances of emotional control and the physical effects to which ~that disturbance gives origin. Heredity and Personality

T h e hereditary factor in the make-up of the personality is not, perhaps, as large as some would think it. T h e disentangling of the hereditary and the environmental can only be carried out in one way, namely, by the" study of those " identical " 7 i.e., monozygotic - - twins who have been separated since infancy. Here the heredity is the same, b u t the environment is different. Several such studies have been made by Newman" and others, and whilst the physical attributes of such " identical" twins are very closely similar, in the mental world, and more especially in regard to the personality, the influence of heredity is comparatively small. Mathematical ability, for example, appears to be much more * Paper read to the North-Western Branch of the Society of M.O.H., Liverpool, January 23rd., 1948.

124 acquired than hereditary. I n relation to mental deficiency - - a p a r t from idiocy and imbecility which have other causes-the hereditary factor is outstanding. When we come to the study of problem families, which exhibit marked departures from normal civilised standards of conduct, we find inefficiency the predominant characteristic according to the authors of " P r o b l e m Families ,,lo ; Savage 15b, Wofinden is and others le~, 17 have shown that in about a quarter of these families the niother's intelligence is so deficient as to place her in or near the category of the mentally defective. But it is evident that even in this case heredity is not the sole cause for the simple reason that mental deficiency is only present in a p r o p o r t i o n of these families, and that the families of mentally defective mothers do not a l l exhibit problem characteristics. What has been passed on, in a number of these problem families is not defective genes but the " worthless heirloom of an atrocious upbringing." Among the 48,000 genes that every cell in our bodies contains there are those which control our intellectual potential. But what we do with our intellect and our emotions is each man's problem. With regard to mental deficiency, a combination of several abnormal recessive genes acting simultaneously is required for mental deficiency to become patent. Ou r failure to discover these mentally defective mothers until they have reached the undesirable status of a problem family mother indicates that our ascertainment of mental deficiency in childhood is still far from adequate.

PUBLIC HEALTH, April, 1948

engaged i n the home ; 50 years later the figure was 56 women in the home. From 4 per cent. of women working outside the home the percentage so employed had risen to 21% in 1930. Again, widowhood occurs much less frequently, but separation and divorce much more frequently. Despite these changes, the social institution which is established permanently in the post-neolithic world, is the family. It has stirvived the decay alike of empires and of social, systems. It is the unit both of society and of physical and mental health. It is creative and co-operative, and it is based on l ove - - t he love of parent for child and of children for parents, and for sibs, though the latter is often tinged with jealousy. Families are the bricks out of which society is built, and as are the bricks so will l a r g e l y be the building, whoever the architect or builder. As health is the article in which we are intensely interested, it behoves us to study the family. T h r o u g h the health visitor and the sanitary inspector, we enter every house, contact every family. At the ante-natal and post-natal clinics we have unique opportunities--of which we have but partially availed ourselves--to mould to their advantage the individual and the family. If and when Part I I I of the new Health Act comes into operation we shall--and we should seize i t - - h a v e the opportunity to get into touch through the general practitioner. T h e study of the influence of the family on the individual is one of prime importance. As every individual is unique in inheritance and environment, it follows that every family is, equally, unique, and so The Development o f Social Organisation requires individual study and approach. At first glance the " M a n , " said Aristotle, " is a social animal." T h e beginnings appalling similarity of problem families--in which life is of his social organisation are lost in the mists of the past. We reduced physically to its simplest t e r m s - - t o each other may can but guess at the life of our remote cousins the cave people, blind us to their unique individual character ; as soon as you but the most primitive tribes, such as the Australian Arunta, begin to enquire closely the differences present themselves. in the food-gathering, Stone Age stage of development, show T h e specialists who work in hospitals are detached from the a most complex organisation based, not on the family, as such, families from which the individuals they treat are derived. ' b u t on the tribe or g e n s , whose purpose and achievement is T h e y work in an artificial atmosphere like a biologist working mutual aid. It is by mutual aid 7 that man has risen to his in a zoo, and it may often happen that with little or no knowp r e s e n t stature, defective and inadequate though that may led.ge of the home and family from which the individual patient often be. In such a Stone Age society the individual's responsicomes they are at a loss to know the causation of the disbility towards that society is shown in almost every act he ease--say asthma or peptic ulcer--from which the patient does, and perhaps even more in those which he does not do suffers. Only through the almoner, or chance interviews of, because they are taboo. say, the ward sister, do they get a glimpse of this. Indirectly, With the coming of agriculture, with its concomitant through the almoner, they may get in touch with family development of pastoral life so vividly depicted in the Bible, welfare associations or similar bodies in conta:'t with the the knowledge of the part played by the father in the genera- home. Richardson, of N ew York, in a work entitled " Patients tion of children changed that organisation, and we see the Have Families, ''la has recorded some team work endeavouring development of family life, largely patriarchal in type, placed to make what one may call an ecological study of the patient commonly in the setting of the village community ; but never- in relation to his family setting, and this study reveals that, theless, many survivals of the. tribal stage co-existed, for in a number of cases, the hospital physician was at fault in his example, the Scottish clans. T h e mediaeval open fields system diagnosis, and even more in his treatment, for the lack of this showed the modification of communal dwnership and interest study of the patient in relation to h i s - - o r her--family. by private or rather family cultivation of separate plots. In One of the methods Richardson adopted was the case conIndia the village community has a very real survival. ference. This has always been a feature of the child guidance T h e industrial age, with its simultaneous developments of clinic, and Ryle has introduced it into the hospital. I have mixed agriculture and of industry, further weakened the been chairman of a weekly case committee of the Liverpool communal ties. T h e population became aggregated in urban Personal Service Society for a number of years; the case or semi-urban communities, but, only too often, individuals papers are largely family ones. Latterly, we have started such and families became psychologically isolated, with profound conferences in relation to problem families with the twofold results upon the individual personality and upon society, object, firstly, of bringing all sources of information to bear results which we are only dimly beginning to recognise. It upon a given family, especially useful i n problem families probably took many millenia for man to adjust himself to tribal where so many bodies, official and unofficial, are acquainted organisation. We are only just beginning to make the psycho- with different facets of the family; and secondly, to avoid logical adjustments necessary for an urban civilisation. T h e overlapping of responsibility and excessive--which means repeated decay of empireg based on urban civilisation, typified vexatious--visiting. Case conferences are time-consuming, by the fall of Babylon, occurred as much from psychological but the time is well spent and the appropriate officers should as from physical causes. We have not, so far, replaced the be allowed to attend whenever necessary. strong individual sense of responsibility of Stone-Age man by Mental health begins in the nursery; let us cgnsider ngw a comparable responsibility in the changes arising from the the new-born babe lying in its m~ther's arms, provided with progressive increase in liberty that has since taken place. certain reflexes and a strong instinct for survival. He has a. Perhaps the present age, in this country, lays too much stress potential capacity--which he must learn to develop--for on rights and too little on duties. ~reason and for co-operation, but his present need is to survive. T h r u s t into a cold world he finds, at his m~ther's breast, The Family warmth and nourishment for his physical needs ; Eut he has T h e social institution of the family has undergone s o m e an equally clamant psychological need and this his m ~ t h e r ' s recent changes of importance. Myrdal. s points out that in constant care and love will g i v e - - i f constant it be. T h e hand Sweden in 1880 for e'bery 100 men and women engaged in that rocks the cradle m ay rule the' world, but it certainly reremunerative work o u t s i d e the home, there were 102 wo m e n minds the baby in it that mother is still there. But love alone

P U B L I C H E A L T H , April, 1948 is not enough, there m u s t b e wisdon too. On this love the child can make a foundation of a sense of s e c u r i t y - - o f being wanted. F o r n o t to be w a n t e d t h r o u g h o u t life--yes, even in old a g e - - i s a perilous passage for the mind. T h e child is fully conscious of his own helplessness, a p y g m y in a world of giants, and needs to be constantly reassured that he is not being overlooked, that he is in the picture, preferably in the limelight. In his incessant activities this desire for recognition is seldom very distant from his purpose, whether conscious or unconscious. C o m m o n l y it is marked in the only child and gives rise to m u c h Hvalry where there are sibs? ~ Variously modified and canalised, it persists in all of us t h r o u g h o u t life.

125 line of conduct, he will p r o b a b l y continue oi1 that line. If spurious successes can be checked d u r i n g the malleable period of infancy and early childhood, h o w m u c h unhappiness and illhealth can be avoided it is hard to compute. I t is evident that the instruction of the parents in the m a t t e r of the upbringing of their children is a task of the u t m o s t importance. A r e our present endeavours in this m a t t e r adequate in comparison with its importance ? I cannot think that t h e y are. Indeed, we have concentrated on saving the lives and the physical health of the new-born. But we have m u c h neglected the later pre-school years in regard to physical, and m o r e especially mental, health.

i~ersonal~ty and Mental Health The Desire for Success F r o m this background there is derived a universal desire It has been suggested to me that this is an over-simplificafor success, a desire that is unappeasable and persistent. tion, as a description of the building up of personality and mental health. T h e r e is, of course, m u c h to be added, and I Nevertheless, each individual has his own objective, his own standard of success, his own m e t h o d ; at some time during shall put a few m o r e touches to the picture i t time permits. T h e picture can, of course, be painted in other words, though the first few years of life these objectives, these standards, these methods, become m o r e or less fixed, and when fixed t h e r e are I believe it t o be essentially true. L e t m e quote an extract f r o m Eysenck's recent w o r k entitled " Dimensions of Perfew that can depart from t h e m ; they constitute the individual's style of life. Success, you will appreciate, is a positive sonality. ''~ T h i s records the results of the examination of s o m e ten thousand neurotic patients in M i l l Hill. A team of aim in the psychological rather than the physical sphere. A d l e r has indicated how, in many, a desire for success becomes an ten scientists with a wealth of statistical skill have analysed urge for " superiority," which is based upon an inward feeling these data. A n d Eysenck has summarised their results. In relation to aspiration, he says : - of inferiority. T h e s e objectives are individual, indeed egotistic, " Flugel (1945), in a very suggestive discussion o f the in nature ; man, however, does not live by himself ; his success origin and functions of the ego-ideal, relates Level of m u s t be among his fellows, in a social milieu. Only by m u t u a l Aspiration experiments to F r e u d i a n theory. H e points aid has man risen. H e has a strong potential capacity for co-operation, which is capable of indefinite expansion and o u t that in the realms of ideals, " m u c h depends on w h a t m i g h t be termed the distance between the real self and the development. W i t h o u t having t h e force of an instinct, m a n has a powerful urge to co-operate. H e has to m e e t this twoego-ideal. I f there is an immense g u l f between the ideal fold objective in a social milieu. W e can apply to his answers and reality, we shall inevitably feel dissatisfied, guilty and to life's questions the following criteria: (a) are they coinferior . . . . H e r e we see a vindication of Adler's contention as to the widespread desire for superiority, operative or non-co-operative ?; (b) are they courageous or cowardly ? ; (c) are they constructive or destructive ? ; (d) and at the same time a justification of F r e u d ' s theory of are they useful or useless ? (e) are they reasonably altruistic ' secondary narcissism,' attaching not to the real self but to the ideal one . . . . T h e r e is little d o u b t that a vast or are they essentially egotistic ? In so far as it tends towards the first answer an action tends towards a g e n u i n e success; a m o u n t of psychogenic misery is caused by this setting of too h i g h a standard for one's own self." in so far as it tends towards the latter the action tends towards Flugel goes on to insist on the dangers i n h e r e n t in the a spurious success. Only too often conflict between these two motivations attitude of those who pitch their ideals too low, and proceeds m a y arise. T h e neurotic tends to lack courage and to give a to support his theoretical position by reference to Brahrnaehari's dusty and evasive answer to life's questions. H e tends n o t to experimental studies into " Moral Attitudes in Relation to say either " Y e s " or " N o " but to give the answer " Y e s - U p b r i n g i n g , Personal A d j u s t m e n t , and Social Opinion " (1937). b u t , " and it was w i t h p r o f o u n d understanding that Shakespeare " T h i s interpretation of u n d u l y high level of aspiration said " But me no buts." The_ answer tends in the neurasthenic to take the f o r m " Y e s - - b u t I have a terrible headache," and as caused by the hyperdevelopment, of the super-ego, then to achieve the limelight he seeks, he may add, " N o one and of u n d u l y low level of aspiration as caused by the h y p e r d e v e l o p m e n t of-the id in relation to the super-ego, ever had such terrible headaches as I have." T h e hysteric says in effect, " I would, like to help y o u - - b u t m y leg is param a y be regarded as one possible explanation of our differlysed," or what you will. I have known a girl, w h o developed ential findings with respect to hysterics and dysthymics. I f this a r g u m e n t could be w o r d e d in such a way as to writer's cramp to escape one job in which she had no interest, and w h o later could never hold a job down during the War, avoid the personification of mental m e c h a n i s m inevitable finally throw an epileptiform fit on the m o r n i n g that she had in F r e u d i a n terminology, it m i g h t o.ffer a satisfactory to report to the L a b o u r Exchange for direction. T h i s fit was beginning of a theory to account for o u r findings." seen by a c o m p e t e n t observer and it presented the character of O n e can only ask where is the necessity to use this termintrue epilepsy, b u t p r e s u m a b l y was hysterical. She has had no ology ? Medicine has discarded the Galenical terminology. other fit since. She achieved h e r objective with one. But let me return to the reactions of the child in the In setting themselves a standard of success some set their family.l% lb, 1~, Generally the m o s t i m p o r t a n t person in the standard too high, unattainably so ; these are the perfectionists child's life is the mother. T h e m o t h e r ' s first task is to give who worry themselves m e l a n c h o l y with their failure to achieve the child the firm conviction that it is w a n t e d and loved for itself. T h i s is the foundation of security. But now, having the impossible. Probably the c o m m o n error i s to set the given that, it is her further task to interest the child in others, standard of achievement too low, to be satisfied with w h a t m o s t of us w o u l d consider failure ; if the objectiy~ is purely, t o make the child courageous and co-operative. Socrates' or mainly, egotistical, they often come into diiedi~ or indirect last injunction to his sons was " learn c o u r a g e . " Hatred, conflict with society. H e r e are the criminal, the alcoholic, f r o m w h i c h Socrates was so singularly free£ and als0 jealousy, have their roots in fear. Courage m a y be impaired in m a n y the d r u g addict, the prostitute, and others of life's failures. So displayed their activities are essentially useless and uncoways. Parents can as easily teach their children fear as t h e y operative. If we look back into their childhood we m a y often can courage. In particular, the presence of a physical defect find that they got away w i t h spurious successes in early life. ---for example, lameness or d e a f n e s s - - m a y tend to discourage T h e child has to answer life's questions immediately, out of the child. T o this defect the child may react in one of three the darkness of his own i n e x p e r i e n c e ; is it n o t inherently ways. It m a y become d i s c o u r a g e d ~ t h i s is the uncourageous reaction. Secondly, it m a y use its imperfection as an appeal probable that he will make m a n y mistakes ? I f he appears ad misericordiam, seeking to obtain an advantage by exaggerating to h i m s e l f - - a n d he is n o t in a position to make an adequate its v e r y d e f e c t , this is egotistic. Finally, it m a y overcome its j u d g m e n t - - a t the m o m e n t to have succeeded on a particular

t26 defect by an effort of will. T h i s is the courageous reaction and is exemplified by the lives of many great" men, such as Demosthenes and Winston Churchill, who had speech defects and yet became orators of renown, or Beethoven, who had deafness from early life. T h e y had learnt courage. T h e frequent relationship between bodily defect and discouragement--the so-called inferiority complex--is one of the reasons why child guidance should be under medical direction, and not merely a branch of educational psychology, as is the tendency of the moment. Correct guidance can only l~e based on a knowledge of the individual--the whole man. Rees m considers that there is danger ,of child guidance becoming regarded as a matter for the educationalist rather than the doctor. T h e diagnosis u p o n which treatment is based necessitates a very wide training. Learning to Co-operate

But above a~l the child must be taught to be co-operative, to be interested in others. T h e pampered child who is allowed to have his own way has not these characteristics. His mother has failed in this respect, has allowed him to gain spurious successes to his own eventual disadvantage. T h e child that tyrannises over his mother and others, who in effect says to himself " I must rule," is not prepared adequately for life in a larger sphere. Learning to regard a person as a chattel--something which belongs to the c h i l d ~ i s to take a step along a road which may have a disastrous end. Let us take the m a n - - w e cannot call him the lover, and there was one such in Birkenhead recently--who, forbidden to associate longer with the girl he was courting, knifed her. H e is like the child who breaks his toy rather than that another should possess it. " N e ' e r a peevish boy Would break the bowl from which he drank in joy," said O m a r Khayyam. But Kha3qcam was in error; that is exactly what Heath did. T h e ultimate demonstration of possession is destruction. Some psychologists regard this desire for dominance, especially when it assumes the form of aggression, as due to frustration. " A n y proposal t o bring up children without frustrating them," said Bowlby 3 in a recent discussion on "Aggression and Emotional Development," " i s manifest nonsense, but on the extent to whicD it was possible to reduce frustration depended in a great measure the prevention of mental illness and instability." But does not the frustration arise because the child has not been taught co-operation ? Bowlby goes o n : " Children would develop favourably and without undue aggression if in their early years they were continually with parents who wanted and enjoyed them, and who were able to develop a give-and-take relationship, neither insisting on autocracy nor making doormats of themselves. This was not to prescribe the impossible." It is also common sense. T h e mother, therefore, must train her child to be interested in others. She must no more regard the child as a property than the child should so regard her. Much mischief is done by the over-possessive mother. And the first person in whom she should interest the child is the father. In so doing she may have to show some self-sacrifice, overcoming her own possessive interest in the child. One may interject, in parenthesis, how much harder this must be if there is marital disharmony, of which more later. In so doing she will be opening the door to an ever-widening interest. " ~¥hat began in relation to the father," said Freud, " ends in relation to the community." The School of Family Life

When a second child is born the mother necessarily devotes most of her attention to the new-born. T h e r e is a period of tension for the elder child, especially if he has not previously been prepared for the advent. He is suddenly thrust out of the limelight into outer d~irkness ; he is a dethroned monarch perhaps. T w o things the mother can do to prepare the firstborn for this : the wise mother can interest him in the father, who can now be of especial value to the child, and she can inform the child of the advent of a playmate before the event. But are all mothers wise ? Can we not teach mothers these things, give them that wisdom in the ante-natal clinics ?

PUBLIC HEALTH, April, 1948 It is among the fellowship of his equals, the siblings his brothers and sisters, that the child gets the best preparation for life. T h e r e is always emulation and rivalry between them, usually upon friendly terms, but nevertheless situations arise which leave their impress upon the mind. T o some extent we are all of us influenced by our numerical position in the family sequence. T h e elder child tends to impose his authority upon his follower ; he acts as a pacemaker to the second child, but has no pacemaker himself and so occupies a unique position. He tends to be authoritarian and conservative. T h i s was doubtless recognised in the rights of primogeniture in land holding. T h e second child usually tries to overtake the pacemaker, and not infrequently does so, to the great discomfiture of the first, who in such a case may cease to strive and become a dolt. T h e rivalry may be especially keen if the first child is a boy and ~he second a girl, for during the early formative years the girl's intellectual development is more rapid than the boy's. If the boy has masculine privileges, she may resent this and gain an additional spur. S o the second child tends to be revolutionary, opposed to authority, individualist--sometimes crafty. Remember the story of Esau and Jacob. T h e youngest child is, again, in a unique situation, because he has one or more pacemakers but no successor, no hardpressing rival. He may be discouraged because of his disparity, arising from age, or pampered because his mother wants to keep him as her baby. Whether the fairy tales in which the youngest child goes out into the world to make the family fortune contain a germ of truth or were merely told to encourage the youngest into a valiant attitude towards life, I cannot say. T h e innmnerable permutations and combinations of birth intervals and sex differences and of family situations and sequences, and the attitudes that children can adopt towards their particular situation, would form a s u b j e c t for a book rather than a paragraph. T h e illegitimate, the orphaned, the child who is parked out among a succession of relatives, lacks the background of security, and suffers, commonly, some degree of lifelong defect of personality. And in even worse plight is the child hated by a parent or more probably a step-parent. N o t much happier - - i f any--is the child of the family where husband and wife are at loggerheads. He is torn by divMed loyalties and may be made a pawn in the game of marital discord. His security is gravely affected and his view of marriage and his conception of the relation of the sexes is likely to be distorted, thinking that it is a contest rather than a co-operation. T h e head of the Society for the Prevention of Cruelty to Children said of the homes from which delinquent children come that they were " Not necessarily the poorest homes ; nor even from the homes where the parents are criminals; most delinquent children come from the homes where the parents are openly hostile to each other." In her book, " Branch Street," Marie Paneff, with grea.t knowledge of, and insight into, children's minds, found that, in a London slum district, the children, though ill-fed, verminous and lawless, were responsive to kindly approaches up till about eight years of age. U p till then they trusted her. Later they became wildly antagonistic. What had happened was that their parents reserved their love for their babies. T h e children knew of no other affection. They- had mostly been taught the Christian r e l i g i o n , but had never seen it practised. W h e n it was shown to them they realised it was utterly opposed to their way of life and they rejected it utterly. Can one blame them ? T h e y have learned to live without love. But i n all these matters psychological, the uncertainty principle prevails. There is no certain inevitable result, the child is a law unto himself, and this principle is of general application. - T h e loveliest flowerings of the human mind can blossom in apparently desert surroundings and have often done so. One cannot reduce man to a mathematical equation. Every man's life story and life style are alike unique. Mind and Body in Mental Health U n d e r the heading mental health we must envisage the prevention not only of maladjustment, behaviour disorders,

PUBLIC HEALTH, April, 1948 neurosis and psychosis, but also psychosomatic disease. The action, reaction and inter-action of m i n d and body makes up the man. By nerves and hormones the mind plays upon the b o d y ; we blush for shame, flush with anger, blanch with fear, and tremble with fear and wrath; fear can make the mouth dry or relax the sphincters. Of these external effects we are only too conscious. But of the similar effects upon the viscera we are often unaware. Wolf and Woolf ~° have described the effects of emotions upon his gastric secretions of a boy called Tom. As the result of swallowing a mouthful of hoe clam chowder, T o m had an undilatable stricture of the oesophagus for which a gastrostomy was carried o u t ; owing to a crisis during the operation, a collar o f mucosa pouted from the opening. This varied in colour from a pale yellowish-pink to a brilliant scarlet in accord with T o m ' s emotional state of mind. He was employed in a physiology lab., and observations were made there upon these reactions and the concomitant variations in acidity of the gastric juice. Fear made his mucosa yellow and anger made it scarlet; decrease or increase of acidity of the gastric juice secreted occurred respectively with blanching or flushing of the mucosa. Similar observations had previously been made on Alexis St. Martin, who received a shot-gun wound in his stomach. T h e light thrown in these observations upon the causation of peptic ulcer or dyspepsia is obvious. Perhaps t h i s observation will also help us to understand how other organs may be affected by emotional disturbance. " U n d e r normal conditions," according to Katz, Winton and Megibow, 6 " there is a constant dynamic fluctuation in the function of the organism as an expression of its adaptivo capacity to its environment or to the immediate internal demands of one organ system upon the others. This adjustment is achieved by the autonomic nervous system and by humoral mechanisms initiated by the endocrine system. Similarly in the neurotic, the summation of psychic stimuli, regardless of its pattern, must exert its effect through either one or the other subdivision of the autonomic nervous system, with modification by direct or indirect influence on the endocrine glands." They go on to state that emotional disturbances acting through the hypothalmic centres, and otherwise, m a y produce a variety of upsets to the tonic balance of the cardio-regulatory centres and cause (1) depression or stimulation of the primary pacemaker of the heart, producing sinus tachycardia, sinus bradycardia and sinus standstill; (2) increased irritability of subsidiary pacemakers, giving rise to paroxysmal tachycardia or paroxysmal auricular fibrillation with flutter, and even, possibly, to ventricular fibrillation with sudden death; and (3) heart block, i.e., sino-auricutar or auriculo-ventricular block. I have three times seen paroxysmal tachycardia develop as the result of fear or other emotion. One was in a young man going to a severe climb shortly after an accident had occurred to a friend. I was at pains to prevent any undue importance being attached to the attack; he climbed next d a y a n d the tachycardia never recurred. The other two cases fell into the hands of cardiologists, who fussed about with cardiographs and the like ; these two continue to have attacks from time to time. The list of emotionally affected organs could be much extended, but one can especially refer to allergic diseases, such as asthma and many forms of skin diseases which are especially subject to psychological causes. One might mention a woman who suffered from asthma only when she visited her parents, no matter where they were. How these emotional disturbances arose in the first place is a matter, in each case, for investigation, and the possibility of prevention of the disorder of personality which gave rise t o that disturbance is a further step. I n the boy who developed paroxysmal tachycardia, I knew the family history, and the primary fault lay with one of t h e parents, though this would take too long to relate. I n many such cases a wise family ~ractitioner might be able to improve the family situation, though in this ease I doubt it. But one may ask again the question, " Are all family practitioners wise, or if so, have they the time ? " Let us now study, briefly, the practical applications of this

127 train of thought. Whilst every child has freedom of choice, only too often do we see a succession of errors handed down as worthless heirlooms from generation to geperation. " T h e fathers have eaten sour grapes and the children's teeth have been set on edge." I think we are entitled to say that in many of the children's mistakes it is the parents' error or inability that gave rise to those mistakes ; further, that those mistakes can often be corrected, by child guidance or even simpler methods , if detected early in the plastic years of development ; and thirdly, that in many cases the parents' errors quite often arise from ignorance rather than from perversity. How can we break the vicious circles--and the word vicious may often be taken literally ? There are certain points in the circle when we can helpfully step in and when the persons concerned often or usually de~ire to be helped. I believe that most young people desire their marriages to be a success. I believe that most mothers want to do well by their children ; before the first child comes can they not be taught the basis of mental as well as of physical health ; can this not be instituted in our ante-natal clinics and carried on in our infant welfare clinics ? Do we tell the mother that there is such a thing as chiM guidance in case of need ? Do we even attempt to lay" the basis of happy married life by dispelling ignorance and teaching the basis of what should be an intimate and happy co-operation before the marriage takes place ? Alva MyrdaI, in her book on " Nation and Family," states that " the content of education (in Sweden) was devoid of any attempt to disseminate knowledge which would prepare for better functioning of the intimate relationship within the family." Is this not equally true of England ? T h e task of our generation, she considers, is to reintegrate the family into t h e larger society. Myrdal states further that " T h e educational programme for family life must start with a considerable curriculum of teacher courses." At this point the programme passes out of the medical sphere, but may we not substitute the word health visitor for teacher and bring it back into our sphere ? It is evident that the progress towards mental health must go in unison with other aspects of social welfare. T h e Peckham Health Centre clearly points that out, though it is evident that any considerable extension of such centres is, for the present, out of the question. But there is a pointer here as to the parallel deyelopments which will render our own task the easier.

Marriage Disharmony It will not have escaped your attention how often marriage discord has been referred to in my remarks. It recurs in relation to problem families, j u v e n i l e delinquency, a variety of neuroses and psychosomatic diseases, a n d is one of the most' fruitful sources of deformation of the personality of the child and the production of behaviour disorders. Marriage guidance is largely a new venture and has y e t to develop a technique ; once serious disharmony has arisen it is one of the most difficult tasks that can be assumed to endeavour to straighten out the tangle. On the other hand, education is m u c h simpler ; advice and guidance should be available for all who are willing to accept it before marriage, and its availability should be widely known. Probably the best method is to act through a variety of organisations, especially youth organisations, not always expecting immediate results by such public lectures, but rather to bring to the attention of young a d u l t s t h e availability of advice, which they may later seek. Those who are advised before marriage may still have much to learn, but it is found that if cracks in the family appear they are much more likely to bring their difficulties in the early stages before irreparable damage has been done and the couple are unappeasably hostile. Such matters as the teaching of elementary cooking, often learnt and forgotten in school, should not be overlooked. One feature which is useful to remember is that marriage is much more likely to be happy if courtship habits can be retained a f t e r marriage and the mother be relieved of the care of the children--with grandparents or otherwise - - w h i l e the young couple have a night out t o g e t h e r . T h e beneficial effects of this were well shown at Peckham. May I plead for your goodwill in relation to marriage guidance

PUBIAC H E A L T H , April, 1948

128 so that those w h O take on this difficult work m a y have adequate m e a n s to e a r r i / i t through. T h e D e n n i n g C o m m i t t e e Report, published in F e b r u a r y , 1947, r e c o m m e n d e d that bodies carrying o u t this difficult work should receive public subsidY, b u t so far no effect has been given to this recommendation. W e have such a voluntary organisation in Liverpool u n d e r the control of a W o m a n doctor. T h e set-up of these bodies is largely due to the energy and enthusiasm of Dr. M a c e of the M a r r i a g e Guidance Council. Problem

Families

P r o b l e m families still remain the bane of the health visitor and are a p r o b l e m for all concerned. T o reintegrate t h e m into self-respect and into society is no easy task. T h e Pacifist Service U n i t s 1° which worked at M a n c h e s t e r and Liverpool, have b e e n now incorporated in a National F a m i l y Service U n i t s Organisation, u n d e r distinguished patronage. The combination of mental deficiency and marital d i s h a r m o n y so frequently present is indeed a formidable task to overcome. U n i t s like Brentwood, and the F r i e n d s ' Rehabilitation U n i t set up u n d e r the Elizabeth F r y Centenary F u n d should be m u l t i p l i e d ; by rehabilitation for this connection "is intended the reformation a n d education of m o t h e r s d~harged-with neglect of their children. M a n y medical officers of health x~, 10b, As, ~7, xeb, are n o w interesting themselves in these semi-savages in our midst, a n d w h e n we recollect that the infantile mortality rate of these families is double that prevalent in the town in which t h e y live and treble w h e n the m o t h e r is mentally defective, they have a verN excellent reason to do so, especially as they are f r e q u e n t sources of the reinfestation of schools with lice. I f we can catch such families early in their downward career we are m u c h m o r e likely to succeed in rehabilitating t h e m ; the persons m o s t likely to see these families in the early stages are health visitors, w o m e n house managers and general practitioners. W e shall be worthy of condemnation ourselves if we do not e n d e a v o u r to check t h e " g r o w t h of these cankers in the heart of urban civilisation. Blacker, summarising 2 the preventive aspects of mental disorders, points out that environmental and genetic causes combine in the causation of men'tal infirmities. " E n v i r o n mental conditions would be i m p r o v e d if m i n i m u m standards were introduced, social security attained and educational standards r a i s e d . T h e genetic causes will be b r o u g h t into greater prominence. It was an important conclusion of the W o o d R e p o r t (1929) that families containing cases of primary amentia present multiple social problems and are an i m p o r t a n t seed-bed of mental aberrations." M y r d a l s points out that p o v e r t y of e n v i r o n m e n t is deleterious to citizenship. " Q u a l i t y is threatened n o t by racial waste, but by social waste of the h u m a n material." The Size of the Problem

N o w let us attempt to assess the m a g n i t u d e of the task lying before us. Rees, in " T h e Shaping of Psychiatry by W a r , " considers that the neurotic and maladjusted n u m b e r 3,000,000 and w i t h 20 m a n - h o u r s of t r e a t m e n t each the figure of 60,000,000 m a n - h o u r s of t r e a t m e n t is reached. T h i s is colossal, b u t if psycho-analytic methods are used then the calculation b e c o m e s astronomical. Halliday gives a total of 60,000,000 m a n - h o u r s of illness in wage earners per a n n u m and about one-third of psychological origin or 20,000,000 m a n - h o u r s lost per a n n u m at a cost of probably about £10,000,000. Surely a little expenditure on prevention is justified. Rees ~2 gives the .needs of mental hospital beds as 1,000 per quarter million population, and a probable figure for bed-space for neurotics in general hospital as 5%. Also, he says the separation between ills of the m i n d and of the b o d y m u s t be done away with. " T h e isolation of mental hospital staffs m u s t be e n d e d . " " M e n t a l health services are to be integrated with the general health service." " N e w emphasis," says Rees, " m u s t be placed on the preventive aspects of our (mental) work, upon early t r e a t m e n t with all the various ancillary measures that are available." " First-aid of psychiatric breakdown can be done a s well or even better by the general physician than by the specialist." " W e should be foolish not to recognise that our frontiers have w i d e n e d . " Eighty years ago Florence

Nightingale said, " Building children's hospitals is n o t the proper r e m e d y for infantile sickness--the true r e m e d y is in i m p r o v i n g their h o m e s . " T h e co-ordination of mental health services, says Blacker,~ u n d e r a medical officer of mental health, has been widely advocated. T h i s officer's duties m i g h t include the followi n g : psychiatric out-patient services; the ascertainment of mental defectives and their c o m m u n i t y care.; problems of industrial and criminal psychiatry and of d e l i n q u e n c y ; cooperation with education authorities in administering special schools and h o s t e l s ; the education of the public in mental health ; the carrying out of surveys and follow-up enquiries. H e w o u l d have dealings w i t h m a n y organisations and persons ; and if his w o r k developed fully he would require a considerable staff, whole or part-time. In order that the w o r k of such an officer be co-ordinated with all the w o r k done o n e n v i r o n m e n t - - e s p e c i a l l y housing - - a n d the close connection with the w o r k of health visitors and others of the public health d e p a r t m e n t staff, I would strongly suggest that such an officer should therefore be on that staff and subordinate to the medical officer of health. " W e have still to learn tile rudiments of the disorders of groups, communities and nations." " Irrational emotions can sway ~¢¢hole countries as well as individuals." L e t us make a start on the study of families. REFERENCES 1 ADLER, ALFRED. (a) (1917). " Study of Organ Inferiority and its Psychological Compensations." London. .... (b) (1932). " What Life Should Mean to You." London. - (c) (1938). " Social Interest." London. 2BLACKER,C . P. (1946). " Neurosis and the Mental Health Services." London. '* BOWLBY, JOHN. (1947). Discussion on " Aggression in Relation to Emotional Development, Norrfial and Pathological." Brit. mad. 27., 2, 1049. I DENNING "Co1vtMITTEE REPORT. (1947). Final Report of the Committee on Procedure in Matrimonial Causes. H.M,S.O. EYSENCK, H . J . (1947). " Dimensions of Personality." London. 5~ ISAAeS, S. (1933). " Social Development of Young Children." London. 0 KATZ, .L.N., WINTON, S. S. & MEGIBOW, R . S . (1947). psychosomatic Aspects of Cardiac Arrhythmias. Annals of Internal Medicine, 27, 261-274. 7KROPOTXIN, PETE. (1902). " M u t u a l Aid." Reprinted in Penguin Series. s MYRDAL, ALVA. (1945), " Nation and Family " (Trans.). London. g NEWIVrAN, I-I. H. (1942). " Twins and Super-twins.', London and New York. 18 PACIFIST SERVICE UNITS. (1947). " Problem Families." Edit. T o m Stephens. London. 11 PANEFF, MARIE. " Branch Street." 13 REES, J . R . (1945). " The Shaping of Psychiatry by War." 13RICHARDSON, H. B. (1945). " Patients Have Families." New York. ~1 ROPER, W. F. (1947). " When the Family Fails." 1~ SAVAGE,S . W . (a) (1946). " Rehabilitation of Problem Families." Mad. Off., 75, - (b) (1946). " Intelligence and Infant Mortality in Problem Families." Brit. mad. J., 1, 10 STALLYBRASS, C. O. (a) (1935). " The Life We Live." An inaugural address. Medico-Chirurgical ~., 151. - (b) (1946). " Problem Families." Mad. Off., 75, - - ( c ) (1947). " T h e Social Implications of Medico-psychological Disorders." Ibid., 78, 213. 17 TO~rLINSON, C. C. (1946)." " Families in Trouble." Luton. IS WOFINDEN, R . C . (1944). " Problem Families." PUBLICHEALTH, 57, 136. 19 WOOD COMMITTEE REPORT. (1929). H.M.S.O. 28 WOLF, S. • WOOLF, H. G. '( H u m a n Gastric Function." London.

We regret that, for reasons outside our control, it has not been possible to publish Dr. W. Rees Thomas's address to the Society n the mental health services under the 1946 Act. However, much of the advice which he gave has now been incorporated in the booklet "Provisions relating to Mental Health Services " circulated with Ministry of Health Circular 33/4B of March 17th, 1948.