- Email: [email protected]
THE GAS-LIGHT PHENOMENON
1258
Mental Health
was travelling between hospitals in Brighton; for part of the time the ambulance was taking an infant from one hospital to another. Two adults were inside the ambulance for most of the period, and they were joined by a third for the remainder (2.49 to 3.00 P.M., and 3.19 to
3.30 P.M.). The day was clear, crisp, and sunny, with a mean temperature during the run of 6°C and a wind speed of approximately 7 m.p.h. (about 11 k.p.h.). Air temperature in the vehicle was measured by a thermistor suspended centrally. The internal surface temperatures of the windows and roof were determined from thermistors attached to the surfaces by adhesive tape. The results obtained are given in the figure. Variations in the weather are referred to along the time-axis of the figure, and in addition the occasions when the ambulance heater was on or off and when the doors were open or closed are also indicated. The chief variations in air temperature were associated with the opening and closing of doors, and with the operation of the heater. The changes in air temperature (maximum minus minimum 17’2°C) were greater than the variations either of the internal-roof-surface temperature (maximum minus minimum 9-4°C) or of the window temperature (maximum minus minimum 3’9°C). The mean air temperature over the period of recording was 16-9°C, the mean roof temperature was 156°C, and the mean window temperature 10-8°C. These may be combined to give an " environmental temperature ", which incorporates the effects of both convective and radiant heat transfer,’ of about 16°C. The largest component of environmental variation was associated with changes in air temperature, and not with changes in surface temperatures. These surface temperatures determined the mean radiant temperature, but this was less than air temperature. Considering now an incubator carried in the type of ambulance studied, if the mean environmental temperature in the ambulance was considered to be 16°C and the incubator air temperature 32°C, the incubator wall2 would be at about 25 °C. The mean environmental temperature for the baby inside the incubator would therefore be approximately (32+25)/2-i.e., 28-5°C, considerably below the temperature indicated by the incubator thermometer. For practical purposes, the ambulance was like a room at about 16°C (i.e., mean of radiant and convective effects) with doors opening and closing and letting in draughts of cold air. The effects on adults and on incubators and the babies inside them would be those to be expected under such conditions-that is, not extreme, but perhaps uncomfortable for the adults, and potentially serious for babies. In this connection the high incidence of hypothermia amongst babies with congenital malformations of the central nervous system3 is important. We thank Dr. W. S. Parker and Mr. A. J. Sumpter for their interest and cooperation. Air and surface temperatures were measured by thermistor probes supplied by Light Laboratories, Brighton. Requests for reprints should be addressed to T. P. M., Royal Alexandra Hospital for Sick Children, Brighton BN1 3JN,
THE GAS-LIGHT PHENOMENON RUSSELL BARTON FROM SEVERALLS
HOSPITAL, COLCHESTER,
AND PRESTWICH
HOSPITAL,
MANCHESTER
THE play Gas Light by Patrick Hamiltonis a classic piece of 20th century victoriana. Its theme is a husband’s plot to get rid of his wife by driving her into a lunatic asylum. The medical literature does not appear to have many accounts of plots of this type. A select committee of the House of Commons in 1763 concluded that some people were committed to asylums as a method of solving family and social problems.2 Several workers have put forward various ideas on rejection as a cause of mental illness; and in 1965 some concern was shown over misuse of Section 29 of the Mental Health Act 1959.3-6 We describe here two cases in which there were definite plots to remove an unwanted and restricting relative by securing admission to a mental hospital, and one case of an old lady admitted to a mental hospital following induced incontinence. Unimportant details in the case-records have been changed to prevent identification of the patients and their families by people connected with them but unaware of what happened. CASE-RECORDS
Case 1 Mr. A.
admitted one evening to a psychiatric hospital as His general practitioner, when asking for his admission, had said he was mentally "ill and had attacked his wife. He came into hospital as an informal " patient but was accompanied by a mental welfare officer, who confirmed the story of violence. On admission the patient said he had felt tense and depressed for about six months and related this to his wife’s changed attitude towards him. He said she had become " cold ", and he thought she might have been seeing another man. He denied he had been violent and thought he had been sent into hospital because of his " nerves ". He was a mechanic of 48 who had been married for ten years and had three children. He had never been ill before and did not think there had been any mental illness in his family. He described symptoms of anxiety and depression which fluctuated according to his wife’s behaviour. He felt better when she was affectionate and worse when she was " cold " towards him. His wife said he had changed during the previous six months, and had become irritable, bad-tempered, and liable to unprovoked violent outbursts in which he sometimes hit her and once struck her with a hatchet. She also claimed that his he lost his way in places had deteriorated and that memory previously familiar to him. She denied having changed in her attitude towards him and said there was no truth in his accusation that she had been associating with another man. When examined, the patient was found to be rather tense but otherwise there was no clinical evidence of either mental or physical disease. He remained in hospital for twelve days and became more relaxed without any specific treatment. No signs of irritability or violent behaviour were observed, and he appeared to function at a fairly normal level. Investigations were all normal; and psychological testing produced results within the normal range. an
was
emergency.
1. 2.
Hamilton, P. Gas Light. London, 1939. Leigh, D. The Historical Development of British Psychiatry. Oxford,
3. 4. 5. 6.
Barton, R., Haider, I. Lancet, 1965, i, 912. Enoch, M. D., Barker, J. C. ibid. p. 760. Whitehead, J. A. ibid. p. 865. Barton, R., Haider, I. Medicine, Sci. Law, 1966, 4, 147.
1961.
Sussex1. Mount, L. E. The Climatic Physiology of the Pig. London, 1968. 2. Hey, E. N., Mount, L. E. Archs Dis. Childh. 1967, 42, 75. 3. Accidental Hypothermia. Royal College of Physicians of London, 1966.
J. A. WHITEHEAD
1259 He left
hospital
and attended
a
week later
as an
outpatient.
He said he had remained well and was considering returning to work. His wife claimed that he was a little better but said that he was still irritable and bad-tempered. Two weeks later he was seen again. He had returned to work but once more felt tense and depressed. He said his wife had started taunting him, saying he was mad and should be in a mental hospital. His wife said that his mental condition had considerably worsened and that he had attacked her twice. She asked for his readmission, but the patient refused to come back into hospital; he said that he was well enough to work and denied any violent bahaviour. It was considered that compulsory admission could become necessary, and arrangements were being made to discuss this possibility with the general practitioner when the patient’s employer asked for an urgent appointment. The employer said he had overheard a conversation in a local inn the previous evening. Two men had been discussing Mr. A., and it was apparent from their conversation that one was Mrs. A.’s lover and the story of Mr. A.’s violent behaviour had been concocted in an attempt to gain his admission to a mental hospital compulsorily. They apparently believed this would make divorce possible so that the lover could marry Mrs. A. The employer told a convincing story and Mrs. A. was seen and confronted with it. She finally agreed that she had plotted with her boy-friend to get rid of her husband, but claimed she had been led on by him and now very much
regretted her behaviour.
Following some family counselling Mr. and Mrs. A. became reconciled and five years later were still living happily together. Case 2 Mr. B., a publican of 45, was admitted to the alcoholic unit of a psychiatric hospital at the request of a general physician. He had been admitted to a general hospital owing to symptoms of peptic ulceration. While in hospital his wife had told the ward doctor and sister a long story of her husband’s heavy drinking, erratic behaviour, and aggressive outbursts. The general physician, having heard this story and noted some evidence of agitation and depression in the patient, decided he was an alcoholic suffering from alcohol withdrawal. On admission to the unit Mr. B. gave a history of domestic difficulties and described mild symptoms of anxiety and depression. He said that he drank a little regularly, but denied heavy drinking and claimed there was no question of his drinking being uncontrolled. He agreed that he was irritable but said that he had never been aggressive and did not acknowledge any of the common symptoms of alcoholism. He had been married for fourteen years, and the marriage had been fairly successful until recently when his wife had lost interest in him and had started associating with younger men. She often stayed out all night, and when he asked her about this behaviour she told him not to be silly and accused him of being a drunk who should be put away. Immediately before his admission she told him she was leaving him. Clinical examination revealed only some evidence of anxiety and mild depression. Investigations were all normal. The patient was treated with superficial psychotherapy and chlordiazepoxide and quickly lost his symptoms of anxiety and depression once he had made up his mind about leaving his wife and obtaining a different job. He remained in hospital for two months, not because of illness but because accommodation was hard to find. Alcoholics are notorious liars about their alcohol consumption, but it was considered that Mr. B. was possibly telling the truth. He was allowed complete freedom in the hospital and was actually encouraged to have an occasional drink in the local village inn. He never drank more than two half-pints of beer according to the local publican, and he showed no evidence of alcohol dependence. As a result of a number of accidental findings certain features became clearer. A member of the hospital staff knew the local manager of the brewery that owned Mr. B.’s inn and found out from him that Mrs. B. had informed the brewery that her husband was an alcoholic and told them that
he should not be allowed to retain the tenancy. She had followed up this information by asking for the tenancy for herself, and was rather surprised when this was refused. Another member of staff, through a relative of Mrs. B.’s, discovered that she had confided in another relative that she had fooled the doctors that her husband was an alcoholic and now hoped she would get rid of him, keep the pub, and then
really
start
living.
Mr. B. finally left hospital and obtained a job. Five years later he was well, drinking only occasionally, and he appeared to be very glad that he had left his wife.
Case 3 Mrs. C., a widow of 72, was referred to a psychiatric hospital because of a " confusional state " and faecal incontinence. She was living in a private old persons’ home, and the fxcal incontinence was given as the major reason for her being unacceptable to the home. On examination after admission she was found to be a pleasant-mannered old lady. She had a moderate degree of Parkinson’s disease and had difficulty in walking. There was evidence of slight to moderate dementia with memory defect, but she was in touch with the situation around her and had preserved a good social facade. She remained in hospital for six weeks while efforts were made to re-establish her in the community, and finally left hospital for her own home. She managed satisfactorily out of hospital but later entered an old people’s home again. There was no evidence of fsecal or urinary incontinence while she was in hospital or afterwards. During her stay in hospital certain facts came to light. The lady running the home had been unable to develop a good relationship with Mrs. C. and considered " she was a naughty old thing making life difficult for me, my staff, and other folk on purpose ". For some weeks before admission to hospital Mrs. C. had been receiving ’Dulcolax ’ tablets one three times a day. This had produced the expected effect with occasional " accidents " due to Mrs. C.’s mobility difficulties. The evidence suggested that Mrs. C. was not wanted in the home and induced incontinence was used as a method of getting her removed to
hospital. DISCUSSION
These cases raise important points. A few psychiatrists may regard them as crude examples of a common cause of mental illness, while others will dismiss them as rarities. Perhaps the truth is somewhere in-between. The group or family can use more sophisticated ways of getting rid of unacceptable members, and even these cases could have ended differently. Despite legal safeguards Mr. A. could have been admitted compulsorily to a mental hospital. His general practitioner and a mental welfare officer believed his wife’s story, and he would have been admitted under Section 29 of the Mental Health Act if he had not agreed to come into hospital " informally ". His wife’s story having been sanctified by those with authority, his further detention would have been possible. Ultimately it would have become apparent that he was not subject to serious mental illness, but by then he would have suffered considerable trauma and his future might have been jeopardised. Society still distrusts, fears, and ostracises people they consider lunatics, jobs are difficult to find, and certain countries bar the immigration of people who have been detained compulsorily in a mental hospital. Alcoholics usually lie about their drinking and Mr. B. could have been an alcoholic on the evidence provided by the normal sources. Again, the wife’s story had been reinforced by authoritative repetition. The general physician believed the wife’s story and labelled the patient as an alcoholic. Once such a label has been
1260
applied it can continue to affect the patient even when it is be incorrect. A deaf man known to
found
to
one of us (J. A. W.) was originally from diagnosed suffering schizophrenia. The diagnosis was made mainly on the evidence of his sister, but it later became apparent that his sister was ill and not the patient. He continued to live with his sister and was referred for readmission to hospital on several occasions by his general practitioner when he was approached by the disturbed sister. The general practitioner always referred to him as having schizophrenia although he had been informed to the contrary on a number of occasions. as
of Mrs. C. differs from the other two and is possibly an example of a not-uncommon situation. Most geriatricians and psychiatrists know of old people admitted to hospital because of reported behaviour that was not confirmed once they were in hospital. Sometimes the change in behaviour is the result of coming into hospital, The
case
Parliament Last Round in the Commons THE Children and Young Persons Bill passed its third reading in the House of Commons on June 9. Mr. JAMES
CALLAGHAN, Secretary of State for the Home Department, said that it introduced a greater element of fairness and a greater opportunity for certain children. Children should be dealt with according to their individual needs. The Bill required the exercise of sensible discrimination by the police, by local authorities, and by all other agencies concerned in deciding how best to deal with the individual child.
Higher Pensions-Better Benefits A Bill to increase benefits and contributions under the national insurance and industrial injuries schemes was read for the first time in the House of Commons on June 10. In a statement, Mr. RICHARD CROSSMAN, Secretary of State for Social Services, said that, as the House already knew, standard benefit rates of the national insurance scheme and certain supplementary benefits were to be increased in November. To finance this, E360 million had to be found from increased contributions and the Government had decided to raise this by additional contributions on an earnings-related basis rather than by putting the whole burden on the flat-rate contributions. The flat-rate increase had been held down to ls. per week, lld. for women, whereas the present 1/2% graduated contributions on earnings between El 8 and S30 per week were to be raised by 21/4%. These additional graduated contributions would earn additional pension rights. In answer to questions he said that the object of the increases had been to restore the real value of benefits to that of October, 1967. The major scheme of superannuation, which would be introduced in the big Bill next session, would abolish flat-rate contributions completely. But this could not be done now and the present plan was an up-rating in which the Government was moving towards an earnings-related scheme as far as was possible in the existing framework. He also thought that the increase of sickness absenteeism had to be looked at with great care. Special inquiries were already under way.
Health Hazards from
Cigarettes, cigars, and pipes
Smoking
denounced as instruments of torture in the House of Commons on June 10. Mr. JOHN DurrwoonY’s private members Bill to provide for the labelling of cigarette packets to give warning of the dangers to health from cigarette smoking was read for the first time. Mr. Dunwoody said he wanted the label to be a personal direct warning to the individual. No doubt the great majority of people accepted that there was a health risk from smoking cigarettes, but hardly anyone accepted that it applied to him or were
but in some cases there is no change of behaviour because the original information was either untrue or exaggerated. Relatives, companions, or the staff of old people’s homes may want old people in hospital for a variety of reasons other than the medical or psychiatric state of the patients. If old people are being rejected it is important to know what is happening. It may be possible to re-establish them in the family or home or to find another niche for them in the community. Admission to hospital is never the right answer.
The cases reported here show the importance of examining very seriously the whole situation before admitting a patient to hospital. Home assessment, obtaining information from as many sources as possible, and a reasonable degree of scepticism, coupled with attention to the patient’s own account, should prevent the maturition of most " gas-light " plots. her personally. Mr. ROBERT CoolcE opposed the Bill because it dealt with only part of the problem. The smoke from pipes and cigars was far more noxious to the non-smoker than cigarette smoke.
Pay
for Service Doctors
A report by the National Board for Prices and Incomes on Services pay has recommended new scales of pay for Service doctors and dentists, based on an average salary ofE4000 a year for those not living in official quarters. By a rise of about 14%, their pay will be brought into line with that of civilian general
practitioners.
QUESTION TIME Distinction Awards for Hospital Consultants MR. HAROLD WILSON, the Prime Minister, announced that the Government had accepted the advice of the Review Body on Doctors’ and Dentists’ Remuneration to increase the number of distinction awards available to hospital consultants in view of the, rise in the total number of consultants, and the increase in the standard of their skill generally and particularly in certain specialties. The Body has recommended 5 more A-plus awards at the rate ofS5275 a year, 20 more A awards at the rate of E4000 a year, 70 more B awards at the rate of E2350 a year, and 140 more C awards at the rate of E1000 a year. This makes available a total of 105 A-plus awards, 360 A awards, 1100 B awards, and 2250 C awards. The Review Body did not recommend any increase in the value of awards. Abortion Notifications Since the Abortion Act came into operation on April 27, 1968, 41,496 abortions had been notified in England and Wales, up to May 27. Of these, 16,650 were in approved places, 101 elsewhere, and 24,745 in Health Service hospitals. They were performed on the following grounds: Risk to life of woman Risk to physical or mental health of woman Combined risk to health of woman and risk of abnormality in child Risk to health of existing children .......... Risk of child being severely handicapped ........ Risk for two or more reasons............ ...........
......
1827
29,945 690 1629 1232 6098
The 1968 figure of abortions carried out where the operating did not join in granting the certificate was 10,727, Notifications in England and Wales totalled 18,322 for married women, 19,617 for single women, and 3416 for widowed, divorced, or separated women. Up to Dec. 31, 1968, 5% of women on whom abortions were carried out gave a place of usual residence outside the United Kingdom.
practitioner or 45-4%.
Health Centres in Scotland In Scotland in the three years to 1967-68, 5 health centres were completed; and in 1968-69, 3. In 1969-70, 6 centres at present under construction should be completed and work should begin on another 13.
Mental Health
was travelling between hospitals in Brighton; for part of the time the ambulance was taking an infant from one hospital to another. Two adults were inside the ambulance for most of the period, and they were joined by a third for the remainder (2.49 to 3.00 P.M., and 3.19 to
3.30 P.M.). The day was clear, crisp, and sunny, with a mean temperature during the run of 6°C and a wind speed of approximately 7 m.p.h. (about 11 k.p.h.). Air temperature in the vehicle was measured by a thermistor suspended centrally. The internal surface temperatures of the windows and roof were determined from thermistors attached to the surfaces by adhesive tape. The results obtained are given in the figure. Variations in the weather are referred to along the time-axis of the figure, and in addition the occasions when the ambulance heater was on or off and when the doors were open or closed are also indicated. The chief variations in air temperature were associated with the opening and closing of doors, and with the operation of the heater. The changes in air temperature (maximum minus minimum 17’2°C) were greater than the variations either of the internal-roof-surface temperature (maximum minus minimum 9-4°C) or of the window temperature (maximum minus minimum 3’9°C). The mean air temperature over the period of recording was 16-9°C, the mean roof temperature was 156°C, and the mean window temperature 10-8°C. These may be combined to give an " environmental temperature ", which incorporates the effects of both convective and radiant heat transfer,’ of about 16°C. The largest component of environmental variation was associated with changes in air temperature, and not with changes in surface temperatures. These surface temperatures determined the mean radiant temperature, but this was less than air temperature. Considering now an incubator carried in the type of ambulance studied, if the mean environmental temperature in the ambulance was considered to be 16°C and the incubator air temperature 32°C, the incubator wall2 would be at about 25 °C. The mean environmental temperature for the baby inside the incubator would therefore be approximately (32+25)/2-i.e., 28-5°C, considerably below the temperature indicated by the incubator thermometer. For practical purposes, the ambulance was like a room at about 16°C (i.e., mean of radiant and convective effects) with doors opening and closing and letting in draughts of cold air. The effects on adults and on incubators and the babies inside them would be those to be expected under such conditions-that is, not extreme, but perhaps uncomfortable for the adults, and potentially serious for babies. In this connection the high incidence of hypothermia amongst babies with congenital malformations of the central nervous system3 is important. We thank Dr. W. S. Parker and Mr. A. J. Sumpter for their interest and cooperation. Air and surface temperatures were measured by thermistor probes supplied by Light Laboratories, Brighton. Requests for reprints should be addressed to T. P. M., Royal Alexandra Hospital for Sick Children, Brighton BN1 3JN,
THE GAS-LIGHT PHENOMENON RUSSELL BARTON FROM SEVERALLS
HOSPITAL, COLCHESTER,
AND PRESTWICH
HOSPITAL,
MANCHESTER
THE play Gas Light by Patrick Hamiltonis a classic piece of 20th century victoriana. Its theme is a husband’s plot to get rid of his wife by driving her into a lunatic asylum. The medical literature does not appear to have many accounts of plots of this type. A select committee of the House of Commons in 1763 concluded that some people were committed to asylums as a method of solving family and social problems.2 Several workers have put forward various ideas on rejection as a cause of mental illness; and in 1965 some concern was shown over misuse of Section 29 of the Mental Health Act 1959.3-6 We describe here two cases in which there were definite plots to remove an unwanted and restricting relative by securing admission to a mental hospital, and one case of an old lady admitted to a mental hospital following induced incontinence. Unimportant details in the case-records have been changed to prevent identification of the patients and their families by people connected with them but unaware of what happened. CASE-RECORDS
Case 1 Mr. A.
admitted one evening to a psychiatric hospital as His general practitioner, when asking for his admission, had said he was mentally "ill and had attacked his wife. He came into hospital as an informal " patient but was accompanied by a mental welfare officer, who confirmed the story of violence. On admission the patient said he had felt tense and depressed for about six months and related this to his wife’s changed attitude towards him. He said she had become " cold ", and he thought she might have been seeing another man. He denied he had been violent and thought he had been sent into hospital because of his " nerves ". He was a mechanic of 48 who had been married for ten years and had three children. He had never been ill before and did not think there had been any mental illness in his family. He described symptoms of anxiety and depression which fluctuated according to his wife’s behaviour. He felt better when she was affectionate and worse when she was " cold " towards him. His wife said he had changed during the previous six months, and had become irritable, bad-tempered, and liable to unprovoked violent outbursts in which he sometimes hit her and once struck her with a hatchet. She also claimed that his he lost his way in places had deteriorated and that memory previously familiar to him. She denied having changed in her attitude towards him and said there was no truth in his accusation that she had been associating with another man. When examined, the patient was found to be rather tense but otherwise there was no clinical evidence of either mental or physical disease. He remained in hospital for twelve days and became more relaxed without any specific treatment. No signs of irritability or violent behaviour were observed, and he appeared to function at a fairly normal level. Investigations were all normal; and psychological testing produced results within the normal range. an
was
emergency.
1. 2.
Hamilton, P. Gas Light. London, 1939. Leigh, D. The Historical Development of British Psychiatry. Oxford,
3. 4. 5. 6.
Barton, R., Haider, I. Lancet, 1965, i, 912. Enoch, M. D., Barker, J. C. ibid. p. 760. Whitehead, J. A. ibid. p. 865. Barton, R., Haider, I. Medicine, Sci. Law, 1966, 4, 147.
1961.
Sussex1. Mount, L. E. The Climatic Physiology of the Pig. London, 1968. 2. Hey, E. N., Mount, L. E. Archs Dis. Childh. 1967, 42, 75. 3. Accidental Hypothermia. Royal College of Physicians of London, 1966.
J. A. WHITEHEAD
1259 He left
hospital
and attended
a
week later
as an
outpatient.
He said he had remained well and was considering returning to work. His wife claimed that he was a little better but said that he was still irritable and bad-tempered. Two weeks later he was seen again. He had returned to work but once more felt tense and depressed. He said his wife had started taunting him, saying he was mad and should be in a mental hospital. His wife said that his mental condition had considerably worsened and that he had attacked her twice. She asked for his readmission, but the patient refused to come back into hospital; he said that he was well enough to work and denied any violent bahaviour. It was considered that compulsory admission could become necessary, and arrangements were being made to discuss this possibility with the general practitioner when the patient’s employer asked for an urgent appointment. The employer said he had overheard a conversation in a local inn the previous evening. Two men had been discussing Mr. A., and it was apparent from their conversation that one was Mrs. A.’s lover and the story of Mr. A.’s violent behaviour had been concocted in an attempt to gain his admission to a mental hospital compulsorily. They apparently believed this would make divorce possible so that the lover could marry Mrs. A. The employer told a convincing story and Mrs. A. was seen and confronted with it. She finally agreed that she had plotted with her boy-friend to get rid of her husband, but claimed she had been led on by him and now very much
regretted her behaviour.
Following some family counselling Mr. and Mrs. A. became reconciled and five years later were still living happily together. Case 2 Mr. B., a publican of 45, was admitted to the alcoholic unit of a psychiatric hospital at the request of a general physician. He had been admitted to a general hospital owing to symptoms of peptic ulceration. While in hospital his wife had told the ward doctor and sister a long story of her husband’s heavy drinking, erratic behaviour, and aggressive outbursts. The general physician, having heard this story and noted some evidence of agitation and depression in the patient, decided he was an alcoholic suffering from alcohol withdrawal. On admission to the unit Mr. B. gave a history of domestic difficulties and described mild symptoms of anxiety and depression. He said that he drank a little regularly, but denied heavy drinking and claimed there was no question of his drinking being uncontrolled. He agreed that he was irritable but said that he had never been aggressive and did not acknowledge any of the common symptoms of alcoholism. He had been married for fourteen years, and the marriage had been fairly successful until recently when his wife had lost interest in him and had started associating with younger men. She often stayed out all night, and when he asked her about this behaviour she told him not to be silly and accused him of being a drunk who should be put away. Immediately before his admission she told him she was leaving him. Clinical examination revealed only some evidence of anxiety and mild depression. Investigations were all normal. The patient was treated with superficial psychotherapy and chlordiazepoxide and quickly lost his symptoms of anxiety and depression once he had made up his mind about leaving his wife and obtaining a different job. He remained in hospital for two months, not because of illness but because accommodation was hard to find. Alcoholics are notorious liars about their alcohol consumption, but it was considered that Mr. B. was possibly telling the truth. He was allowed complete freedom in the hospital and was actually encouraged to have an occasional drink in the local village inn. He never drank more than two half-pints of beer according to the local publican, and he showed no evidence of alcohol dependence. As a result of a number of accidental findings certain features became clearer. A member of the hospital staff knew the local manager of the brewery that owned Mr. B.’s inn and found out from him that Mrs. B. had informed the brewery that her husband was an alcoholic and told them that
he should not be allowed to retain the tenancy. She had followed up this information by asking for the tenancy for herself, and was rather surprised when this was refused. Another member of staff, through a relative of Mrs. B.’s, discovered that she had confided in another relative that she had fooled the doctors that her husband was an alcoholic and now hoped she would get rid of him, keep the pub, and then
really
start
living.
Mr. B. finally left hospital and obtained a job. Five years later he was well, drinking only occasionally, and he appeared to be very glad that he had left his wife.
Case 3 Mrs. C., a widow of 72, was referred to a psychiatric hospital because of a " confusional state " and faecal incontinence. She was living in a private old persons’ home, and the fxcal incontinence was given as the major reason for her being unacceptable to the home. On examination after admission she was found to be a pleasant-mannered old lady. She had a moderate degree of Parkinson’s disease and had difficulty in walking. There was evidence of slight to moderate dementia with memory defect, but she was in touch with the situation around her and had preserved a good social facade. She remained in hospital for six weeks while efforts were made to re-establish her in the community, and finally left hospital for her own home. She managed satisfactorily out of hospital but later entered an old people’s home again. There was no evidence of fsecal or urinary incontinence while she was in hospital or afterwards. During her stay in hospital certain facts came to light. The lady running the home had been unable to develop a good relationship with Mrs. C. and considered " she was a naughty old thing making life difficult for me, my staff, and other folk on purpose ". For some weeks before admission to hospital Mrs. C. had been receiving ’Dulcolax ’ tablets one three times a day. This had produced the expected effect with occasional " accidents " due to Mrs. C.’s mobility difficulties. The evidence suggested that Mrs. C. was not wanted in the home and induced incontinence was used as a method of getting her removed to
hospital. DISCUSSION
These cases raise important points. A few psychiatrists may regard them as crude examples of a common cause of mental illness, while others will dismiss them as rarities. Perhaps the truth is somewhere in-between. The group or family can use more sophisticated ways of getting rid of unacceptable members, and even these cases could have ended differently. Despite legal safeguards Mr. A. could have been admitted compulsorily to a mental hospital. His general practitioner and a mental welfare officer believed his wife’s story, and he would have been admitted under Section 29 of the Mental Health Act if he had not agreed to come into hospital " informally ". His wife’s story having been sanctified by those with authority, his further detention would have been possible. Ultimately it would have become apparent that he was not subject to serious mental illness, but by then he would have suffered considerable trauma and his future might have been jeopardised. Society still distrusts, fears, and ostracises people they consider lunatics, jobs are difficult to find, and certain countries bar the immigration of people who have been detained compulsorily in a mental hospital. Alcoholics usually lie about their drinking and Mr. B. could have been an alcoholic on the evidence provided by the normal sources. Again, the wife’s story had been reinforced by authoritative repetition. The general physician believed the wife’s story and labelled the patient as an alcoholic. Once such a label has been
1260
applied it can continue to affect the patient even when it is be incorrect. A deaf man known to
found
to
one of us (J. A. W.) was originally from diagnosed suffering schizophrenia. The diagnosis was made mainly on the evidence of his sister, but it later became apparent that his sister was ill and not the patient. He continued to live with his sister and was referred for readmission to hospital on several occasions by his general practitioner when he was approached by the disturbed sister. The general practitioner always referred to him as having schizophrenia although he had been informed to the contrary on a number of occasions. as
of Mrs. C. differs from the other two and is possibly an example of a not-uncommon situation. Most geriatricians and psychiatrists know of old people admitted to hospital because of reported behaviour that was not confirmed once they were in hospital. Sometimes the change in behaviour is the result of coming into hospital, The
case
Parliament Last Round in the Commons THE Children and Young Persons Bill passed its third reading in the House of Commons on June 9. Mr. JAMES
CALLAGHAN, Secretary of State for the Home Department, said that it introduced a greater element of fairness and a greater opportunity for certain children. Children should be dealt with according to their individual needs. The Bill required the exercise of sensible discrimination by the police, by local authorities, and by all other agencies concerned in deciding how best to deal with the individual child.
Higher Pensions-Better Benefits A Bill to increase benefits and contributions under the national insurance and industrial injuries schemes was read for the first time in the House of Commons on June 10. In a statement, Mr. RICHARD CROSSMAN, Secretary of State for Social Services, said that, as the House already knew, standard benefit rates of the national insurance scheme and certain supplementary benefits were to be increased in November. To finance this, E360 million had to be found from increased contributions and the Government had decided to raise this by additional contributions on an earnings-related basis rather than by putting the whole burden on the flat-rate contributions. The flat-rate increase had been held down to ls. per week, lld. for women, whereas the present 1/2% graduated contributions on earnings between El 8 and S30 per week were to be raised by 21/4%. These additional graduated contributions would earn additional pension rights. In answer to questions he said that the object of the increases had been to restore the real value of benefits to that of October, 1967. The major scheme of superannuation, which would be introduced in the big Bill next session, would abolish flat-rate contributions completely. But this could not be done now and the present plan was an up-rating in which the Government was moving towards an earnings-related scheme as far as was possible in the existing framework. He also thought that the increase of sickness absenteeism had to be looked at with great care. Special inquiries were already under way.
Health Hazards from
Cigarettes, cigars, and pipes
Smoking
denounced as instruments of torture in the House of Commons on June 10. Mr. JOHN DurrwoonY’s private members Bill to provide for the labelling of cigarette packets to give warning of the dangers to health from cigarette smoking was read for the first time. Mr. Dunwoody said he wanted the label to be a personal direct warning to the individual. No doubt the great majority of people accepted that there was a health risk from smoking cigarettes, but hardly anyone accepted that it applied to him or were
but in some cases there is no change of behaviour because the original information was either untrue or exaggerated. Relatives, companions, or the staff of old people’s homes may want old people in hospital for a variety of reasons other than the medical or psychiatric state of the patients. If old people are being rejected it is important to know what is happening. It may be possible to re-establish them in the family or home or to find another niche for them in the community. Admission to hospital is never the right answer.
The cases reported here show the importance of examining very seriously the whole situation before admitting a patient to hospital. Home assessment, obtaining information from as many sources as possible, and a reasonable degree of scepticism, coupled with attention to the patient’s own account, should prevent the maturition of most " gas-light " plots. her personally. Mr. ROBERT CoolcE opposed the Bill because it dealt with only part of the problem. The smoke from pipes and cigars was far more noxious to the non-smoker than cigarette smoke.
Pay
for Service Doctors
A report by the National Board for Prices and Incomes on Services pay has recommended new scales of pay for Service doctors and dentists, based on an average salary ofE4000 a year for those not living in official quarters. By a rise of about 14%, their pay will be brought into line with that of civilian general
practitioners.
QUESTION TIME Distinction Awards for Hospital Consultants MR. HAROLD WILSON, the Prime Minister, announced that the Government had accepted the advice of the Review Body on Doctors’ and Dentists’ Remuneration to increase the number of distinction awards available to hospital consultants in view of the, rise in the total number of consultants, and the increase in the standard of their skill generally and particularly in certain specialties. The Body has recommended 5 more A-plus awards at the rate ofS5275 a year, 20 more A awards at the rate of E4000 a year, 70 more B awards at the rate of E2350 a year, and 140 more C awards at the rate of E1000 a year. This makes available a total of 105 A-plus awards, 360 A awards, 1100 B awards, and 2250 C awards. The Review Body did not recommend any increase in the value of awards. Abortion Notifications Since the Abortion Act came into operation on April 27, 1968, 41,496 abortions had been notified in England and Wales, up to May 27. Of these, 16,650 were in approved places, 101 elsewhere, and 24,745 in Health Service hospitals. They were performed on the following grounds: Risk to life of woman Risk to physical or mental health of woman Combined risk to health of woman and risk of abnormality in child Risk to health of existing children .......... Risk of child being severely handicapped ........ Risk for two or more reasons............ ...........
......
1827
29,945 690 1629 1232 6098
The 1968 figure of abortions carried out where the operating did not join in granting the certificate was 10,727, Notifications in England and Wales totalled 18,322 for married women, 19,617 for single women, and 3416 for widowed, divorced, or separated women. Up to Dec. 31, 1968, 5% of women on whom abortions were carried out gave a place of usual residence outside the United Kingdom.
practitioner or 45-4%.
Health Centres in Scotland In Scotland in the three years to 1967-68, 5 health centres were completed; and in 1968-69, 3. In 1969-70, 6 centres at present under construction should be completed and work should begin on another 13.