“The present system, which compels all persons, except those able to pay adequately for their maintenance, to apply to the Poor Law authorities in order to secure treatment, is unsatisfactory and unjust. In doubtful and undeveloped cases temporary care can be given only in workhouses or Poor Law infirmaries, which, with very few exceptions, lack proper facilities for treatment.
A system which artificially creates paupers in order to obtain medical treatment necessarily acts as a deterrent, so that too frequently there is serious and even disastrous delay.”[52]
This is not exactly locking the stable door after the horse has gone; it is double-locking him thoroughly, expensively and often unnecessarily, in someone else’s stable.
Let us, for a moment, compare this state of affairs with that existing in the case of tuberculosis. Nobody now believes that the scientific way of treating this disease consists in waiting until the patient has become a positive danger to others, and then locking him up. This point needs no elaboration. But another fact in this connection should not be forgotten. The tubercular patient usually seeks the doctor of his own free will, often obtaining treatment in a relatively early stage of the disease.
There are, however, many reasons that deter the mental sufferer from seeking medical help. One of the strongest of these is the wish to cure himself by his own unaided efforts. This is a laudable desire and one which is extremely helpful and important in mild and uncomplicated cases of relatively recent occurrence, but of which, as we have seen,[53] the gratification is not always possible. Another factor is the natural disposition which the patient shares with the rest of conventional humanity, to conceal his worries, not only from his friends, but perhaps above all from those of his own household. This tendency to concealment, however, often only aggravates his mental distress. Particularly is this the case in adolescents. As is well known, a talk with a kindly, sympathetic and wise person, or even a confession to such an adviser, frequently means the end of many painful mental conflicts.
But in addition to these very natural reasons for deferring recourse to medical help, there are in our own country special causes for delay. These are due to the prospects imagined by the sufferer to be awaiting him if he discloses his trouble.[54] The treatment of incipient mental disorder is often a long and complicated process for which the average general practitioner has seldom either the time or the special training. In very few hospitals in this country is out-patient attendance for such maladies practicable. For the mental sufferer whose means are not considerable, there exists nothing if the efforts of the general practitioners fail, but trying to cure himself, or, if he becomes worse, admission to an asylum. Unfortunately, however, the average asylum, with its one doctor to 400 patients, does not and can not meet his needs. The successful treatment of mental disease usually requires individual care, often lasting over long periods. When it is remembered that the asylums contain a considerable percentage of patients whose bodily diseases, apart from their mental troubles, require the doctor’s attention, and further, that by the time the patient reaches the asylum, his disorder has usually passed through its initial stages, it is easily seen that our asylum system in its present state—to put it mildly—is far from conducive to recovery from mental disease. Considering that, in spite of these drawbacks, 33 per cent. of the patients are discharged,[55] we can only gladly recognise the efforts made by the asylums; we are, however, bound to ask: What percentage of the inmates need ever have entered the asylum? It may be objected that it is easy, but unfair, to ask such a question seeing that no satisfactory answer can be given. To this objection there are two replies: first that, judging from the present state of affairs, this question cannot be publicly asked too often; secondly, that materials for an answer are already forthcoming. It is conclusively proved by the experience of other countries that a large proportion of the patients might have been cured without being sent into an asylum. Thus, for example, in Germany, in the province of Hesse, by reason of suitable treatment during the early stages of mental illness the authorities were able to postpone for ten years the erection of a new asylum.
“The Psychopathic Hospital at Boston, Massachusetts, ... was built by the State expressly to deal with recent acute cases. No fewer than 1,523 patients were received in its first year, and of these 590 were received under a temporary care law, which provides for a week’s detention only; large numbers were also received on a voluntary basis, so that during the year 48 per cent. of all patients escaped the usual lunacy procedure.
On reading the reports of work done, one is struck with the enthusiasm of the medical staff and the vast field of research undertaken. During the two years eighteen medical men describe their work covering almost every department of psychiatry: juvenile crime, tests for feeble-mindedness, incidence of syphilis, alcoholism, hydropathy in its influence on red blood cells, treatment of delirium, prophylaxis, analysis of genetic factors, salvarsan treatment, tests of cerebro-spinal fluid, and last, but not least, the value of out-patients’ departments and after-care. There is a special social service department for the purpose of following up cases in their homes, and it was found that of every 100 admissions 20 needed supervision on discharge, 24 needed advice, 3 required assistance in arranging their discharge, and 10 showed a need for prophylactic work in their families.
This bald statement of the activities of the Boston State Hospital shows plainly what an important service it renders in providing treatment apart from ordinary asylum associations. It shows how it is possible at such a hospital to organise a medical service which covers all departments of psychiatry; and further, that when the mental symptoms clear up, a patient need not be thrown back into old associations without help or supervision.
This hospital at Boston is but one of many that have been established in the United States in recent years. Some of the others are due to private munificence; in particular, reference may be made to the Henry Phipps Psychiatric Clinic at Baltimore, the medical staff of which consists of a director, assistant director, a resident physician, two assistants, and five [resident medical officers]. In addition to these are the heads of three research laboratories dealing (1) with clinical pathology and bio-chemical investigation, (2) with neurological research, and (3) with psychopathology.” (Bedford Pierce, op. cit., p. [42].)