The Munich Psychiatric Clinic
and the present movement for the foundation of similar Institutions in England.
- Author:
Mapother, M.D.
Dr Mapother kindly allows us to print extracts from the English version of an article by him which appeared last year in the Allgemeine Zeitschrift fur Psychiatrie und Psychish- gerichtliche Medizin, in honour of Professor Kraepelin s 70th birthday.
In view of the findings of the Royal Commission and the general interest which has been aroused in the provision of facilities for early treatment, and the relationship between the General and the Mental Hospital, we feel sure that our readers will note with interest Dr Mapother’s remarks. His position at the Maudsley Hospital gives htm unique opportu- nities of judging the advantages of early treatment.
It is probable that in the minds ot” future generations, the fame of Professor Kraepelin will depend chiefly upon his additions to our purely scientific know- ledge. His classification, discriminating various clinical types of psychosis, i.e., syndromes with a relatively constant prognosis, has been almost universally accep- ted. Hardly anyone now questions its enormous practical value in enabling us to forecast the probable future of a given case from the symptoms present at an early stage of their developments.
It is true that in connection with every variety oi syndrome we meet with a number of cases whose course proves a surprising exception to the rule. How far, therefore, the syndromes distinguished by Professor Kraepelin are truly unitary and each essentially dependent on the presence of one indispensable tactor, may be a matter for future investigation.
In regard to this, Professor Kraepelin himself has always exercised a wise moderation in statement. His method has always been the truly scientific one of laborious accumulation of great masses of observed fact as a preliminary to generalisation rather than that uncontrolled speculation which has tended to enjoy a certain vogue in Psychiatry during recent years. Thus, our gratitude is due to him no less for keeping ever in our minds the sure, though tardy, method of seeking truth than for the results which he has himself achieved.
But there is another aspect of Professor Kraepelin’s life work which has been hardly less inspiring to those of us who, if not exactly contemporaries, have at least been engaged in the practice of Psychiatry during a period that partly coin- cided with his. I refer to his achievements in connection with the oiganisation and development of the Psychiatric Clinic of Munich, particulaily as a centre for early treatment, teaching and research.
Though I had desired to visit it for. many yeais, vaiious ciicumstances had prevented my doing so until the end of 1921. In spite of all that I had heard of the Clinic, the reality far surpassed my expectations.
The whole atmosphere of the hospital was one of kindness and minute attention to every detail of the patients’ welfare. But combined with this was such a degree of scientific enthusiasm as I had never met elsewhere?a spirit obviously due to the influence and example of Professor Kraepelin himself.
For the first time I saw an institution for mental disorders whose wards wei’e almost indistinguishable from those of a hospital for bodily disease. Greatly as one admired the efficient and unobtrusive arrangements for the safety of the patient and the completeness of the equipment for diagnosis and treatment, what struck one above all was the surprising quietude of the wards. This was not due to isolation of troublesome cases in single rooms, and I was assured that it did not depend upon exclusion of disturbing patients nor upon their speedy removal. The employment of sedatives was very limited, their customary place being largely taken by hydrotherapy. The peace and order of the wards appeared to depend above all upon the provision of a medical staff adequate to give each patient the necessary attention, and upon the kindness and devotion of the nurs- ing staff, whose relations with the patients appeared ideal.
One point which I noted was that, in spite of the attractiveness of the hos- pital, its patients seemed to be mainly examples of fairly well-defined psychoses. I understood that cases of the neuroses were mainly treated in the Policlinic, and that the function of this was largely separate from the hospital. This point has some bearing on differences in existing and proposed arrangements in England.
The arrangements for the educational work of the Clinic seemed to me even more remarkable than those for treatment of patients. At that time, nothing resembling such arrangements existed in England where the require- ments as to instruction of medical students in Psychiatry are incomparably lower than in Germany. I left Munich with a feeling that in its clinic I had seen the model which it was one’s duty to imitate as far as certain differences of purpose would allow. I have since seen eight other clinics in as many different countries of Europe without finding reason to modify that conviction.
In England, the arrangements for the care of the chronic insane are prob- ably equal to those of any country in the world. On the other hand those for the treatment of early and curable cases are about twenty years behind those of the most advanced countries of Europe. Since the clinics devoted to early treatment everywhere form also the chief centres of research and education, it almost necessarily follows that the standard existing in both matters in England is deplorable.
It is, however, an interesting fact that in spite of the real excellence of the English asylums, the public attitude towards them is one of almost universal suspicion. Stories of illegal detention and of neglect or ill-treatment in them have a widespread popularity. These seem to owe their first origin to certain classic novels, drawn entirely from imagination, and their persistence to the efforts of sensation mongering journalists and societies of well-meaning paranoiacs. On the other hand, until within the last few years there has been an extreme degree of popular indifference with regard to defective provision for curable cases and for research and education.
Possibly this has been due to the fact that the defects are much less glaring in respect of the treatment of the well-to-do. Nominally the English law pro- hibits private treatment for payment of any person whose mental state would justify detention in an asylum except upon a detention order from a magistrate and other formalities.
In practice, acute psychoses of all kinds in the well-to-do are temporarily treated in ordinary nursing homes without formalities, and a fair proportion of chronic insane patients are similarly treated. Moreover, there are facilities for reception of those able to pay as voluntary patients in private asylumsj^upon then- own application. However imperfectly, these provisions for treatment come some of the worst deficiencies which exist in the case of the poor.
In the case of the poor, there are practically only two’ the treatment of mental breakdown. On the one hand the patient can i to treated in the workhouse. Most cases are sent there m the firs place, and such asmre st”t0rfget we!1.withi? ? frforpropSatreatment of an acute psychosis are staff and material conditions tor proper nf naunerism entirely lacking- in most such institutions. i ore rrom readilv seeking associated with these institutions deters the selt-respecting from readi y g admission.
T , tt tiip nnlv alternative place of treatment is the asylu^Tn m&lce treatment are much better. But, as already ^nentloned, the asylums are by most poor partly on grounds that are without foundation, bu. alscin part because ot their functions as homes for the chronic insane an p desirous of treat- obnoxious. It should be noted that even if a poor per:son. beso desirous cq e ment that he would be willing to enter an asylum, he rannot clo so without the unnecessary indignity of being legally depiivec o l . Naturally, these conditions practically result ini posttrealtment until urgent necessity compels the friends ot the patient to apply for such treat ment as is available.
Of late years, there has been a growing movement in Engiand for Uie reform of the present state of affairs, particularly an increasing agi a ion p of special facilities for the treatment of willing and of recoverable cases. One aspect of this agitation is the demand for such changes in the law as will greatly extend the possibilities of treatment without the indignity ot a dete tion order.
It is now almost universally recognised as absurd that this should be a .pes- sary preliminary of treatment for mental disorder in cases where the patient is willing, or so confused, as to be incapable of either refusal or consent. It seems fairlv certain that in the near future the law will be so modified as to permit of the reception in public asylums of both the latter classes wit lout detention orders?in fact, with the minimum of legal formalities necessary to guard against abuse.
It is, however, also recognised that such relaxations of the present law will never alone satisfy requirements in the way of provision for early treatment. Owing to the attitude of the public towards the asylums, it is certain that these will never in the near future attract any considerable proportion of hose suffering from early and minor forms of mental maladies This is not entirely due to their unjustified disrepute in respect of treatment of chronic and unwilling patients. It is, in addition, attributable to the unalterable fact that they are and must remain chiefly institutions for the care of such patients. Ihe very presence of such is apt to induce an atmosphere of pessimism and discontent which will always deter the early and hopeful patients from voluntarily seeking admission.
It is, therefore, now generally agreed that in addition to changes in the law there is urgent need for some provision of accommodation for patients With minor and recoverable forms of mental disorder in hospitals entirely apart from those institutions undertaking- the care of chronic cases. There is, however, considerable disagreement as to the length to which this principle should be carried, and corresponding difference as to exactly what new forms of institutional treatment should be provided or financed.
At one extreme is a group mainly composed of those specialising in organic neurology, in whose opinion the main requisite is the endowment of treatment in the ordinary wards of general hospitals for neuroses and similar minor abnorm- alities. Those who are of this opinion maintain that patients who are not manage- able under such conditions, even if willing and recoverable, should still be sent direct to the asylum.
At the other end of the scale stand those who, like myself, maintain that every curable patient, whatever the nature and intensity of symptoms, and whether willing, unwilling or incapable of expressing choice, should be given the opportunity of treatment to recovery outside an asylum. Those of us who advocate this principle are pressing for the establishment of two new types of institutions where all suitable cases might be treated, if necessary, for about a year before transfer to the asylum, which would thus ultimately be reduced to a home for chronic cases.
One new type of institution (the voluntary clinic) would be intended for the treatment of all cases of neurosis and psychosis that were regarded as curable and that were either desirous of treatment or incapable of expressing choice. The sole exception would be patients who were either willing- or non- volitional, but intolerably disturbing to others.
The second type of hospital (which might be called the involuntary clinic) would receive all curable cases that were either unwilling to submit to treatment or too objectionable in symptoms for the voluntary clinic.
If cases in the voluntary clinic after admission became either unwilling to remain or unduly objectionable, their relatives would be called on to remove them. The relatives might, if necessary, be given advice to apply for the admission of the patient to the involuntary clinic, but no transfer to this or to the asylum would be undertaken except upon the initiative of the relative.
Some such guarantee against admission to the voluntary clinic proving but the initial step in an automatic progress to the asylum seems the indispensable condition in England of such clinics proving useful for the treatment of possible neuroses and early psychoses who cannot be compelled to accept such treatment. There would be no prospect in this country, I think, that any considerable number of such patients would be persuaded voluntarily to seek treatment at a clinic like that of Munich, where a considerable portion of those admitted do subsequently pass direct to the asylum.
In England, as I have already said, there is a movement to mask the essen- tial continuity of the psychoneuroses and minor psychoses with graver forms by admitting cases of the former to general hospitals and relegating the severer cases still in the first instance to asylums. I regard such a policy as utterly retro- grade and vicious, and I have tried, in addition, to show that it is unnecessary. I believe that it is necessary at present to treat those recoverable cases that are respectively willing and unwilling to accept treatment in separate clinics, and both apart from chronic cases.
But the institution of all three kinds should, I believe, be under the manage- ment of one authority in order that they may be co-ordinated for treatment, fesearch and teaching”: their staff of all kind should have free opportunities of interchange.
What I saw at Munich impressed upon me most strongly the view that the work done within its own walls is but a part of the function of a clinic. Equally important is its influence in the way of raising the level of the work done elsewhere by serving as a centre to which those engaged in the asylums and in other forms of practice can resort in order to study methods of investiga- t’on and treatment that have been recently introduced or to acquire the necessary technique for research that they can carry out after leaving the clinic. Every Possible effort is being made at the Maudsley Hospital to profit by the example Set m this respect, as in so many others, by the Psychiatric Clinic of Munich.
The Maudsley Hospital is a recognised school of the University of London, and in addition to treatment of curable mental maladies, has the two other main Purposes associated with University Clinics, namely, research and the teaching both ?f medical students and of those specialising in Psychiatry. It was generally thought that the policy of restricting admission to those whose consent could be obtained ^ould greatly handicap the hospital in respect of clinical material for teaching, this has not, in practice, proved true to any material extent. Briefly, one may Say that though not every case of any form of mental disorder is capable of admission, some cases of every type can always be found in its wards, including examples of all the major psychoses, psychoneuroses, and of many organic nervous diseases.
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