Mental Deficiency. Stoke Park Studies
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Book Reviews and Abstracts
First Series. :Author: R. J. A. Berry, M.D., F.R.C.S., F.R.S.E. Pp. 249. Mac- millan & Co. 10/6.
This volume is the first contributed by the medical and consultant staff of the Stoke Park Colony, near Bristol, under the editorship of the Medical Director, Professor Berry. It is dedicated to the memory of the late Reverend H. N. Burden, who founded the Colony and who, until his death in 1930, acted as Warden, a position now held by Mrs. Burden. It gives, in a memoir on the life of the founder, the history of the founding of the institution and Particulars of the actions taken by the late Warden and the present Warden to foster re- search in mental deficiency.
The work is well presented in a very read- able form, and is amply illustrated by photo- graphs, charts and diagrams. There are seven- teen articles on various scientific and clinical aspects of the subject. Not all the work has been done at Stoke Park, but there is in- eluded certain work done elsewhere at various times by the Staff. A comprehensive biblio- graphy is given at the end of the volume. Much of the work is on anatomical lines and there are several interesting articles deal- lng with the neurological aspect. One con- tribution by the Editor deals with a practical njeth?cl of the detection of potential social in- efficiency and high-grade mental deficiency, and is based on a former work published by 11111 in association with Professor Portens.
The value of head measurements in diag- nosis is greatly stressed. One would, however, 1 ‘ a^on8” with most clinicians, to regard hese as by no means generally accepted as e<?nclusive, but to be considered in their place with many other diagnostic points, the accurate psychological examination of jle lowest grades has always presented prob- jjllls- A very suggestive and helpful article by ^j1, R- G. Gordon on the application of the foerriH-Palmer tests promises much useful in- fRation. More details are to be given in a Work which will be published at a later of> article gives the family histories of some ti0nle Patients in the Institution. The atten- 1 ?f all who work with mental defectives is naturally, just now especially, directed to this aspect, owing to the researches in hand for the Departmental Committee at present con- sidering the causation of mental, disease and inefficiency and the possible utility of steriliza- tion. Professor Berry, by reason of his being Chairman of the B.M.A. Committee on Mental Deficiency, which recently reported its find- ings, speaks with considerable authority. His plea for a greater recognition of the hereditary factor might be carefully studied by advocates of sterilisation on a large scale amongst mental patients. He very rightly makes the point that the real crux of the problem is the un- certified person who produces the defective offspring, and, one might also add, the un- detected ” carrier.”
A most instructive contribution is an ab- stract from a paper by Dr II. L. Gordon on the mental make-up of a young man who was recently hanged in Kenya Colony for the mur- der of two young women. The effects of both heredity and environment are clearly shown. The bearing of such a case on the safety and well-being of any community is important. The latter certainly needs much more education in matters dealing with mental abnormality, and the attitude of the law altering, before one can feel reasonably happy about the treatment of the mentally abnormal.
This is certainly a book which can be recom- mended for the careful attention of all who are interested in Mental Deficiency. It shows that the mental deficiency service intends to keep its subject as well forward in research as arc other branches of medicine.
A.M.McC. Human Values in Psychological Medicine. C. P. Blacker, M.C., M.D., M.R.C.P. Ox- ford University Press. Pp. 179. 8/6. The first impression made by this book is good, the plan of approach is admirable, and the exposition most lucid. The positive con- tribution, however, is nevertheless most disap- pointing, nothing really new is offered for either the theory or the practice of psycho- logical medicine.
Dr Blacker professes a deep debt to Freud but shows no evidence of having assimilated or applied the essentials of psycho-analytical theory, namely, the conception of the uncon- scious. He criticises fairly and brilliantly the theory of the death-instinct, yet himself em- ploys the conception of instinct in a casual and obscure manner. Thus he talks of social re- flexes, of a socialising instinct, and again, of an instinct of acquisitiveness, in a way that would be condemned by any serious thinker. He ob- viously finds no satisfaction in any of the class- ifications of instincts and instinct values that he discusses, but he replaces them by equally abstract social ethical values. The pivotal values that Dr Blacker wishes us to accept are themselves highly derivative, and only pivotal in the theorising mind of the onlooker. That there is some flaw in their pivotal quality Dr. Blacker seems to be uneasily?if only intuitive- ly?aware when at one moment he defines those values as the factors that ” unify and justify life, give it coherence and make it on the whole worth living,” while later he tells us of people who have not got pivotal values and do not feel the need of them and who yet apparently do find life worth living.
Theory, in this book, has taken the bit be- tween its teeth and has left practice and the writer behind. Much as one approves of the author’s intention?the discovery of the fun- damental drives in human life by a study of the individual’s social activities?to the re- viewer at least it seems to have failed in its purpose.
J.S. Social Development in Young Children : A Study of Beginnings. By Susan Isaacs, M.A., D.Sc. Geo. Routledge & Sons, Ltd. 480 pp. 15/-.
This book has been eagerly awaited by all those who enjoyed Dr Isaacs’ ” Intellectual Growth in Young Children,” and who have followed the research projects in recent years. After a clear statement of plan, the enquiry proceeds to set forth the valuable descriptive material gathered at the Malting House School and elsewhere. This is fascinating reading. The second part of the book is concerned with the interpretation of these facts. An admirable concluding section applies principles to prac- tical problems of the teacher and the parent. It might be thought that psychology has passed beyond the stage when the straightfor- ward observation and recording of children’s behaviour could contribute anything new. This is quite fallacious. A good deal of psycho- logical literature proceeds to theories and ap- plications as if all observation were finished : Dr Isaacs does a valuable service by remind- ing us that the groundwork of accurate ob- servation has still to be completed, particularly in regard to the sex life of young children in a free environment?a subject which finds even most psychologists regrettably ignorant.
One would wish that all these records had been more extensive?dealing with various ages and the whole of the waking day. New and interesting facts might well have emerged from statistical comparisons of different ages. It is unfortunate, too, that the first-hand ob- servations were confined to a small and highly atypical group of children. No mental ages appear to have been worked out, but any psychologist familiar with the average (elemen- tary school) infant will recognise at once that these Malting House children must have I.Q.’s in the neighbourhood of 140, a fact of great significance in interpreting their behaviour and drawing conclusions from it for average child- ren.
If the times and subjects of observation are arbitrary, the classification of records is at least equally so. Admittedly, as the writer points out, it is very difficult to separate com- pletely interpretation from observation. But why are Imitation and Suggestion totally ig- nored in this classification; why do the motives of curiosity, disgust and protectiveness find no place, and why is aggression linked with sexual play ? McDougall’s classification of instincts would have made a better sorting box for the facts, with less prejudice to the eventual the- oretical deductions.
Indeed, it is in the second, explicitly inter- pretative and deductive section, that the great- est misgivings come upon one. However well disposed one may be towards psychoanalytic explanations, the time has come when one ex- pects that they shall be put to the touchstone of scientific method. It is humbug to refer the reader to the so-called “researches” and “dis- coveries ” of the ” classic literature.” These intuitions should by now have been supported by classic experiments. And it is utterly un- conscionable that serious workers should imagine that they can continue indefinitely }? evade the responsibility of presenting statis- tical and other confirmatory evidence. If half of the ingenuity displayed in speculative elaborations of the theory had been devoted to finding methods of establishing the main theories we should now be in possession of valuable and dependable principles.
There is an air of completeness about Dr. Isaacs’ theoretical explanations which doubt- less makes them attractive to the busy prac- titioner, but which at once differentiates them from the tentative, trial and error structures of a growing science. When the writer speaks at the outset of ” gathering confirmatory evi- dence from other sources ” (italics mine), one perceives that the theories are the main in- terest, not the facts displayed, as a formality, beforehand.
Dr Isaacs’ ” Notes on the Incidence of Neurotic Difficulties in Young Children” gives ?ne hopes that she was about to undertake the formidable task of establishing by statistical and analytical methods, a true basis for the understanding of problems of emotional and Social development. The present books runs away from any such laborious or skilfully Planned approach.
The discussion, however, is full of stimula- ting suggestions. It manifests a sane touch in detecting the main themes in emotional en- tanglements and a shrewd common sense born ?f wider experience in this field than is given t? most psychologists. The behaviour records are admirably lucid; condensed where con- densation is permissible and full wherever detail is likely to be significant. Psychology and Social Progress, by Ray- mond B. Cattell, M.A., B.Sc., Ph.D. The C. W. Daniel Co. 1933. Price IS/- net. pP. 418.
It is difficult to do justice to a book of this Sc?Pe and complexity in the course of a short Gview. The author has approached his vast ield of enquiry from the threefold point of lew of the scientist, the psychologist and the Ucationist, and the stress laid on the two r fi?1 asPects gives the work a particular and W li 1 un^(lue value. The whole work is very ^ documented and we would draw attention ^ the excellent bibliographies at the end of vh aPters? these are particularly helpful bo CU’ llccessity, many of the subjects must cursorily treated.
the 1 var*ous chapter headings arc perhaps >est indication we can give the reader of the scope of this approach to Social Progress : Nation and race, their significance for human progress; Rich and poor, the biology of class interaction; Ultimate morality and natural science; Progress and the presence of God; Man and woman in civilised life; The Control of destiny; The Conquest of obstruction; Education; and finally, Summary of essential aims in a society for constructive racial con- trol. Every chapter has a final paragraph sum- ming lip its main thesis and this is always a help to the general reader, who may not be conversant with the varied authorities cited in a very condensed form.
Dr Cattell endeavours to show the historical background of the various phases of evolution in social progress, and to give some indication of the roads by which we have travelled to arrive at our present deplorable social chaos and disorganisation. He is not an optimist, as indeed few can be at the moment. Whatever aspect of social progress he looks at he sees the same disastrous conditions, no settled ideals or policy, no enlightened leaders (accepted as leaders) and with power to implement their ideas, nations of poorly endowed and badly educated men clinging to the older methods, oblivious of the fact that advances in biology and other sciences should enable men in an enlightened community to control and guide their destinies towards a harmonious social adaptation. We are at a turning of the ways and unless we realise this, and the nations of the world definitely equip themselves to meet the new conceptions with new ideals, the civil- isation of these days will go the way of the older civilisations. The picture is a gloomy one, and this clinging to the past in all our social and national ideals can only spell ruin. And above all he sees a disgenic trend in society which if not checked will certainly reduce the population of the civilised peoples to so low a general level of vigour and cap- acity that they will succumb to the forces of disorganisation. ” Side by side with the pomp of outward and visible progress in hu- man conditions which has gone on during the last five centuries there has proceeded with special rapidity in recent years, an invisible decay of the average inborn vigour and capac- ity. There is going on now a close race be- tween an almost galloping decline and the efforts of a few scientifically educated people to institute constructive measures.” (p. 407.)
This is the key-note of the book; it seems to us somewhat forced, one-sided and dogmatic, ignoring other trends such as better general health, which may more than compensate for the survival of some weaklings, greater feel- ings of social responsibility, a more vivid real- isation of the value of the individual, a sense of duty towards the less fortunate members of the community.
The remedy for the author lies in an im- provement of the race by definite constructive methods such as are advocated by eugenists, sterilisation, segregation, the encouragement of children from good stock; but he very wisely stresses the absolute necessity for an under- standing education guided by biological and psychological principles if this better individ- ual is to bear his full share in the regeneration, or rather in the re-orientation of our social re- lations. He lays stress on the debt we owe to Freud and the psycho-analysts for the light they have thrown on the problems of the in- dividual and he emphasises anew the import- ance of the education of the infant and the adolescent 011 sound psychological and there- fore scientific lines. He points out that only the individual unhampered by the many inhib- itions due to our present outgrown educational systems will be able to make the experiments which the new conditions demand. With many of these arguments and contentions readers will be in accord. Where they are more likely to differ is as to the means to bring about such an educational system as to secure the desired results.
Dr Cattell suggests placing the control of education in the hands of a few leaders, the best experts, but he does little to tell us where they are to be found (unless he has in mind the body of Inspectors of teaching whom he so highly praises 011 page 389), nor how their very progressive and even revolutionary views are to be accepted by the bulk of the nation under such different conditions.
The practical difficulties underlying such sweeping reforms loom large in the eyes of the reader who is seeking a solution to his own par- ticular problems, whether educational, psych- logical or social. Many questions such as crime, are very sketchily touched on with too little consideration of the reliability of evidence (vide the Jukes statistics, pp. 164-5), but this is inevitable in so wide and oeneralised a sur- vey. Dr Cattell has, however, made a prac- tical contribution to the study of many present- day problems, inasmuch as his book will be illuminating and helpful to many readers who are either not specialists or who are anxious to see something of the relation of their own particular interests to other social and educa- tion problems.
E.F. Child Upbringing and the New Psychol- ogy. By Richard Amaral Howden. Oxford University Press. 5/-. This book, written by ” a parent, an ex- schoolmaster, and one who has had months of treatment along the lines of modern psycho- therapy,” discusses the value for parents and educators of the findings of the new psychol- ogy. It has the defects and the excuse of deal- ing with wide and controversial issues in a hundred small pages.
Mr. Howden is on the side of sanity. He desires to indicate a course ” which can help the ship of childhood to steer between the Scylla of unrestrained liberty and licence and the Charybdis of suppression and anxious fear.” This moderation he achieves. For the general public the advice given in the earlier chapters seems somewhat obscured by the use of Adlerian terminology and by diffuse writing. There are clearer and more practical sug- gestions in the last chapter on sex education. The book is addressed to those whose children are exposed to the perils of nurses and public schools.
P.C.S. The Nineteenth Annual Report of the Board of Control for the Year 1932. H.M. Stationery Office. Pt. I. 2/-.
Mental Disorders.
The Board’s Report begins with a considera- tion of the working of the Mental Treatment Act. Stress is laid on the need for close co- operation between the general practitioner and the psychiatrist in charge of a clinic. The num- ber of clinics remains substantially the same a* last year, but the general progress in this form of early treatment is on the whole satisfactory- The Board, however, find the number of tem- porary patients with on I certi fication admitted to public mental hospitals still disappointingly small. It appears that the observation ward of the Public Assistance Institution is still too largely used even when the case is acute and transfer to a mental hospital is inevitable. The result too often is serious disturbance to a patient and consequently certification. The Board realises that to recommend a patient for treatment in a mental hospital involves respon- sibility and sometimes causes friction with re- lations, but they say ” we feel sure that if doctors only realised how their poorer patients are prejudiced, the percentage of rate-aided temporary patients would soon approximate to that already obtaining in the case of private patients. It seems remarkable that in only two per cent of the total direct admissions during 1932 was this procedure used, though there is a notable exception in the num- bers admitted to the Derby Borough Men- tal Hospital, where no less than 34 out of the 100 admitted were received as temporary patients. In forty mental hospitals no ” tem- porary ” patient was admitted. .Special atten- tion is called to the new mental hospital of the County Borough of Swansea, which has been able to establish its work from the beginning under the new conditions. The figures ob- tained there are such as to encourage the Board to think that not less than 60 per cent, of all rate-aided patients should receive treatment without certification.
No new proposals under Section 6 have been before the Board for the reception of mental Patients in general hospitals. The Board make ^Pecial reference to the opening of a ward at Ring’s College Hospital as an annexe to the ^audsley for the reception of 30 female Patients, and this development in a hospital M lth a medical school is of significant value. Reference to the good results of occupation therapy is briefly made and a separate report 011 this subject is now available. (.See separate ‘CVIC7V in this issue.)
1 he value of social service is emphasised, and ls being increasingly used in carrying out ^obstructive work in the patient’s home and in ^cilitating boarding-out, though as the Board ftiark, the movement is a recent one and has 01110 at a time when expansion is difficult.
An investigation is being carried out into ^’le dumber of patients in Mental Hospitals who are suitable for transfer to a Mental De- ficiency Colony or Public Assistance Institu- tion. In two mental hospitals the numbers were 11 per cent., and this enquiry may prove of great importance, when the heavy cost of Mental Hospital accommodation is considered. The new forms for costing’ returns issued re- cently by the Board will in future show very clearly the comparative costs of institutions, and the transfer of suitable cases will effect considerable economy.
Mental Deficiency
We are very glad to note that in the Intro- duction to the Report the Board refer to the allegations made that the consent of parents to the admission of children to institutions is ob- tained without their full appreciation of the conditions. The Board say that ” in 110 case has any positive proof been obtained that con- sent has been improperly obtained. But the frequency with which such allegations have been made is in itself disquieting ” (p. 10.) We have not infrequently heard parents say that they consented because they understood the child was to get training, but they had 110 idea they could not later have the patient home as and when they wished. The Board’s view is ” that anything approaching a want of can- dour in dealing with the parents of defectives is indefensible.” In this we heartily agree. Ascertainment.
Once again, the Board refer at length to the inequalities of ascertainment in different areas, seven areas exceeding the estimate of the Wood Committee (4.52 per 1,000) and fourteen areas showing less than 1.50 per 1,000. Many Local Education Authorities are still behind- hand in notification, and in 17.8 per cent, of cases notified, no action was taken. It is ob- vious that further use of notification is desir- able and could be greatly extended, even though the law requires amendment so as to admit notification of feeble-minded children leaving any school at any age and not only the ineducable and those leaving Special Schools.
Of the 102,345 defectives reported to local authorities during the year, 917 were in receipt of poor relief and in accordance with the Local Government Act, 1929, were ascertainable by the Local Authority.
Accommodation. The paramount importance of institutional training in colonies for the young is again shown, and the Board advocate comprehensive planning whereby Public Assistance Institu- tions may be used for the accommodation of low grade adults and certain idiot children and the most expensive colony accommodation for the trainable young. Though 2,146 beds have been provided during the year, there are still 3,480 cases reported as awaiting removal to an institution.
Community Care
On January 1st, 1933, there were 1,592 de- fectives on licence (an increase of 89 in the year). Licence as an integral part of the plan- ning of an Institution’s work is discussed at length, and the need is emphasised for the further development of hostels attached to the Institution for the accommodation of patients before they are placed out in the general com- munity. Success has attended the careful or- ganisation of licence in close co-operation with the mother institution, and extension of this form of care, and if possible the appointment of a social worker is clearly desirable. Cases under Guardianship increased by 359 during the year, bringing the total up to 2,558. There are now 153 occupation centres, 19 industrial centres and classes and 8 clubs. It is interesting to note that 5 of the clubs are managed by Toe. H., and we believe that their services might be enlisted in other areas, as they have often been found ready to give- help to individual mental defectives. Board of Control. Memorandum on Occupa- tion Therapy for Mental Patients.
Pp. 27. H.M. Stationery Office, Kingsway. Price 6d. 1933.
By a review of what has already been done on the Continent and in the United States of America and in a few mental hospitals in this country, the Board seek to urge the Medical Superintendents of all Mental Hospitals to make Occupation Therapy a recognised part of the treatment of varying types of patients. It is claimed that almost the whole of the in- mates of a mental hospital can be suitably oc- cupied, as were 98.7 per cent, on the day when the Mental Hospital at Gutersloh, under Dr. Simon, was visited. Similarly at Santpoort, the proportion was 91.3.
At Gutersloh, where Dr Simon introduced the principles of occupational therapy as early as 1905, the work is organised by the usual staff and is mostly of a utilitarian character; at Santpoort, which adapted the methods of Gutersloh in 1926, and placed the responsibility 011 the nursing staff (who received special train- ing) it has recently been found advisable to appoint technicians, who are not nurses, in the central workshops.
Occupation therapy in many of the principal Hospitals of the U.S.A., is firmly established, and there special occupation therapists are ap- pointed, who have as a rule not less than two years’ training in handicrafts as well as train- ing in mental hospitals.
The Board recommend that in England oc- cupation therapists with similar training should be appointed (at a suggested salary of ?200 to ?300 p.a.), that certain certificated nurses who have special aptitude should be appointed as craft workers, and that all nurses should receive a certain amount of special training as part of their general course. In addition, it is considered by the Board that it will be nec- essary to appoint a small number of skilled artisans to instruct the patients in the more difficult occupations and crafts. There should be 110 limit to the quality of work taught where patients become capable of achieving a high standard of production.
A fear has sometimes been expressed that a general increase in staff per patients Avould be necessary if occupation therapy were intro- duced into a hospital. The Board have gone into this question, and find that divergencies of percentage of staff have been noticeable be- fore reorganisation and are not attributable to it. It is indeed to be anticipated that if a patient is happily occupied he is likely to give less trouble, and thus the requirements of staff for occupation therapy are offset by the re- duced need for other attention. The Board envisages that an occupation therapist (who might advisably be non-resident) would be re- quired on each side of a hospital of 1,000 beds; that she should be assisted by two or three nurses to be appointed as craft workers, and by the general nursing staff; and that in ad- dition to the present staffs in the existing shops and service departments, a few technicians should be appointed as instructors. For the additional occupation to be provided, five huts costing about ?700 each would be required i11 a hospital of this size.
Individual Psychology and the Child. Individual Psychology Publications. Med- ical Pamphlets Numbers 7 and 8. The C. W. Daniel Company. 1933. 2/6 each.
These two pamphlets are concerned with the application of the principles of Individual Psychology to education. The first contains an address by Dr Seif to teachers and others at Birmingham, in which he points out that our study of the individual is directed towards making him a happy and fruitful member of society, and makes clear some of the most important factors which determine the ” style of life ” of the individual at a very early age. A description of the work done in Child Guid- ance Clinics follows, by Miss Rayner, and a third paper by Frau Zilahi gives an enthus- iastic account of the development of her infant daughter as guided by the principles of Indiv- idual Psychology.
The second pamphlet contains two papers read by Drs. Laura Hutton and Hilda Weber respectively, in which the influence of lack of parental love, and of discord between the parents is revealed later in the development of neurotic personalities. Both papers contain interesting case histories, and rather lead up to, than start out from, the principles of Indiv- idual Psychology. Dr Beran Wolfe con- tributes a paper on the nervous child, in which he uses the analogy of the small Ford endeav- ouring to compete in the life race with the Rolls Royce. He discusses the function of the mother, and shows how the psychiatrist may be called in to help those who have the best ?f intentions, but do not know the rules of the Vcrv complicated educational game.
N.M.B.
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