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English Mental Care through American Eyes

THE LANCETLONDON: SATURDAY, FEB. 19, 1949

RECENT books by former patients have given adiscouraging account of life in public mental hos-pitals,l and we publish this week the rather unhappyexperiences of a doctor who entered a private hospitalas a voluntary patient. But if there is much room forimprovement here, it seems that conditions are,to say the least, no better in -many of the State

hospitals in America. An article in Life, early in1946, carried photographs of patients in such hospitalswho appeared much neglected : and the story toldby a former attendant in two State mental hospitals 2is a painful description of the humiliations and hard-ship which patients often suffer, and the inhumanityengendered in those employed to care for them.Dr. DALLAS PRATT, who in 1947, on behalf of theAmerican National Mental Health Foundation, madea survey 3 of 16 English public mental hospitals,thought our standards, on the whole, much betterthan those in the United States--despite the highlevel of care in such famous American hospitals asthe Phipps Clinic and the Institute of Living.Since Dr. PRATT’s aim was to indicate practices

that backward State hospitals might usefully follow,he dwells more freely on our highlights than ourblack spots ; but it is encouraging to learn there areenough of these to strike a stranger’s eye. His

experience was not confined to our best hospitals(though these formed a large proportion of the 16) ;.he deliberately visited 4 of " less progressive type,"of which 2 were definitely backward. From informa-tion given him, he graded the 101 mental hospitalsin England and Wales as: " progressive," less thana quarter; "average," more than half;

0" back-ward," a quarter. Judged by the same standard,he thinks that half to three-quarters of AmericanState hospitals could be classed as backward, and thatmost of the rest are average ; " very few indeed canbe considered progressive." It would be interestingto know the information on which this grading wasmade. We cannot call to mind any official reportgiving the necessary data, and it seems likely that itwas founded on impressions of members of the Boardof Control, or on material available to them. If so,our own medical profession would welcome the

opportunity to share the information given toDr. PRATT.He was particularly impressed by the fine grounds,

freely used by patients, which surround many of ourmental hospitals; boy the curtains, flowers, andunbarred windows which give a pleasant atmosphereto wards and day-rooms, regardless of whether theyhouse quiet or disturbed patients ; by the absence of1. Lancet, 1947, ii, 880.2. Orlansky, H. Politics, 1948, no. 3, p. 162,3. Published by the Foundation, 1520, Race Street, Philadelphia 2,

U.S.A. 1948. Pp. 28. $.50.

physical restraint (he saw leather cuffs, such as areused in America today, exhibited with chains andmanacles as relics of an archaic age) ; by the generaluse of occupational therapy ; and by the fact thatour mentally sick are looked after by nurses, trainedor in training, and not by attendants. On the last

point he may not have fully realised the differencebetween State registration and the certificate of theRoyal Medico-Psychological Association. Since thecertificate was withdrawn, the mental section of theState register has offered the only qualificationopen to mental nurses ; and it may be that fewermental nurses will take this than were wont to takethe R.M.P.A. examination. In the coming yearsthis may result in a fall in the number of " trained

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mental nurses, and a rise in the proportion of assistantand part-time nurses-without any change whateverin the type of men and women undertaking the work.

Dr. PRATT also approved the continuous super-vision of our mental hospitals by the Board of Control,their small size compared with American hospitals,the low two-story buildings, the self-containedadmission units, the high proportion (54-2% ofadmissions in 1946) of voluntary patients, the

adequacy of linen and bedding, the individual look ofpatients’ clothing, the widespread use of physicaltherapies, and the many outpatient clinics attachedto mental hospitals. No less than 15 of the J6 were

running their own outpatient clinics, staffed by thehospital psychiatrists. Some of these clinics were

held in the mental hospitals -themselves, but morewere-held in the general hospital of the area. Some

hospitals were running several clinics-thus Mapperleyhas nine, Warlingham Park three, and Netheme

reported 4000 - outpatient sessions during - the year.In 1943, when Dr. C. P. BLACKER made his neurosissurvey, there were 216 psychiatric clinics in Englandand Wales, all but 66 of them being based on mentalhospitals. This gave 1 clinic to every 170,000people, which Dr. PRATT compares with 688 clinicsin the United States, in 1946, or 1 clinic to every204,000 people. Such clinics, he notes, benefit themental hospitals themselves, since they bring thestaff face to face with the community’s need fora better mental-health service, and stimulate themto provide it.

Against these compliments must be set some

adverse findings. One of the 16 superintendents was" opposed in principle " to occupational therapy,saying that enough occupation was provided iri his

hospital by the " clipping of hedges, the carting awayof rubbish, and the digging of holes." This habit of

regarding the patient as a form of cheap labour forthe use of the hospital is most undesirable., In thebetter hospitals it is recognised that if occupationis to be used as a remedv it must serve the needs ofthe patient, in preference to the needs of the hospitaladministrator. Dr. PRATT also found that some

county councils are inefficient and unduly hamperedby red tape, and that some poor areas have main-tenance-rates which are too low-though even thelowest, he says, are more than double the lowestrates in the U.S.A., and the average is about half asmuch again as the American average. He was

writing before the National Health Service was

launched ; under it, these economic differencescan surely be adjusted. It might even be possible, on

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some grant-giving plan, to encourage backward

hospitals to bring their standards up to those of thebest. This is the system applied to general hospitalsby King Edward’s Hospital Fund for London, andit has been singularly effective, over a period of years,in persuading the laggards to modernise their kitchens,improve their nurses’ quarters, increase the staffingof their almoner’s departments, or take other welcomesteps towards perfection. Mental hospitals work somuch in isolation, each a little cosmos under a seniorofficer whose word is law, that they have few chancesof emulating one another. A grant-giving bodysuch as the King’s Fund could help them -to developa spirit of healthy rivalry.

Dr. PRATT was also disappointed with some of ourmental hospital equipment, notably the X-ray plant,

laboratories, and lavatory accommodation. The lasthe found to be inadequate Jn some mental hospitalssurely a serious indictment at a time when the wardsare notoriously overcrowded. He also finds us moreprone to give physical than psychiatric treatmentto the mentally ill, and was a little dubious of theuse made of sedation in one of the hospitals he visited.(It will be remembered that the patients who havewritten books on life inside our mental hospitalsagree in thinking that sedation is often used for theconvenience of the nurses rather than the benefitof the patients.) Finally, Dr. PRATT observed that thepsychiatrists, nurses, occupational therapists, andsocial workers attached to our mental hospitals aretoo few, as we well know. Thus the picture is insome respects imperfect even to the eye of the kindlyvisitor. But the number of mental hospitals in thewhole country is so small that it should not be beyondus to make them an absolute credit to the greatpioneers of humane treatment for the mentally sick.

The OximeterTHE theoretical basis of cyanosis is now well

understood. Oxyhaemoglobin is bright red, whilereduced haemoglobin is darker and bluer. It is theundue preponderance of reduced haemoglobin in theskin capillaries that makes some people look purpleor blue. The blueness may result from imperfectoxygenation of the blood leaving the left heart.This, in turn, is consequent on defective oxygenationin the lungs or even partial bypassing of thelungs, as in congenital heart disease, and is calledcyanosis of central origin. In peripheral cyanosis, onthe other hand, the blueness results entirely from alocal disturbance of the circulation, with sluggishblood-flow and excessive removal of oxygen by thetissues from the relatively stagnant blood. Hithertothe clinical differentiation of the two types has beenbased simply on appreciation of their existencecombined with shrewd guess-work. Examination ofa sample of arterial blood will often decide, but manyclinicians hesitate to adopt this procedure, and inany case the prompt analysis of samples for theirgas content requires laboratory facilities which arenot found in every hospital. ,

The possibility of using optical methods for

estimating the degree of oxygen saturation of arterialblood has been recognised for at least fifteen years.lOxyhaemoglobin transmits red light more readilythan reduced haemoglobin does, and, by using a photo-electric cell with appropriate filters the percentage

1. Kramer, K. Z. Biol. 1934, 95, 126.

of the total haemoglobin which is formed by oxy-hsemoglobin can easily be calculated when these

pigments are in solution. The same method is

applicable, though with less accuracy, to whole blood,and SQUIRE 2 applied the device to transilluminatedliving tissues. This device was further developed byGOLDIE 3 and MILLIKAN 4 during the late war, when itfound a special place in the study of the reactions ofairmen exposed to low oxygen pressures. The impetusof these technical advances is now being felt in

ordinary clinical investigation. The oximeter, as theapparatus is called, is being increasingly used in theUnited States...It consists of an ear unit fitting overthe pinna, with an electric bulb in front and a photo-electric cell behind. The heat generated by the bulbdilates the vessels of the ear and increases the blood-flow sufficiently to make the ear blood equal in

oxygen content to the arterial blood. Galvanometersconnected. to the instrument indicate the amount oflight transmitted by the ear, and hence the oxygensaturation of arterial blood can be estimated.The method, however, is not yet completely accuratewhen used in this way, as Beer’s law relating tooptical density of translucent solutions cannot applyexactly to whole blood in tissues. Thick ears andthin ears add to the variables. The method has an.error of 3-7% in absolute readings. But it reveals

changes in a patient’s oxygen saturation much moreexactly. In a normal person the arterial blood is

95% saturated with oxygen. - If he is given oxygento breathe the oximeter reading will rise about 5%as the haemoglobin becomes fully saturated. Thisforms the basis of an informative test.By observing these oximeter responses GODFREY

and his colleagues 5 have obtained some useful clinicaldata. A rise of more than 5% in the arterial oxygensaturation indicates previous subnormal saturation.In patients with congestive heart-failure the oximeterresponse to oxygen breathing was usually about

10-15%, showing a definite but moderate degree ofarterial unsaturation (85-90% saturated). The

response of patients with primary pulmonary diseasewas mixed. Sometimes there was a remarkable

improvement in arterial oxygen saturation on breathingoxygen=in one case + 27 %-but sometimes the

response was relatively small, possibly because theblood was continuing to flow through completelyunaerated parts of the lungs, so that even oxygeninhalation could not correct the deficiency. Similarlypoor responses would be expected in the blue formsof congenital heart disease, where blood is shuntedfrom the right to the left side without going throughthe lungs at all. A further report by GROOM et a1.6shows how the oximeter can be adapted for use withcardiac catheter studies in obscure congenital heartdisorders. The exploration of such hearts by this

technique is no easy matter, and an immediate

approximation to the oxygen saturation of blooddrawn from various positions within the heart is ofimmense value to the investigator. The Mayo Clinicinvestigators simply draw blood back through a

transilluminated polythene tube, the light falling onan oximeter cell. This permits immediate recognition2. Squire, J. R. Clin. Sci. 1940, 4, 331.3. Goldie, E. A. J. sci. Instrum. 1942, 19, 23.4. Millikan, G. A. Rev. sci. Instrum. 1942, 13, 434.5. Godfrey, L., Pond, H. S., Wood, F. C. Amer. J. med. Sci. 1948,

216, 605.6. Groom, D., Wood, E. H., Burchell, H. B., Parker, R. L. Proc.

Mayo Clin. 1948, 23, 601.