The British Medical Association Report on. Although this report was prepared for, and concerns. problem, By A. M. McCUTCHEON, M.B., Ch.B., F.R.F.P.S.

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1 The British Medical Association Report on By A. M. McCUTCHEON, M.B., Ch.B., F.R.F.P.S. Although this report was prepared for, and concerns mainly the medical profession, it contains much that is of great interest to all workers with defectives. As was to be expected, the Committee found that the enquiry presented so many different aspects that they have considered it from several points of view. In doing this, they have touched on all sides of the save problem, the purely educational one. The constitution of the Committee was so arranged as to allow for the proper presentation and consideration of these various view points. Report of the Mental Deficiency Committee of the British Medical Association. House, Tavistock Square, W.C.I. Price 1/- net. B.M.A.

2 80 MENTAL WELFARE As the different grades of mental deficiency are legally defined and the practitioner must work to these, the Committee have accepted them. At the same time, they rightly point out that these grades are not sharply defined, but tend to one merge into the other. There seems, to judge from the form of over the moral defective. In the report, to have been the usual difficulty practice, one finds the number who can be so designated to be small, but none cause so much difficulty and anxiety in diagnosis. Emphasis is laid on the necessity for the exclusion of all other probable diagnoses, and for a full investigation into the environmental factors, the lack of which investigation might lead to a wrong diagnosis. Attention is called to the importance of this class when considering illegitimacy and sexual offences. A most helpful suggestion in connection with these difficult cases is for the provision of a proper diagnostic clinic. Even more helpful from the point of view of other defectives is that, when a definite diagnosis has been made, moral defectives should not be sent to an ordinary certified institution, where are a they constant source of embarrassment, but to a special State institution. The same point of view might with equal force be urged with to regard the feeble-minded confirmed absconder and rebel, a certain number of whom are met in every large institu- tion, and for whom the State institution is not now available as, according to present legal interpretation, they are not or dangerous violent. The best that can be done at present is to institute within the Colony something of the nature of a " refractory block." It would seem better if this could be avoided, because it tends to single out these defectives within the as Colony, different from the remaining population. The report considers it essential for the existing law to be altered so that it be the duty of the Local Education Authority to notify to the Local Mental Deficiency Act Committee, all defective children whether or not they have attended a Special School. The existing law on this point is most unsatisfactory, as it deprives many defectives of the advantages Parliament intended them to have under the Mental Deficiency Acts, with consequent loss to themselves and to the public. The present unsatisfactory state of affairs thus permits among some defectives during adolescence or early adult life, certain social disasters otherwise preventable if more complete notification were enforced. The report follows the lines of the Wood Committee in suggesting that the certification of defective school children should be abolished. It is arguable whether, in practice, this would in the end mean very much difference from the present method, since these children would still require to be carefully ex- amined and selected, and to receive some form of specialised individual instruction, no matter what label is or applied what course is followed. It is, however, an anomaly that, in view of the fact that mental deficiency is an incurable condition, certain school children designated defectives, cease to be so solely on account of their reaching the end of their school career at 16 years of age. In the section dealing with causation, there would appear to have been some difficulty in arriving at any definite conclusions on the role of heredity,

3 MENTAL WELFARE 81 although the Committee agree that this does play a part in certain cases. Many of our best-known British experts, who are constantly dealing with large numbers of cases, estimate from 50% upwards, as the figures in which heredity is held by them to be involved. In America, as far as can be judged from the literature at present, there appears to be a swing towards crediting environ- ment with a very much larger share. Even if this be true, and it is by no means generally accepted in Britain, it is not at all certain that the same type of case is always being described and dealt with. In England, the social criterion is incorporated in the legal definition, whereas in America, so far as can be ascertained, many of whom British practice would class as dull and backward cases appear to be grouped with the defective, which puts quite another complexion upon the results. So much so, that in Davies's " Social "... are Control of the Mentally Defective," page 376, is found a quotation curing their morons even after they have been all but ruined in the public schools and are sending them out no longer feeble-minded." The B.M.A. Committee conform to the current British belief that mental deficiency is an incurable condition. The Report discusses some of the difficulties involved in obtaining reliable family histories, urges the need for more research, and strikes a very cautious note, preferring to express no opinion as to the relative importance or frequency of hereditary influence. It is suggested that, to more supply information concerning the marriage of cousins, marriage registration forms should record any blood or family relationship of the marriage partners. held to The Report sets out in some detail the various conditions usually be the causes of mental deficiency. With regard, in particular, to alcohol and tuberculosis in the ancestors, there are doubtless difficulties in assessing the proper values to be assigned. There is, however, no doubt as to the marked frequency with which these are found in the family histories of defectives. When speaking of diagnosis, the Report points out the difficulty often experienced in correctly interpreting the legal requirements of the certificate under the Education Act. The Board of Education appear to take the view that, if the child will benefit from the specialised school instruction, he should be given the benefit of the doubt. At the same time, it is well to remember that in the medical officer's certificate are used the words " feeble-minded within the meaning of the Mental Deficiency Act." This on implies, the face of it, the social as disability well as the educational one. The number of exspecial school children who afterwards rise to positions of some responsibility, in itself, would indicate that there must be many who, in spite of this wording of the certificate, were defective only educationally and not as socially well. The certifying medical officer is often placed in a very difficult as position, the correct diagnosis may only be possible after some considerable period of time. The suggested abolition of the certification of such school children might thus he a distinct relief to the school medical officer. With regard to diagnosis for

4 82 MENTAL WELFARE the purposes of the Mental Deficiency Acts, the Report diagnosis in a way most helpful to the practitioner, and points altered conditions created by the amending Act of sets out the differential out also the In a most interesting biological section is given an account of the present knowledge and views on the structure and development of the nervous system, and certain pathological findings in defectives. Also the biological standpoint on heredity is explained, while the respective roles of heredity and environment are made easily understandable to the non-expert reader. Since the position of the defective in society is the ultimate test of all work with defectives, the Report attaches great importance to a progressive social policy. It points out that no matter in what form this is undertaken, the medical practitioner must play a responsible part in its execution. An important paragraph should dispel the mistaken belief held by many that the defective is of necessity markedly anti-social. It is true that in institution work the numbers of such anti-social types may be somewhat high. On the other hand, it must be recalled that the Wood Committee estimated that at least two-thirds of defectives can safely be dealt with under some form of community care. Some reference is made to community-work in America, and in all our minds is the work done throughout this country by the various Associations for Mental Welfare, co-ordinated by the Central Association. The same methods are by no means applicable to all areas, as local conditions vary much, but great developments in this direction must be urged forward, if the benefit of the good already done is not to be lost. Provided the right sort of instructed help is given, and recent happenings indicate that the public are at last understanding the value of this, the problem of mental deficiency is by no means the hopeless and one depressing that some would have us believe. On economic grounds alone the work is fully justifiable. It is to be hoped that the present national emergency will not lead to undue interference with the carrying on nationally of the necessary construc- A marked dislocation would, indeed, in the fullest sense, be tive work. uneconomical. The Report goes on to give various official statistics, details of the various lines of treatment in use, studies in illegitimacy, and concludes with some observations on the marriage of defectives, a subject upon which the Board of Control has several times expressed the official view that there should be some restrictions. On the thorny subject of sterilisation the Report does not say much, no doubt because of the lack at present of reliable information, and possibly because this is now the subject of an expert Government enquiry, from which it is hoped some light will emerge. The Committee recommend that all Local Authorities should press forward with their statutory duties, and that every known step be taken to prevent mental deficiency, with its attendant risk of lessening the full value to the State of such afflicted citizens.

5 MENTAL WELFARE 83 The most important features of the Report to a medical man are the realisation of the necessity for the medical to practitioner receive more instruction in this increasingly important branch of psychological medicine, and the urgent need for further research, some suggested lines of which are indicated. Attempts have, in the past, been made to interest the Universities and Teaching Schools in the great need for further up-to-date practical tuition in this subject. With the conspicuous exception of London University, in conjunction with the Central Association for Mental Welfare, and of Edinburgh University, unfortunately these efforts, up to the present, seem to have proved unsuccessful. Possibly this Report to the profession itself, may stimulate the Authorities to the necessary action. The facilities already available and the work being done in all directions, require very little special organisation to provide a clinical field equal to any in the world. The man professional would then be in a position to take his full share in the co-ordinated effort required for the handling of the mental deficiency problem. The Report consolidates our knowledge on the subject, indicates and emphasises the special aspects needing more attention, and is worthy of the closest study by all who have at heart the welfare of the mentally defective.