definite lesions, either in special sense organs (especially hearing), nerve continuity, vascular system or endocrine system, we should not use the term psychosis to imply something wholly and essentially different from a psycho-neurosis.

TREATMENT

Treatment at the clinic. As the clinic is primarily for cases with what are designated nervous disorders, that is to say, functional cases in which the most marked symptoms are those appertaining to the mental life of the patient, the principal treatment is psychotherapy. Before, however, discussing the different ways in which psychotherapy is used, a few remarks as to general treatment might be useful. General treatment resolves itself mainly into the administration of drugs or the invoking of some other department in the hospital.

As regards the former, when there is a definite physical disability, there does not appear to me to be any reason why drugs appropriate to the case should not be given, but it should be impressed on the patient for what reason the drug is administered. One explains that one hopes it may assist the recovery of health, but that it is not the only hope of the patient and will eventually become unnecessary.

Nearly all patients have a great dread of hypnotics. They are afraid themselves, or their relatives are afraid, that they will become addicted to the habit of drug-taking. Clinical experiences prove this fear to be in most cases groundless. It is better to give a drug judiciously and get rest than to exhaust the patient by withholding a hypnotic. Many medical men at the present time maintain that they have never found the drug habit induced by the proper use of hypnotics. It is only where patients use drugs themselves or on the advice of misguided persons that harm may result. If sleeplessness is due to physical pain, the cause should first be ascertained and if necessary relieved by drug treatment. No psychotherapy can be applied to a person exhausted by want of rest, and the exhaustion must first be alleviated. It matters not, whether the primary cause is psychic or physical. Exhaustion means a lowered metabolism, and a consequent lessening or loss of acuity in perceiving fresh stimuli. Our stimuli reach us through our nervous system (physical nerve fibres and cells), and if our body is exhausted our nervous system suffers too. In fact, in a sense the nervous system, for the reason that it is more highly organized and complex, suffers most, therefore external stimuli received through this mechanism are less complete. To illustrate, the expression "half blind through fatigue" is true in a physical sense. Med. Psych. VII

4

We have had, for example, a man brought into hospital so exhausted by want of food and exercise that he was in a deep stupor from exhaustion. When he woke from the stupor he appeared quite amnesic, did not know who he was or where he came from. A very short talk of about half an hour combined with food and a hot bath completely restored him. His memory returned. He was in other words blind through fatigue, in the sense that whilst in this condition of fatigue external stimuli did not enter consciousness. Hypnotic drugs therefore are prescribed in a few cases if considered necessary. Other drugs are also sometimes used, but they can generally be quickly dispensed with as psychotherapy proceeds.

It is hardly necessary to point out the use of other departments, for their utility appears so obvious. Thus, massage after hysterical contractions of long duration, electrotherapy, examination by oculists, aurists, dentists, surgeons--all are indispensable to a clinic for nervous disorders.

Psychotherapy does not ignore the patient's bodily health, but is an adjunct in assisting the medical man to make a correct diagnosis, as by means of psychotherapeutic technique information which would otherwise be hidden may be elucidated. Thus an underlying physical cause for an illness which had been designated 'hysterical' may be discovered, for often some forgotten episode in the history of the patient causes a misleading mental attitude towards the real physical disability from which he is unconsciously suffering or which he is hiding.

It has already been reported on a previous occasion how the recovery of an amnesia in a case of head injury enabled the surgeon to determine the exact spot at which to trephine.

Among the methods of psychotherapy employed at the Oxford Clinic are suggestion, explanation and persuasion. Hypnosis was employed in the past and is still occasionally used for alleviating pain and for inducing sleep; but as a general practice it has been discontinued, as suggestion, with voluntary relaxation of muscles, appears usually to have equal therapeutic value. Hypnosis, or the idea of it, usually raises great opposition in the patient's mind. Analysis appears the most useful form of psychotherapy, and, as far as my own experience goes, gives the most lasting results. I do not propose to discuss here the various disputes and contentions about the danger of psycho-analysis. A surgeon's knife in the hand of a child may be a dangerous weapon, but in the hand of a surgeon it is the instrument with which he may save life. The surgeon is not blamed because he operates in the last extremity and the operation fails. As to the respective merits of suggestion and analysis, it would

appear logical to suppose that the latter, where it can be employed, is preferable, for the same reason that a radical cure for hernia is preferable to wearing a truss.

RESULTS OF THE CLINIC

It is extremely difficult to state accurately what the results of the clinic have been, although it has now existed for eight years. The following points may be mentioned:

In the first year of the clinic there were only 33 cases of civilians treated. At this time there were a large number of pensioners in addition. During the year 1925 there were 156 civilian cases and 25 pensioners treated. It does not appear logical to suppose that unless some of the patients had reaped a certain amount of benefit the numbers attending the clinic would have increased to this extent.

From 1918 to the present date only 18 cases have been admitted to the mental hospital who had previously been attending the clinic. All but seven of these were suffering from advanced organic disease; and two of the seven have been discharged from the mental hospital, and as far as is known are doing well1.

During the years 1911-13 the admissions to the mental hospital were 185 males and 207 females.

During the years 1923-25 the admissions to the mental hospital were 149 males and 198 females.

That is to say, there were 36 fewer males admitted in the period 1923 to 1925 and nine fewer females in the same period. The fact that the decline in male admissions is so much greater than the decline in female admissions may, I venture to suggest, be accounted for by the fact that a large number of men were treated during the War and immediately afterwards by psychotherapy as pensioners, whereas such a large number of women were not under the same treatment during this period.

There is a general tendency for the average age of admissions to increase, though this is a difficult fact to prove in short periods, as one may have an admission of several very young feeble-minded cases, which will bring the age incidence down for that year. The death rate during this latter period is lower by approximately 3 per cent., so that this factor tends to show that the numbers are not reduced through an increased death rate, and also points to the fact that improved treatment tends to diminish the death rate in spite of increase in the average age of admissions. The recovery rate, including those relieved, shows an upward

1 See appended extract from Board of Control's Report.

rise of males of approximately 11 per cent. and for females of approximately 8 per cent. or a total rise of approximately 10 per cent. The numbers remaining of those admitted in the years 1923-25 as compared with those of 1911-13 show a decrease of 27 males and 30 females, and rather points to the fact that the treatment acts in the same way on both sexes.

In conclusion, taking into consideration the figures available from the Board of Control and available from our own statistics from the clinic and the mental hospital, there is some indication that where an out-patient clinic is run in co-operation with the mental hospital, good results are to be expected. Psychotherapy appears to be of direct therapeutic value not only in early cases, but also in cases in which the illness is more advanced, and moreover the practice of it appears to give us a wider view of the whole problem of illness, and enables us to improve the medical practice as a whole.

It can be argued that not only is psychotherapeutic technique of use to the profession, but it is also of value in training the nursing staffs of both the general and mental hospital. In this respect a co-operation in training between the two hospitals has, I think, proved of some utility.

There is no doubt that the establishment of a clinic at a general hospital does encourage patients to come for treatment at an earlier stage than they have hitherto done, and in this respect I think that the future advance of psychotherapy will enable us not only of ourselves to recognize cases and so treat them earlier, but to realize that the seeds of a great many so-called 'nervous disorders' are due to environmental conditions in the early life of the patient. If this hypothesis is correct, the subject is not only one of interest and importance to the medical profession, but also one in which the physician will be able to give advice to both parents and educationists in the bringing up of the young.

Finally, it must be remembered that the technique of psychotherapy is still in its very early infancy, and at the present time one should be guarded in taking too optimistic a view. The only thing one can say is that there appears to be enough evidence to justify us in making further efforts in this direction.

EXTRACT FROM BOARD OF CONTROL'S REPORT

DATED 6TH NOVEMBER, 1925

The number of patients chargeable either to Union or to County and Borough rate is thus seen to be now 478, which is a steep fall as compared with 663 in 1915. The average for the five years 1911-15 was 657 while the corresponding numbers on the 1st of January in each of the years 1923-25 were respectively 530, 503, and 500. The fall is not to be explained by any increase of chargeable patients under certificate. in Poor Law Institutions, because their average number during the years 1911-15 was 67, while 51, 51 and 47 were their numbers on January 1st 1923-25. Expressed as ratios per 10,000 of the general population of this area the total number of certified mental cases used to be 38 in contrast with 29-6 on the 1st of last January. Highly satisfactory as this fall is, it by no means connotes a reduction in the number of cases of mental illness arising yearly in the area and requiring treatment; but, in the absence of other explanatory factors, it does suggest that intensive treatment within the hospital and the growing volume of out-patient treatment of mental cases at the Radcliffe Infirmary are making their effect felt.

DISCUSSION ON DR GOOD'S PAPER

DR MAPOTHER said: I should like to express my admiration of the work by Dr Good upon which his paper is based, and secondly to apologize to him in advance. I shall ask him to remember that I have only a few minutes to define profound disagreement with the conclusions stated and the impression left by his paper. I realize that probably some differences between us are in emphasis and in our perspective of various factors. But I have to stress differences as briefly, clearly and forcibly as I can, so I propose to enliven these proceedings by calling his paper a public danger.

My essential grievance against Dr Good is the extent of his satisfaction with the conditions under which he has done excellent pioneer work and with his results; this satisfaction is doubtless due to the very enthusiasm that has made his work possible.

This is a meeting for ascertaining facts not for propaganda and above all I want to keep away from politics. But I think it is fairly obvious to every one that exaggeration at this moment of the extent to which outpatient departments can be an adequate substitute for expensive clinics is a public danger and it is in this sense I use the term. I feel it so strongly, that I have mainly foregone constructive statement in favour of criticism.