A Psychiatrist's Choice

The Spectator recently invited a number of scientists to answer the question: If you were beginning your career now what branch of science or field of research would you choose ? This article is a reply by a distinguished psychiatrist who works at a well-known teaching hospital in England.

IF I were starting again I should try to re-enter my main field of work, namely, investigation of all the varied physical methods of treatment of the brain and their selective uses in varying types of patient. And I should first of all, before entering psychiatry, try to learn more basic biochemistry, neurophysiology and electronics rather than psychology or philosophy. Or I might seriously consider becoming a neurosurgeon with a specialised psychiatric train- ing. Either way, one's future would then be more certain as far as finding out how to help the greatest number of nervously ill patients was concerned. Skilled treatment of the mentally ill must still remain the overwhelming priority and concern of psychiatry today. For, first of all, we must demonstrate ou.r abilities to cure our patients before even thinking of daring to advise the world and his wife on their numerous everyday problems. IF I were starting again I should try to re-enter my main field of work, namely, investigation of all the varied physical methods of treatment of the brain and their selective uses in varying types of patient. And I should first of all, before entering psychiatry, try to learn more basic biochemistry, neurophysiology and electronics rather than psychology or philosophy. Or I might seriously consider becoming a neurosurgeon with a specialised psychiatric train- ing. Either way, one's future would then be more certain as far as finding out how to help the greatest number of nervously ill patients was concerned. Skilled treatment of the mentally ill must still remain the overwhelming priority and concern of psychiatry today. For, first of all, we must demonstrate ou.r abilities to cure our patients before even thinking of daring to advise the world and his wife on their numerous everyday problems.

This may sound a strange viewpoint to the general public who have now come to believe in large numbers that a prac- tising psychiatrist is mostly preoccupied with specialised psychotherapeutic techniques and beliefs, often derived from Freud's work, which have been indoctrinated into him by several years spent on an analytic couch, before being permitted to practise what often amounts to an esoteric mystery with a dominant sexual theme. Psychoanalysis is now no longer always the pursuit of a science, but is tending to include an acceptance of almost rigidly held beliefs concerning a meta- physical psyche, and the mind of the psychoanalyst generally becomes blinkered in the process to advances arising in the various fields of general medicine and surgery and suddenly becoming applicable to the treatment of the mentally ill.

To show the reason for my present attitude of mind,,it is only necessary to look back to the time twenty years ago when I first entered psychiatry from general medicine. The dogmas and techniques of Freud, Adler and Jung were in existence then and very little different from those of today. They had been practised in this country for many years previously, but had made no appreciable dent in the number of the nervously ill. . It is sometimes forgotten today how old Freudian prac- tice really is. During the First World War medical students at one of the London teaching hospitals were being told by one of the founders of the English school of psychoanalysis that some people were possibly afraid of zeppelins because they were phallic symbols. No increasing number of patients, however, are provenly leaving mental hospitals because of an increasing use of psychoanalytic methods in the last thirty years, and by now it is becoming extremely doubtful if they ever will.

* Where, therefore, can one look for hope of more rapid practical progress? One menial disease only was really being cured in 1934, and that was early syphilis of the brain. This discovery had at last been made when it was shown that the giving of a series of malarial rigors could kill effectively the spirochaetes of syphilis in the human brain. Now injections of penicillin can be equally effective. The illness had at one time been called the ' moral neurosis.' Little was then known as to its real cause except the patient's past life, environment and experiences, and the grandiose and wish-fulfilling nature of many of the symptoms shown seemed self-evident.. Large churches in the hospital grounds are testimony to the only real therapy provided for such patients at that time, who might form up to a third of all those in some mental hospitals. Today, since injections of penicillin given in a general hospital may be all that is needed, psychiatrists may see as few as one of these patients in a year. at the impending change in their sexual status, and even saw patients being psychoanalysed for this complaint. Since the discovery of cheaply produced female sex hormones, however? the symptoms can now be cured with the greatest ease and simplicity despite all the postulated efforts of the subconscious mind. Likewise, in the southern states of the USA a group of persons became neurotic or mad in the spring of each year. They could only be encouraged psychologically to bear the apparently obvious precipitating burdens of poverty, poor food and dismal homes. Again the discovery of vitamin B, now allows a simple drug to be given them which cures their mental symptoms despite their poverty and environmental stresses, until more vitamins become available to them in the growing crops.

It is certain that many other major types of mental disorder will eventually be found to have a physical basis. Schizo- phrenia or ' split mind ' also used to be explained to me as being due to a subconsciously motivated withdrawal from reality, and states of depression are still taught by some as being the late results of breast frustration in infancy. But up to 70 per cent. of patients treatedin the first three months of an attack of schizophrenia can now have their symptoms relieved by a series of insulin comas, and a feiv electrically induced • epileptic fits can quickly remedy a severe state of mental depression. Psychological dogina and psychiatric treatment have, in fact, started to become wildly at logger- heads, and only the Freudian faithful in psychiatry can still apparently ignore such discrepancies between their beliefs and present-day advances in physical treatments of the brain.

An excellent example of this discrepancy is seen in the problem of chronic pathological anxiety. Again the sub- conscious mind had 10 be called in as usual to explain this phenomenon. Convulsion therapy, too, while relieving depres- sions can make such anxiety states worse. But now it is being shown that the cutting of one special tract in the frontal lobes of the brain can reduce crippling chronic anxiety +% ith- out any impairment of the patient's intelligence, and the theoretical subconscious can be forgotten. Such operations are now, therefore, being used even in the chronic neuroses: and in severer cases of mental illness nearly 10.000 frontal lobe operations have already been performed in this country, re- sulting in about a third of those, hitherto considered incurably insane, being able to leave hospital.

Epilepsy, also previously treated by attempted exorcism of the Devil, is now being controlled by ever more efficient chemical anti-convulsant drugs, and sometimes by operations on the brain to cut out small damaged areas where abnormal electrical discharges are occurring, which may fire off a major fit. Operations may soon be expected to reduce or ab6lish imaginary voices or hallucinations that play such a part in creating madness because of their understandable reality to the patient experiencing them.

These are some of the actual types of practical treatment measures being worked on in psychiatry today by many who are far too busy to beat the propaganda drums, discuss sex symbolism in Bloomsbury, or claim in theory to be able to prevent future wars by better child guidance clinics. Parasites in the blood stream, and vitamins had not even been thought of. As scientists, we must be prepared to wait perhaps another hundred years or more before even starting to learn how the human brain really works. Why I would not change my present line of work is because we are only at the very beginning of its possibilities rather than near the end of an already over-explored and dogma-ridden field. There is also the very urgent problem to be worked out of trying to achieve some sort of synthesis between already provenly valuable methods of psychological healing and the newer physical ones. Russia is probably leading the way so far in this particular field at the present time. Their scientists know that little can be expected from metaphysics in a problem primarily involving the human brain. At the same time, their leaders know only too well the supreme importance of learning how to implant beliefs and behaviour patterns very firmly in the organic brain structure. All Russian medicine was therefore compulsorily re-orientated along Pavlovian lines before Stalin's death. And Pavlov always insisted that in 'natters relating to the brain one should experiment and never theorise. Dogs were initially more useful than humans in this research simply because they could not talk themselves and so confuse the issue for the experimenter. Arising out of this experimental work on animals, however, have come the present terrifying brain-washing ' methods by which the stoutest human heart and mind can be made to change its patterns of thought and behaviour, and whole nations are being indoc- trinated with new beliefs. We shall continue to neglect such work only at the gravest peril to western civilisation, and yet bow few in England seem to realise this fact at the present time The psychiatric treatment problem at home is also a desper ately urgent one. Half the total hospital beds in England are still filled with psychiatric patients. The suffering involved is unimaginable to those not themselves mentally ill. It has been predicted that seventy thousand persons now living in Greater London alone are, for instance, fated to kill themselves, mainly becatise of mental illness and sometimes solely to avoid having to go into a mental hospital. Even hopeless cancer patients rarely suffer to the point of setting out to destroy themselves deliberately as do the mentally ill, even in the earlier stages of their illness.

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Research has also hardly begun in prisons where few special- ised physical treatments of the brain are as yet used. Psycho- therapy and religion are provided, but current psychothera- peutic methods can never even dent the criminal treatment problem, just as they have failed in the psychiatric field, if only because of the large numbers involved, while religion has lost its sense of certainty which was its most valuable treatment weapon.

The criminal field is now lying open to major advances and new lines of research once present policy is broadened. What is needed is to provide better research and treatment facilities in the now admittedly hopeless impasse that has been created by too much concentration on sometimes wrong objectives. As only one example of future possibilities, it is now known that crimes of impulsive violence are not only mostly committed by young persons, but by those whose elec- trical brain waves show a defect in normal brain maturation for their particular age. The broken and violent childhood home from which they so often come is not the cause, but often only further evidence that this 'particular brain defect is an inherited abnormality from one or both parents. The abnormality generally rights itself by the age of 40, and impul- sive violence then dies down for no other apparent reason. Simple drugs will almost certainly be found to correct this the form of delayed `maturation process in the brain of he the boy,' who, maybe of normal intelligence but has al impulsive and selfish emotional responses seen normally la very much younger children. facts he legal mind is inclined to laugh at psychiatry. 'But 11 acts are of importance before passing judgement, it might lust wonder why the ordinary mental hospitals today contain many more violently anti-social people than the prisons, many more potential murderers and disturbers of the peace, who are ,handled with half the fuss and bother, and allowed in or out of hospital according to their prevailing state of mind and behaviour. Furthermore, they get skilled treatment rather than punishment for their abnormal behaviour, in addition to essential short or very long periods of compulsory detention.

No person with any sort of skill in medical research can help making some sort of contribution to this whole new field in his lifetime, judging by the happenings of the past twenty years. But so deep is the present cleavage between concepts of mind and body that even among doctors 'themselves too few have the sense to see it. Also, psychiatry has had its status altered in recent years by the increasing number of more talkative, philosophic doctors flooding into it as a refuge from the concrete scientific approach now demanded by general medicine, and surgery. These do too much of the talking at present and too little of the actual treatment of patients. They, could have remained very happily in the general medicine of old, since most diseases could then be so easily and so convincingly explained to the patient by an interaction of metaphysical forces akin to the modern superego, ego and id, though at that time they were thought of in terms of humours," vapours ' or innate heats.' Patients did not recover with the treatments based on such philosophical theories, but it still took centuries to get rid of them as they were so attractive to those who still demand or must give a plausible explanation for any sort of observable phenomenon.

It is a pity that medical philosophers have had to seek an asylum in psychiatry in more senses than one, for pSychiatry's only proven hope of practical progress is to return to a general medical outlook instead of seeking to create an ever- widening gulf between medicine and itself. It is too often forgotten now that medicine has only been able to make its spectacular advances in the last hundred years by deliberately giving up all-embracing metaphysical theories, seeking for empirical physical remedies, and then perhaps only many years later finding out how and why they work. Even now we do not know how penicillin or insulin really acts though the lives of tens of thousands have already been saved by them.

Another reason why I would not change my present and admittedly rather limited ' viewpoint is due to a present paradox in medical research. Everybody realises the impor- tance of taking into account the whole' man and his environment. Yet far greater practical progress has actually been achieved by deliberately neglecting this obvious truth and first studying perhaps the blood, liver, heart, brain, or chemical changes occurring in the body regardless of thousands of happenings that may all be influencing these in theory. When we have..learned how to make the unstable brain and nervous system more capable of withstanding environmental stresses, better able to think and learn from experience, or be indoctrinated successfully if needed, I personally would then be prepared to hand it over to the philosophers, priests and politicians, and let them carry on in their own fields what is essentially their proper work. Today too many psychiatrists are neglecting the brain itself, and trying to interfere in functions outside the proper province of medicine; while men of God, philosophers and politicians are working on the theory that better religion, better houses, or larger prisons can always remedy the badly functioning brain.

Meanwhile the whole national economy of Great Britain and the balancing of the Budget have come to depend entirely on two proven physical remedies for nervous tension—alcohol .and tobacco; and in addition millions of tablets of phenobarbi- tone have to be given free under' the NHS to supplement these. Yet even the Medical Research Council still provides only a very small amount out of its large government funds for psychiatric research of the type discussed in this article. Are we all a bit mad, or just plain stupid ?