In the foregoing paragraphs we have pointed out the vital importance of research in relation to mental disease. All properly conducted clinical work is of the nature of original investigation; and in the examination of patients suffering from mental disturbance this is particularly the case. But a vast amount of research work must be carried out in properly equipped hospitals and laboratories if we are to deal with the problems of lunacy in the same efficient manner as we have learnt to treat tuberculosis. In this connection it is important to emphasise the lack of an adequate knowledge of normal psychology among many of the medical officers and the absence of psycho-pathological research in so many of our asylums.
It must not, however, be inferred that the only reform needed is an increase and improvement of the mental treatment of mental disease. It is not merely the psychological side that is neglected. The most depressing aspect of the present state of affairs is the comparative absence of all research. Investigations into the material basis of mental disease, while certainly more numerous than psychological investigations, are at present few in number. Hosts of problems concerned with the nervous system are awaiting investigation, and the admirable results obtained by the small band of energetic workers in our country serve to show how sadly our nation is neglecting its golden opportunities for accomplishing much more in this respect. Important problems in connection with the normal and morbid anatomy of the nervous system, its pathology and its bio-chemistry, suggest themselves to the worker at every step. The physiological and psychological effects of different diets, of drugs like the hypnotics, et cetera, how little we know of them! Are we to rest content in leaving this vast unknown land to be charted by other nations?
Original research is thus urgently needed in all those departments which should be included in asylum work. But it is also necessary for the researches to be co-ordinated. Not a few individual doctors in our asylums, usually members of the junior staffs, are endeavouring to carry on original investigations; but in the majority of cases the absence of any prospect of direct or indirect personal benefit from this work damps their enthusiasm, if it does not make such work wholly impossible. And, of course, without the willing co-operation of the asylum authorities co-ordinated researches cannot be carried out.
We shall again quote from the report of the Medico-Psychological Association in justification of our statement:—
“Research is largely dependent on individual enthusiasm, but can certainly be stimulated and maintained by the co-operation of the senior medical staff. There is reason to fear that such work is undertaken in some quarters without any guidance or encouragement from seniors, and laborious original investigations have received little or no recognition from those in authority.... Although there is no uniformity of practice, report is made that in many asylums junior medical officers are placed in charge of chronic cases only, and have no duties in reference to the treatment of newly-admitted cases. This appears to be most undesirable. Junior medical officers, in addition to their statutory routine duties, should be given the opportunity of co-operation with their senior colleagues in clinical work. Consultation between the various members of the medical staff in doubtful and interesting cases is very desirable....” (p. [30].)
If the reader will pause for a moment, and in imagination put himself in the position of a junior medical officer, “placed in charge of chronic cases only,” he will not only come to understand the “stunting of ambition and the gradual loss of interest in scientific medicine” of which he has read, but may admire the self-restraint of a report which can speak in temperate language of such a state of affairs.
Another difficulty that stands in the way of this urgently needed reform in medical education is the inadequacy of the text-books available for the student. In many of these text-books the introductory chapters contain some, often irrelevant,[86] morbid anatomy, and the remainder deals with “psychology.” The latter frequently consists largely of anecdotes, often “funny” and sometimes more appropriate to the “after-dinner” hour than the text-book, and enumerations of the mental symptoms of the cases. In practically every available English text-book the latter are depicted only as they appear after they have become fixed, habitual, hardened and rationalised. Such “units” of terminology as “delusions,” or “delusions of persecution,” “hallucinations,” etc., are freely used. In other departments of clinical medicine the text-book writer does not describe a patient as suffering from a cough, and leave it at that; yet the phrase “suffering from delusions” is the veriest commonplace in the text-books. Yet just as a cough may be due to tuberculosis of the lung, pharyngeal irritation, hysteria, or a variety of utterly different causes, each class of case requiring a different treatment, so the causes of delusions are even more infinitely varied.
But the gravest defects of these text-books is that few of them make any attempt whatever, except in the case of such forms of disease as have an organic cause, to explain the development of the trouble, the precise nature of the primary cause or causes and the way in which the disturbance of the patient’s personality has been gradually effected.
Unfortunately there are serious defects in many of the works upon general psychology which render them almost useless to the student of psychological medicine. This may explain, if it does not excuse, the quaint selection of subjects, often wholly irrelevant or inappropriate, which form the contents of the psychological section of many English books on mental disorders. But this deficiency is not a sufficient excuse for the neglect of the kind of instruction that is of vital importance for the proper understanding of such disorders. When books such as those written by McDougall, Stout, Hart, Shand, and Déjerine and Gauckler, are available, it is possible to use the facts of normal psychology as the natural, rational and necessary means of explaining and interpreting departures from the normal state.
We may summarise here some of the chief defects of our national system of treating mental disorder. First and foremost is the serious waste of time which almost invariably occurs before the mental sufferer comes under medical care. This is due to a variety of causes—all of them preventable. The chief is that, lying in the path of patients who would voluntarily seek help, there is the insurmountable obstacle of the asylum system and its restrictions. The men in the asylum service, who have the opportunity of acquiring an intimate knowledge of mental diseases, are forbidden to carry that knowledge into the outside world for the benefit of the mental sufferer. If a patient, suffering from a mental disorder in its earliest and easily curable stage, should voluntarily go to an asylum and ask for advice, all that can be done for him is to suggest that he should consult a medical man outside, or to recommend him to call and see the relieving officer. Now, unless the patient has considerable means, it is practically certain that he will be able to consult no medical man who is conversant with—much less expert in—the treatment of early mental disorder. And, though the relieving officer’s intentions may be of the best, it is just his ‘help’ and all that it means, that the unfortunate is so desperately striving to avoid. In short, all that the officials under our present system can say to such a man is, “Go away and get very much worse, and then we shall be allowed to look after you!” Can stupidity go farther than this?