Shell shock and its lessons

by Grafton Elliot Smith; T. H. Pear

We have quoted at length this vivid and accurate portrayal of the distinctive feature of British methods of clinical instruction in order to emphasise the fact that in the teaching of psychological medicine the British utterly neglect this excellent method of instruction which Dr. Flexner considered so admirable a feature of our medical schools. The British method of teaching psychological medicine, so far as the subject is taught at all,[84] is that of class-demonstration, but, as we have seen, the avoidance of exclusive reliance upon this method is the feature on which Dr. Flexner congratulates the British schools. On the other hand, while the Germans are criticised for their adherence to the class-demonstration, it should be remembered that, although this source of weakness appears in their undergraduate classes, it is they and not we who provide facilities, in their clinics, to the post-graduate student for free contact with patients in incipient stages of mental illness.

Therefore we have neglected to apply, in the case of mental diseases, the very methods which in all other branches of medicine have been so conspicuously successful as to be selected by an impartial critic as the distinctive merit of British medical training.

We have indicated briefly the type of instruction in psychiatry obtaining in our medical schools at present. Its educational value is certainly very slight; and—what is worse—it serves to give the future doctor a hopeless outlook on insanity. For the instruction of students in the nature and treatment of tuberculosis we do not send them to some sanatorium to gaze upon patients dying from the disease. They personally examine patients in the early stages and learn to recognise the subtler manifestations of the onset of the tubercular attack, when there is some hope of giving useful advice and saving the sufferer. Why cannot mental disease be dealt with in the same way? Why cannot our students be afforded, in general hospitals, the opportunity of personally examining patients in the incipient stages of mental disturbance? They would then not only acquire a knowledge of the real nature of insanity, but would also learn, in the school of experience, the individual differences which are exhibited in the working of the normal mind, a lesson which would be of the utmost value to them in dealing with all their patients, whether their ailments be bodily or mental. But in addition such a training would impress on them, in a way that nothing else could do, the vitally important fact that mental disease is curable, and is not the hopeless trouble which is likely to be suggested by the spectacle of a few asylum patients in advanced stages of lunacy.

Even, however, if the asylums afforded better facilities for the proper study of mental disease than unfortunately is the case in most institutions in this country, they are usually not sufficiently near the medical schools to permit the student properly to acquire his knowledge, as he does of other diseases, by frequent and regular attendance for a considerable period of time. Nor, as yet, have many of the medical officers in our asylums sufficient up-to-date knowledge of psychiatry to enable them usefully to co-operate with the medical schools and the teaching staffs of the general hospitals in achieving the desired aim. We know that there are some exceptions to this general statement, and fortunately they are becoming more numerous. But viewing the condition of affairs in the country as a whole, in respect of this important matter, one can only accurately describe it as deplorable. These are hard words, and we are well aware that their use may expose us to the charge of superficial, uninformed and even spiteful criticism. Let us, therefore, turn to the gratifyingly frank and honest statements of the asylum workers themselves, embodied in the report from which we have quoted.

“The tendency of routine to kill enthusiasm and destroy medical interests.

The promotion or advancement of a medical officer depends so little upon his knowledge of psychiatry that he has no inducement for that reason to devote himself to an earnest study of the subject. His work is apt to begin and end with the discharge of essential routine duties to the exclusion of careful clinical and scientific investigation.

The work assigned to junior medical officers is, in the majority of cases, monotonous, uninteresting and without adequate responsibility. For those whose personal enthusiasm keeps alive in them the desire to extend their knowledge, such opportunities as that of study-leave are rarely afforded them. The existing system, therefore, leads to the stunting of ambition and a gradual loss of interest in scientific medicine. It tends, therefore, to produce a deteriorating effect upon those who remain long in the service.”[85] (pp. [8] and [9].)

Methods of Making Appointments.

“Appointments are made by lay committees, which, though they are generally wishful to appoint the best candidate, are in most cases without expert advice, and without adequate knowledge of the factors involved. The results are, therefore, generally haphazard in character, often dependent upon influence or personal consideration, as they frequently bear out little relation to the actual claims and qualifications of the candidate.” (p. [7].)

We submit then, that our expression of opinion is but a paraphrase of the authorised report. The study of this publication as a whole will only deepen this impression in the reader.