Mental hospital life in the 50s

The year was 1952. Straight from medical school to a junior house post in a mental hospital. An unusual move, even then. Not possible nowadays. The idea was to get a modicum of psychiatric experience before undertaking National Service. The grapevine suggested that such a move would get me into army psychiatry as opposed to regimental duties (which it did).

Day 1 found me in the Physician Superintendent’s office. Padding my way towards him, I had a curious sensation. His white-haired head appeared set against a black and white backdrop on the wall behind his desk. Momentarily, I thought of Byzantine murals. The reception I got was genial and friendly. My role and responsibilities were described. On call all the time except for a 36-h weekend once a fortnight. Not nearly as onerous as it sounds. My peers in medical and surgical house posts were worked much harder. The second half of the induction interview was something of a surprise. My attention was drawn to the large photograph on the wall behind – the image which had earlier intrigued me. It was the hospital’s dairy cow, recent winner of the national trophy for the highest milk yield in the country. There followed an animated introduction to dairy farming – the different breeds, pasturage, supplementary feeding and modern milking machinery. An amicable handshake brought the meeting to a close. On the way out, it struck me that the information provided would have been of more use to a vet.

I shared my responsibilities with another houseman who was on the same career plan as myself. Our quarters were palatial. Pleasant bedrooms, a small dining room, a large, stately lounge and a billiard room. The matron had her suite in the same block. A team of three maids – black and white outfits in the afternoons – looked after the three of us.

Two patients also contributed to our comfort and well-being. First, there was Big John who looked after the fire in our lounge. Diagnostically, I did not know what to make of him. I now realise he was on the autistic spectrum. His head would appear round the door. As needed, he would stoke up. Early on I tried to show him my appreciation. He was mute and did not react to my presence or remarks. His only concern was the fire. I had the uncomfortable feeling that I was of no more significance than the wallpaper. This experience came my way on many occasions in succeeding months. It left me feeling uneasy about myself – my inability to communicate and make contact. As time went by, I came to accept it as part of mental hospital life. Then, there was Lizzie, a warm-hearted lady in her 60s. From the start, she called me Sunshine. Her role was to polish my shoes before breakfast. One morning, I was called to an emergency about 6 am. Approaching the breakfast room much later than usual, I heard anguished cries from within. It was Lizzie, hysterically upset that I had gone to the wards with unpolished shoes. Needless to say, I immediately vacated my footwear.

The 800-plus population that became our concern was heterogeneous in terms of age, intellectual level, physical state and social class. Acute admissions were mainly of depressive disorders, schizophrenia and senile dementias. On the wards, the diagnostic range was broader and included learning disorders, epilepsy, paranoia and obsessional states. The general health requirements of such a large community kept us busy – chest infections, minor injuries, epileptic seizures and urinary retention, to mention a few. Resources were limited, but at least we had antibiotics. There was a small ward for tuberculosis patients where most of the beds were located outdoors. In our endeavours, we were supported by the hospital’s one registrar. Rare visits by specialist consultants were appreciated as they kept us in touch with the “real world” of medicine. In treating the psychiatric problems facing us, one would think our raison d’être, we had little to offer. This was a world where the term “tranquilliser” was unknown. Bromides, chloral hydrate and barbiturates in various forms were our usual standbys. Their dangers and side effects were recognised. Paraldehyde was effective but had its drawbacks. It was unpleasant to take by mouth and painful intra-muscularly. Sometimes it was administered rectally. It certainly helped some distressed or agitated patients. ECT was prescribed for severely depressed patients only. This was administered without anaesthesia or muscle relaxants. I had heard that modified procedures were in use in some hospitals and I felt unhappy we did not do the same. But I did what I was told. In this hierarchical world, working practices were not discussed. The two house officers did most of the treatments. There were always two nurses on each side of the patient, holding limbs when tonus set in. In spite of that, on one occasion a shoulder dislocated. I felt very uneasy about this procedure. I did derive some comfort speaking to patients a day or two after their treatments. None of them had any recollection of what had happened. Though often confused and disoriented, most seemed less depressed and prepared to have more treatment if necessary. My feeling at the time was that the ends justified the means.

Most wards were visited on a daily basis. Recent admissions and private patients were usually keen to talk to the doctors. Most of the long-term patients paid us little attention. I was disappointed I would not be wearing a white coat, which to me symbolised modern medicine and a recognition that patients with mental illness should be accorded the same respect as those with physical illness. Since then the pendulum has swung twice, and white coats have come to be seen as semi-noxious garments distancing physicians from their patients.

In my early days in post, I often asked nursing staff and attendants why particular patients were in hospital. Usually, I would be told they were incapable of looking after themselves and there was nowhere else for them to go. Their families lacked the resources to cope with them at home.

Some of these men and women remain somewhat hazily in my memory: the wiry little octogenarian, mute, restless and remote who had been an inpatient since the previous century; the warm kindly highlander, riddled with masturbation guilt, melancholic but otherwise in touch; the sad Parkinsonism sufferer, intelligent, mentally intact, with whom colleagues and I regularly played bridge; three withdrawn, inert women all in their 60s, who had similar admission histories – puerperal sepsis in a pre-antibiotic age plus depression – subsequent recovery from which appearing to go unnoticed, with consequent non-discharge.

Most of my contacts with patients were mediated through ward staff, particularly charge-nurses and ward sisters. Many of these trained personnel were open-minded, thoughtful and positive about their role and their work. Some showed exceptional kindness. One charge-nurse gave up a Sunday every year to take an elderly patient to visit his old home up in the hills. From experienced staff, I learnt much. They themselves received no formal educational support. It has to be said a sizeable proportion of the staff saw their duties as custodial, though care and concern also figured. Ordinary physical problems such as accidents and chest infections were dealt with effectively and considerately. The tangible nature of this kind of hands-on work appeared to give more job satisfaction than the misty world of mental illness so little understood by all of us.

The organisation of medical records proved to be a big surprise. Individual patient records did not exist. Data were located in huge, leather-bound volumes: one for every calendar year, containing information about all the patients in the hospital for that year. So, if one wanted to find out about a patient that had been admitted 20 years earlier, 20 volumes had to be taken down and consulted. Often there would be a one-line entry for a year’s residence. Some curious wording appeared in the 19th-century tomes. There was the patient who was “confined to the cells for the furious”. The fragmentation of these records was a striking reflection of the absence of concern for patients as individuals.

On Sunday evenings, certified patients’ outgoing mail had to be censored. I quietly expressed my disapproval of this practice but was told to carry on with what was a standard hospital procedure. Patients’ missives, I was given to understand, could upset or hurt relatives or friends. Only about a hundred letters went out each week – not many considering this was the only contact with the outside world. There was no access to phones. I stopped the letters of only one patient. These were the work of a withdrawn, educated lady. When I noticed three weeks in succession, she was sending out sensitively written bereavement letters, I thought she might need some support herself. I asked the ward sister to investigate. She found that the lady in question routinely studied the Death Notices in the local paper. The ward sister pointed out to her that as she did not know the families concerned, well intentioned though her efforts were, letters might distress them. The letters stopped.

After 63 years, the tragedy of one patient remains in my mind’s eye. This was a 24-year-old girl from the Shetland Isles who had been certified insane. One of the certifying doctors had described her as confused, disoriented and seeing things that were not there. The doctor further described her as being “deluded in thinking that faeces were coming out of her stomach”. A 24-h journey without nursing support brought her by sea to the hospital. On arrival, she was in a fevered, acute confusional state. Examination immediately revealed an abdominal fistula through which faeces were, indeed, leaking. She was sent to the local general hospital where our diagnosis of tuberculosis was confirmed. She died a few days later. The deluded party was the doctor.

Though there were no occupational therapists on the staff, attention was paid to occupational and recreational issues. Occupational activities included ward sweeping, gardening, farm and laundry work. There were a few lighter employments such as store and office work. Recreationally, there was a variety of outlets. The cricket and football teams, which participated in local leagues and competitions, had both staff and patients on side. In the summer, Sports Days and coach trips to the seaside or to the glens were popular. In the winter, local drama and musical groups provided entertainment. Male and female patients sat on opposite sides of the hall. The matron and the doctors sat in isolated majesty in the balcony.

Dancing had always been a feature of asylum and mental hospital life. Elegant ballrooms were often the architectural highlights of Victorian institutions – some still survive. Patient behaviour at these functions was impeccable. All concerned knew that misbehaviour could lead to loss of attendance privileges. The sexes sat on opposite sides of the dance hall. When the band struck up both sides rose en masse, met in the middle and partners were selected. These were animated, much enjoyed occasions. Among the lively throng were one or two patients who in their ordinary ward life were almost catatonic. Hospital staff seemed to enjoy these functions, and it was good to see they tended to dance with patients rather than with other staff.

The lack of educational support mentioned above in relation to nursing staff also held true on the medical side. I learnt what I could on the infrequent ward-rounds and case conferences. My position was more of an apprenticeship than a trainee-ship. There were no tutorials. There were no textbooks, journals or recent relevant literature. I had my own copy of Henderson and Gillespie’s Textbook of Psychiatry, a popular work at that time. My fellow houseman and I shared a paperback collection pertaining to Freud, Jung and general psychology. The only educational asset available to us was time to read. Concepts such as “postgraduate education” were still decades away.

When my six-month appointment came to an end, I went on my way comfortable in thinking I had carried out my duties adequately. I was unaware then that institutional care, in which I had played a part, had damaging as well as healing properties. A further four or five years were to pass before sociologist Erving Goffman’s researches in New York mental hospitals were to make this clear.

In my own hospital, I had not sensed any functional stresses or strains, led as it was by a strong, straightforward Physician Superintendent. Even in that pre-tranquilliser era, many patients were benefiting from the limited treatments on offer. I could feel, three years into the National Health Service, an air of optimism blowing through the corridors. Yet, it was obvious that much needed to be done. Efforts to get patients back into the community were minimal. There were few case conferences and no social workers to link the hospital to the outside world. And it sorely needed the establishment of an outpatient department and an updating of ECT procedures.

As planned, next step was National Service as an army psychiatrist, before return to witness progress in the NHS dismantling the above memories, largely for the better …