Mary Barkas at the Maudsley: 1923–1927

Mary Barkas was, until recently, largely forgotten. ¹ Articles on the early years of the Maudsley Hospital only mention her as one of the four medical officers appointed at its opening, with some discussion of her work with children and endocrine treatments.^2,3After that, she vanishes from the Maudsley literature. In contrast, the activities of Edward Mapother, the medical superintendent^4,5and William Dawson, the senior medical officer,^6,7 are well documented.

A unique insight into the Maudsley environment, with comments on the doctors, illnesses and treatments, comes to us from her letters to her father Fred in New Zealand, often written on a daily basis. This correspondence is only insider account we have of the first crucial years of the hospital.

Mary Barkas came from Christchurch New Zealand. She excelled at her studies, getting the BSc in 1908, followed by an MSc. In 1913, she went to London and commenced medicine at St. Marys Hospital and the London School of Medicine for Women, gaining the MRCS and LRCP in 1918. ⁸ The following year, Barkas got the Certificate in Psychological Medicine of the Medico-Psychological Association, the predecessor of the Royal College of Psychiatrists. She became the first female house physician in the 600 year history of the Bethlem psychiatric hospital, ⁹ no mean achievement in view of the prejudice against women doctors that existed at the time. ¹⁰ Within three years, Barkas obtained the MBBS and the DPM, followed by the MD in 1923. ¹¹ Her mastery of psychiatry was impossible to ignore. She was awarded the university medal for the MD and in 1924 the prestigious Gaskell prize and medal of the Royal Medico-Psychological Association. ¹²

The circumstances that had made it possible for Barkas to study medicine – the departure of men to fight in the war – now meant that returned soldiers got preference. Struggling to find regular jobs, she decided to become a psychoanalyst. In 1922, Barkas went to Vienna for a training analysis with Otto Rank. This lasted for three months (rather than the six months that Freud had recommended ¹³ ) and was regarded as suitable preparation for her to commence psychoanalytic work. She met Freud and was influenced by Rank’s ideas on birth trauma, separation anxiety, psychosis and culture. On her return, Barkas made regular presentations at the British Psychoanalytical Society. ¹⁴ Her work problems however failed to improve.

In 1907, the eminent psychiatrist Henry Maudsley offered the London County Council (LCC) £30,000 for the establishment of a new psychiatric hospital to treat acute and voluntary (rather than chronic involuntary) patients with out-patient facilities and teaching/research facilities modelled on the hospitals in Germany. The intention was for the hospital to treat early cases of psychosis to prevent the condition from becoming intractable and patients then having to be sent to country asylums. ¹⁵ The project was delayed by cost overruns and the onset of First World War, which required the use of the buildings to treat war veterans with shell shock and from August 1919 to October 1920 to treat ex-servicemen suffering from neurasthenia. ¹⁶

In January 1923, the Maudsley Hospital reopened in Denmark Hill with Edward Mapother as medical superintendent. He was to be a significant figure in determining the approach followed at The Maudsley (as it is widely known to this day). The role of the Maudsley in British psychiatry should not underestimated. It became the centre of psychiatric research and to this day doctors seek to go there for advanced training. Mapother sought young doctors who had trained in general medicine and neurology, rather than psychiatry, to encourage new ideas: ‘They were given temporary appointments in the hospital and were encouraged to go their own way, learning their psychiatry from the bedside more than from books or lectures’. ¹⁷

Mapother distrusted philosophies which attempted to explain all the symptoms of mental distress through reference to a single cause and was to attack the ‘therapeutic chanticleers’ of psychoanalysis who mistook diagnostic concepts for clinical entities. Yet, within the Maudsley he tolerated all forms of therapy, from hormone treatment to psychoanalysis.

On 12 December 1922, Barkas went for the interviews of four women and six men conducted by Dr Mapother and the committee. Afterwards a tall man introduced himself as Dr Dawson and said that she should not have mentioned her analysis as ‘they were not keen on it there’ although there was no objection to its practice. Based on her past experiences, she did not feel optimistic and promptly wrote away for two other positions.

On 19 December, she passed the DPM and, shortly afterwards, Mapother told her she had ‘got the job’ at Maudsley (22 December 1922). Thanks to her father Fred’s efforts, she was listed, somewhat prematurely, in the New Zealand social columns as being ‘in charge’ of the Maudsley. ¹⁸

Her mood lifted, but it did not last; she doubted she would stay for more than two years in view of the vague terms of her appointment. Then she would do analysis in Rotorua.

This proved unnecessary. Barkas, appointed as a (temporary) assistant medical officer, stayed until 1927, becoming one of four psychiatrists working under Mapother. ¹⁹ AWW Petrie, WS Dawson, W Moodie and Barkas, supported by a number of junior doctors, served 157 patients in 6 wards. A matron, assistant matron, 6 sisters and 19 staff nurses with at least three years’ general hospital training were supported by 23 probationers and 12 male nurses. This was a higher staff ratio than found in the general asylums.

Among this cohort, Barkas stood out as a woman with psychoanalytic training. She was to have a close association with William Siegfried Dawson, third in the hierarchy after Mapother, who became a mentor. ²⁰ Dawson was to become an important figure in the development of Australian psychiatry after he came to Sydney as professor of psychiatry in 1927 ²¹ and to write a well-regarded textbook. ²²

On 18 January 1923, Mapother showed Barkas round the Maudsley, telling her that he was amenable to her doing analysis despite his scepticism about its efficacy. She was to work on the female side with Dawson from 9 a.m. to 6 p.m., although, in reality, the hours were often a lot longer.

On 7 February, she got a letter from Mapother that as inpatients and outpatients were increasing, she should take up her duties the following Monday.

On 12 February, she joined Dawson at breakfast before they looked at the patients already admitted and then ‘did office’, the daily medical superintendent’s meeting. The cases were split up. She was to have the upper ward, while the rest came under Dawson. She missed out on a hysterical case from out-patients, but instead got a young woman with dementia praecox who believed that she was dead (Cotard Syndrome), as well as an alcoholic woman she had known at St Mary’s – both were suitable for analysis. There was a case of paralysis agitans (Parkinson’s) with hysterical overlay and a nurse who had ‘a bad mental breakdown’. Already she had enough work to constitute 4 hours of analysis on alternate days.

Mapother, she decided, was a very good sort – kind and interested, swaying between the old psychiatry and new approach from psychoanalysis. Possibly nervous, quite intellectual and a mix of narrow and broad mindedness. Her other colleagues had the LCC mentality fixed in their minds which meant that the hospital would become a half-way house for acute cases.

The Maudsley’s in-patient population was about 40% male and 60% female, the same proportion for out-patients. Most adult patients were middle-aged. It is an indication of how rapidly the workload increased that by 1924 the hospital had seen 500 voluntary in-patients and 1000 out-patients.

On admission, an extensive history was taken from the patient, an approach derived from Meyerian psycho-biological dogma. The resulting notes often ran to 20 pages. There were elaborate case sheets from the mental hospitals to fill out but these were unsuitable for detailed neurological examinations. How effective this was as a clinical method was questionable. William Sargant, who was there in the 30 s (and recalled a case that required 30 pages), argued that the comprehensive histories reflected a sense of clinical impotence; detailed note taking gave ‘us a feeling that we were doing something for the patient by learning so much about him, even if we could not yet find any relief for his suffering’. ²³

During the 1920s, psychiatrists had little to offer in the way of treatment, apart from restraint and sedation. Great emphasis was placed on fresh air to prevent the spread of infectious diseases both in themselves and as possible triggers for mental illness. Malariotherapy, the first successful treatment in psychiatry, was given to patients with General Paresis of the Insane (GPI), but this was only relevant for a limited number of the patients. Mott (who ran the laboratory and had originally come up with the idea of establishing the Maudsley) and Mapother attempted to create an ‘atmosphere of cure’ based on diet, fresh air, control of infection and graduated exercise. Patients were encouraged to take part in games such as tennis, social activity (dances and coach trips) and occupational therapy (raffia, rug-making, weaving, knitting, sewing and carpentry). ²⁴ In the winter, a weekly concert, dance or whist drive was organized, while in the summer a fortnightly picnic in the countryside took place.

Cases were pouring in and Barkas anticipated having to stay till midnight to deal with the work. By 20 February, her ward was nearly full and it was hard to get the time for 6 h of analysis when she had to do out-patients as well. She would work all day and get home after 8 p.m., have a meal and sleep (25 March 1923). Over the weekend, it was long haul and she could only finish at 11 p.m. On 8 March (1923), she had eight patients needing an analytic hour but could only fit them in from 5 to 8 p.m. – presumably she did not see them every daily, or shortened the length of the sessions. They were to open a third ward on the female side, a total of 75 patients; the male side was nowhere as full.

There is no doubting her versatility. She presented papers on organic disorders, ranging from tabes dorsalis to encephalitis lethargica (EL or sleeping sickness).^25–27 The paper she wrote on post-encephalitic oculogyric crises was one of the first to document an important diagnostic feature of EL. ²⁸ With Dawson, she wrote a paper detailing the use of somnotherapy (Deep Sleep), ²⁹ later noting that its benefits in dementia praecox (schizophrenia) were limited. ³⁰ They presciently added that it was a dangerous treatment likely to cause cardiac failure. She participated in the hospital teaching program, lecturing on organic mental disorders and the genesis of mental symptoms, ³¹ in addition to talks to the nurses and Girl Guides.

She now had the two upstairs wards where the neurotics were kept. Her work as the only trained analyst at the Maudsley was constantly mentioned in her letters. She complained to Fred that it was a pity she was the only one with the right training; rest, suggestion and electricity just did not work. The unconscious material she was obtaining was surprisingly consistent with Freud’s theories. She was looking at shorter methods of treatment, harking back to her training with Rank (8 April). The patients would often improve in hospital only to break down when they left. A tic patient would lose her symptoms, only for them to recur. Another case had a feeling of terror connected to her teeth but they got to the root cause of the problem.

After being so ‘sniffy’, the other psychiatrists were starting to appreciate that her analytic work on neurotics was getting good results. The problem of long-term treatment of analytic patients needed a better solution. She had an episode ‘vainly wrestling’ with a patient who refused to accept psychotherapeutic intervention to cure her delusions (23 February). She had 10 cases in analysis and another 20 who got shorter 30-min sessions as a compromise.

Mapother only had a simplistic idea of how analysis worked, based on Freud’s earliest hysterical cases whose symptoms were relieved by catharsis. Dawson for his part, was ‘trying his hand’ on a hysterical girl, but only making her resistances harder. She felt he did not have knowledge or temperament for this type of work and his patient would be coming to her soon.

With neurotic patients Barkas sought to identify the traumatic experiences and then enable the patient to overcome this impasse. Psychotic patients needed a different approach which she drew from the work of John Rickman. She maintained that such individuals had regressed ‘from the reality principle to the pleasure principle, auto-eroticism and pre-genital modes of gratification’. ³² In hospital, there was a ‘letting off of steam’, an escape of libido from the repressions. When there is a readjustment of the emotional forces, there was the opportunity for the analyst to make sure this does not occur again. ‘Violent’ positive and negative transference occurs towards the staff and the patient should be allowed to regress to the ante-natal stage, and then relive the subsequent phases of development to develop a new ego-ideal. ³³ These views would no longer be accepted as mainstream analytic approaches.

The hospital included an out-patient department on two afternoons a week which soon increased to four. ³⁴ The idea of treating psychiatric disorders without admission was in its early days. Dawson and Barkas worked together at the clinic which played a significant role in the rise of child psychiatry in Britain. ³⁵ Her approach was influenced by psychoanalytic theories. At the Maudsley, patients could regress to an ‘antenatal state of freedom from stimulus and effort’ from which doctors could begin the socialization process. Psychoanalytic treatment was reserved for teenagers who were encouraged to recollect traumatic events and recount dreams and were asked for associated thoughts and feelings.

In 1918, an epidemic of Encephalitis Lethargica broke out in the UK. The number of reported cases rose rapidly, peaked in 1924 and continued to be reported until 1927. ³⁶ The EL epidemic had a profound effect on affected children, with psychiatric effects often as severe as the physical consequences. ³⁷ Approximately one-third of affected children underwent a rapid transformation from normal behaviour to delinquency, often leading to institutionalization. So drastic were the changes that a formerly gentle girl or boy could become ‘an intellectual, tormented and cruel monster’. ³⁸ The dramatic, aggressive personality changes were described as ‘Apache’.

This caused a surge in referrals of ‘demoralised’ children to the Maudsley – this referred not to loss of enthusiasm, but complete lack of moral control. Post-encephalitic children were remarkable for their ‘state of irritability, lack of inhibition, and consequent impulsiveness’. ³⁹ They were also excitable, noisy, restless and frequently destructive. Mapother believed that the moral sensibilities of these children were affected by the illness, rather than their intellectual capacity – ‘conative’ rather than cognitive disturbances. These children were notoriously difficult to treat, not only because of lack of knowledge about the illness and lack of effective medication, but also because of their behaviour. Barkas saw a number of affected children and described the problems encountered in such cases. ⁴⁰

Barkas enjoyed the Maudsley camaraderie and social environment, being a regular at the weekly dance classes. There were regular tennis matches with the pathology lab. ⁴¹ If the weather was cold, they would dance instead. She often went with Dawson to concerts and plays like Hamlet, As You Like It and Tess of the d’Urbervilles. There were political discussions over tea with views ranging from conservative through liberal to socialist. When Mott expressed his views on ‘war hate’, she restrained herself, feeling they would be shocked to learn her communist sympathies (7 January 1924) – she was an active member of the National Guilds League. Petrie, who had a breakdown earlier in the year, spent too much time at work so she and Dawson stood over him until he agreed to do the dancing class, which he enjoyed. He needed analysis, she decided (23 October 1923).

Barkas, as a woman, was not to remain isolated at the Maudsley. In this male-dominated environment, she was joined by Isabel Emslie Hutton, a Scottish doctor who had, if anything, a worse time getting a permanent position. Because the LCC strictly forbade the employment of married women, she was employed as an honorary psychiatrist for seven years with no official post or salary. Hutton graduated in medicine in 1910 and gained her MD in 1912 with a thesis on the Wasserman test for syphilis, an indication of her interest in mental and nervous disorders. During the war, she distinguished herself with service in Serbia, Salonika and Sebastopol. ⁴²

Hutton was not reticent about her difficulties. ⁴³ In 1928, she wrote to The Times (26 March 1928, 12c), regretting the universal dismissal of medically qualified women as soon as they married, and the way in which women were ignored as candidates for honorary positions. Women were not barred in many foreign countries, and to ignore them was a dreadful waste of ‘trained and eager’ women. ⁴⁴

The two women got on well and had discussions about their experiences as women in an unfriendly profession.

In the 1920s, it was hypothesized that viral or bacterial infection might play a causal role in psychiatric disorders ⁴⁵ or that they were the consequence of a metabolic imbalance produced by a malfunctioning endocrine system. Pituitary and thyroid extract had been given to patients suffering from shell shock, and in the post-war period, trials were extended to major mental illness. Maudsley psychiatrists were enthusiastic about hormone treatments for women with mental illness. ⁴⁶ They believed that that since women experienced mental illness with stresses around their life transitions (especially puberty, childbirth, and menopause), hormone disruptions were the cause and administration of hormones was the treatment of choice. ⁴⁷ The hormone treatments in the 1920s and 1930s helped to shape how psychiatrists approached other therapies in the 1930s and 1940s.

Barkas and Hutton shared an interest in the relationship between psychological theories of the instincts and glandular functions, prescribing glandular extracts. ⁴⁸ Her enthusiasm for endocrine therapy is listed in a case letter about a menopausal woman whose skin sensation, hallucinations and delusions led to the belief that she was infected with vermin. Treated for her thyroid deficiency, her condition improved although she maintained the delusions. ⁴⁹ Thyroid or ovarian secretions led to dry, scaly skin, the basis of the delusions which followed. ⁵⁰

In January 1925, Barkas was reappointed by the hospital committee for another year, so the frustrating search for regular employment was delayed for the time being.

Another honour came her way – to read a paper on the social factors in the production of mental disease at the Royal Institute of Health on a panel with Dr William Brown and Helen Boyle (27 March 1925).

Despite periods of optimism, as well as her intense involvement in work, the pressure was getting to her. The concerns about her future were always present and it seems she was getting depressed again. Her father, who was staying with her in London, noted that after working 10 h a day for the last year, she had The Jumps and needed a break tramping in Italy and Austria to ‘steady her nerves and recover her soul’.

Midway during her time at the Maudsley occurred the strangest attempt to find a solution to her problems. She contacted one of the most notorious figures of the day, no less than the epitome of evil: drug fiend, sexual deviant and proponent of the occult, Aleister Crowley. Barkas’s interest in metaphysical or spiritual issues went back to 1919 when she noted that the Aura, as described by the Theosophists, could be the physical medium of unexplained phenomena, like telepathy, but there was a vast gulf between those working in spiritual matters and mental health workers. The loss of weight of ectoplasm could explain the changes in mental disease. This could explain events such as intuitive thought as well as religious mysticism, but any psychiatrist who suggested this publically would risk being certified as insane (30 November 1919). In 1922, she read The Story of a Drug Fiend, Crowley’s novel based on his extensive drug experiences, which she thought was the best book of its kind since de Quincey, a vivid picture of psychology and pharmacology (18 December 1922).

On 24 June 1925, Barkas received a six-page letter back from ‘The Beast’ in Paris, commencing with his notorious leitmotif Do what thou wilt shall be the whole of the Law. The letter was classic Crowley, outrageous in its claims and entirely lacking in modesty. He claimed, improbably, that Henry Maudsley was his old teacher and that Freud had only entered into a minute section of the Magick tradition. While the Abbey of Thelema was no longer in existence, Barkas was welcome to join them and would find nothing in his system that would interfere with her work. She should come there to immerse herself in his Magick system to learn about herself.

The reason for her interest in joining Crowley can only be speculated. Firstly, the idea of a country farm/spa/sanatorium for treatment of neurotics in an idyllic rural setting was something that she had mentioned several times, although located in New Zealand. However, she must also have been aware of the scandals associated with the Abbey, which was closed down and Mussolini deported Crowley from Italy in April 1923. In the next few years, he moved around, mostly in France. She must have thought that his cult was just a version of the country farm/clinic she had wanted to establish for neurotic patients. The matter was taken no further and there was to be no further mention of Crowley.

Frustration was beginning to mount. Dawson could be seconded away and Mapother assured her that he would support an application to take his place despite the ruling that only one of the junior jobs, i.e. hers, could be given to a woman (20 July 1925). While Dawson was amused by the situation, Petrie – a queer creature – took to bed for two days with neurotic pain at the thought of a woman having responsibility. The new arrangement would leave Mapother free to deal with his private practice with which he was filling the hospital with unsuitable cases.

Barkas was getting tired of the Maudsley, which was admitting too many insane patients and beginning to resemble a typical asylum. Mapother, she now decided, was too weak to deal with the LCC committee to prevent it from becoming just another asylum, rather than a leading teaching and research institute (28 December 1926). He had fought as hard as he could with the Central Office over their criteria on sex and length of experience, but it was a pointless battle. If she applied for a position at St Mary’s as registrar, they would take it as her resignation. Dawson, away in America, was unlikely to return (1 November 1925), leaving her even more isolated. There was no point in staying as she would not be given his job. Mapother asked her to think about a job as Inspector for the Board of Control but she rejected this out of hand.

The deathstroke came when the committee formally notified her that she was sacked with no slur on her character – which could hardly have been much consolation. Her position would be taken by Dr Rosalie Lucas, coming from America (20 January 1927).

The Medical Superintendent's report states that her appointment would be terminated on 12 December 1927 on the grounds that tenure of medical appointments at the hospital would be limited. ⁵¹ While the Maudsley Sub-Committee was within their rights in not renewing her contract, this stricture was not applied to anyone else. Information from the hospital archivist is that the other medical officers continued their service and this sanction was not applied again before 1938 when the administrative arrangements changed. ⁵²

Why did her career at the most prestigious psychiatric centre in Britain end? Firstly, despite having appointed Barkas (and later Hutton) to the Maudsley, the prejudice against women persisted. Secondly, Barkas was the only psychiatrist who openly espoused psychoanalysis. Mapother was ambivalent about it, to say the least although he did not prevent its use on the patients; Dawson, by contrast, was more amenable. If the attitude of Aubrey Lewis, appointed the following year, is any guide, the Maudsley was not to be a place for those with psychoanalytic views. Dawson left the Maudsley in March 1927 when he was appointed professor of psychiatry at Sydney University. Did the departure of a close ally leave her without support?

From the correspondence, we learn only one thing. She believed there was no future for her there as a woman. Mapother expressed his support and encouraged her not to give up but conceded that his entreaties to the LCC made no difference.

The next year Barkas was appointed Medical Superintendent of The Lawn Hospital in Lincoln, a small private asylum. ⁵³ The Lawn, like many private institutions, had financial problems. These worsened in the Depression. It was a constant struggle to increase patient numbers and maintain hospital income.

Following her father’s death in 1932, Barkas returned to New Zealand and moved to remote Tapu in the North Island. Although registered as a medical practitioner, there is no evidence that she practised again. ⁵⁴ What went wrong remains a matter of speculation. There are suggestions that she was disillusioned with both psychiatry and psychoanalysis and found no alternatives in her personal life. These questions remain to be answered.

Mary Barkas died of ‘a long illness’ on 17 April 1959. ⁵⁵