Psychoanalysis and Psychotherapy
The Story of a Mental Hospital: Fulbourn, 1858-1987
by David H.Clark.
3 A New Superintendent
At the time of my appointment I was aged 32 and was a Senior Registrar at the Maudsley Hospital. I was the son of a medical scientist and had grown up and been educated in Edinburgh. Having trained in medicine at Cambridge and Edinburgh, I qualified in 1943 and then spent three years in the Army. This was followed by psychiatric training for three years at the Royal Edinburgh Hospital with Sir David Henderson and for another three years at the Maudsley under the redoubtable Sir Aubrey Lewis. While there I had had a personal psychoanalysis and trained in individual and group psychotherapy with the founder of group analytic psychotherapy, S.H. Foulkes. In this, so far, fairly ordinary career, however, there were some periods which would prove to be relevant to the work I undertook at Fulbourn.
During my time in the Army I did a limited amount of medical work. I trained as a parachutist and spent much of my time as a Section officer in a Parachute Field Ambulance leading a group of men into action; what was particularly valuable for me was that half my section were Conscientious Objectors, brave, intelligent but argumentative men who did not hesitate to question any order they doubted. I was with the armies that conquered North Germany in 1945 and saw the abominations of the Nazi Concentration Camps. Later in 1945 I was sent to the Far East and for three months was in charge of a camp of 2,000 Dutch civilians in the jungles of Sumatra far beyond the British lines, having to negotiate with the Dutch and their former jailers, the Japanese, to prevent a massacre by the Indonesian nationalists. These experiences taught me something of the perils and responsibilities of command, as well as showing me many of my own personal limitations. They also showed me the abominable things that people would willingly do to one another and left me with a deep distaste for locking anybody up.
My motives for applying for the Fulbourn job were mixed. I was married, with three young children and I wanted the security of a Consultant post. We wanted to get out of London and to live in a pleasant town. I also had an enduring desire to do something to improve the lot of the long-stay, back-ward patients. In my early days in mental hospitals, I had felt deeply concerned for these patients; I had seen them left, neglected, to their hallucinatory ramblings, or worse, locked in padded rooms, strait-jacketed or mistreated by staff because of their violence. I had seen a young raging patient, suffering from psychosis, die of the injuries inflicted by frightened staff. I had enjoyed my time at the Maudsley, but felt guilty whenever I went out to a mental hospital and saw the neglected hundreds. I thought that rather than spending my time on a few people with minor difficulties I should be working for the much greater numbers of suffering and abandoned people incarcerated in long-stay mental wards. I was also keen to see whether the group methods of consultation and decision making which I had seen to be so effective in the Army could be applied to a hospital hierarchy.
I was appointed, therefore, with a good general knowledge of clinical psychiatry, and a background of research and academic psychiatry, but no experience of hospital administration. I had never worked in an English County mental hospital. I had worked with long-stay patients in Scotland, but the Lunacy Laws of Scotland were different from those of England. I felt very aware of the deficiencies in my experience.
I did, however, have certain strong ideas, feelings and beliefs which I wanted to try out. In the army I had been impressed with how mens psychological health could be influenced by the way in which they were led. In my psychiatric training I had been struck by the difference between the patients in demoralised, static hospitals and those in hospitals that had lively, vigorous and hopeful leadership. I had studied social science and its psychiatric applications and in particular found fascinating the writings of Stanton and Schwartz, who analysed the daily social life of a private mental hospital in Maryland, USA. They had shown how nurses, doctors, attendants and patients interacted, and how patient upsets could be linked to staff animosities and collusions (Stanton and Schwartz, 1954). I felt that such social studies could teach us a great deal about what really goes on in a mental hospital. I had found group analytic psychotherapy personally rewarding and very valuable for my patients some of whom made more progress in a group than in individual therapy and I felt that group therapy was full of promise.
All these feelings led me back to the long-stay patients with the belief that somehow with the application of group methods, of human relations, of lively administration and strong leadership, I could find a way to change the hospital for the benefit of the long-stay patients. It was this vision which helped me overcome the offputting first impression I had of Fulbourn. During the three months between April 1953, when I was appointed, and August, when I started, I was busy winding up my London life and preparing for Cambridge. During the last two months of my psychoanalysis I faced again all my anxieties over separation and weaning. I concluded my research projects. I terminated, or handed over, my psychotherapy patients and said farewell to the groups that I had been conducting.
More than ever aware of the things I did not know about the Medical Superintendents task, I scurried about trying to fill out my knowledge. I read up English Lunacy Law and enquired how to certify a patient and what powers the Board of Control had. I paid visits to a number of mental hospitals and spent a day at the Social Rehabilitation Unit at Belmont run by Maxwell Jones. This unit was just becoming famous and I found the visit exciting and disturbing. Belmont Hospital, at Sutton, in Surrey was a former London County Council mental hospital, damaged by the war and housing several experimental units. One was the Social Rehabilitation Unit, run by Maxwell Jones which was just becoming famous for its pioneering social therapy. It ran as a therapeutic community, something I had heard of but never seen. The first event of the day was the community meeting; about forty people, all dressed informally sat round in a large circle; after a few reports discussion became general. Any visitors were called on to identify themselves. The community meeting was intrigued to hear I was about to become a Medical Superintendent; they commented that I seemed young for the task and told many tales of doctors in mental hospitals their neglect of patients, lack of concern and hypocrisy and the tyranny exercised by nurses. The Unit itself perplexed me. There were no uniforms everyone dressed alike. I was confused as to whether the people who addressed me in the community meeting were patients, staff or visitors. However, I felt this atmosphere of free and open discussion to be stimulating, helpful and possibly what was needed at Fulbourn.
I asked everyone about Fulbourn Hospital. I could find out little; no one seemed to have even heard of it. I found that many who knew Cambridge did not even know that there was a mental hospital outside it. One or two had heard vaguely I believe its a dump. Its said to be pretty backward, but little else. Dr Walter Maclay, the Senior Commissioner of the Board of Control and a visiting Consultant at the Maudsley, however, told me more. I remember Fulbourn with affection; it was where I was first introduced to psychiatry. Of course, nothing has happened there for years; its quite run down. Thats why they want an active person. You cant go wrong! Its like taking over a drunkards practice anything you do will be an improvement! Not that the old man was a drunkard by no means! He was a charming old boy and very fond of his patients. But he just couldnt stand up to his Management Committee and nothing got done. Of course, there are some pretty live wires there nowadays and youll have to watch out and keep your end up. Some of them seem to think that all psychiatry is in the outpatient clinics or the admission wards. Youll have to look after the back wards. You should find it an interesting job.
Some of my teachers were reassuring and said they thought I was just the man for the job. However, the more I heard, the more doubtful I felt and I began to wonder if I could get out of it, or whether I could get back to London in a year or two. The time to commence approached; last visits were paid, farewells said, files closed, responsibilities handed over. I was ready to go. We went for a seaside holiday, and then, leaving the family in London, I travelled down to Cambridge and to Fulbourn Hospital.
My contract had stipulated that I start on 1 August which was a Bank Holiday Saturday. I assumed I must start literally on the first and it was a measure of my ambivalence about my new task that I left it until the Friday evening after supper to drive down. As a result, I arrived at the hospital in the dark at about 10.30 p.m. on the evening of Bank Holiday Friday.
I walked up to the big front door, where I had been welcomed on my previous visit to the hospital, and found it locked. On either side of the door were large brass bell handles, much polished. I pulled one, then the other. Nothing happened; the handles moved, but there was no peal inside the building. I peered through the glass door; all was dark inside. I wandered along the front of the building; there were other doors, all firmly locked. Finally, I hammered on one of them and after a long time a torch light came bobbing along the passage. The door was unlocked. A squat figure with an uncouth accent asked what I was doing. It was some time before it became clear to him that I was the new doctor about whom he had had a message and I realised that he was the night porter. He rang the duty doctor, and I was welcomed and installed in a little flat which had been allocated to me. Later, I discovered that the porters lodge was at the back of the building, not the front; that was the true entrance, which patients, relatives, nurses and callers used. The Front Door was reserved for the Management Committee and Senior Staff and was only ever used in the daytime.
My first three days Bank Holiday, Saturday, Sunday and Monday, continued in a curious dreamy fashion. All clerical staff were away; most doctors were on holiday; there was only a skeleton staff on the wards. I was shown the Superintendents office, which contained a vast rolltop desk full of papers, a broken swivel chair and three notice-boards covered with notices, curling and dusty, all out of date; there were several relating to wartime air raid precautions (eight years after the end of the war).
This first day began the process of getting to know the people I was to work with a business of mutual exploration that went on for many weeks. I felt anxious and hesitant about them, for I had garnered a few revealing but often discrepant comments on each person before meeting him. They, of course, were all interested, concerned and even frightened about me, as I was to be a major factor in their lives in the coming years.
The first to meet me was the Deputy Medical Superintendent, Leslie Buttle. He had come to Fulbourn in 1949 just after the Health Service began, as a Consultant Psychiatrist; he was some ten years older than me and had trained in pre-war asylums and served as a Forces psychiatrist. He showed me where all the papers were, commented how much he had disliked his three months curacy of the Medical Superintendents post (as his interests were clinical and he did not enjoy administrative work), and left me to its problems.
Next came the Group Secretary, Charles Mitchell, a tall, courteous, slow-spoken man. He welcomed me and hoped that I would enjoy my time at the hospital. He told me that he had been brought up on the hospital estate, and had worked all his life in the clerical department, first under the Committee of Visitors and now under the Hospital Management Committee. He spoke with grave precision of the decisions made and with hesitancy of the prospect of their completion. He invited me to call on him whenever I wished for clarification of procedure and showed me the file of minutes of Committee meetings.
While we were talking, the Matron, Miss Brock, burst in on us. Several people had spoken of her, saying she was an impossible woman. She had been Deputy Matron for years and when the old Matron had retired in 1952 there had been an attempt by the Consultants and some members of the Hospital Management Committee to prevent Miss Brock from being appointed Matron. They had failed in this, partly because my predecessor, Dr Thomas, a close personal friend, had been her vigorous ally. The battle had left a bitter taste with all. Miss Brock had been told of things said at the confidential appointment committee and felt bitter against those who had opposed her. It seemed that I was in for great difficulties here. She briskly demanded that I go round the female wards with her forthwith.
During the Saturday afternoon I toured the hospital first the womens wards with Matron, then the mens wards with the Chief Male Nurse, Mr Tucker. The attitudes of my two guides contrasted greatly. Miss Brock introduced to me more people than I could remember; she pointed out many things that were amiss, as if challenging me to do something about them; she told me of the battles she had fought with junior doctors, with Consultants, with the Management Committee and how they thwarted her at every turn. Youve got to fight, doctor, youve got to fight. Theyve blocked me at every turn and I know that some of them would like to get rid of me. But no ones going to stop me doing the right thing by the patients, doctor, no one, not even the Regional Board themselves! She left me exhausted by her intensity and combativeness, by the magnitude of the problems, and all the difficulties.
With Mr Tucker, I strolled in leisurely fashion around the wards, where I was saluted by deferential patients and staff while he told me little tales of those we met. He spoke modestly of what they had achieved, but indicated that they were just waiting for my help to go ahead. He asked for my consent to certain easily granted proposals and indicated plans for the future. He hinted at difficulties with other departments and slyly indicated their failings, but was on the whole benign and cheerful. Of course, weve been held back, Sir. There were a lot of things we wanted to do, Sir, but they were refused. But now that youre here, Sir, I am sure we shall move ahead. Itll be a great help having you with us, Sir. We wandered out around the farm and inspected the pigs and the vegetable garden and he told me something of the difficulties of gardening on this chalky soil. I left him feeling smoothed, comforted and somehow elevated.
I spent Bank Holiday Sunday going through the files and papers. I found very little. It seemed that Dr Thomas relied on his memory rather than a filing system; I found several drawers containing broken pencils, untwisted paper clips and bits of string and one full of jumbled Committee papers, but little else. I read all the notices on the boards and took down all those more than a year old; this certainly made some room. I looked at the books, mostly the ancient journals and out-of-date surgery textbooks. I spent the evening in Mr Mitchells office reading back through the minutes of Management Committee meetings. These minutes provided a picture of a strange body, constantly concerning themselves with minutiae of hospital life and passing strongly-worded resolutions on many subjects.
I took my meals in the doctors dining room and gradually met the medical staff as they came on duty. They were a varied lot, including a man who had been in the Colonial Service, another who had worked in a number of mental hospitals, a young doctor just starting in psychiatry, a former general practitioner and a woman who had taken up medicine after an academic career. They were pleasant people, but all soon started pouring out dissatisfactions. The food in the doctors dining room was poor; the training programme was inadequate; the nursing staff blocked their attempts to help the patients; the Consultants were only interested in their private practices; the administration was incompetent and anti-medical; the Management Committee did not understand their problems. It seemed that their morale was low; several of them had applied for jobs at other hospitals. I remembered Leslie Buttles expressed dislike of his three months running the hospital; it was clear that it had been a painful period for all concerned.
On Tuesday the routine of the hospital resumed. I found that I was expected to sit in my office while various people came to see me to report Leslie Buttle, Miss Brock, Mr Tucker, each of the doctors. This was a lengthy process, especially in the first days, as I had many questions to ask and each person had much to explain. I got in early and went through the mail before my visitors began arriving a bewildering mass of requests for leave, pathologists reports, Official Notifications, drug advertisements and unexpected letters of all kinds.
There were two telephones beside the desk, one linked to the internal hospital system, the other a line to the hospital switchboard and the outside world. At first they were mostly silent, but as people began to know my whereabouts frequently both telephones were ringing at once. I asked about secretarial help; I was told that the medical secretaries were in the Admission Villas, where the doctors needed them. In later years, it seemed to me symbolic of the administration I inherited that if the Medical Superintendent wanted to dictate a letter, he telephoned for a secretary who came on a bicycle to take it down in longhand.
But there was no time to think of changes. There were new people to meet, and problems began to flood in on me. Part of my appointment was to the Psychiatric Department of Addenbrookes. Dr Noble, the senior psychiatrist at Addenbrookes called me on my first morning and asked me to come to see him. He told me that he was going on holiday and would like to hand over his patients. Within a day, I discovered that the other two Consultants had also departed on holiday and that they had also given the only Senior Registrar permission to take a fortnight off. Thus, I, the new arrival, found myself single-handedly responsible for scores of outpatients and about a dozen general hospital inpatients. Many patients had been booked to attend the outpatient clinics without any arrangement as to who was to see them. On one afternoon, I found that two full clinics had been booked and that I was expected to see them all. I arranged to go to Addenbrookes daily.
After a week or two, I got the clinics down to reasonable proportions. I felt bitter about this and upbraided the Consultants when they returned. It was, however, typical of the disorganisation of this group of senior doctors and the general disregard of the needs of others both colleagues and patients that they could all independently arrange to depart without ascertaining who was going to do their work. In one sense, however, the experience proved to be a boon. It kept me busy practising clinical psychiatry seeing new patients, making diagnoses, arranging treatment, writing to doctors one of the few medical tasks that I knew I could do fairly efficiently, and so my confidence increased. Within Fulbourn, too, there was plenty of clinical psychiatry to be done; there, too, the Consultants had left patients in my care, and new patients were being admitted daily. I took to doing regular rounds in the Admission Villas and doing the best I could with the problems presented.
I gradually met other important figures. Harry Merrin, the engineer, came to see me about my accommodation. The Medical Superintendents house, though built in 1930, was a large, rambling building planned on a nineteenth-century scale; it was said to be very cold in winter. I had heard dire stories of the difficulties of the last tenant. The garden was a barren desert of chalky soil, overrun by rabbits and raided regularly by voracious pigeons. Prior to moving my wife and I said that we must have central heating and had obtained estimates of the cost. We had sent these to Mr Mitchell who in due course informed us that the Management Committee had agreed the work should be done forthwith. (It was only in later years that I realised how exceptional this speedy approval was.) Since this work would take some time, I had arranged for the family to stay on in London. Now, Mr Merrin reported that the work had not yet begun and might take many months. He told lugubrious tales of previous delays and explained that because the HMC could not bribe suppliers as the private builders did, we always had to wait for special parts. Since he told all this with a cheerful grin, I did not believe it could really be so bad, but it was. We did not get into the house until February of the next year!
By that time Mr Merrin and I had had many talks. I learned he was a most able engineer who knew everything about the hospital, having worked there for many years, but that he had a puckish sense of humour and a delight in discomfiting the pompous and the important. He had apparently always been enterprising and subversive. He told with delight of his service in the First World War in the Fleet Air Arm when he had been decorated twice and court martialled twice. He maintained feuds with most other senior officers of the hospital and had been at odds with my predecessor for many years. He particularly despised those who did not fight for their rights or who would not engage in battle with him. After several battles of my own with him, he and I established a jovial comradeship, based on mutual respect.
These senior officers, whom I met first, all lived in the hospital grounds Mr Mitchell, Mr Merrin and Mr Tucker in houses, Miss Brock in a flat adjoining the womens wards. Several doctors and their families also lived in flats in the central building of the hospital.
There was one person whom I did not meet at least until later but whose presence pressed in on me from the first day: my predecessor Dr Thomas. Nearly everyone prefaced every request or comment with Dr Thomas always often usually dealt with the matter so. He came to occupy my mind and even my dreams. I had met him briefly at the appointment interview a vast man of 6 feet 2 inches who towered over me, with a great belly and two double chins. I began to wonder more and more what sort of a person he was and how I could ever fill his shoes.
I gathered that he had been at the hospital for many years, that he had known every patient and every staff member personally; that he was a talented conjuror and entertainer at Christmas parties and had been for many years a very good cricketer. I was told that he had played for the London Welsh Rugby Team when a medical student and had won a Military Cross as a battalion medical officer on the Western Front in the First World War. He had come to Fulbourn in the twenties and in the thirties had married the Assistant Matron; they had had one son the darling of the hospital.
Although talented in many directions, however, it seemed Dr Thomas could never make a decision and that he was terrified of the Management Committee, especially the powerful ladies on it; Dr Thomas had been a bosom friend of the Matron, but hostile to the Chief Male Nurse and the Group Secretary, and so on and so forth. Clearly, Dr Thomas had been a sick man in his latter years and had let many things slide.
I met Dr Thomas again one day when he came up to watch the cricket team play he was as big as ever, 22 stones and manifestly short of breath. Charming and friendly, he wished me well. Later that month he invited me for dinner when he and Mrs Thomas (also large) provided a gargantuan meal and much friendliness. He told me that he had greatly enjoyed his life at Fulbourn, which had become his home. This was why he had bought a retirement house only half a mile from the hospital he hoped to keep in touch. He spoke happily of his work on the wards with the patients and the staff but said frankly that he regretted taking the Medical Superintendency in 1945. I didnt like the administration the Visitors Committee the anxieties . And all this National Health Service and the Regional Hospital Board it has all been a great strain. I havent enjoyed the last years. If it hadnt been for the pension I would have retired earlier. He seemed a decent, defeated man. His health was indeed broken. He was seldom well enough to come up to the hospital and after several bouts of congestive cardiac failure he died in March 1955.
As I went to and fro through the hospital, I got to know more and more people first, those who worked directly with me, such as the fussy, incompetent, mischief-making woman allocated to me as my secretary, the porters who handled my mail and listened in to my telephone calls and the gnarled elderly patients who brought the food to the doctors dining room. Then there were those that I met frequently about the place the Matron, the Chief Male Nurse, the Engineer, the hospital chaplain, the hospital messenger, the senior nursing staff, the ward charge nurses and sisters. Some of them immediately stuck in my mind as idiosyncratic figures with marked abilities or manifest faults. One ward sister was a craggy wooden-faced woman, hostile to me and angrily contemptuous of her charges; another was refined, lady-like and sadly resigned to the incompetencies of the world. Some of the charge nurses were clearly former Army non-commissioned officers who saluted me with military precision and scattered their talk with an explosive Sir! in every sentence. I got to know patients either because they accosted me with petitions and demands or when I had to see them because of some letter, request or official enquiry. Some soon impressed themselves on me.
I found I could understand the Cambridge accent fairly well but I was for long defeated by the vowels of the people from the Fens, Wisbech and March the Fen Tigers. I gradually became accustomed to the excessive deference paid to me everyone springing to their feet as I came into a room, male nurses and patients constantly saluting me.
One group I quickly got to know were the patients who resented their detention. They were few, but they soon demanded my attention. They accosted me as I came in through the locked doors of their wards, protesting that they were illegally detained and that something should be done about it. In one mens ward I was stopped by a tall white-haired venerable figure who roared at me in a broad Scots accent Ah am illegally detained in this place! Ah have been brocht here by a perversion of the judeecial process!! There must be an Enquiry!! The Prophetess has spoken!! and then stalked away. In one of the womens wards a thin gaunt woman sidled up to me and in an educated voice requested me to investigate her case I am sure there has been a mistake. I fear that my husband told untruths to Dr Beresford Davies to persuade him to certify me. I am sure if you look into it, Dr Clark, you will see that there has been a terrible injustice brought about by that evil man. Others pressed petitions on me. Conscientiously I listened to their stories and investigated the case notes and the legality of their detention. In each case the legal papers were in good order; often there was a long and clear history not only of paranoid and deluded utterances, but also of antisocial behaviour. Mr McTavish, the Scotsman, had been a local farmer; a known eccentric, no one had objected to his practice over years of proclaiming the imminent coming of the Prophetess from a wagon in the market square. It was only when he took to attempting to convert his neighbours with a shotgun that the Police had had to take action! His denunciation of the Magistrates from the dock had ensured his committal to the asylum. The staff said he was well-behaved and helpful on the ward but always protested his detention to any visitor. The lady, Mrs Broadbent, was the wife of a solicitor in a nearby town; for years she had harried him with accusations of infidelity but it was not until she was found lurking in the shrubbery outside his office with a bag full of sharp flints that action had then been taken; it was her disordered rambling in court that had persuaded the Magistrates that she should be sent to us. Again, she had established herself as a leading and privileged citizen of her ward, always critical of the way things were being run, and always insisting on her half-hour interview with the Commissioners of the Board of Control during their annual visit.
I walked around the grounds whenever I could in the warm summer days and I soon became aware of the groups of working patients. Some of them were sad groups leaning on hoes being looked at by bored young nurses in overcoats. They seemed to be achieving little and not doing themselves much good either. But other groups were more effective.
There was the Farm Gang, a group of about ten men who were clearly central to the operations of Mr Banyard, the Farm Manager. When harvest came they carried out the main work, forking sheaves and humping sacks. The relations between them and the farm staff seemed cheerful and cooperative; they conversed in an incomprehensible rural dialect with sly jests and outbursts of bucolic laughter. Amongst the Farm Gang I noticed one man, Hugh, who seemed to do more work than any other two men put together. I tried talking to him, but got nowhere because he turned shyly away and mumbled. His case notes told me that he had come to the hospital 15 years earlier as a perplexed adolescent full of anxious ruminations, hallucinations and thought disorder. He had never been violent or troublesome; he had never had any specific treatment. He had gradually moved to a long-stay ward and then to the Farm Gang where he contentedly did the work to which he had been bred in his village. There it seemed likely he would remain, quiet and contented, for the rest of his days.
Another interesting group was the Engineers Gang, those patients who did the labouring work for the Engineer, Mr Merrin. They were always to be seen digging holes, clearing foundations, trundling barrows of building material to and fro.
The atmosphere of the groups and the attitudes of the men in charge varied a good deal. Once I came across one group of patients sitting down; up to me bustled a portly figure wearing an overcoat and a brown overall, who hastened to tell me of his charges. Im just letting them have a rest, Sir. Its better like that, Sir. You see, Sir, they are mostly EeePees, Sir, and theyre better for a rest at times. I know EeePees, Sir, know them well, Sir; Ive been doing this job for 20 years, Sir. You can rely on me, Sir! At first I could not understand what he was trying to tell me. Then I realised; some of them were epileptics (EPs) and, because such patients were usually difficult to handle, that gave him his cue and justification for idleness and tyranny. As I shook off the toadying creature the one thing of which I felt sure was that I could not rely on him! In contrast, at another time I found eight men digging a ditch vigorously. I asked who was in charge and they pointed to a figure vigorously swinging a pickaxe in the deepest part of the ditch, saying Aubrey, there, hes in charge. Out of the ditch came a cheerful friendly man who told me with enthusiasm of the jobs he and the Engineers Gang were doing, and how good they were at it. I noted the name of Aubrey Gentle; he took the lead in many of our projects in later years. He did not categorize and denigrate his patients; he regarded them as fellow workers in a common, valuable enterprise.
Harry Merrin told me about these working patients of his how he selected them and looked after them. Many of them were epileptics who, he said, were the best workers in the hospital. They knew how to look after one another and to deal with the occasional fit. He gave them extra tobacco and other privileges and they worked for him with devotion.
I began to realise that working for the hospital could be many things. At the worst it was dreary, degrading peonage, where people were given worthless things to do just to keep them occupied. It might even be exploitation. At best it might give a patient challenging and responsible work and an honoured status within the institution. I wondered what I could do that would work to the best advantage of all patients.
One day Mr Merrin asked me if he could have Jack back on the gang. I made enquiries and discovered a strange asylum story. I asked where Jack was and found him in Male 5, the male disturbed ward. A massive countryman, broad shouldered, big bellied and round faced, he sat there scowling grimly. The nurses informed me that they did not dare to interfere with him because he was an epileptic with a furious temper and massive strength who refused to do any ward work because Dr Thomas had said he was never to go out on Mr Merrins gang again. It appeared that about a year before, on the day the Commissioners of the Board of Control were visiting the hospital, Jack had cut his throat and had nearly died. Dr Thomas had had to leave the Commissioners to deal with the bleeding and was infuriated and shamed. Matters became worse when it emerged that Jack had done the deed with a knife purloined from the ward and clandestinely honed to razor sharpness. This meant that at some time a knife had gone missing in the ward and that the loss had either not been detected by the ward staff, or worse, had been covered up.
I talked to Jack though with some difficulty because of his dialect. He talked in surly monosyllables. He showed me the long scar on his throat. He said he wished that Dr Thomas had not saved his life, because he was going to have to sit indoors forever now. He told me his story and why he had tried to kill himself. He had been in Fulbourn for 20 years; he had been brought to the hospital from a Fenland village as a young man when his fits and his outbursts of temper had become too much for his family. He had found a good situation for himself as the strongest man on Mr Merrins gang the man they called for when there was a stone or a tree trunk or a sack too heavy for anyone else to lift. He never heard from his family. Then one day he saw a man from his village delivering gravel to the hospital and got into conversation with him. It emerged casually that Jacks mother had died three years before. She had been buried and the home dispersed and no one had even bothered to tell him! He had fallen into a state of bitter anger, gloom and resentment and had cut his throat, both to end a miserable existence and to spite them all his family, the ward staff, Dr Thomas, the lot.
His act had, in a perverse way, been successful. His two sisters and his brother, shocked by the news of his act, came to visit him and had kept in touch since. The ward staff treated him better. Mr Merrin wanted him back. But Jack believed the Superintendent would not let him go out to work again. (I think he thought I was another new young ward doctor.) I wondered what to do then decided to take a chance. I told Jack that Dr Thomas had gone and that I was now in charge, that Mr Merrin had asked for him and that I was willing to let him go back to work. But I pointed out the trouble his throat cutting had made for the nurses, for Mr Merrin, for Dr Thomas and asked him to promise me not to do it again. If he felt miserable again, to ask to see me and tell me about it but not to cut his throat it made such a mess!
Jack went back to work. Mr Merrin was pleased, as was Aubrey Gentle, in charge of the gang. The ward staff were glad to be quit of the rumbling volcano who had sat in the armchair all day. Whenever I saw Jack he gave me a respectful salute and a rumbled Mornin, Superintendent Clark. He and his group of epileptics, always an elite group within the disturbed ward, became more cooperative and helpful on the ward.
Gradually I discovered contented eccentrics settled in various parts of the hospital. On every ward there were the ward workers who did all the heavy and dirty work under the direction of the nurses. Submissive deferential middle-aged people, they showed little sign of mental disorder when I talked to them. Any suggestion that they might move, however, was contested by the staff with dire tales of breakdowns, suicide attempts and disturbed relatives. The hospital messenger, William, was a grave, courteous, well-dressed man who cycled into Cambridge daily and was always available for any errands or shopping that I might require. If ever I wanted something from Cambridge in a hurry, Mr Tucker would say Ill just have a word with William, doctor, hell get it for you and he did. I sometimes gave him a lift in my car when he would tell me at ponderous length about the latest happenings in the Hospital Chapel where he was a sidesman and a key member of the choir. I discovered that he was the simple-minded son of a well-to-do commercial family in one of the Fenland towns who had worked in the town for many years as an errand boy until he was brought to hospital in a state of acute middle-age depression following his elderly mothers death. Here he had settled to a similar life. He had a room to himself; he sang in the church choir; he had no desire to move. Attempts by keen young doctors to rehabilitate him produced a recurrence of his weeping, distress and agitation and people had learned to leave William alone.
Then there was George who worked in the hospital stores. It was some time before I met George for he was never on the ward. It was only when I had to go into the hospital stores a gloomy warren of shelves and boxes and bales that I became aware of a tall, bald-headed man with a long, sad face. He was wearing a white apron and was always moving round the back fetching and carrying. Then I met him at ward parties, well dressed and deferential, gravely greeting me. He had been in the hospital many years, having originally come in during a severe depression following his wifes death. He was well settled in the stores and had no desire to move. The only crisis we ever had with George was at his 65th birthday when someone suggested he should retire. He became very distressed and begged to be allowed to go back to his place. So we let him and he remained there serving a very useful role, for he knew exactly where everything was.
The Engineers Gang had a considerable array of tools picks, shovels, axes and saws, mauls and drifts which were kept in a hut in the Engineers yard. These were cared for by Ernest, a small wizened man who sat there all day cleaning, mending, sharpening, polishing and oiling them. He had developed a small garden outside the hut by clearing rubble and had a number of roses growing. Discussion revealed no sign of mental disorder and one doctor even tried to discharge him. But a combination of the efforts of Mr Merrin and the ward staff, who valued him as a useful worker, brought a stop to that.
There were also elite groups of workers amongst the women. In the laundry, apart from a few paid overseers, all the toil was carried out by squads of sturdy women who heaved the heaps of soiled bed sheets to and fro in great baskets and fed them into the boilers and then on to the great calenders for ironing. In the Sewing Room a group of long-stay women under the direction of a sempstress stitched endlessly, mending torn hospital sheets and tattered dresses. There were other womens groups for rough and hard work. Attached to the kitchen was a Vegetable Preparation Room a phantasmagoric, Dickensian place, full of steam and dripping water where placid red-faced women sat peeling endless tubs of potatoes, carrots, turnips and parsnips with scarlet chapped hands. There was a Scrubbing Gang that scrubbed the hospital corridors. I stepped gingerly past them every day grey-haired, grey-overalled gnomes, kneeling on wooden boards, scrubbing endlessly at the grey flagstones.
One of the most active of the maids who served the doctors and the Matron was Caroline. I noticed this short, squat, ugly, bustling figure who cleaned rooms with an angry vigour and tried to talk to her. Her face was marred by a badly mended harelip and the cleft palate behind it made her remarks at first quite incomprehensible to me. Later I got to know her better and at last began to understand her a little; I realised that it was not only a cleft palate, but a strange East Anglian dialect with many odd phrases that puzzled me. I checked the notes; she was classified as a feeble-minded epileptic with behaviour disorder. I could see that she was not very bright but suspected from the way she did her work that her intelligence was not far below normal; certainly she was not feeble minded. She had not had a fit for years. I saw no evidence of antisocial behaviour now.
She told me that she was an orphan who had grown up in the Yarmouth Workhouse. When she had fits they used to beat her and when she got too big to beat they put her into the local asylum. At the beginning of the war she was transferred she did not know why to Fulbourn Hospital where she soon landed in Fives the disturbed ward and then in the pads. Many days I spent in them pads, Doctor, till I learned to beave meself. I were a proper terror in them days, Sister says. For some years now she had been doing better. The Matron liked her thorough, capable work and her cheerful obedience. Caroline was often offered to newly arrived doctors wives as a useful servant and nanny. She very much liked working in the flats and homes and looking after the babies. She had known no other life than that of institutions and hardly ever went out of the hospital. She attended the hospital church devotedly and sang loudly and tunelessly in the choir. When I asked her where she might live in the future she said I dunno. Ive always been in ospital. Its me ome like. I dont know no other.
I also noticed a tall man stalking freely about the hospital. He was wearing very good clothes including suits of fine cloth of which the arms and legs were too short for him, so that his bony wrists and ankles stuck out of them. He talked to me cheerfully and deferentially, in rather simple language. He always enquired how my shooting was going. I had had to get a shotgun to rid my garden of raiding pigeons, rabbits and hares and sometimes walked around the estate in the evenings trying to shoot the marauding pigeons. I learned that this was Charles who had for many years been the personal servant of the former Superintendent, Dr Travers Jones. When Dr Jones, a short plump man, died, he left his large wardrobe of good suits to John who was still wearing them! For many years John had been the only patient in the hospital allowed to have a watch, as he had to go down from his ward to the Medical Superintendents house in good time to wake Dr Jones with his morning cup of tea. As Dr Jones personal servant, he was responsible for the doctors clothes and used to cut the doctors hair once a week. Another of his duties was to feed the partridges in the hospital fields. In the 1930s Dr Jones partridge shoot had been one of the best in the county and invitations to his shooting parties and the excellent dinners afterward were much prized. Charles had helped with all this. I later found out that Charles, now aged 63, had been admitted to the hospital in 1906 as a disturbed mentally defective adolescent and had remained there ever since. Charles was one of the first successes of our rehabilitation programme; we got him a job as a potboy and bootblack at one of the best hotels in Cambridge and he left hospital in 1954 after 48 years residence!
One day I was shown the hospital library which was a small cell full of ancient shabby books and magazines and there I met Arthur the Librarian, a small deferential grey-haired man with a genteel voice, wearing a good suit. He lost no time in telling me that he was a graduate of Cambridge University, a member of a famous College and that he had been a special protege of the late Sir Arthur Quiller Couch, the famous novelist and Professor of Literature. Intrigued, I chatted with him often; his tales of distinguished acquaintances became gradually more grandiose and he hinted at familiarity with the Royal Family, particularly the Dowager Queen Mary. He showed me the collection of books with great pride and encouraged me to borrow them. Later when my family lived in the grounds he welcomed my daughter into his library and encouraged her reading, presented her with books and instructed her in the degrees of royalty.
It was not till years later than I found out the full story of Arthur. He was the son of a local catering family and had been briefly an officer in the First World War during which time he had attended the University on a short wartime course. He had been a consistent fantasist whose continual spinning of tales and running up of bills had exhausted the patience of his parents and then that of the wealthy woman he had persuaded into a wartime marriage. About 1930 he had been put into a private asylum and then when the money ran out he was transferred to Fulbourn where he had remained ever since, always grandiose, somewhat deluded, always deferential to authority, quietly reading and writing in his library.
For quite a time I relished his conversation and was pleased with the attention he gave to me. It was only gradually that I realised that he had made what was supposed to be a library for all the patients into a private and personal one. He was assiduous in finding books for staff and their families and for a few patients whom he regarded as fit to use the library, particularly university graduates, former teachers and other educated people. But he considered that most of the patients were too ignorant to be fit to handle his books and gradually discouraged them from visiting the little room.
Apart from the exceptions mentioned, the patients were on the whole fairly shabby in appearance. The mens suits were crumpled and their shirts did not fit. The womens dresses hung lopsidedly and their stockings sagged down round their ankles. Overcoats were too tight and buttoned uncomfortably. All this was seen as an indication of their mental disorder and their self-neglect. Sometimes this was the case, but often it was due to their having given up the fight against institutional pressure. All clothing belonged to the hospital. It was regularly gathered and despatched to the hospital laundry and there boiled. There was no individual clothing, not even underwear. In some womens wards a basketful of knickers would be dumped on the floor and the women would then scramble to get something that might fit. The apathetic invariably ended up with clothes that did not fit.
When I attempted to challenge or change this system I ran into difficulties and many reasons were given for maintaining the status quo the nurses were overworked and could not be responsible for private clothing; private clothing got lost in the laundry; there was not sufficient competent staff to keep trace of it; many materials disintegrated with boiling, especially wool, so only coarse cotton garments would survive; the laundry costs must be kept down and so on and so forth. Hard wearing material for patients clothing was chosen by the Visitors Committee from the lowest tender of firms that specialised in asylum clothing. The budget would not allow for changes. The present system was fairest no one did better than anyone else. It was little wonder that most of the patients, defeated by life and by the system, put on what they were given and shuffled about shabbily in it. The astonishing thing was that there were in fact a few people who still struggled to maintain their personal standards. On the wards for the hospital workers a few men were smartly turned out at weekends with collar and tie and with a suit neatly pressed, and a few women had their hair washed and curled, wore dresses that fitted and had been ironed and had put on a few touches of lipstick. But these attempts at improving appearance were pathetically few.
The head and face hair of most patients was untidy and uncouth. They must not be allowed razors or scissors, so the overpressed nurses had to do the work. The male patients were shaved once a week by junior male nurses, with blunt razor blades, so they always looked unshaven. Their hair was cropped once a month. The womens hair was chopped off in a pudding basin style, so that they all had similar mops of dull grey hair.
Many patients always seemed to be carrying around lots of things with them. The women had shabby handbags, packed to overflowing. The mens jackets bulged and investigation showed that their pockets were filled with old envelopes, documents and newspaper cuttings which they would produce earnestly to prove their paranoid allegations. This was often cited as another example of behaviour typical of mental disorder as it sometimes was. But more often it was a reflection of the fact that most patients had no receptacle no locker, no drawer, no private box that they could call their own. The only place for treasured oddments was the handbag or the jacket pockets regularly searched, of course, by the staff. Private storage places were discouraged by the staff they only hoard rubbish, doctor and were regularly and punitively searched for contraband such as sharp instruments, knives, money for escapes and so on. So anything valued had to be carried around all the time.
Amongst the women milling around in the womens disturbed ward, F5, I noticed one who carried herself taller and more upright than most. She seemed to dominate the throng physically, though she was not part of the pushing and shoving. I tried talking to her. She had a perplexed look on her plump face and although she spoke with an educated voice her responses were flat, banal and brief. I was told that Elizabeth was one of the most dangerous women on the ward, very strong, and given to outbursts of raging fury when she attacked staff mercilessly. I checked her story and found out that she was the daughter of a professional family who had entered the Womens Air Force during the war and had become an officer. She had then had a severe psychotic breakdown. She had been sent to the special officers psychiatric hospital where she had spent five years having all the treatments insulin coma therapy, electroplexy and a prefrontal leucotomy to very little effect. After the war ended the officers wards were closed and the family had been told that she would have to be transferred to her local county mental hospital namely Fulbourn. She had been several years with us, and everyone accepted that she would probably be with us for the rest of her life. The family had broken up; her parents had divorced, her brothers and sisters had made their own lives; no one visited her. Her strength and violence made her a major problem for the staff and no one knew what to do with her there except put her in the pads with an injection and wait till she cools down. Certainly I could think of nothing else to do.
So I gradually got to know some of the people who inhabited this bizarre asylum world; many seemed fairly settled in their situation and none seemed to expect much change. I often felt utterly daunted by the task of altering and moving things and feared that I might be utterly defeated by the apathy of the place and fail to achieve anything and, as I put it in a letter to a friend, sink without trace into the mud of the Fens.
One of the first major problems I had to tackle in my early days at Fulbourn concerned the relationship between a staff member and a patient. Miss Brock told me that she was very worried about one of the senior nursing staff and a woman patient who was medically qualified. The patient, who had a long history of alcoholism, instability, drug addiction and obscure physical complaints, had recently been readmitted for treatment of drug addiction. She was a middle-aged foreigner, born to wealth, qualified as a doctor, but had not practised for years, and cut off from her family. During her previous admission, she had met the nurse and they had become friendly; the nurse had tried to help the unfortunate woman. Things had gone wrong and the patient was found in the nurses room unconscious from a suicidal dose of drugs. The nurse had been reprimanded, the patient resuscitated and then discharged. Now the patient was back and the nurse, on night duty, was seeing a good deal of her; other staff were saying she spent long periods in the patients room. The Matron was distressed and angry with the nurse. Shell have to go, doctor; she was warned last time. We cannot have this sort of thing going on. Something must be done right away! They should never have readmitted that woman to this hospital; shes far too troublesome for us with our shortage of staff.
I thought of the triangular conflict described by Stanton and Schwartz in which there is a situation where a patients behaviour is fed by a conflict between two staff members. This seemed very likely to be such a case. Could I demonstrate the value of the sociological approach here? The Matrons suggestion was simple: force the resignation of the nurse and arrange the transfer of the patient to another hospital. I suggested that perhaps this was a challenge to us and that we ought to try and do rather better. I went to see the patient a woman time-worn but possessing both intelligence and charm, who fluently explained away all her behaviour in terms of a biochemical upset due to mistakes by various earlier doctors. As a result of this she needed, she said, constant sedation. She could not help smoking in bed all through the night; she had to call the nurses constantly. One evening, I saw the nurse and talked with her; she told me what a brilliant and charming woman the patient was, with a tragic and misunderstood life story; she felt that she could help her greatly if she were allowed to. The nurse spoke most bitterly of the other nurses and the Matron they did not understand, they did not care for the patient, they were only interested in maintaining the rules. I pondered what to do, but realised that I had at least to do something as the Consultant in charge of the case was one of those that had gone on holiday. I told the patient I was taking over her care; I changed her sedation and arranged a medical consultation. I told the Matron we would aim to keep both the nurse and the patient. I talked again at length with the nurse, letting her freely express her anguish and her altruism and then trying to show her how others viewed her excessive zeal.
Two nights later there was a fire in the patients bed. She suffered extensive, though superficial, burns to her stomach and thighs. It seemed probable that this had been accidental, due to surreptitious smoking in bed while she was fuddled with sedation, but it might have been deliberate self-damage. A surgeon was called, the burns were dressed, and she was moved to the sick ward.
I saw the nurse again. She was distressed and inclined to blame herself; she had provided the cigarettes. The Matron was even more incensed and very worried lest the patient might die; then there would be an inquest and an enquiry as to why such an ill patient was smoking in bed. She reiterated the demand that the patient should be moved.
I could not decide what to do. The patient was ill, and might die. Then I remembered that Stanton and Schwartz emphasised the importance of the two staff members reaching a consensus. When I enquired, I found that the nurse and the Matron had not actually spoken to each other for weeks.
I arranged a meeting with them both, with adequate time to spare. I prefaced this by seeing each of them and pointing out that they had to work together and then, when we met, I started from the position that this patients physical illness and psychopathic personality was a challenge to all of us; that this was the sort of problem our hospital existed for (among others); that we could not pass it on to someone else; that we must work out what to do. The meeting was quite tense and difficult. However, we all displayed our concern and desire to help; the nurse talked about her friendship for the patient and her desire to help her, and offered to resign; the Matron refused the resignation, but pointed out some of the problems created and proposed certain duty shifts so that the nurse was not in direct professional charge of the patient; I agreed to certain changes of sedation and routine.
Things continued stormy for a day or two. The patients wounds became infected; she developed skin sensitivity to her antibiotics; her demands for medication and sedation were immense. Then, she began to settle. Her wounds healed and she could get up and about. She revealed the charming and cooperative side of her nature. We managed to cut down her sedation. Some weeks later, she became resentful of regulations and quarrelsome and demanded her discharge. Her skin was healed and she was fairly stable, so I gladly let her go. I had succeeded in keeping the nurse, and the patient had recovered at least moderately. I felt strengthened in my ideas, but exhausted by the episode.
On another occasion the Chief Male Nurse brought a nasty problem to me. A patient on the privileged workers ward had lost 16 pound notes from his wallet. Mr Tucker said the nurses reckoned they knew who had taken it a patient with a criminal record but though they had searched him and later everyone else on the ward as well, they had not found the money. What should they do?, he said, looking at me. I decided to begin by asking questions and this soon led me to the ward and examination of all the people concerned. This ward contained a mixture of recent admissions awaiting discharge and long-stay patients who were good workers. The patient who had lost the money, Jim, was a young schizophrenic, a popular ex-soldier who had been two years in hospital. He had a knack for repairing watches and had mended several for staff members. He regularly bet on the pools and had won the £16 four months earlier and had carried the money round since then in his wallet.
The suspect was an evasive, jumpy creature with a long history of military and civilian crime, mostly petty theft, who had been admitted in an acute anxiety depressive state. This had settled satisfactorily, and he was now awaiting discharge. He denied guilt volubly. The staff were upset, anxious and self-defensive. It was clear that the whole ward had been thoroughly upset by the searches; a number of recent patients had demanded to leave because of the indignities to which they had been subjected. I was not sure what to do, or what my powers were, but I put out tentative questions to find what Mr Tucker, the ward staff, or the more articulate patients felt should be done. However, I got very little help and had to judge the matter for myself. Eventually, good sense came to my aid. The money was gone and there seemed little chance of getting it back. Everyone was upset and needed calming down; there was no evidence that any staff member had been remiss or thoughtless. I therefore announced that no further action would be taken; that I saw no purpose in calling in the Police; that this incident showed the necessity of handing in large sums of money to safe custody. If a patient on a crowded ward kept money on his person, it was a temptation to the less honest and that everyone should be more careful in future. This judgement seemed satisfactory; I heard no more.
One aspect of my job with which I had to come to terms was how much people lied to me. This was not a complete surprise. In the Army I had often heard the old soldiers saying Never tell the truth to an officer. For three years I had lived in the corrupt and corrupting society of the Army where I also had to learn to lie fluently and convincingly to senior officers and to accept that anything said to me by soldiers and NCOs might be true, but might equally well be a glib lie designed to divert my attention. But then for seven years, after leaving the Army, I had worked as an ordinary doctor, with people who did their best to tell me the truth in order to obtain my help. For the last two years at the Maudsley I had worked in psychotherapy where many strove strenuously to tell the truth, however painful. Now I was back in a position of authority as Medical Superintendent the person to whom everybody in the hospital tended to lie. The fact that I had the power summarily to dismiss any member of staff was a further cause for caution. I was frequently called on to investigate mishaps bruises, broken bones, sudden death, thefts and fights. Always there were shifty-eyed witnesses telling improbable tales sticking stubbornly to their lies for fear that something worse might be uncovered.
I also came to spot the warning systems used by staff when I was going round the hospital to signal my impending arrival in the next ward. Such signalling systems were used in most mental hospitals. In Fulbourn they passed the message from ward to ward by tapping with a key on the central heating pipes, one tap for the junior doctors, two for the Chief Male Nurse, three for the Superintendent. Another method was to have trusties on watch. In the disturbed mens ward there was one patient who always sat by the door; whenever I came in he leapt to his feet and shouted Doctor at the top of his voice. At first I thought he was welcoming and saluting me but then I realised that his real function was to warn the Charge Nurses so that they could conceal any improper practice before I reached them.
As people got to know me they told me tales of Superintendents, of my predecessors, of doctors at other hospitals, and so on which showed malignant perversity, devilish investigative ingenuity and even deliberate sadism by Superintendents. I realised that the staff half expected that I would behave like that, too. There were tales of Medical Superintendents who were on the constant lookout for slackness by the staff, Superintendents who crept round the hospital at night in soft shoes trying to catch night nurses sleeping on duty, Superintendents who went round removing the valves from staff bicycles left unattended. At times I even felt myself being pushed toward this sort of behaviour.
In one case I had to try to deal with, a husband complained that his wife had been beaten by the women nurses and dragged round the ward by her hair. The woman was certainly bruised but was too muddled herself to say how she got the bruises. Some of the onlooking patients confirmed the story, others denied it. The nurses all told the same story denying culpability which I felt sure was untrue. Finally all I could do was to come up with the ancient and illogical verdict I find the case not proven but if you ever do something like this again, I shall dismiss you forthwith. The calm way in which this was accepted showed that I was right in my suspicions but also that I had behaved in the way expected of a Superintendent. I had shown the nurses that I knew that they were lying, but had let them keep their jobs.
Some of the other tasks brought to me as Superintendent seemed rather bizarre. A patient died, and I was informed that at Fulbourn the Medical Superintendent always did a postmortem. Slightly surprised, I complied, calling on some brief experience of morbid anatomy. I was assisted by an overactive and garrulous charge nurse, who flattered me constantly on my technique Ah, I can see you know this job, Sir; I can see you are an old hand. You have a very deft touch with the knife, Sir; I can see I shall have to keep them especially sharp for you, Sir. As he chattered, I gained the impression that my predecessor had done postmortems partly because he enjoyed doing them, partly as a way of checking up on the medical skill of the junior doctors (by checking whether they had missed some major illness) and possibly in order personally to obscure evidence that might be embarrassing at a coroners inquest. As I pondered on this, I wondered whether doing incompetent postmortems on patients who had died of natural old age was really a sound use of the time of a Consultant Psychiatrist, and further whether it would not be better to improve the medical diagnosis and treatment available for the patients while they were alive, rather than seeking to catch the doctors out when the patient was dead. I began to ask on the sick wards for more frequent consultations with the specialist physicians, and to suggest that if a postmortem was really needed, then a competent pathologist was the man to do it.
On my very first Tuesday, I had had to attend a meeting with two members of the Management Committee. A Subcommittee was holding an Enquiry, and I was asked to join them for lunch. Major Symonds was a middle-aged man, a former school teacher and army officer, who had until recently been the Member of Parliament for Cambridge; Mr Boyle was an elderly businessman who seemed to know a lot about labour relations. They were both very friendly and helpful with suggestions about life in the area; most of lunch was spent discussing the difficulties of growing vegetables in the differing local soils. It was only gradually I sensed some of the under-currents that the ex-MP was one of the bright young men of the postwar Labour Party, with a background of boyhood and university socialism, while the businessman had spent his life defeating Union men in negotiations; that the Major had seen war service and Mr Boyle had not, and seemed resentful of it; that Mr Boyle was a local boy made good, while the Major talked like a university graduate. They were worlds apart, but they seemed to get on well together and to be united in their interest in the hospital and its welfare. Only towards the end of lunch did they talk about their Enquiry. Some months earlier, it had been discovered that a good deal of ward stock that is, bed linen, patients clothing, cutlery, equipment was missing from the mens wards. Everyone had been very upset and these two members had been asked by the HMC to investigate and find out what had gone wrong. At present, they were conducting hearings; the only certainty was that far more was missing than they had at first thought, but how it had gone, whether it had been stolen or been lost and who was to blame all this was unclear. They asked me if I wanted to be in on the hearings; I said I thought not, and since the incident had taken place before my time, they agreed.
On another occasion Mr Mitchell called me because the cook had reported the loss of a leg of mutton; would I hold an Enquiry? Somewhat surprised, I complied, and spent the morning cross-questioning cooks surly men with strange rustic accents, using curious words of special local meaning and kitchen workers, voluble Latins and taciturn Eastern Europeans. I established that there had been a leg of mutton in a double-locked larder and that now it had gone. But who had taken it, and how, I never discovered. The Enquiry was finally closed and the matter reported to the Management Committee. Again I wondered whether this was really the proper use of a doctors time.
Alongside constant problem solving, I was also gradually meeting other people connected with the running of the hospital. One day, I had a message that Mrs Adrian, the Chairman of the Management Committee, would like to come and see me if it was convenient. My trepidation in preparing to meet her was quite unnecessary; unassuming and charming, she spent an hour with me in my office, talking of common acquaintances and her hopes and plans for the future. Mrs Adrian was the wife of E.D. Adrian, Professor of Physiology, Nobel Prizewinner and Master of Trinity College. She told me she had always been interested in the welfare of the mentally ill and handicapped. Two years before, she had undertaken the Chairmanship of the new HMC of Fulbourn Hospital. I realised that she was an intelligent, well-informed, tolerant and well-intentioned lady, but she spoke so modestly of her own contribution that it was only as the months went by that I came to understand why she held so many important positions in the town and was so widely respected. She was Chairman of both the Magistrates Bench and of Cambridgeshire Mental Welfare Association. Whenever there was an insoluble situation in the welfare field, Mrs Adrian was asked to head the Committee to sort it out. She brought a powerful intellect to the study and assimilation of documents and would give endless time to mastering the details of any situation. More important was her ability to see the positive in all the diverse people she worked with and to draw out their best contributions to the common aim. However, this first meeting was merely for her to see what sort of a young man they had got for Fulbourn. I felt comforted and reassured by her kindness.
Miss Brock and Mr Tucker both took their holidays and I had to deal with their deputies. Miss Legge, Miss Brocks deputy, was a good soul, devoted to her absent chief, and totally under her guidance. All matters had to be left until Miss Brocks return. Mr Allen, Mr Tuckers deputy, was very different: an able, thrusting, vigorous man, he was full of schemes. He had been at the hospital only a few years and had poured his energy into anything that came to hand. People had pointed out to me a small building going up in one corner of the grounds, which was to be a new staff social club house. The club had been founded by Mr Allen, who had persuaded Mrs Adrian and the HMC to put up amenity money for the building. Mr Allen had restarted the hospital flower show. He had been active in starting football and cricket teams among the patients; the cricket team had won a cup from the other mental hospitals of the region that summer. He told me of all these activities, but also laid before me some other projects he would like to see go ahead. In particular, he felt that the male patients could do much more and better work. I was excited by his enthusiasm and gave Mr Allen encouragement; he soon brought me many plans, some of which seemed eminently reasonable. However, he also started voicing criticisms of Mr Tuckers regime and I realised that there would be a problem here. How grave it might be became clear to me when Mr Mitchell mentioned that the enquiry into the missing stock had originally started when Mr Allen, acting in Mr Tuckers absence, had carried out a thorough check of the stock on one ward and found many things missing.
As the long hot days of August raced by, I slept fitfully in my little flat and longed for the easy, uncomplicated life of a Senior Registrar. I began, however, to recognise the people I met, and even to remember their names, and began to feel some familiarity with my work.
One aspect of hospital practice in which I quickly became involved at Fulbourn was that of the English laws relating to mental illness. At the Maudsley Hospital everyone came as a Voluntary Patient; they had to agree to come in and agree to stay, and indeed many clamoured to be admitted. But at Fulbourn I came face to face with the archaic and often degrading process of enforced admission to a public mental hospital. This procedure had evolved to some extent during the history of asylums, but for the past 50 years little had changed.
Fulbourn Asylum was originally set up in 1858 by the Magistrates who also controlled the workhouses. They and the parish overseers decided who should go into the workhouse. If in the workhouse a pauper was found to be insane the Magistrate called for medical advice and then signed a Receiving Order directing the Medical Superintendent of the Asylum to take the patient in. The 1890 and 1891 Amended Lunacy Acts standardised these procedures and in 1953 these Acts were still current law.
The Magistrates had to receive advice from two doctors. This advice was recorded on certificates and thus patients were certified. In the 1950s the details of this process were carried out by an officer of the local authority, for many years known as a Receiving Officer but now known as a Duly Authorised Officer (DAO). As Medical Superintendent I found myself receiving certified patients most days of the week. I had to scrutinise the documents to see if they were in order; I had then to examine the patient and see if he was indeed mentally disordered and a proper person to be detained. In the majority of cases there was no doubt, but there were sometimes challenging problems people who were ill physically rather than mentally, people who did not seem to be mentally disordered, people who were drunk rather than mad.
The local DAOs were a mixed bunch. Fulbourn served seven different independent local authorities and each had a Medical Officer of Health, jealous of his independence, who controlled and instructed his DAOs. The DAO for Cambridge County, Mr Monty Bowyer, was a quiet compassionate man with a vast memory, who had been looking after the mentally ill and mentally defective of Cambridgeshire for over 20 years. He knew them, he knew their histories and he knew their families; he would bring them to the hospital with understanding and firmness. But some of the others were quite different. I recall one DAO, an ex-policeman, telling me with glee how he tricked one unfortunate person by telling her that he was just taking her for a nice ride in the car to see your auntie. Another small man seemed to relish violence and would turn up at the hospital with a posse of policemen and the patient handcuffed and lashed onto a stretcher.
For many people admission to Fulbourn Hospital in the early 1950s was a terrifying and degrading experience. After weeks of mounting tension, mental disorder and distress, things came to a crisis. There were secret conclaves of relatives and doctors; doctors whom they did not know came to talk to the patient. Finally, policemen, ambulances, motor cars and a Magistrate all arrived at the house, to the fascination and horror of the neighbours. The patient was dragged into the ambulance and whisked off to Fulbourn, there to be stripped, bathed, roughly examined and drugged. Little wonder that many of them were confused, angry, paranoid and resentful by the time I saw them.
Many members of the Management Committee of the HMC were also Magistrates and sometimes they would chat to me about their experiences of certifying people. Some disliked it and would evade it by opting for other even nastier magisterial tasks, such as inspecting slaughterhouses. Others clearly enjoyed it and prided themselves on their skill in interrogation and the detection of madness.
Once a month I had to prepare a list of certified patients ready for discharge and present it to two Magistrate members of the HMC for their approval. Mostly they accepted the list and signed it, but sometimes they would spot an acquaintance on the list and ask me many questions How had she got on? Was she really better? Did she still accuse her husband of having an affair with a barmaid? Had I talked to the mother-in-law? I resented these enquiries; not only were they questioning my medical judgement, but it often seemed that this was just prurient probing and gossip. I then discovered that in some hospitals the HMC insisted that the patient proposed for discharge was actually paraded before the HMC members and questioned. If the committee members were not satisfied by the answers of a patient and his cringing relatives, he was not allowed to leave! Our Fulbourn HMC, it seemed, was comparatively enlightened!
I was also required to examine regularly people who had been in the hospital for years. The regulations stated that every patient must have one physical examination and one mental examination every year, and every few years the Medical Superintendent had to sign a statement justifying a patients continued detention. I used to spend one half-day a week doing these Board of Control Examinations. I would be shown into a dormitory full of people lying naked on beds and invited to do physical examinations on them all. No one cared how brief or perfunctory the examinations were, the patients did not comment or complain, but I became unpopular with the nurses waiting to clear the dormitory if I insisted on doing the job properly. The mental examinations were brief interviews in a ward office, with the Charge Nurse standing behind me and briefing me on each person (just a mental defective, Sir, no trouble ... this ones an EP, Sir, a lying treacherous little sneak ... This ones cunning, Sir, but ask him about Queen Victoria ... and youll get him). Many of the patients had gone through this routine before and would rattle off the day of the week, the date, the year and the name of the Queen, her children and the current Prime Minister before I even started asking questions. Some were wily and great skill was needed to trap them into admitting their strange beliefs or talking about their bizarre experiences of hallucinatory voices. All this was watched with amusement by the Charge Nurse. His main interest was to see if the new Superintendent was as clever at interrogation as his predecessor had been.
The antiquated Lunacy Acts gave us many unnecessary difficulties and caused a great deal of paperwork. But more worrying was the underlying social contract. The Medical Superintendent was personally responsible for the custody of every certified patient that he received. It was his duty to see that they did not escape. If one of them did escape and caused some harm, the person harmed could sue the Superintendent, though not the patient, who being certified was legally not responsible for his actions. The Lunacy Laws and their interpretation over the years by the Law Courts, by the Commissioners of the Board of Control and by successive Superintendents of Fulbourn had produced a vast amount of folklore and anecdotal history all of which operated to check spontaneity, to discourage initiative and certainly to prevent any risk-taking. No Fulbourn patient might have money he might use it to escape. No patient might have a knife he might use it to cut his throat. All cutlery must be counted and checked after every meal in case someone took a knife and used it. No patient must be allowed to handle a key a former Medical Superintendent had sacked without a reference a nurse he saw hand a key to a patient to open a door. All patients, by definition, were irresponsible, incapable of intelligent or reasonable behaviour, potentially violent, always on the lookout for chances to escape.
The Law, therefore or what was alleged to be the Law was a constant check on us, forcing us into rigid, restrictive, punitive behaviour. I wondered if it had to be like that. I felt that the Laws themselves were hopelessly out of date and hoped that some day they might be changed.
I was not alone in feeling that these 1890 Laws hindered us in practising modern psychiatry. The feeling was widespread and in 1954 the Government set up a Royal Commission to examine the Lunacy Laws and report on them. To our delight, Mrs Adrian was named a member. Over the next three years she often discussed what she heard and saw at her meetings; she brought back many good ideas to Cambridge and also asked many pertinent questions of me.
My birthday falls toward the end of August. I started the day gloomy and oppressed. Nobody at Fulbourn knew it was my birthday and there was nothing to mark the day. I had always reviewed my years work at the time of my birthday and this year I concluded that I had taken on a job that was too big for me, for which I was too young and inexperienced. I also missed my family, my wife and children; I missed my analyst, who had been a constant companion and supporter (if also an irritant and disturber of my mental peace) for the last two years; I felt far from home and those who loved me, far from anyone who cared that it was my birthday.
My feelings of gloom were well justified as it was on that day that what was to be one of my major tests and lessons occurred. On my morning round I stepped into the womens Admission Villa to find an atmosphere of crisis. The ward doctor, harrassed and concerned, asked for my help with a patient who had collapsed while having ECT. I was taken into a room where an obviously shocked and ill woman was gasping for breath; I involved myself in the emergency, giving oxygen, ordering stimulants, lifting the bed ends, rushing about. As we worked, I gathered the story a middle-aged melancholic patient, second course of ECT, third treatment, sudden collapse after the treatment. Listening to the chest, I could hear much bubbling which suggested lung oedema, but I was puzzled by what I heard, and did not really know what was wrong or what to do. We got her into the ward and into bed, and she seemed to improve but shortly before lunch I heard that she had died.
I was puzzled by this death, uncertain what had to be done, fearful of what might emerge. I did not have long to ruminate, however, for events swept on their inevitable course. The Matron was on to me at once. The coroner must be told! This was terrible! She must have had a bad heart! Who would see the relatives? Why did these things always happen when certain staff were on duty? When would the postmortem be?
I got on with the necessary tasks. I told the coroner, who seemed little concerned; a postmortem was arranged. The relatives came up, a stolid brother and sister-in-law; I began talking, full of anxiety and remorse and promising a full investigation. I soon realised, however, that they were thinking quite differently. Poor Annie, it was very sad; but she had never had much of a life; perhaps it was all for the best, poor dear; she was probably much better off now; there was no point in making a fuss; they certainly did not want anything in the newspapers. They were not very keen on a postmortem, and were rather upset when they realised that the matter was now out of our hands; the coroner had been informed and the machinery of investigation must go forward.
That evening one of the doctors sidled up to me and said he had been making some enquiries and had discovered that the patient had by some oversight been given a cup of tea and a biscuit before her treatment. (The danger of electroplexy with anaesthesia was that foodstuff might be vomited up and then sucked down the air passages; a rigid rule was therefore enforced that patients must not have anything to eat the morning before they had ECT and that if they had eaten anything, the treatment must be stopped.) I thought of rushing down to the ward there and then and making immediate enquiries, but then refrained because I knew how upset all the staff were already.
Next day, I attended the postmortem. The pathologist was a cheerful fellow, who chatted about cricket and the prospects of partridge shooting while going about his grisly work. He knew the hospital well and did many coroners postmortems. Little unusual was seen until he came to the lungs, which were heavy with fluid. When he cut them open, they showed what to my eye was indubitable food material in the air passages. However, the pathologist merely said, Some terminal oedema, and turned to the heart. He commented on its flabby state and continued his search. When nothing further emerged he said, Well, nothing very definite, is there, doctor? Still I think theres enough in that heart. Well say acute heart failure with subsequent pulmonary oedema. I think that should satisfy everyone.
That night, I pondered long. I had no doubt in my own mind that the patient had died because she had inhaled food contents and that if she had not had tea and biscuits that morning, or if her treatment had been cancelled when this was known, she would now be alive; I was certain that the ward staff, the nurses and doctors, had been careless. I also felt that if I had been more competent when I was called in, I might have saved her life. But what was to be done now? The patient was dead; we could not help her now. The relatives wanted as little fuss as possible. The pathologist either had not seen the cause of her death, or worse, had seen it, realised the possible consequences of drawing attention to it, and had decided to keep silent; perhaps (horrid thought) he was accustomed to incidents like this at Fulbourn Hospital. Should I hold an Enquiry and harry the staff? But the coroner was going to do that anyway. I finally decided to await the inquest, but determined to take steps to see that such a thing never happened again.
The inquest was brief and uneventful. It was held in a room in the hospital and apart from the patients brother and a sleepy reporter, all present were hospital staff or officials of the Court. The expected evidence was given. The coroner, a friendly local solicitor, found a verdict of misadventure and commented that this was one of those things that happened in the best of hospitals and that he was satisfied that no one was to blame. The crisis was over; there had been no public scandal.
But now I had to concentrate on preventing any further tragedies of this kind. My first impulse was to descend on the ward, cross-question everybody, possibly sack someone and then issue written orders that patients must not have food before ECT. But then I stopped and thought. Everyone knew this before yet they had allowed it to happen. Writing orders was apparently of little value. Was it an individual failing? But the people at the Admission Villa were regarded as some of the best staff in the hospital; we had no chance of getting any better! My task was to help them to do a better job next time. I thought of interviewing everyone individually and telling them off. But then I remembered that this, from what they said of him, was precisely what my predecessor had done. Always after an inquest, Dr Thomas used to go round all the wards questioning everybody, they said with a laugh. It appeared that this had upset everyone and made them irritated with him, without doing much to improve things. I decided to try and find a positive rather than a negative solution to this crisis.
A week later, when everyone was calmer, I called a doctors meeting and said that I thought we should all discuss this episode openly, since we had all been thinking about it, and that maybe we could evolve a better ECT procedure. A very lively and positive discussion developed. First, we discussed the actual incident and pooled our knowledge. We agreed that whatever the coroner might have said death was due to food material going down the air passages. We discussed whether we could have done better first aid and I was told that several requests for suction apparatus had been turned down on grounds of economy. Several doctors contributed tales of patients that they had lost (or saved) in similar crises; I told a tale of a patient I had lost; a warm group feeling of shared catharsis and confession developed. Practical suggestions soon emerged. Two of the doctors volunteered to write some formal ECT instructions for all staff. I undertook to get the suction apparatus; and by making a great fuss, I obtained it within two weeks. We decided to carry on with medical meetings, since they were so valuable. This was the beginning of clinical meetings at the hospital.
Some time later, I discussed the whole incident with the Matron; the nurse in charge of the ward on that day had been unqualified and possibly did not realise the danger of allowing the patient tea and biscuits. The Matron suggested that we confine ECT to certain days and she said she would see that adequate trained staff were present. I agreed gratefully.
Towards the end of my first month came two major hurdles the annual visit of the Commissioners of the Board of Control and my first meeting with the full Managment Committee. Everyone else in the hospital seemed to regard these as very important events. Endless myths had gathered around the yearly Board of Control inspection. Fulbourn, like every other mental hospital, had many tales of the day the Commissioners came. Some of this I had met in other hospitals, but I now experienced the full blast of communal anxiety when I mentioned that I had had a little note saying that the Commissioners would be coming in a few weeks.
Alarm and scurry was apparent everywhere. Miss Brock related all the things the Commissioners had seen and commented on last time, which had not yet been put right. Mr Tucker said he would check all the drug cupboards at once, and asked whether we had better lock up Jack whom I had just freed as it was he who cut his throat the previous year when the Commissioners were visiting. Even Mr Mitchells department sprang into activity, producing masses of statistics and depositing on my desk a vast leather-bound volume, containing the reports of previous visiting Commissioners. All sorts of curious lists were produced for my inspection all the foreign-born patients by name, all those who had ever had a Police conviction, the number of broken bones during the year, the number of people placed in seclusion, the number of escapes and each time I was told that the Commissioners always ask for this. I was taken to see all sorts of things and places in which Commissioners had expressed an interest at one time or another; I was taken into departments and workshops that I had never yet seen and I was led to much that was squalid and inadequate, especially plumbing. I went round the hospital again and again, looking at lavatories (shabby and smelly), bathrooms (steamy and rusty), drug cupboards (containing hoarded sugar, nurses purses, bunches of keys and everything except drugs) and kitchens (with battered plates swilling in lukewarm greasy water in chipped basins). I spent all one evening reading back through the reports of the Commissioners. They were exhaustive they seemed to have looked at everything and usually commented unfavourably. I felt that they could not fail to be dissatisfied with what they saw of the hospital and its new Superintendent.
In the last few days the tension mounted steadily higher. Wards and windows were washed and polished; patients appeared in new clothes; flowers appeared in the wards, and even picture magazines. The paranoid patients served notice that they wanted interviews in private with the Commissioners.
Fortified by an adequate sedative the night before, I faced the morning of the visit, with all the necessary lists piled on my desk. At a leisurely hour, two elderly gentlemen arrived at the front door by taxi. Instead of rushing to business forthwith, they settled into my office to savour the coffee and biscuits provided. Waving aside the proferred lists, they asked me how I was getting on; they told funny stories about Dr Thomas; they enquired about the local crops, the prospects for shooting that season, and the local medical gossip. Not until an hour had passed did they decide to go and look at the wards.
As we went round, however, I realised that their lethargy was only apparent. Their questions were shrewd and their enquiries were pressed. They looked into lavatories, drug cupboards and kitchens; they talked with patients, they tasted the lunch, they went to the workshops. They gave long private interviews to the paranoids. They questioned Mr Mitchell at length about the recent administrative rearrangements. Then, to my surprise, they invited me out to dinner that evening.
We had an excellent dinner at a good hotel; they told me many tales of the Lunacy Service and of great personalities from the past, and they drew me out about myself. The next day was pleasant and relaxed, and one of them spent a good deal of time advising me on the garden I was just starting. He also gave me a short list of hospitals which I might profitably visit.
That afternoon they wrote their report, a critical but fair assessment of the hospital, with a warm and friendly reference to myself. It was a better report than for several years and I was delighted. I went round the hospital and thanked the members of staff for all that they had done.
I had survived the visit by the Board of Control and now the week was to end with my first meeting with the full Hospital Management Committee. Although I had already met a number of members, I had yet to see them all together, and again the staff attitudes prepared me for an ordeal. On almost everything, it seemed, the final damper was the HMC: Well, wed like to, but the Committee wont allow it, or Its been like that for years, but the Committee always refused to mend/repaint/replace/improve it.
After lunch, we went into the Board Room and some fifteen members arranged themselves round the big table with Mrs Adrian at the head, Mr Mitchell at her right hand, and myself on her left. The other officers, Mr Merrin, the Engineer, the Supplies Officer and the Finance Officer, sat at a little table by the window; a clerk sat in one corner, and a press reporter in another. Every person had a pile of papers before them.
Much of the business seemed to consist of going through minutes of previous meetings and of subcommittees. In each case they would be lengthily introduced and then discussed in a rambling, irrelevant fashion. There seemed to be a good deal of irritability in the room and gradually various characters defined themselves by their frequent interjections. There was a tiny white-haired woman with a fierce authoritative voice, who was sharp in her condemnations; her remarks nearly always drew rumblings from a very fat man, whose bright red face seemed on the point of apoplexy. Mr Boyle was often on his feet, explaining a point so as to obfuscate it further. This particularly irritated a tall woman with the precise tones of an academic, who often corrected him. Mrs Adrian, using a gavel, did her best to maintain order among this strange group, and the business slowly progressed.
Most of the members of the HMC were elderly in their sixties and seventies but a few were younger, like Major Symonds. I noticed one tall young woman, Mrs Pauline Burnet; Mrs Adrian said she had just recruited her to mental health work. She appeared cheerful and friendly. I did not guess how long we would work together.
The Committees concerns seemed to be material and financial buildings and their maintenance, fields and their rents, clothing and its repair, food supplies and their cooking. The Committee seemed to me at that time to take little account of the treatment and welfare of the patients, which I saw as the only reason for any of us being there. They took the news of a number of deaths of patients and the inquest with equanimity, but when it was announced that swine fever had broken out in the pig herd, they were deeply concerned. A long discussion ensued with much heat; I found it difficult to follow as the accents of the speakers were so broad; a lean grey-faced man in old-fashioned clothing with a broad gold watch chain across his waistcoat was criticising another red-faced man who hotly defended his policies, while the apoplectic member constantly interjected remarks in a broad North Country accent.
It was clear that something had gone wrong and that everyone was keen to pin down or to evade responsibility for it. The members frequently directed questions at the officers, but spoke little to me after my initial official welcome until the very end, when several asked about things they had seen or heard that morning. I answered these questions smartly and brightly and was pleased to win a ripple of laughter but not so pleased when I saw the remarks in cold print the following evening in the local paper!
I went home to London that weekend much relieved. I felt that I had survived two major tests and done fairly well. I felt that I now knew the hospital and could see some prospect of doing this terrifying job.
|| Home | What's new | | Psychoanalytic Writings | Psychotherapy Service | Email Forums and Groups | Process Press | Links ||