by Ian Wheeler
It is no secret that padded rooms were a feature of asylum life and there were occasions when patients had to be confined for their own safety or that of others. However, this was uncommon and precise routines and records had to be kept if a padded room or other form of restraint was used. Also, an attendant was always present, usually outside the open door unless the patient was particularly violent. The Commissioners would comment favourably if there had been no cause to use either ‘seclusion’ or restraint. These were generally a last resort since sedatives – albeit primitive opiates such as laudanum, or paraldehyde – were often helpful.
It is not pleasant to contemplate steel bars in a mental hospital but a number of iron gates were fitted in the corridors in 1923. The reason was entirely based on the occupants’ comfort, since the gates permitted otherwise locked doors to remain open, affording much better circulation of air in hot weather.
Restraint being regarded as a last resort, all instances had to be recorded in this register. (Reproduced by permission of the Berkshire Record Office)
Hygiene
Early records mention the ‘lime-whiting’ or whitewashing of the ward walls – usually because it was overdue. Whitewash has deodorant properties and Dr Gilland evidently thought it an aid to health.
From the outset, baths and hot water were provided – at least while Haden’s heating system was behaving itself – and patients were bathed weekly unless otherwise required. Two baths could sometimes be found in a single bathroom, a state of affairs picked up by the Commissioners as late as 1933, who recommended a screen or curtain for the sake of patients’ dignity. Hair was to be kept clean and brushed. Male patients were shaved twice a week and their hair cut monthly. Men could cultivate their facial hair, provided that the results were tidy; however, no patient was ever allowed to touch either razor or sharp scissors, for fear of disastrous consequences.
Given these words that, in January 1912, flowed from the collective pen of the Commissioners for Lunacy following a tour of inspection, it is impossible not to mention something as fundamental as toilet paper in the context of patient wellbeing:
In the interest of cleanliness, the absence of any soft toilet requisites27 such as are now almost invariably used in asylums is to be regretted.
The informed response from the Visitors, besides advocating thrift, was in some ways positively visionary:
One of the communal washrooms that survived up to closure. (Bill Nicholls)
As the cost of this innovation would be very considerable – about £50 per annum, without any apparent benefit to the patients – we do not see our way to recommend the substitution. There would be great waste from misuse by the patients and the constant temptation to place the rolls of paper down the W.C. pans and block the traps. There has been no anal disease from the use of the ordinary newspaper.
Perhaps, by 11 April 1924, Commissioner R.H. Trevor had recovered from this rebuff when he observed, ‘I notice that only newspaper is supplied in the W.C.s: an uncomfortable practice now obsolete.’
Returning to January 1912, it was recorded that some poorly enamelled washbasins installed in the 1881 extensions were unsightly and unsanitary. Ever thrifty, the Visitors’ response – astonishing to modern sensibilities – was to have the remaining white enamel removed from the metal basins and to continue using them. However, expenditure was authorised in March to replace some badly rusted examples in the Female hospital with modern equipment from the well-known firm of Doulton & Sons. The relatively mundane saga of substandard washbasins, and the ‘sanitary annexes’ in which they were situated, dragged on until well after the Second World War and contributes to the impression that the hospital suffered from lengthy periods when either money, clear direction or initiative were in short supply.
Dentistry
This subject receives little mention. Surprisingly, a March 1925 report by Commissioner Rollisham tells us ‘it was unsatisfactory to find that neither tooth or nail brushes are issued to the wards for the use of any patients who desire to have them’. The July 1948 report brought the good news that ‘A room has been fitted up as a dental surgery adjacent to the Laundry Ward’, balanced by this slightly barbed observation:
At present the dentist attends on one half day each fortnight only. We think however that the former weekly sessions should be re-introduced, and until the arrears are overtaken even more frequent visits are desirable.
Physical Disease
The physical wellbeing of patients was quite as important as their mental condition and this consideration extended to the nursing staff, who were vulnerable to dangerous diseases in this densely populated and closed environment.
On 19 November 1886, Acting Superintendent Barron reported that, since the heating had been turned on for winter, there had been outbreaks of unusual illnesses including erysipelas (a severe and potentially fatal skin infection that can follow ‘strep throat’ or an infected wound). Sufferers were confined to the isolation hospital28 and, in December, Barron saw that they were on the mend. A further five cases developed the next January, when very cold weather again confined patients to the wards. Although they were again cured, there is no record of the treatment actually used: nothing as convenient or effective as penicillin existed at that time.
March 1887 saw the first monthly report of Superintendent J. Harrington Douty, who noted that both the Male and Female hospitals (meaning the infirmary wards) were very full, but with what he considered to be unextraordinary cases, ‘chiefly pneumonic’ and calling for no special notice. But he also had to record the death from pneumonia of male attendant Philip Hardy, who had probably been infected in the course of his work. The unfortunate Hardy was buried in Cholsey churchyard and his colleagues subscribed a total of £8 to purchase a headstone.
Influenza was a danger to a closed community like the BMH, especially in the lethal 1918–20 pandemic. Happily, outbreaks were usually short-lived and without fatalities. Perhaps more worrying were the likes of scarlet fever and diphtheria. In June 1887, Douty had to cope with an outbreak of scarlet fever and succeeded in isolating it in Female 8. Nevertheless, additional staffing was needed, which stretched the system to its limit. As his staff responded well, he requested handsome gratuities of 10s for both of the volunteer nurses who assisted in the isolation ward. Another outbreak in 1909 was introduced on a doll, brought by family members as a gift to an 11-year-old asylum patient. En route, the family had visited a baby with the disease, who must have handled the doll.
A 1939 report tells us that, owing to a diphtheria outbreak that had lasted all year and affected nurses, Schick testing had been carried out and ‘positives’ immunised, but that throat and nasal swabbing was impossible in the continued absence of a pathology laboratory. Testing was still not regularly available at the hospital, being carried out either in Reading or Oxford.
Taking a random example, the Commissioners found that, of 779 patients resident in October 1923, only sixty-six were in bed: thirty-four receiving psychiatric treatment; twenty with senile debility and twelve for ‘ordinary sickness … a condition that speaks well for the general health of the institution, which seemed to me very good.’
Thankfully, smallpox does not seem to have affected the hospital.
Medicinal Alcohol
Sensitive readers, already reeling from the above-mentioned account of beer prices, may wish to brace themselves before learning that August 1887 brought an initiative from Superintendent Douty to reduce the asylum’s outlay on spirituous liquors for medicinal purposes. He asked the Visitors if he might be allowed to administer Scotch whiskey at 19s per gallon, instead of brandy at 24s per gallon!
Enteric Diseases
Typhoid, diarrhoea, enteric fever and dysentery cropped up periodically, sometimes confined to particular areas, sometimes widespread. At various times from 1874, well and borehole water was tested and found blameless, although a shallow well was condemned in 1889. Faults in the drains, soil pipes, water closets, etc. were rep
aired. Suspicion then fell on the sewage beds – especially when relatively close to the affected parts of the hospital – and only farmyard dung was to be used for gardens, while vegetable growing in the sewage-fed gardens was banned for three years with no benefit. New sewage beds were created close to the river by Messrs Bailey & Denton, sanitary engineers. Disease ‘carriers’ were implicated and floors lifted to disinfect the soil beneath, but staff members as well as patients suffered and died. Other asylums were also affected, although not as badly as the Berkshire Lunatic Asylum. Laundry practices may have been partly responsible, as related in Chapter 3.
Enteric diseases remained a worry. The BRO holds a lengthy report that relates outbreaks of enteric diseases to the asylum’s sanitary arrangements and extensive measures to prevent infection. There was a trouble-free period in the 1920s and 1930s, followed by a series of outbreaks beginning with paratyphoid fever in September 1941. The water and milk were scrutinised ‘but neither … is likely to be the source of the present infection, as the outbreak is confined to one female ward, Ward 6’. Immunisation was undertaken, plus a search for carriers in Female 6 and the kitchens. Meanwhile, all drinking water was boiled. The outbreak lasted through the autumn and re-appeared in April 1942, spreading to the Male side with a total of thirteen cases. Meanwhile, Sonne dysentery appeared in March 1942 and spread from Female to Male, totalling forty cases. The outbreaks were brought under control soon after.
Two active carriers of typhoid were found in Male 4 in 1944 but precautions proved effective and just one case in 1945 caused all the staff and admissions patients to be inoculated.
After a trouble-free interval, 103 male and 338 female cases of dysentery ruined the winter of 1947–48. Sulpha drugs were administered and only two cases remained as the NHS era dawned in July 1948. The outbreak was traced to a male carrier who had been cleaning kitchen utensils. The entire hospital population was screened via the Public Health Laboratory in Oxford.
Tuberculosis was present from the asylum’s earliest days and there seemed always to be at least a few cases – often more per capita than in comparable institutions. Although commendable figures were achieved through the 1920s and 1930s (10 cases in nineteen months, recorded in 1923), 1942 saw 12 cases per 1,000 against the national average of 11.3, although the death rate of 8 per 1,000 was below the national figure of 8.7. There were twelve deaths in the reporting period. This revived an apparently endless campaign to acquire X-ray equipment and verandahs where patients could be treated in the fresh air (see here):
The Public Health Service of Oxford under Professor Wilson continues to render very important aid to the hospital in dealing with its infectious diseases. It is hoped that in the near future micro-radiography for the early diagnosis of pulmonary tuberculosis may become available; meanwhile chest radiography is done at the Royal Berkshire Hospital, and the examination of sputum is carried out in the small pathological laboratory … made by the adaptation of a staff bedroom off Male 2 ward.
The disease remained troublesome, increasing as the hospital came under NHS control. The County TB Officer was a frequent visitor but there was neither X-ray equipment nor chest physician until 1950. The Bungalow was again in use as a TB sanatorium in 1957.
Fresh Air
The beneficial effects of fresh air, notably for cases of tuberculosis – or phthisis, as it was then known – were understood and had frequently been advocated since about 1912. The absence of verandahs was a sore point for decades, starting in that year, when the Visitors and medical staff hoped that open-air treatment could commence; there were plans for a lean-to shelter alongside the external corridor serving Female 8 but none for the Male side. That July, a shelter was approved by 5 votes to 3 but a glass roof over it was rejected by 5 votes to 4, sanctioning only a slate one. It was November before the Lunacy Commissioners themselves authorised an outdoor shelter in the Female airing court, but even this was deferred for six months and never materialised.
The long-awaited c.1930 verandah on the rear of Male 8 (Hermitage) ward. This and an equivalent on Female 8 (Ipsden) are clearly shown on a 1936 Ordnance Survey map. (Spackman collection)
April 1924 dawned with the lament, ‘There are no verandahs or other facilities for nursing suitable cases in the open air.’ Prevarication finally gave way to stern demands by the end of 1927, when Female 8 dormitory at last acquired a balcony on its south-east side. Harking back to earlier reluctance to spend money on doing the job properly, the Commissioners observed: ‘When a glazed roof is added, it will make an excellent verandah.’ The imminent arrival of an equivalent on Male 8 in May 1929 (first reported as being in use in March 1931) suggests that the investment proved worthwhile. However, the subject recurred in 1947 and 1948, when there were twenty cases of TB crowded into the ‘F6 sick dormitory’ for want of a verandah, and again in 1954 when there was apparently still no Female verandah.29
Interventional Psychiatric Therapy
A history of its development is not in the scope of this book but, in the simplest terms, interventional treatment – as distinct from mere sedation – required facilities, skilled personnel and, when appropriate, specialised drugs.
In 1926 there was mention of eleven deaths from general paralysis (neurosyphilis) and a query as to whether arrangements could not be made for ‘pyrescial’ (fever-related) treatment of this disease at a suitably equipped hospital, by the proven method of induced malaria. General paralysis, schizophrenia and depression could be relieved by infecting the patient with the malaria parasite or, from about 1930, by means of cardiazol shock or insulin coma therapy, which induced convulsions and coma. The procedures were not without risk but were undertaken at the BMH. By 1939, three doctors supported the superintendent in such matters but they still lacked a treatment area; consequently these alarming treatments might be administered in the wards, albeit behind screens.
‘Electric shock treatment still gives satisfaction for cases of depression, but cardiazol is favoured for the treatment of schizophrenia. Epanation (meaning trephination or trepanning) is proving satisfactory in the treatment of epilepsy.’ (1941)
Electro-convulsive Therapy
Appearing in about 1940, electro-convulsive therapy (ECT) was considered less traumatic and more convenient, although it was still used alongside modified insulin shock therapy in at least 1947. The patient’s convulsions could result in broken bones and ECT’s reputation flagged until new muscle relaxants and sedatives were available to prevent injuries. It remains in use but has largely been supplanted by effective drugs.
Student Nurse Einar Haukland works in the ECT Treatment Clinic of the George Schuster Hospital. (Spackman collection)
Carmel Parkinson and Einar Haukland preparing ECT equipment in the Schuster in 1972. (Spackman collection)
A posed illustration of ECT in the early 1960s, taken in the George Schuster Hospital. (Spackman collection)
Brain Surgery
No information has been found about trephination at the BMH, except that it was thought to be effective for epilepsy. From 1948, some surgical procedures were carried out in the new operating theatre, including pre-frontal lobotomy (leucotomy). More complex procedures were still carried out at the Royal Berkshire Hospital or the Oxford’s Radcliffe Infirmary. Although often successful, direct brain surgery carried risks of serious collateral damage and this procedure was also largely superseded by drugs. The last operation was carried out in about 1955, after which the theatre was adapted for other uses.
Therapeutic Drugs
This account cannot do justice to the development of drugs that were of value in psychiatric disease. Little enough was available around 1900, other than sedatives such as bromides, laudanum, morphine, hyoscine, chloral hydrate and paraldehyde. The early barbiturates appeared from 1904, serving as sedatives and anticonvulsants. Chlorpromazine (Largactil), an anti-psychotic, made an enormous impact in the 1950s, along with phenobarbitol, a barbiturate anti-convulsant. By 1960 the Commissioners were abl
e to observe the striking tranquillity of the patients, not least because diazepam (Valium) and antidepressants had further advanced the cause of cure as opposed to containment. Such progress reduced the pressure on hospital accommodation and facilitated ‘care in the community’ approaches. There are those who remain unconvinced that this is a valid strategy but at least the spectre of long-term confinement is thankfully fading as medication hastens the demise of the traditional mental hospital.
In this posed shot, the injection is administered by Momena Wright, who later held a senior administrative position. (Spackman collection)
Readers may care to look up an excellent account of earlier treatment methods, compiled by Epsom & Ewell History Explorer, which at the time of writing can be found at www.ezitis.myzen.co.uk/briefhistorytreatments.html.
7
TWO WORLD WARS
The traumatic events of 1914–18 and 1939–45 influenced the fortunes and functioning of the BMH, although not always directly; shell-shocked and traumatised servicemen, for example, do not seem to have figured large in the story. More to the point were the knock-on effects of military requirements, shortages and the inevitable shifts in the nation’s scale of priorities.
Specific information from the Great War period is scarce, especially while patient records remain closed. The BRO does, however, inform us that a number of the nation’s asylums were taken over for military use, displacing large numbers of patients to other facilities. We hear that the Sussex County Asylum had to transfer patients to the BMH, which also took in a small number of German prisoners of war, although it otherwise saw little change in its fortunes except in staffing. Over the decades, many of the superintendents’ monthly reports highlight the endemic problem of finding enough competent care staff, but male attendants going away to war caused particular concern. Despite rising patient numbers, days of form-filling and every legitimate manoeuvre – including attending local military tribunals in pursuit of exemptions – Superintendent Murdoch was unable to prevent his male contingent being whittled down from thirty-eight to twenty-four by 1916.