Against the Tide

by Noël Browne

  SIDE by side with my political life, with all its uncertainties, I had to consider the question of my medical career. Tuberculosis was no longer a disease of significance in the Republic, and those of us who worked in sanatoria necessarily became redundant. The inadequacy of our personal financial position now became both frightening and precarious. Throughout the years during which I had worked in Ireland, it was correctly assumed by my employers that I was content to work for nothing in the care of those suffering from pulmonary tuberculosis. On principle I would not take private patients. Yet although I had completed my postgraduate years of study in two famous English chest hospitals, both before and following my period as Minister for Health I found it impossible to get work in tuberculosis in Ireland in any hospitals other than Newcastle, which was a small voluntary hospital.

  It was now imperative that I commence to train in a new and different speciality. The Marine Port and General Dock Workers’ Union had offered to accept me as a general practitioner within their trade union service. Once again, with regret, I declined, because neither Phyllis nor I believed that we should work within the ‘fee for service’ form of medical practice inseparable from private medicine in Ireland.

  It was clear that the only other form of medical practice for which there was a considerable state sector in Ireland providing for the non-paying poor patient was in psychiatric medicine. In my late forties, I returned to university to begin life again as a student. Following over eight years of study and work in the most menial of medical posts I finally qualified with a Diploma of Psychological Medicine and membership of the Royal College of Psychiatrists. Once again I was qualified to work in medicine, and was appointed as consultant psychiatrist to the Eastern Health Board in 1972.

  The years of training were to be particularly lean ones for myself and my family. The small lump sum of money given to us following the final closure of Newcastle Sanatorium was completely absorbed in my own studies at university and the maintenance of my family.

  On hearing about the impending closure of the sanatorium our bank manager foreclosed on a loan of £800 with which we had bought the semi-derelict house in Bray in which we lived. With no money and no credit, and with all our furniture on the lorry of our kind neighbour Mr Costelloe, we limped off to occupy a condemned two-room national school. It had neither running water nor sanitary facilities, and the roof was riddled with woodworm. Worse still, we did not have the £300 needed to pay the caretaker to whom the school had been given by its former owners. By some kindly sleight-of-hand our sympathetic solicitor made some loan arrangement with the owner, who himself at one time had been under my care. With Phyllis, Ruth and Susan, I began to make a home in that derelict outhouse.

  With moving and unselfish generosity, a number of craftsmen friends of ours from the Newcastle area combined to make the place habitable. Sitting around a fire of scrap garden timber, the concrete blocks, baulks of timber and barrows of cement crisscrossed between us, we drank our tea in our primitive sitting-room. Windows, doors, gutters, slates, all bought by myself and carted home, came from scrapyards around Dublin. Our half-glass front door had once opened into the ancient Apothecary’s Hall in Holles Street. The insignia was faintly etched on the glass, making an elegant entrance to our new home.

  I now began a long and searingly painful training in the tragic environment of our grim and cheerless mental hospitals. I attended lectures and courses, but needed in addition long periods of residential hospital training at the level of house physician. This poorly-paid, much exploited and shamefully overworked job I had last left behind me nearly twenty-five years earlier. The transition from Minister for Health to house physician was in itself a considerable shock for myself and my family.

  Knowing that it was reputed to be the hospital with the highest standard of mental care for its patients, I first called on Dr Norman Moore at St Patrick’s. Dr Moore gave me to understand that he had no work for me but would help me to get work in England, but I declined his offer. Work in an English mental hospital at that time was easily found, but we had no intention, if it could be avoided at all, of being driven out of Ireland.

  My medical colleagues of all denominations made it clear that no matter what my qualifications, they would not permit me to practice medicine in Ireland again at any level. I was even rejected as unfit for one job whose only responsibility was to distinguish between the abnormal and normal chest X-ray picture, work at which I had spent all my medical life; instead a former student of mine was appointed.

  The ugly peculiarity about a boycott is the measure of moral cowardice which it induces. Individual value judgements are suspended. An uncritical consensus takes over. Without doubt there were clerics, doctors, politicians and others who, though silently in sympathy, were too fearful of the boycott to protest openly against the injustice to myself or my family. There is no self-pity in this assessment — I had well known what would be the consequences of my actions for myself. Phyllis and I had no regrets, except for our children, who were innocent of having inflicted hurt on anyone. Ruth and Susan were refused admission to a number of schools, both Roman Catholic and Protestant. Ruth was told that because she lacked artistic talent, she must leave the National College of Art. Within weeks of leaving, she had won first prize in the national Caltex competition, in which there were twenty-two thousand other competitors, and second prize in another.

  During the period of greatest hostility to us, I sat waiting to have my hair cut in Prost’s hairdressers in Stephen’s Green. Nearby sat a well-known Dublin anaesthetist Dr Tom Gilmartin, a friend of ours whom we had last met at a diplomatic cocktail party at the Italian Embassy while I was Minister for Health. There we had held the usual animated and friendly conversation. On this occasion, however, he leaned furtively across to me, momentarily grasped me by the shoulder and gave it a sympathetic squeeze. Without uttering a word, he passed on to his waiting chair. A kindly man, no doubt, he was sorry for me, but at the same time unwilling to be seen saying so.

  Finally, as my last hope, I went to see the RMS at St Brendan’s Hospital. The last occasion on which I had visited Dr John Dunne had been in my capacity as Minister for Health. Dr Dunne received me again with the same courtesy and anxiety to help. We were now two medical consultants meeting on equal terms, and he was puzzled at the reason for my visit. He was understandably shocked to hear me ask for a job as one of his house physicians, but he quickly recovered his aplomb. A vacancy was available, and I got the job in January 1964. I hurried to tell Phyllis that we had reason to hope again. Shortly afterwards I suffered my fifth relapse with tuberculosis, and once again was put out of action with no pay.

  St Brendan’s may be all the fearful things which it is claimed to be at regular intervals in the national press. Yet there is another way of looking at it. For the aspirant consultant psychiatrist in his late forties with little time or money, St Brendan’s is an encyclopedia of human distress in every possible form and point of development. A weekend duty there was a truly educational yet wounding exposure to intense mass suffering. Of much interest to me too was the effect of that suffering on others, in particular the response of the so-called normal population to that collective despair.

  Never before had I heard such a varied litany of adult cries for help which came to me over my house telephone. How useless I felt! These calls went on for most of the day, through the weekend, and much of it at night. A man had broken a window and tried to hang himself from the window bars. A high security ward patient had escaped in his pyjamas with an open razor, and was threatening the staff in the hospital grounds. A deeply depressed young girl had broken glass and cut her wrists. A patient had taken an overdose and was unconscious. There was word of an old lady wandering the streets, talking to herself, at three in the morning. There was a drunken singing pub visitor, suffering from an overdose of alcohol, who needed a bed for the night. A woman patient had barricaded herself behind the sturdy mahogany hospital furniture, and was bombarding the
staff with flower pots; could she be given 10 ccs. of chloral hydrate — the usual knock-out drops of that time?

  Much later on I was told what such a procedure entailed. A young girl told me of her terror when faced with this injection. Following a misunderstanding, she had been shocked, frightened and confused. The female nurses, either intent on making an example of the recalcitrant patient, or simply fearful of getting hurt by her, usually called in the male nurses to help them. When all was ready, armed with loaded syringe, they formed a wall of white coated nurses, a threatening sight. Like a cavalry charge they advanced in line to fall on and physically subdue the victim. They then sank the needle into the victim’s thigh. Its effect was total swift oblivion. It is difficult to believe that it is not as distasteful a job for nurses as for the patient.

  Though being woken by telephone at night to get up and admit someone could never be pleasant, I rarely walked across from the residency to the admission block in driving rain or under a summer moon without a sense of the privilege of my medical calling. On behalf of the people I had been entrusted with responsibility to care for, even if inadequately, the rejects from society. Some had been turned out of their own homes; as ‘mental patients’ they had been turned away from every other hospital and home in the city. They came to me at any hour of the day or night; we could not give them much but we would not turn them away.

  Having chosen to study the problem of mental illness in Ireland, I hoped to understand its social origins and implications. As with tuberculosis, the mentally ill predominantly are members of the poorest social class, the victims of job insecurity, over-crowding, poor housing, over-large families. I had no idea of the infinite canvas of distress that would unfold before me in the years ahead. The one doubtful virtue of mental illness over tuberculosis was that you could die of tuberculosis. With mental illness, though desperately wanting to, you need not die. With a restless mind that cannot find comfort or rest, to know that you are not going to die is often the greatest source of distress for man or woman. In addition, the effect of mental illness seems to be all-pervasive, involving thousands rather than hundreds. Mental ‘disease’ is impossible to categorise as a series of predictable signs and symptoms. The population of a mental hospital reflects the hidden-away, private agony of thousands. They are either under sedation and asleep, or nearly asleep, or restlessly awake and inconsolable. Some, heavily doped for the rest of their lives, bide their time in the benevolent jails we call mental hospitals until their release in death. There is a tacit conspiracy between psychiatrists and the public to imprison without public trial, for months, years, sometimes even for life, our dissident social nonconformists, the misfits or the inconsolably miserable. For the most part they are there simply because we, the ‘normal’ population, can no longer tolerate their distress, of much of which distress we are the cause.

  My introduction to the mental hospital service came at the end of the era of repressive custodial care for the mentally disturbed, following the introduction of powerful new ‘mood changing’ drugs. Before this, the nurse in a mental hospital was called a ‘keeper’. He was dressed in a policeman’s style uniform and carried a thick stick. This was the period of brute physical restraint of the patient in the padded cell, naked, wild-eyed, clothes ripped, squatting in scattered food and filth. For the most intractable there was also the unthinkable awfulness of the straitjacket. The new drugs stupefied their victim into an inert conformity, creating the effect of a ‘no touch’ benevolent straitjacket. By their means human beings were transmuted to non-resisting, remote, mindless automatons.

  Within the main hospital at St Brendan’s there was the desolate ‘hospital’ sector, a special unit in which passive dummies lay under heavy sedation, a long line of misery-ridden human beings who already unsuccessfully had tried to end their tragic lives by suicide and if given a chance would try once again. It was sufficient simply for the doctor across the telephone to command that a patient ‘be put on the line’. There was an aura of congealed misery hanging over that line of silent men and women, linked by their common despair and the will and intention to kill themselves. No flowers, no books, no photos, simply a reluctant resignation to the agony of living.

  It was to this ill-lit Dickensian hospital that one night I was called out of an exhausted sleep to the real-life nightmare of a middle-aged man who simply wanted to die. He refused to eat in the hope that, no matter how painfully in the end, he could die. He had nothing and no one left for whom or which he wished to live.

  The procedure was, that I, the lowly house physician, on the orders of my consultant psychiatrist, would force-feed him. A non-violent man of peace, I would have found it easier to have shot him. I had to ram a semi-rigid inch thick rubber tube down his throat into his oesophagus and stomach. Meanwhile two silent purposeful nurses, suffering no doubt my own sense of revulsion, held our victim by his shoulders, his body, head and neck forcibly thrown back. Revolted at the prospect of so mauling a fellow human being and subjecting him to such humiliation, my face must have disclosed my feelings. A sympathetic experienced nurse who, no doubt, had had to become hardened to such experiences, intervened to release me from my ordeal. Briskly and expertly he passed the tube down into the stomach. A great white enamel funnel was put into the end of the tube, and down through this was slowly poured a cement-coloured mix of gruel, designed to keep that wretched man alive. It seems that one other purpose of force feeding is the intimidating crude deterrent of fear. But do the victims not resolve that at the earliest opportunity, ‘cured of their depression’, they will leave the hospital so that alone in peace and with dignity, they will kill themselves?

  Yet another treatment procedure comparable in repulsiveness was the use of electric shock so as to alter an individual’s vision of his unhappy life. To the end of my days in psychiatry I could not accept that an electric shock would transform the parent mourning for a dead child, or the spouse for a lost partner, from being deeply depressed to being the classic ‘happy man’. To me it was wholly reminiscent of the many futile, sometimes dangerous, procedures used in desperation by us in the 1930s to save the life of the dying consumptive.

  The procedure was carried out in a long, low-ceilinged, barn-like ward, divided into a waiting space and a smaller operating centre. My job as house physician was to provide a completely purposeless ritual presence. I would stand at the head of the patient as he was anaesthetised and then apply an electric terminal to each side of the sleeping patient’s skull. It was the anaesthetist’s job to apply a plier-like instrument, so as to force open the mouth, into which he inserted a thick rubber biting pad. A series of standard shocks was then applied through the terminals. The effect on the sleeping body was both disturbing and repellent to watch; the whole body sprang into a tense involuntary series of jerking spasms. Meanwhile the patient was forcibly held down, to avoid self-injury, by an attendant nurse. The patient was revived with oxygen inhalations, then wheeled out. Later, as consultant psychiatrist, under no circumstances would I submit a patient to that procedure. What is more, I found that they had no need for it. The unexplained rationale of the procedure was much too reminiscent of the use of cupping, blood-letting and the application of leeches.

  The anaesthetist I worked with was Dr Gilmartin, the same man who could not resist the sympathetic pat on the shoulder in the barber’s shop. Through those long afternoons, with their hours of waiting and watching, we discussed every conceivable aspect of life, society and medical practice in the Republic. One afternoon he went on to express radical opinions about the ideal organisation of medical practice in an enlightened society, ideas with which I could agree. Suddenly, aware of the dangerous talk of which he had just been guilty, he concluded abruptly, ‘I must give up that kind of thing. If I were to express those kind of ideas publicly and freely I would soon find myself like you, on the outside in our profession, doing a boring badly-paid purposeless job, such as yours. I wouldn’t like that’.

  I came to know w
ell the many faces of that great hospital, its out-patient clinics, the over-crowded wards, the bare pictureless walls, the narrow-fretted prison windows, the uncarpeted floors, the absence of colour or flowers except in the show-piece admission unit. In the back wards the grey-suited, sallow-skinned, tired yet restless men and women padded around and around like prisoners in an unending circular death march to nowhere. Then there were the wards for the aged, row after row of neatly packaged humanity, for the most part unwanted at home by their ‘loved ones’. Yet another side of the ‘closely-knit’ Irish family was represented by the featureless, cattle-penned wards for the recalcitrant young, the once well-loved but now misunderstood, rebellious and unwanted adolescents, all victims of broken family relationships. What went wrong after that glad newspaper birth notice, ‘the gift of a child’? Who was to blame? Within all this for me was my own equivocal custodial healing role as jailer/physician. It was my unenviable job to untangle the complex vortex of emotions that had engulfed the tormented victims of these disturbed relationships.

  For over a century we doctors have manned our mental hospitals. Over these years, each of us in our different communities has structured and moulded our mental hospitals according to our cultural ethos to serve the needs of our communities. In western societies the recent use of the Thymoleptics mind-moulding drugs has rescued us from the ugly violence of bedlam. In contrast to our own uncaring concern for the aged in their homes, county homes and mental hospitals, I recall the brightly decorated and furnished old persons’ flats which I visited while Minister for Health in ‘godless’ Sweden. We have such homes here in Ireland too, but as with so much else in our society they are reserved for that privileged few who can pay.

  In mental illness diagnosis and treatment are both culturally determined, varying in time, place and community. Does this variety in both diagnosis and treatment not establish the age-old truth in medical practice? Where there are many cures, we know there is none. For the most part the mental hospital service is that great black rarely-upturned flat stone lying at the heart of every modern society, under which no one readily cares to look or, once looking, lingers over for long.