Dr John Hopton

Senior Lecturer

School of Nursing.Midwifery and Social Work

University of Manchester

THANK YOU FOR THE KIND PERMISSION TO USE THIS REPORT

In 1921 Montagu Lomax published his book The Experiences of An Asylum Doctor, in which he used his experiences as a locum at Prestwich Hospital to criticize standards of mental health care in Britain. Lomax‘s criticisms of Prestwich Hospital led to a Royal Commission and the 1930 Mental Treatment Act. However, many of the circumstances described by Lomax could still be observed at Prestwich in the 1960s and 1970s. The oral testimony of nurses who worked at Prestwich between 1922 and 1975 and documentary sources are considered in an attempt to explain how a hospital which had been the centre of debates about psychiatric reform in the nineteen-twenties failed to emerge as one of the country’s more progressive psychiatric hospitals.

Introduction This paper is primarily an oral history of nursing within one psychiatric institution, but it raises some important questions which may be pertinent to wider discussions. These include why there was so little progressive change inside the institution until the nineteen seventies despite changing professional and social attitudes; and why extensive changes did finally take place during the 1970s. The study is largely based on oral history interviews with staff who had worked at Prestwich Hospital between the years 1922 and 1975.

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As published in History of Psychiatry, x (1999), pp349-369

∗ The author is grateful to Bob Dunn and Vicki Coppock for their support and helpful comments on an earlier draft of this paper, to David Glenister and Trevor Adams for their encouragement and support, and to the anonymous referees at History of Psychiatry for their constructive comments. Address for correspondence: 64 Peveril Close, Whitefield, Manchester M45 6NR.

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John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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As published in History of Psychiatry, x (1999), pp349-369

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Notes on methodology The oral history interviews were recorded in 1993 and involved twenty-five people with first-hand experience of life at Prestwich Hospital.1 The collective experience of these people stretched back until 1922 and included people still practising clinical nursing at the institution or employed in the affiliated college of nursing in 1993. As a safeguard against inaccuracy only information which was supported by more than one respondent has been considered to be significant. It was unfortunate that only one ex-patient was interviewed, but ethical considerations dictated that it would be inappropriate to approach directly patients still resident at the hospital, and only one ex-patient responded to the requests written to newspapers.

While the sample is small and provides a perspective which is almost exclusively that of hospital staff, this is not dissimilar to the size and composition of samples used in other studies. For example, Glouberman’s account of institutional life in the 1980s was based on lengthy interviews with 60 staff in 27 institutions.2 Similarly, Nolan’s study of the history of British mental health nursing was based on somewhat vaguely defined ‘research, observations and talks with hundreds of people’ associated with an unspecified number of institutions.3 Further, the validity of many of the interviewees’ comments has been confirmed by referring to documentary sources such as Visitors’ Committee Minutes, Reports of the Board of Control and Manchester Regional Hospital Board Minutes.

Prestwich Hospital Prestwich Hospital is situated approximately four miles north of Manchester city centre and was opened in January 1851 as Lancashire’s second County Asylum for mentally distressed paupers and was built because the county’s first asylum at Lancaster could no longer meet the demand. At that time it had 350 beds, but in common with many other Victorian asylums rapidly expanded. Additional accommodation was provided in 1853, 1869, 1874 and 1875, while an 860-bed annexe opened in 1883 bringing the Asylum’s inmate population to 2,300.4, 5 In 1867 a Lunacy Commissioners’ Report referred to the newer wards being ‘extremely good’ in respect of accommodation and the provision of amusements but expressed concern about the condition of other wards and quality of care provided for noisy and violent patients; sentiments which continued to be expressed by hospital staff in later years.6 Further wards were opened at the Main Hospital in 1894, 1895, 1904 and 1913; while in the 1930s there was a programme of demolition and rebuilding which was halted by the Second World War.7 In 1956 the patient population was 3,029 but despite decreasing to 2,101 by 1967, in 1983 it was still the second largest hospital of any kind in Great Britain with 1,478 staffed beds, all of which were for psychiatric patients.8, 9

The Community Care Act of 1990 redefined the boundaries of Prestwich’s catchment

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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area (which had previously included the whole of the City of Salford, parts of the City of Manchester and the town of Prestwich which is the southernmost part of Bury Metropolitan Borough), limiting it to the City of Salford and thereby accelerating the rationalization of services at Prestwich Hospital. In 1990 an eighty-seven-bed unit known as Meadowbrook was opened at Hope Hospital in Salford, thereby re-locating acute services in the centre of the catchment area. By 1996 the majority of long term residents had been returned to their districts of origin, and in April 1994, the hospital and its various ‘satellite’ units became Mental Health Services Salford NHS Trust. In 1996 the Trust comprised 12 community sites in addition to the Meadowbrook and Prestwich sites. In addition to community-based day centres there is a total of 240 beds in community-based sites and 173 beds on what remains of the Prestwich site, much of which has been sold and redeveloped as a supermarket, petrol station, restaurant and hotel. The facilities remaining on the Prestwich site are a 20-bed drug rehabilitation unit, a 24-bed unit for mentally distressed deaf people, a 20-bed adolescent psychiatry unit, a 12-bed secure adolescent psychiatry unit, a 67-bed interim secure psychiatric unit (which may expand to 73 beds) and a 30-bed high-dependency unit.10

The significance of the present study Owing to two key historical events Prestwich Hospital has a special place in the history of psychiatric care in England and Wales. Staff from the institution were instrumental in establishing the National Asylum Workers’ Union in 1910,11 and it was the subject of an influential book about asylum life.12, 13, 14 Montagu Lomax wrote his book, The Experiences of an Asylum Doctor after working at Prestwich as a locum tenens during the First World War. His stated rationale for writing the book was that under the legislation then in force, the psychiatric system for the pauper insane was defective and open to abuse, while the book itself was an indictment of the regime at Prestwich Asylum in particular and psychiatric care in general. He described Prestwich as gloomy, dilapidated, barrack-like and dirty; considered the patients’ clothing and diet to be of poor quality; described the hospital regime as dull and monotonous; and criticized the lack of a system for assessing and categorizing patients according to their needs. He considered that many attendants (nurses) were lazy, vain, unjust, mean and tyrannical but attributed this to long hours, low pay, lack of prospects and generally being treated with contempt by the hospital management.15

The publication of Lomax’s book led to stories in national newspapers, questions in the House of Commons and an internal inquiry to which Lomax himself and the National Asylum Workers’ Union declined to give evidence.16, 17 The inquiry examined evidence from 38 witnesses including 5 inmates, and although the report of this inquiry was generally hostile to Lomax it recommended improvement of diet, the introduction of formal training for nursing staff and improvements in care. However, the Board of Control’s Report for 1923 does suggest that there may have been some validity to Lomax’s claims. Although this report clearly stated that there were no allegations of rough treatment, that patients seemed in good health and that nutrition was ‘satisfactory’,

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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it also made reference to a need to improve arrangements for reception and treatment of new admissions, the poor physical and environmental conditions of some wards, the (albeit limited) use of mechanical restraints and difficulty in recruiting and retaining female staff.18 Thus, while it may have been correct to describe Lomax’s allegations as ‘sensational and exaggerated’, it seems that they may not have been entirely without foundation.19

The internal inquiry which followed the publication of Lomax’s book led to a Royal Commission which published a report dismissing many of Lomax’s allegations but which agreed with his overall recommendation that psychiatry was in need of reform.20 Its specific recommendations included limiting the population of each mental hospital to one thousand patients; permitting only formally qualified specialists in psychiatry to become superintendents of psychiatric hospitals; using seclusion only in clearly defined situations and monitoring its use closely; a review of the quality of food and type of employment for patients; and the development of aftercare facilities for the rehabilitation of patients.

T. W. Harding has written an article which clearly establishes the centrality of Lomax’s revelations to mental health reform.21 Specifically, the publication of Lomax’s book provided the impetus to establish the Royal Commission on Lunacy and Mental Disorder (The Macmillan Commission 1924-1926), which in turn led to the 1930 Mental Treatment Act. However, notwithstanding the influence which Lomax had over mental health reform in general, the similarity between his observations and those of staff who worked at Prestwich from the 1930s through to the 1970s suggests that his observations had less impact on Prestwich itself.

The oppressive institution While there is no shortage of documentary evidence which demonstrates the oppressive potential of psychiatric hospitals,22, 23, 24, 25 systematic studies of the day-to-day routine in individual psychiatric hospitals are comparatively rare, although there are some subjective accounts as well as other oral histories of some of these institutions.26, 27 However, there is an absence of literature which attempts to evaluate the impact which critiques such as those associated with Montagu Lomax, Russell Barton and Erving Goffman have had on policies and practices in the provision of residential mental health care at the level of individual psychiatric institutions.

Within mainstream accounts of institutional psychiatry there is an assumption that human rights abuses in psychiatric hospitals are attributable to the behaviour of deviant individual members of hospital staff (see Masson’s account of other psychiatrists’ responses to Dr Ewen Cameron’s research into the effects of ECT28). Significantly though, one of the least critical historians of mental health services29 observes that inquiries into alleged neglect and/or abuse have usually been instigated by staff who were

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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As published in History of Psychiatry, x (1999), pp349-369

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not fully integrated into the occupational culture of those institutions. This suggests that the abuses uncovered by official inquiries represent practices which had become so institutionalized that those who had been thoroughly socialized into institutional life no longer saw any reason to question them.

This view is supported by much of the evidence collected in the course of this study. For example, nurses recalling the nineteen-thirties spoke of patients walking round and round the airing courts every afternoon regardless of what the weather was like, patients’ clothing being drab and shapeless, wards without any carpets, and all patients eating their meals in one huge dining hail where the sexes were strictly segregated and the cutlery was counted before any of them were allowed to leave. Although there were gradual improvements in ward decor and hospital clothing over the years, it was the mid 1970s before practices such as making patients walk in circles around closed airing courts were abandoned completely.

[The patients] had beautiful dresses and coats but they had horrible shoes and they had horrible underwear. No patient wore a bra; no patient wore any type of foundation garment, and women wore garters and you can imagine what elastic garters can do to one’s legs after a period of time. It was responsible for a lot of varicose veins and they wouldn’t buy any decent shoes or nylon stockings. They were always horrible lisle cotton type stockings by the ton.

Interviewee 60sF1 Female nurse 1963-1969

What I didn’t like was when you saw some of the patients, especially at the Annexe, and they were on the airing court and they had no braces on, no belt on, there were no bootlaces in their boots, and they were wandering round dragging their feet, their hands in their pockets ... I used to think how pathetic [they looked]. But there wasn’t much that you could do about it because there wasn’t the gear. If you asked for anything, [you got] ‘Oh well he’s not worth it.’

Interviewee 60sM2 Male nurse 1963-1967

I can remember on Twos and Threes you had to shave about fifty patients with one razor blade.

Interviewee 70sM3 Male nurse 1972-1982 recalling the early I 970s.

While poor clothing, drab decor, locked wards - and even unhygienic and painful shaving - might be characterized as the inevitable consequences of a lack of resources;

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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consideration of official records reveals that the situation was more complex than that. There is a record of the services of a patients’ dentist being sought as early as 1922;30 a parole system for patients from closed wards was in operation by 1924;31 recreation in the form of dances, concerts, illustrated lectures and exhibitions was well-established by the mid nineteen-forties.32 On the basis of this evidence, it seems that the hospital management had made sincere efforts to improve the quality of life of the hospital’s residents. On the other hand, the first qualified occupational therapist was not appointed until 1944;33 in 1958 the kitchen at the annexe did not meet the standards required by the Ministry of Health’s Adviser on Dietetics and Catering,34 and there was always difficulty in recruiting and retaining nursing staff.35-39 This chronic staffing problem begins to explain how nursing staff on some of the more overcrowded wards began to develop time-saving practices which compromised the dignity of those in their care:

Her hair was right down over her bottom, my nanna, and I think she’d only been in there about three weeks and we turned up one Sunday afternoon and she had a basin cut and we were informed that this was what they had to have.

Interviewee 60s VI Visitor to a patient on a ward for elderly women c1960—1965

I worked on Infirmary Two at the Annexe and ... the bedrooms upstairs and there was about eighty-odd beds upstairs, and nearly all of [The patients] were incontinent. Changing the beds and toiletting patients; we were at it all night from seven at night until seven in the morning ... There were buckets all around the ward where patients could urinate in because they couldn’t get to the toilet or whatever, and it absolutely used to stink.

Interviewee 60sM2 Male nurse 1963-1967

They used to slop out on Sixes and Six ‘A’, the refractory wards. Everybody went to bed at six o’ clock at night except the special patients that worked and they were allowed to stay up and watch telly. But the majority, more or less after tea was over and the medicines were out, were upstairs and into bed

Interviewee 60sMl Male nurse 1963-1967

The bathroom was another experience - down at the annexe. Then there were all these baths in this big room and at the bottom there was the shower. And then you used to let so many patients in and have a bath and then you used to get them off into another room, dry off and they were dressed and off. Then if somebody opened the door the next lot used to be in before the old dirty water had drained away, before you could put new water in.

Interviewee 60sM2 Male nurse 1963-1967

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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As published in History of Psychiatry, x (1999), pp349-369

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On [Fours] every Thursday or Friday dinner-time [the deputy charge nurse] would come out and shout ‘Socks off!’ and they were all eating their dinner, and they’d all take their socks off and throw them into the aisle, and [a nurse] would come along with a big brush, sweeping them up to the top, round the corner and then we had to sort them all out into pairs to send to the laundry.

Interviewee 70sM2 Male nurse 1971-1992 recalling the early 1970s

Although in most of the wards within the hospital greater dignity was afforded to residents than is suggested by these vignettes, practices such as the approach to bathing described above persisted in some long-stay wards until well into the 1970s. Some of these practices may have been adopted to enable nurses to cope with chronic staff shortages, and may have persisted longer than was necessary because staff were suffering from ‘burnout’ (i.e. physical and emotional exhaustion and loss of compassion resulting from intense involvement with other people over a long period of time).40 On the other hand, it is noteworthy that, as late as 1957, the only comment which the Commissioners of the Board of Control made about the modernization of the central male bathroom was to express doubt about the use of showers in some ward bathrooms ‘during the carrying out of the scheme for the modernisation of the male general bathroom’.41 This could be construed as tacit approval of the continued use of the general bathroom.

The long-term problem of recruiting and retaining suitable nursing staff may also explain how the wide variety of occupational therapy evident in some parts of the hospital during the 1930s (craftwork, creative arts and physical training), failed to spread to all parts of the hospital:42

On the wards, the patients used to do work like cleaning - but only if they wanted to; nobody was ever made to work. They used to get paid about £1.50 or £1.75 a week in today’s equivalent, and there were always nurses who helped and supervised them. The others [who didn’t work] got what they called indigence money. There wasn’t any industrial therapy until the therapy buildings were built and they started getting work in from other places; putting cards into envelopes and things like that.

Interviewee 60sF4 Female nurse 1959-1972

Then, they got well looked after but there was minimum care. There was no talking to [patients]. If you spoke to them or carried a conversation on you were considered lazy.

Interviewee 60sF2 Female nurse 1962-1993 recalling the early 1970s

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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As published in History of Psychiatry, x (1999), pp349-369

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The patient’s day started at 7.00 when you came on duty until 6.00 at night and they all had to be in bed when the night staff came on duty. They got up at 7.00 and they were in bed by 7.00 and the night staff came on at 7.00

Interviewee 60sFl Female nurse 1963-1969

There was an airing court between Ones, Twos and Threes and Fives … they were all shunted out [almost everyday] but especially Saturday morning when there was no therapy. Saturdays and Sundays they would just walk round in circles and sit there; walk round in circles just herded together really. During the week there was industrial therapy and a lot of them went off to do that sort of thing; there was gardening duties so there was some work for some of them during the week

Interviewee 60sM3 Male nurse 1969-1976

Given the similar accounts of hospital life in the work of Russell Barton43 and Erving Goffman44 this is not surprising. Scull has shown how the early nineteenth century ideal of the asylum as a place of retreat and recuperation [from mental distress] rapidly became compromised by massive expansion of public provision in the context of restricted public expenditure45 (Scull 1993), but it is more difficult to identify what inhibited progressive change in mental health services during the twentieth century. The publication of Lomax’s exposé of Prestwich Hospital had led directly to the establishment of the 1924-26 Royal Commission on mental health services (The Macmillan Commission), and indirectly to the enactment of the therapeutically-orientated 1930 Mental Treatment Act. Governmental and professional concern to develop humane and sensitive regimes for caring for mentally distressed persons continued to be evident in the nineteen-fifties by the development of milieu therapy (i.e. the systematic creation of [supposedly] therapeutic hospital environments), therapeutic communities, new psychotropic medications, critiques of institutional care, and the enactment of the 1959 Mental Health Act which replaced all previous mental health legislation.46, 47 Despite all these changes though, there were only comparatively minor changes to daily life in many parts of Prestwich Hospital between the 1920s and the beginning of a period of fairly rapid change in the mid 1970s:

The breakfasts were terrible. Two slices of bread with margarine and then the dinner didn’t come until half past twelve and they just had a dinner and a bare sweet. They’d have nothing then until about six o’clock and then they’d finish. But you used to have favourites and we used to take little things in for them. Perhaps a couple of apples or oranges and give them to them and they’d work their fingers to the bone, scrub the floors, do anything for you if you gave them an apple.

Interviewee 30sFl Female nurse 1937-1976 recalling the 1930s

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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As published in History of Psychiatry, x (1999), pp349-369

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We put people into insulin comas and then let them come out of it slowly. …What would happen is you’d take them back to the ward after they’d recover from the insulin shock treatment; take them back to the ward … At night time they’d slip into a coma again; there’d be only one nurse on duty for about sixty patients so it happened that sometimes people would go into a coma and never come out of it.

Interviewee 50sM2 Male nurse 1947-1962 recalling the 1950s

[I]f I wasn’t in the general bathroom I was outside doing laundry. That meant you had to have a mask on and a gown and you had to - by hand - sort the [dirty] laundry out into different piles.

Interviewee 60sF2 Female nurse 1962-1993 recalling the early 1960s

And the grub [at Prestwich]! The only time I saw them get soup was Christmas Day. And if we ran out of potatoes we used to give them bread. And Friday and Sunday it was that salad - I don’t know how they used to cut it but a scalpel couldn’t cut it any finer and they’d have a slice of bread and that was their supper on a Friday night. [The food] was atrocious.

Interviewee 60sMl Male nurse 1963-1967

[Patients] on soft diet would receive a portion of ‘pobs’ which was milk and bread, and whilst there was a risk of them choking themselves and whilst this risk prevailed they were given ‘pobs’ to eat at every meal almost. That’s all they used to eat - it was tragic really.

Interviewee 70sM2 Male nurse 1971-1992 recalling the early 1970s

My first day up on [a care of the elderly ward] - I think there were either 42 or 43 patients on this ward. Many of them were doubly incontinent and many of them weren’t mobile, and very high dependency. And the first day I remember a part-time staff nurse being in charge. ... She greeted me at the door with ‘Hello, come in. There’s only you and I until the part-timers come in at nine, but never mind. We’ll do what we can.’

Interviewee 70sFl Female nurse 1973-1993 recalling the mid 1970s

The central questions here are how and why the nursing staff who had a duty of care to the residents of the hospital failed to respond positively to official policy statements and the development of innovative practice elsewhere. A lack of appropriate training was obviously one factor here:

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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As published in History of Psychiatry, x (1999), pp349-369

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For your RMPA certificate you had to stay on at night. That’s something else you see. We never got allowed that; that was all in [your own] time.

Interviewee 20sMl Male nurse 1921-1953 recalling the 1920s and 1930s

We had to go to lectures in our own time

Interviewee 30sFIA Female nurse 1934-1970 recalling the 1930s

[At] Prestwich I had eight staff with their exams for the whole female side, apart from the officers. I had seven assistant matrons and a deputy who were qualified.

Interviewee 40sF1 Matron 1946-1966 describing staffing arrangements on her arrival in 1946

…The thing that sticks in my mind was things that were said from [The School of Nursing] like it’s the textbook way that we teach you and we’ll not pretend that short-cuts aren’t taken on the wards for various things - but as far as telling you what the short-cuts were: bath day was pretty horrendous [two or three nurses bathing twenty or thirty patients in one afternoon]; tea in a big pot all stirred up with a big spoon and the milk and sugar thrown in …

Interviewee 70sMl Male nurse 1975-1993 recalling the mid to late 1970s

However, the apparent lack of professional education and training is only one factor among many which contributed to the development of an occupational culture wherein the surveillance and control of patients/residents and staff came to assume greater importance than meeting the basic physical, psychological and emotional needs of deeply distressed individuals. Even if individual members of staff were sufficiently knowledgeable about the politics of mental health and skilled in mobilizing resources to bring about progressive change, there were official and unofficial codes of conduct which governed all relationships within the institution as well as formal and informal disciplinary processes which could be brought to bear on anyone who challenged accepted customs and practices:

[We started] a little drama group with the patients ... The next thing was that [a certain consultant] sent for [me] so I went into the office and as I went in he screamed ... ‘Who the hell are you to organise drama with my patients?!’ and he screamed again at the top of his voice, ‘I decide what happens to the patients in this hospital.’

Interviewee 70sAF1 Female Occupational Therapist 1966-1973

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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As published in History of Psychiatry, x (1999), pp349-369

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There wasn’t a lot of mixing with people outside the actual Prestwich staff; a lot of the staff working at Prestwich either married or associated with other people that worked at Prestwich.

Interviewee 60sM3 Male Nurse 1969-1976

You stood up when the doctor walked in and you stood to attention with your thumbs down the creases. That’s how you were supposed to; I mean the charge nurses did that as well. There was the visit of [the matron] who used to come in and all the beds had to be directly in line, and when they were turned down they always had to be from there to there exactly, so you used to measure and she used to measure it as well; and she’d look down to see if all the wheels were turned in all exactly the same.

Interviewee 70sM4 Male nurse 1970-1992 recalling the early 1970s

Patients were treated very much as the underclass and conversations would take place in front of patients about patients as if they didn’t exist, or had no sense of understanding. You couldn’t challenge ... [nursing] practice and there was a conspiracy of silence about what was permitted and what wasn’t, and if you broke that silence ... there were many sorts of sanctions which could be placed on you to prevent you from doing it again,

Interviewee 70sM2 Male nurse 1971-1992 recalling the early 1970s

In terms of inhibiting progressive change, these processes had a dual effect. The first was to compound a lack of staff accountability to hospital residents/patients and their relatives and a lack of ongoing supervision and surveillance of ward staff by senior hospital administrators. The second effect was to suppress the expression of dissent by junior staff, who might otherwise have demanded that bad practice be eradicated. Consequently many archaic practices continued despite the emergence of critiques of total institutions and developments in clinical practice. In addition to the examples already mentioned, other outdated practices that continued in parts of the institution until well into the 1970s included the seclusion of aggressive and violent patients for days or even weeks at a time, and the communal use of ward clothing - including underwear. It should be stressed though that only two or three wards had seclusion rooms, while despite the communal use of clothing being commonplace on long-stay wards, many nurses did strive to relieve the unpleasantness of institutional life for those in their care. However, these practices were largely hidden from public scrutiny by the combined effects of the codes of behaviour and disciplinary processes previously described, and the spectacular communal activities such as the annual sports day, the weekly film show and the weekly dance.

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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These events seem to have originally been introduced into the institution in the sincere belief that they were socio-therapeutic activities, but they had long since lost any real semblance of therapy. (A curious feature of these events is that no-one interviewed was able to recall precisely when these activities stopped. However, there was a consensus that the dances stopped some time in the early to mid seventies, while the sports days were discontinued earlier and the weekly film show - in one form or another - continued until the late 1970s.) Nevertheless their existence created an illusion of staff and patients/residents being united in a shared sense of community. Similarly, participating in the organization of such events may have contributed to the development of a ‘false consciousness’ amongst some staff which may have led them to believe that they were genuinely alleviating the tedium of daily life within the institution:

We had cinema every Friday afternoon. That [started] in the 1950s. Before they brought pictures in they used to bring those slides and they used to go in the hall. That would be early fifties, late forties ... They had the sports day. It used to be a huge thing ... on the cricket field. They’d have all kinds of races for the staff and for the patients; and of course there was staff on every corner in case they wandered off ...They used to have refreshments on the field and everything. It was always a big activity. It faded out [long] before I left.

Interviewee 30sF2 Female nurse 1937-1979 recalling how hospital life had developed prior to the 1970s

Apart from the patients at occupational therapy or industrial therapy which was done off the wards the only time that [male and female] patients mixed was when we had socials like dances and things like that. A once-a-week dance was the only occasion the sexes mixed, and even within the dance hall while the music wasn’t playing they all sat in their different corners of the room. The females sat over there and the males sat over there and once the music started they sort of moved toward each other to go and grab a partner and dance. But once the music stopped they went back like that. That was it.

Interviewee 60sM3 Male nurse 1969-1976

It is important to stress that although staff continued to put their energies into running such in-house ‘entertainments’ until the mid 1970s - by which time an established theoretical principle of psychiatric nursing was to renew or maintain patients’/residents’ points of contact with the wider community48, 49, 50 - these events were not the product of any cynical conspiracy to maintain the power and control of nurses within the institution. Instead, the tardiness of nurses in abandoning such practices is an indicator of a deeply entrenched ideology which held that nursing was learnt by watching the example of others, and based on ‘common sense’ assumptions and concern with nearness rather than on research-based theory. As there were chronic problems in recruiting and retaining

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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nursing staff, the prevalence of this ideology within the hospital may have contributed to practices adopted as a matter of expedience during periods of severe staff shortages becoming the norm.

[On my first day as a nursing assistant] I was immediately taken into the dormitory and [told] “Feed that lady!” I was just horrified by the whole set up. There was no sitting down and talking to you ... making you feel at ease, or introducing you to anybody …

Interviewee 60sF2 Female nurse 1962-1993

I was taken to the ward by one of the assistant chiefs and I was introduced to the charge nurse and he just told me to go into the sick room and join the other male nurses. That was your introduction to the ward ... You weren’t told what your responsibilities were ... you didn’t know what was wrong with your patients.

Interviewee 60sM2 Male nurse 1963-1967

You could be on the same ward at different times and you’d find occasions where patients were talking to staff - playing snooker was another thing that used to happen a lot - and you could be there another time with another bunch of staff and you wouldn’t see them talking much to patients at all.

Interviewee 70sM3 Male nurse 1972-1982 recalling the I970s

The inadequacy of critiques The oral histories collected for this study suggest that although there have always been nurses who empathize with their clients, this might have been attributable more to their own individual efforts than to the existence of an empathic humanistic culture of nursing within the institution as a whole. Furthermore, there was no direct accountability of the staff to the patients/residents in large psychiatric institutions. Several of the people interviewed knew of individual nurses who exploited the lack of checks on the power of staff to steal from patients, have patients do menial jobs for them for little or no payment or who were deliberately cruel to individual patients they disliked. However, although these people were a very small minority, and were generally disliked by other nursing staff, so too were those nurses who were able to make long-lasting changes to the hospital regime. More typically, people who came to work at the institution adapted quickly to the demands of regimes which denied residents/patients privacy, personal belongings and self-determination, but tried to relate to residents on a more compassionate level when in one-to-one situations with them:

I went to the staff dance and I had a new dress - a long one - and [this particularly disturbed patient] said ‘Will you come in and let me see it?’ I said yes so I went in

John Hopton: Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care

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early and I went in her room and I had to twirl round and let her see how it flared out. She was thrilled to bits with this dress.

Interviewee 30sFl Female nurse 1937-1976 recalling the 1930s

My mum and dad lived on Clifton Road at the back of the hospital so if it was a nice day - even when I was on Twelves, the admission ward - depending on the patients I used to take half a dozen for a walk and finish at my mum’s for a coffee ... and they used to be thrilled to bits going to my mum’s because they weren’t treated as patients for an hour;

Interviewee 70sF2 Female nurse 1970-1978

I remember one incident where myself and [another student] actually took two footballs into the airing court down on Fours at the Annexe, and were playing football with the patients. Not allowed. We were supposed to stand at various spots around the perimeter and just observe, and we were more or less told by [the matron] ‘You are not here to play football. You are here purely to observe.’

Interviewee 70sM4 Male nurse 1970-1992 recalling the early 1970s

Individual acts such as these can be understood as genuine efforts by individuals to mitigate the pernicious effects of total institutions described in detail by Barton and Goffman.51, 52 However, although such gestures seem to be have been a feature of institutional life since at least as far back as the 1930s, they were insufficiently co-ordinated and/or insufficiently commonplace to have had any substantive impact on nursing practice. This is exemplified by the following observations by Montagu Lomax about the nursing management of severely distressed individuals, and the apparent persistence of this very practice some twenty years later:

Of all forms of restraint this of being put ‘behind the table’ is resented more than any other by patients of every degree and type of insanity, except those who are past all feeling of resentment whatsoever ... The only possible excuse for the existence of this brutalizing form of restraint is such a paucity of attendants as renders effective supervision of dangerous patients otherwise unattainable. Consequently, had this mode of treatment been merely a war-time expedient necessitated by the dearth of attendants, its uses would have been temporarily justified, however deplorable it might be for other reasons. But this was by no means the case ... Not only is this treatment reserved for refractory and quarrelsome patients, it is used as a method of punishment for minor offences as well … in my judgement there is no form of restraint so utterly uncalled-for, and no ‘punishment’ so deplorable in its effects upon most forms of insanity, as this.53

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Before they brought television in and had these things installed in wards, the usual thing in the dayroom was to have all the violent ones sat behind a big table with a nurse whose job was keeping an eye on them.

Interviewee 40sAMI Male plumber 1946-1966 recalling the 1940s and 1950s

Although this particular practice did not persist until the 1970s, it is cited as evidence that even the most public condemnation of a practice could not on its own ensure that it would be discontinued.

Such gaps between the formulation of policy and the realities of practice were parallelled by gaps between theory and practice. For example, the principles of rehabilitation, promoting independence and ensuring a balance between work-orientated and recreational therapeutic activities, have featured prominently in the theory of psychiatric nursing since at least the early nineteen-sixties.54 Indeed, there is a liberal tradition within British psychiatry which has always emphasized the rehabilitative ideal. This tradition can be traced back to Thomas Withers, William Batty and William Tuke in the eighteenth century; through Samuel Tuke, John Connolly and Daniel Hack Tuke in the nineteenth century; to pioneers of therapeutic communities such as Maxwell Jones, David Clark and David Cooper in the mid to late twentieth century.55-58 Despite this, though, a strictly regulated regime, under which work activities (for patients/residents) tended to be monotonous and recreational opportunities were very limited, persisted in many wards at Prestwich Hospital until the mid nineteen-seventies.

Forces for change It is difficult to pinpoint what factors precipitated the relatively rapid changes which affected the institution in the mid 1970s. None of the people interviewed in the course of this research gave any indication that either the critiques of institutional care associated with Barton, Goffman and others59 or the critiques of psychiatry associated with the anti-psychiatry movement of the 1960s and 1970s,60 had any substantive impact on the practice of mental health care at Prestwich. Similarly, although there is reference to Psychiatric Nursing Today and Tomorrow (The Report of the 1968 Review of Psychiatric Nursing) in official records,61 there is no evidence of any serious attempt having been made to implement the recommendations of that report for the development of ‘advanced post-registration training schemes and an enhanced psychotherapeutic role for nurses.62 A more likely source of inspiration for the changes at Prestwich in the 1970s might be the combined effects of the public inquiry into corruption and neglect at Whittingham Hospital less than 40 miles away,63 and the integration of nursing management with other health service management systems in the 1974 reorganization of the National Health Service.64 Indeed, Whittingham Hospital and Prestwich Hospital were both under the jurisdiction of the same Regional Hospital Board which stated in its response to the inquiry report on Whittingham Hospital that it would ‘endeavour to stimulate the rate of

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progress in whatever way we can and we accept that much can be done without additional expenditure’.65 Significantly though, neither the inquiries at Whittingham and other similar institutions66 nor the reorganization of the National Health Service, were initiated by leaders of any of the mental health professions. Instead, inquiries into practices at mental health and learning disability institutions were usually instigated following formal complaints about levels of care from junior members of staff,67 while the reorganization of the National Health Service was instigated by politicians and civil servants. Thus, contrary to mental health nursing’s68 self-image as a profession which has consistently been at the forefront of implementing progressive change,69, 70 substantive changes in mental health nursing have been the indirect consequence of a crisis of mental health nursing’s legitimacy, rather than evidence of its eagerness to respond positively to critiques of mental health care practice.

Conclusion Having been the focus of an important official inquiry in the 1920s, Prestwich Hospital should have been as likely a place as any to develop progressive approaches to care. However, despite the efforts of some hospital staff to keep up with developments within psychiatry and psychiatric care (the development of occupational therapy in the 1930s, the introduction of electroconvulsive therapy in the 1940s and resettlement of long-stay residents to hostel accommodation in the late 1960s and early 1970s),71, 72, 73 progress was slow and uneven. This uneven pattern of development can be attributed to a combination of factors. These include, chronic difficulties in recruiting and retaining suitable nursing staff; an emphasis on nursing staff learning their trade by watching their more experienced colleagues; the existence of a culture where any questioning or criticism of the practice of others was actively discouraged;74 and the high degree of control which could be exerted on new members of staff in such a tight-knit and hierarchical community. It is less clear, though, why widespread and enduring changes did finally occur in the 1970s.

Possibly, staff who came to work in the hospital at this time had been attracted to working with mentally distressed people through familiarity with the writings of the anti-psychiatrists R. D. Laing and David Cooper who (although marginalized within mainstream psychiatry) were major figures in the counterculture of psychedelia and vaguely left-wing politics which flourished in the late 1960s and early 1970s.75 Also, it is possible that rising unemployment brought about an increase in recruitment of staff who were not from the traditional backgrounds of the armed services or families working at the hospital. If so, these new members of staff may have been more inclined to challenge unreasonable practices, and less intimidated by formal and informal sanctions against dissenters. Although it is impossible to be certain if either or both these factors played a role in precipitating change, student nurses at the hospital in the early to mid 1970s came from a variety of social backgrounds and many had an affinity with aspects of the counterculture:

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And also the big focal point for the staff was the social club and it was all associated with heavy drinking ... And also there was a lot of heavy rock and Pink Floyd stuff amongst the staff and drug-taking; not hard drugs but certainly smoking [cannabis].

Interviewee 70slF Female nurse 1973-1993

It was very regimented [when I arrived] but by that time I’d got some purpose. I’d actually been involved in talking people down from LSD trips in rock concerts and places like that, and I felt that psychiatry would be something similar, and I’d developed some understanding and expertise in that so ... I was determined.

Interviewee 70s2M Male nurse 1971-1992

Staff may also have been encouraged by the new consultant psychiatrists who came to work at Prestwich Hospital in the early 1970s,76, 77 and by the managerial changes resulting from the 1974 reorganization of the National Health Service. Additionally, a series of highly critical inquiry reports in similar institutions may have helped to encourage new staff to criticize what they considered to be bad practice, and encouraged established staff to respond constructively to such criticism. If these hypotheses are correct, there would be a parallel with developments in another type of institution. The regimes of the plantation prisons of the Southern U.S.A. had remained largely unchanged since the nineteenth century but underwent extensive reforms in the early 1970s78, 79and this has been attributed to the previously half-hidden world of the institutions coming to the notice of political activists from a middle-class intelligentsia.80

One thing is certain and that is that neither academic critiques of institutions, nor advances in psychotherapeutic interventions, nor the publication of the 1968 Review of Psychiatric Nursing had previously stimulated the development of progressive approaches to care throughout the whole of Prestwich Hospital. ‘While academic critiques, clinical advances and the optimism of the 1968 review of psychiatric nursing had failed to provide the impetus for modernizing Prestwich and some other psychiatric hospitals, these public inquiries finally precipitated progressive change. However, these public inquiries did not occur in a historical vacuum. They occurred in an era when issues such as ecology, gay liberation, feminism and anti-racism were beginning to force their way onto the mainstream political agenda. This suggests that the gradual transformation of Prestwich Hospital which began in the 1970s was neither the consequence of academic critiques nor the inevitable outcome of clinical advances and the development of new approaches to care within the mental health professions, but was rather the result of interaction between a variety of social, cultural and political developments.

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Leaving aside official documents which provide a contemporary historical record of scandals within individual institutions,81 the existing historiography of British psychiatric hospitals can more or less be divided into three sub-genres. There are histories of mental health services in general,82-84 books and articles which focus on institutions which have at one time or other been at the ‘cutting edge’ of developing new approaches to the care and treatment of mentally distressed people,85-87 and mechanistic accounts of the history of relatively obscure psychiatric institutions, many of which are largely based on unverifiable sources.88-90 Notwithstanding the opening of one of the earliest regional secure units there in the late 1970s Prestwich Hospital was never at the ‘cutting edge’ of mental health care, but its centrality to mental health reform as a consequence of the Lomax allegations does perhaps separate it from other psychiatric hospitals with an otherwise similar history.

The significance of the material on which this article is based is that it suggests that the pioneering approaches to treatment and care of mentally distressed persons associated with hospitals such as Littlemore, Fulbourn and the Maudsley were not adopted throughout the mental health services. Inasmuch as Prestwich Hospital had once been the focus of negative comments about mental health care in the press and in parliament, it might have had more reason than any other institution to wish to be associated with progressive developments. The fact that Prestwich did not follow the example set by other more progressive psychiatric hospitals raises questions about the extent of the influence which they had on the mental health services in general. Official records reveal that successive management groups at Prestwich Hospital had a genuine concern for the welfare of residents (patients),91-94 but that their efforts were constrained by a lack of material resources.95-97 Similarly, the oral testimony of many of the nurses interviewed suggests that actual care did not always match the ideals set out in contemporary nursing literature,98, 99 and this seems to have been the consequence of long-term difficulties in recruiting suitable nursing staff ( an issue raised in Lomax’s book, and which continued to be periodically mentioned in official records until the late nineteen-sixties100). These gaps between intentions and practice suggest that neither changes in mental health policy, clinical advances in psychiatry, nor official inquiries necessarily lead to substantive improvements in the quality of care experienced by service users. Studies similar to this one but focusing on other institutions would represent a worthwhile addition to the existing historiography of twentieth-century psychiatric hospitals, as availability of such material would make it easier to determine what was typical, and what was exceptional about life inside a twentieth-century psychiatric hospital.

REFERENCES

1. Thirteen of these interviewees were contacted via letters to local newspapers, and the validity of their claims to knowledge about the hospital was verified from their descriptions of parts of the hospital and reference to members of staff known (or known of) to the researcher and/or because they had

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been introduced to him by a mutual acquaintance who had seen one of the letters. Most other interviewees were personal acquaintances who were approached directly or who responded to one of the letters, although one woman was a colleague of a personal friend. The total ‘sample’ interviewed consisted of one female ex-patient; one woman who had regularly visited a relative on a female ward; one male finance clerk; one female occupational therapist; one male member of the building and maintenance staff; one male nurse who had previously worked at the hospital as a gardener; ten male members of nursing staff; and nine female members of nursing staff.

2. Sholom Glouberman, Keepers (London: King’s Fund, 1990).

3. Peter Nolan, A History of Mental Health Nursing (London: Chapman & Hall, 1993), notes on back cover.

4. Lancashire County Records Office (Preston), Quarter Sessions Catalogue QAA-QDH/QAM.

5. Prestwich Hospital Archives Department, single page typescript entitled ‘Brief Notes On the Development of Prestwich Hospital’ (dated 9 March 1961).

6. Andrew Scull, The Most Solitary of Afflictions (London: Yale University Press, 1993), 287-8.

7. See 4.

8. Norris McWhirter et at., Guinness Book of Records, 1983 Edition (Enfield: Guinness Superlatives Ltd, 1982), 205.

9. City of Salford Local History Library, Manchester Regional Hospital Board Minutes, Annual Report and Abstract of Statistics for the year ending 31 December 1967, 13.

10. Personal interview with Craig Talbot, Director of Corporate Facilities, Mental Health Services of Salford NHS Trust, 23 April 1996.

11. In the 1940s the National Asylum Workers’ Union merged with other health workers’ unions to form the Confederation of Health Service Employees [COHSE]. In 1993 COHSE merged with NUPE and NALGO to form UNISON.

12. Montagu Lomax, The Experiences of an Asylum Doctor (London: George Allen & Unwin, 1921).

13. Kathleen Jones, A History of Mental Health Services (London: Routledge & Kegan Paul, 1972), 232-4.

14. Tom Butler, Mental Health, Social Policy and the Law (Basingstoke: Macmillan, 1985), 83

15. Lomax, op. cit., 9-24.

16. Butler, op. cit., 83-4

17. T. W. Harding, ‘“Not Worth Powder and Shot” - a reappraisal of Montagu Lomax’s contribution to mental health reform’, British Journal of Psychiatry, clvi, (1990) 180-7.

18. Lunacy: Board of Control, The Tenth Annual Report (London: HMSO, 1923), 169-70.

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19. Lancashire County Record Office, QAM 6/2/21, Visitors’ Committee Meetings Minutes, 19 August 1921.

20. Nolan, op. cit., 82-3

21. T. W. Harding, op. cit.

22. Virginia Beardshaw, Conscientious Objectors at Work (London: Social Audit, 1981).

23. J. P. Martin, Hospitals in Trouble (Oxford: Basil Blackwell, 1984).

24. Louis Blom Cooper, Report of The Committee of Inquiry into Ashworth Hospital (London: HMSO, 1992).

25. Ian Bynoe, Treatment, Care and Security (London: Mind, 1992).

26. David H. Clark, The Story of a Mental Hospital - Fulbourn 1858-1983 (London: Process Press, 1996).

27. Jocelyn Goddard, Mixed Feelings: Littlemore Hospital - An Oral History Project (Oxford: Oxfordshire County Council, 1996).

28. Jeffrey Masson, Against Therapy (London: Collins, 1989), 290-3.

29. Kathleen Jones, Asylums and After (London: Athlone Press, 1993), 189.

30. Lancashire County Record Office, QAM 6/2/21, Visitors’ Committee Meetings Minutes, 16 December 1921 and 21 July 1922.

31. Lunacy: Board of Control, The Eleventh Annual Report (London: HMSO, 1924), 229-31.

32. Lancashire County Record Office, QAM 6/2/29, Visitors’ Committee Meetings Minutes, 16 January 1942.

33. Lancashire County Record Office, QAM 6/2/30, Visitors’ Committee Meetings Minutes, 18 August 1944.

34. Harris Library (Preston), Manchester Regional Hospital Board Minutes, Report of the Planning and Development Committee (Report of the Mental Health Sub-committee) 25 April 1958.

35. Lunacy: Board of Control, The Tenth Annual Report (London: HMSO, 1923), 169-70.

36. Lancashire County Record Office, QAM 6/2/29, Visitors’ Committee Meetings Minutes, 16 November 1934 and 19 July 1935.

37. Lancashire County Record Office, QAM 6/2/30, Visitors’ Committee Meetings Minutes, 15 February 1946.

38. Prestwich Hospital Archives Department, Minutes of Extraordinary Meeting of the Hospital Management Committee, Proceedings with regard to allegations of cruelty to male patients made by Student Nurse F. Cox, 22 January 1952.

39. T. Hourigan, Report of the Committee of Inquiry into Whittingham Hospital (Cmnd 4861); Views of the Manchester Regional Hospital Board (Manchester: Gateway House, 1972).

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40. Peter Hawkins and Robin Shohet, Supervision in the Helping Professions (Milton Keynes: Open University Press, 1989), 20.

41. City of Salford Local History Library, Manchester Regional Hospital Board Minutes, Report of the Buildings and Works Committee, 3 May 1957.

42. Lunacy: Board of Control, The Twenty-first Annual Report (London: HMSO, 1934), 229.

43. Russell Barton, Institutional Neurosis (Bristol: J. Wright & Sons, 1959).

44. Erving Goffman, Asylums (Harmondsworth: Penguin, 1968)

45. Andrew Scull, The Most Solitary of Afflictions (London: Yale University Press, 1993), 267-83.

46. Nolan, op. cit.

47. Jones, Asylums and After.

48. Brian Ackner, Handbook for Psychiatric Nurses (London: Baillière Tindall, 1964), 246-66.

49. Joan Burr, Nursing the Psychiatric Patient (London: Baillière Tindall, 1974), 44-57.

50. Nolan, op. cit., 114-38.

51. Barton, op. cit.

52. Erving Goffman, Asylums (Harmondsworth: Penguin, 1968).

53. Lomax, op. cit., 47.

54. Ackner, op. cit., 246-66.

55. Nolan, op. cit., 26-9.

56. Scull, op. cit., 96-103 and 228-41.

57. David H. Clark, Social Therapy in Psychiatry (Harrnondsworth: Penguin, 1974).

58. David Cooper, Psychiatry and Anti-Psychiatry (London: Paladin, 1970).

59. Kathleen Jones and A. J. Fowles, Ideas on Institutions (London: Routledge & Kegan Paul, 1984).

60. Anthony Clare, Psychiatry in Dissent (London: Tavistock, 1980).

61. City of Salford Local History Library, Manchester Regional Hospital Board Minutes, Planning and Development Committee, Report of Mental Health Sub-Committee, 28 January 1969.

62. Central Health Service Council, Psychiatric Nursing Today and Tomorrow (London: HMSO, 1968), 48-9.

63. National Health Service, Report of The Commission of Inquiry Into Whittingham Hospital (London: HMSO, 1972).

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64. Robert Dingwall et al., An Introduction to the Social History of Nursing (London: Routledge, 1988), 123-44.

65. T. Houngan, op. cit., ii (paragraph 8).

66. J. P. Martin, op. cit.

67. V. Beardshaw, op. cit., 64-83.

68. The term ‘mental health nursing’ is interchangeable with the term ‘psychiatric nursing’. However, since the mid 1980s most members of the profession have preferred the term ‘mental health nursing’.

69. Nolan, op. cit.

70. Mental Health Nursing Review Team, Working In Partnership (London: HMSO, 1994).

71. Lunacy: Board of Control, The Twenty-first Annual Report (London: HMSO, 1934), 229.

72. Lancashire County Record Office, QAM 6/2/30, Visitors’ Committee Meetings Minutes, Annual Report of the Medical Superintendent for the Year Ending 31 December 1945, 18 January 1946.

73. City of Salford Local History Library, Manchester Regional Hospital Board Minutes, Planning and Development Committee, Report of Mental Health Sub-Committee, 13 June, 1969.

74. Prestwich Hospital Archives Department, Minutes of Extraordinary Meeting of the Hospital Management Committee, Proceedings with regard to allegations of cruelty to male patients made by Student Nurse F. Cox, 22 January 1952.

75. David Cooper (ed), The Dialectics of Liberation (Harmondsworth: Penguin, 1968).

76. City of Salford Local History Library, Manchester Regional Hospital Board Minutes, Senior Administrative Medical Officer’s Annual Report on the Consultant and Specialist Services for year ended 31 March 1971.

77. City of Salford Local History Library, Manchester Regional Hospital Board Minutes, Senior Administrative Medical Officer’s Annual Report on the Consultant and Specialist Services for year ended 31 March 1972.

78. Tom Mutton and Joe Hyams, Accomplices to the Crime (London: Michael Joseph, 1974).

79. David M. Oshinsky, Worse Than Slavery (New York: Free Press, 1996).

80. Oshinsky, op. cit., 229-236.

81. Martin, op. cit.

82. Scull, op. cit.

83. Butler, op. cit.

84. Kathleen Jones, Asylums and After (London: Athlone Press, 1993).

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85. Mary R. Glover, The Retreat: An Early Experiment in the Treatment of Mental Illness (London: William Sessions, 1984).

86. David H. Clark, The Story of a Mental Hospital - Fulbourn 1858-1983 (London: Process Press, 1996).

87. David Russell, Scenes from Bedlam: a History of Caring for the Mentally Disordered at Bethlem Royal Hospital and the Maudsley (London: Baillière Tindall, 1997).

88. R. Valentine, Asylum, Hospital, Haven - A History of Horton Hospital (London: Riverside Mental Health Trust, 1996).

89. M. T. Haslam, Clifton Hospital - An Era (Belper: The Golden Flower Press, 1996).

90. A.L. Ashworth, Stanley Royd Hospital Wakefield - A History (Wakefield: Wakefield Area Health Authority, 1975).

91. Lancashire County Record Office, QAM 6/2/21, Visitors’ Committee Meetings Minutes, 18 May 1923.

92. Lancashire County Record Office, QAM 6/2/21, Visitors’ Committee Meetings Minutes, 16 December 1921.

93. Lancashire County Record Office, QAM 6/2/23, Visitors’ Committee Meetings Minutes, 16 March 1928.

94. City of Salford Local History Library, Manchester Regional Hospital Board Minutes, Planning and Development Committee, Report of Mental Health Sub-Committee, 22 April 1958.

95. Lancashire County Record Office, QAM 6/2/21, Visitors’ Committee Meetings Minutes, 21 July 1922.

96. Lancashire County Record Office, QAM 6/2/29, Visitors’ Committee Meetings Minutes, 16 October 1942.

97. City of Salford Local History Library, Manchester Regional Hospital Board Minutes, Planning and Development Committee, Report of Mental Health Sub-Committee, 28 November 1958.

98. Royal Medico-Psychological Association, Handbook For Mental Nurses, 7th edn (London: Baillière Tindall, 1923 reprinted 1939)

99. Ackner, op. cit.

100. City of Salford Local History Library, Manchester Regional Hospital Board Minutes, Planning and Development Committee, Report of Mental Health Sub-Committee, 28 January 1969