In Man, Mind, And Heredity, Johns Hopkins Press, London 1971, pp. 1-23.
The Road to Psychiatry
It must have been about 1919, when I was fifteen, that my father came to see me at my boarding school while on leave from India. At that time he was Professor of Indian Economics in the University of Madras, a post that kept him out of England over a critical period of my career. As I remember it, we went for a walk about the school grounds, and he asked me what I wanted to do with myself in life. I told him I wanted to he a doctor, and I think he must have sighed. My parents were never well off, and it must have been a grievous task to put three sons through fee‑charging "public" schools and a university afterwards. To be asked to undertake the additional cost of supporting a son during the years he was a medical student must have been hard. Yet he did not attempt to persuade me out of it.
I do not know what had made me pick on medicine at that age, and I cannot believe I had any solid reasons. Such decisions, one would think, should really be taken by adults on the basis of a fully informed appreciation of the boy's intelligence, aptitudes, and interests. However, the decision in favour of medicine could claim the support of some good sense. A medical career offers such a variety of occupations, and presents such a variety of niches for personalities of any imaginable kind, that once started on it a young man should be able to find his way to the right spot for him in the end. It was also a good choice from the point of view of what the school had to offer. Leighton Park was a small public school with only about a hundred and twenty boys at the time I was there. It had been chosen by my mother, who had been given the decision by my father away in India, mainly because she was a Quaker and this was a Quaker school, and because she was a pacifist and this school had no military training for cadets. The teaching was somewhat uneven, and was extremely weak on the classical side. The best teaching was in biology, and Mr. Unwin our biology master also ran a Sunday evening discussion group for sixth form boys, the S.I. or Synthetic Iconoclasts, in which we read and discussed such books as Thus Spake Zarathustra. Biology was very attractive, and if one went into biology medicine became the natural final goal ‑ then at least, if it would not now.
I do not think my mother's choice was a wise one; but since I have no regrets for the form that my career finally took, I cannot regret the separate steps that took me there. Half the boys at the school came from Quaker families, that is to say predominantly from very prosperous middle‑class backgrounds. There were many representatives of the big Quaker chocolate manufacturing firms, Cadburys, Rowntrees, and Frys. These boys had no need for scholarship, and after school most of them would go into a secure place in the family business. Very few of them went to a university, and the school had no facilities for educating boys up to university scholarship level. On the mathematical side they had a Wrangler (a first‑class‑honours man from Oxford), but the time allotted to maths was small and I was never taken any further than the first few exercises in calculus. My lack of mathematical training has been a source of regret to me all my life.
To cope with its clientele, the School regarded it as its main task to train not for scholarship but for character. The ultimate aim was that the boy should become a good citizen, a God‑fearing Christian, and a solid asset to the community. Prowess in learning met with no rewards. Annual examination lists were posted on the school notice board, but were the occasion neither for praise nor punishment. Solid financial rewards were reserved in the form of prizes for the results of leisure‑time hobbies. The annual hobby exhibition included such things as items of carpentry, maps, collections of butterflies, etc.; and prizes were given for these and for stories, poems, recitations, public speaking, and so forth. I think we got a very peculiar view of what really matters in life ‑ but who is to say? Maybe the School was right.
Despite my negligible training in scholastic competitiveness, I succeeded when the time came in winning a minor exhibition (a sizarship) to St. John's College, Cambridge. This was worth only £30 a year, and would not do much better than take the edge off the sharpness of the financial difficulty for my father. I always felt rather uncomfortable about being a sizar, since in the middle ages sizars had been a lowly order of creature who earned their remission of fees by doing domestic duties for their College in spare time. There was, however, the opportunity of converting my sizarship into a full scholarship, worth say £100 per annum, if I succeeded in getting first‑class honours in the examinations at the end of the first academic year.
This was not to be. I went to the prescribed lectures and lab courses and dissections not finding great interest in them and spending practically none of my spare time in working on the textbooks. My tutor might have kept my nose to the grindstone if he had been worth his salt, but he wasn't. In fact most of my friends were fairly carefully looked after, and not only had a weekly tutorial, but also had a supervisor who looked after their reading and set questions. When the Mays examinations came along at the end of the first year, I only got second‑class honours, and did not get any promotion.
Later on I resented this experience, perhaps more on my father's behalf than my own, and sometimes would say to myself that if I met that man I would give him a piece of my mind. The opportunity came, not once but twice. This tutor and I both went into psychiatry after Cambridge years, and in the fullness of time ran into one another at a tea‑party of the RMPA (Royal Medico‑Psychological Association). He recognised me, and we had some conversation in the course of which he asked me what kind of a guide and teacher I had found him while I had been under his tutelage. I asked him whether he really wanted to know, and when he said he did, I told him. He was greatly surprised, but did not seem to lose his affability. As he was practising as a psychotherapist, the sang froid may have been professional. Anyway, as fate would have it, we met again only a few months later, this time finding ourselves sitting next to one another at an RMPA lunch. Once more he turned to me and said, "Ah, Slater, I thought I recognised you. Tell me, weren't we at Cambridge together? I fancy I was your tutor." It was quite clear that he had totally forgotten the previous occasion and that the wasp‑sting I had endeavoured to stick through his thick skin had taken no effect. This was quite a lesson to me; on future occasions when I found something rankling I would try to shrug it off, and abandon the absurd dream of one day giving a tit for tat.
The low classes I got in the Mays examinations did not spur me to do better in succeeding years. Instead of cramming, or engaging in athletic pursuits as so many, I spent nearly all my spare time in the excellent library of the Cambridge Union Society, reading works of English literature and some of the easier French classics. English drama particularly attracted me, and I read everything I could lay hands on. That, and poetry. I also tried my hand at writing stories of both a romantic and fantastic kind to take me into another world, and poetry as an attempted abreaction of my miseries in this one. During the whole of my Cambridge career I felt lonely and out of place. I had a few good friends among the boys who had come up to Cambridge with me from my school; but I made few new ones. Above all, I lacked a girl friend. Much of my reading was with a view to finding out what kind of creature the female of the species is, and what was meant by a love relationship. I am inclined to think now that in this way my time was better spent than it would have been if I had worked at my anatomy, physiology, and chemistry with the good will I ought to have had.
Scholastically, the most mediocre successes continued to attend me. This did not stop my being ambitious. Many medical students were contented with passing their strictly medical examinations and otherwise collecting only a pass degree for the diploma of B.A. I had to try higher. At the end of my second year I took the Natural Sciences Tripos Part I in anatomy, physiology, and chemistry. During the chemistry practical I had one of the attacks of complete gormlessness which afflict me at times. I found myself presented with a bottle of colourless, limpid, aromaticsmelling fluid and asked to identify it. Such a task had never yet been given to me, and I was flummoxed. How on earth could one analyse the chemical constitution of an organic compound? With the aid of my sense of smell I identified it as ethyl ether, and found that it was to inspection not distinguishable from the fluid in the bench bottle of ether. This had to be the substance of my report. It never occurred to me to measure any of its physical characteristics, such as the boiling point; and I think it quite probable that I didn't even discover whether it was inflammable. I still do not quite understand how I achieved second‑class honours in that exam.
Despite these indifferent results, it was still a matter for decision whether I should go on with science or turn entirely to medicine. I still felt that chemistry was a fascinating field and that biochemistry was a promised land. My father visited me at Cambridge and together we went to see the Professor of Biochemistry, Frederick Gowland Hopkins, famous for his discovery of vitamins. By his advice I opted to do Part II of the Natural Sciences Tripos in biochemistry, which only that year became a possibility. Those few medical students who went as far as a Second Part of the Tripos practically always did the course in physiology, which was very well regarded; and this was, for instance, the part chosen by the star pupil of my year, John StClair Elkington who won all the prizes and got a double first.
Elkington became a neurologist and went on to the honorary staff of St. Thomas's Hospital at an earlier age than anyone before him. I later became a colleague of his at Queen Square. He was one of the small number of neurologists I have known who have had any respect for psychiatry; and it was to a considerable extent his support which enabled my friend Will Sargant to establish such a flourishing department of psychiatry at St. Thomas's. Though he was most benign to his students and juniors, Elkington resembled many other neurologists in being very cool and remote with patients. It was said of him that in his own consulting room he put his patient in a chair that was screwed to the floor, as he so much disliked the way some patients have of edging their chair closer and closer to the doctor's.
There were only four of us who took Biochemistry in the Second Part of the Tripos; and at the end of it, two got firsts and two thirds. Needless to say I was one of the thirds. Hopkins was much too much tied up in his own researches to pay much attention to the course, and it was mainly organised and run by J. B. S. Haldane. He didn't take to me particularly ("What, Slater, studying astral physics?"). Haldane was a man of genius, but he was no organiser. There wasn't any syllabus for the course, no set books, and no one knew what would be asked about in the finals. My colleagues who got firsts no doubt did so by working hard and systematically reading everything that came their way; this was more than I could or would do, left to myself. I am afraid that I would never have made a good lab worker. On one occasion we were given the material and instructions to carry out a colorimetric estimation of one of the constituents of a specimen of human urine (J.B.S.'s, diluted ten times). We all had to use the same colorimeter, and I noticec that after I had had my turn one of my first‑class colleagues who followed me care fully washed out the glass container with distilled water. I asked him why he did this since distilled water was colorimetrically less like his test material than my test material was. My recollection is that he didn't have a good answer to this question (though the answer is obvious enough); but he did know intuitively, as I did not, that to leave a trace of other test material in the chamber could not possibly be good practice.
I had now reached the end of my third year at Cambridge, and it was clear that I should never make a scientist. I put my name down in the books of the University Appointments Board, but when I told them that nothing would persuade me to take up teaching, they seemed to think that, if that were so, for a third class man there was little left. Some months later I got my first and only notification of a vacancy, for the post of biochemist in one of the dependencies in Africa, salary £500 per annum. But by that time I had at last made some progress with my medical studies.
Up till the end of my last term at Cambridge I had been dogged by lack ol success in examinations on anatomy. I was a messy dissector, and had such a poverty of visual imagery that I had the greatest difficulty in grasping the relation of one structure to its neighbours. I passed in physiology and came down in anatomy in the 2nd M.B. examination at the end of my fourth term and again at the end of the sixth term. It was now the end of the ninth term, and somehow or other I had to pass. If I could not learn things by sight I might learn them by sound. My technique was to attempt to learn more or less by heart the condensed statements in "Aids to Anatomy". On the morning before the written examination in anatomy at 9 A.M., I rose at six (I had meant to get up earlier), and turned over the pages of Grays Anatomy looking over as many as I could of the more important pictures, trying to imprint something on my mind firmly enough to last there for the few hours necessary. The gamble came off; one whole question and a large part of another could be answered with confidence on the basis of what I had seen that morning. I had some hope that I might yet pass, but there was still the oral to come. Here luck continued to smile on me. I found myself facing the external examiner, for whom I was only a number. The first question he gave me was not too bad, and the second was about the shoulder joint. This too I was able to parry, and then I thought I might chance my arm. I asked him whether I might put a question to him about something I had never been able to understand. When he gave permission, I asked him about the way the biceps tendon ran through the shoulder joint quite freely, covered only by the joint endothelium, or whether it had a kind of "mesentery" or membrane connecting it to the joint capsule. I have no idea what his answer was (and I still do not know the answer to my question), but for the next seven or eight minutes or so dizzily and happily I listened to him discoursing about the minutiae of the shoulder joint, which must have been some kind of a pet subject for him.
I did get my pass, and my father could look forward to the pleasing prospect of supporting me in my studies for an additional two and half years. My last term at Cambridge, the tenth, was for eight weeks in the long vacation in the summer of 1925. There were only a few students up, mostly medicals, doing "bugs and drugs" (bacteriology, pathology, pharmacology). We all lived in college, and indeed had to be within college walls by 10 P.M.. This was a painful restriction, as there were half a dozen of us who liked to play bridge in the evenings and would not enjoy having to break off much before midnight. By good luck I was given a set of rooms with one window from which I could step onto a broad ledge over the window below, from there onto the top of a wall, and from there onto a pile of builder's rubble beyond which there was level ground and only one easily scaled gate separating me from the freedom of the Backs, the college gardens alongside the river. My last term at Cambridge, with studies which now came easily to me, with the companionship of friends, and with a reprieve from anxieties, was the only really happy one. Certainly the little town in its summer sleep, shut down at night, with few and dim street lamps to compete with the moon, showed all its magic in those late hours. In the narrow lanes between the black silhouettes of ancient buildings there would be hardly a footfall; and out on the Backs no other soul with whom to share the wide lawns and the great trees and the black and silvery river. Momentarily one was submerged in a cloistered mediaeval town, perhaps a fellow student with Christopher Marlowe.
At the end of the summer I came up to London, having won a minor scholarship to St. George's Hospital. Once again I was the victim of quite unsuitable ambitions. The really prestigious branch of medicine was surgery, and if I were to be a surgeon I should do well to take the primary examination of the F.R.C.S. diploma. Instead of getting on with the job of learning to be a doctor, I took three months off working at the Primary course at St. Mary's Hospital. The medical school there was full of young men who had been given scholarships for athletic prowess (Will Sargant was later to be one such), all very beefy and boisterous. The general atmosphere of the most aggressive type of heartiness didn't suit me a bit. Of course I failed my Primary examination, being totally unfitted for work along this line; and it was with great relief that I discovered what a soothing place a medical school could be when I went to St. George's.
Here the atmosphere was quiet, well‑bred, almost genteel. There was a cult, proceeding by contagion from the more to the less senior students, of wearing fancy waistcoats, cravats and tiepins, and spats even with, say, a light grey suit. If one wore the short black jacket with pinstripe trousers, then one's sombre tie was relieved with a white slip just showing from inside the waistcoat. I never aimed so (expensively) high, though in due course I acquired an umbrella, a gold‑headed ebony cane, and a monocle; more importantly I became aware of the necessity of wearing in immaculate state the dresser's clean white jacket and of having clean hands and spotless finger‑nails. This was a lesson that I learned, but I cannot claim a faultless standard of practice.
The teaching at St. George's was excellent, at a rather humdrum level. Such a standard would not be acceptable nowadays. In fact, we were all apprentices, and were there to learn the art and practice of medicine from teachers to whom we were individually assigned. Medicine as a field of enquiry only existed in a few holes and corners, mainly perhaps behind some partition in one of the labs. St. George's men for the most part got through their exams without difficulty and went into suitable private practices. They had the reputation of becoming very successful general practitioners in the West End of London, recommending themselves to their aristocratic or influential or wealthy patients by their polish and address no less than their competence, kindness, and good sense. The ultimate product of this scheme of apprenticeship and training was not always to be in every way admirable. At a later time I met at the bedside of a wealthy widow one of my contemporaries who was known to be very successful in this little world. The way in which he handled the lady, her parlourmaid, the other consultant, and myself, easy and self‑effacing as it was, seemed to me indistinguishable from that of the upper servant or an old family retainer.
When I came up to London for hospital work, my father suggested that it would he much better than living in lodgings to become a resident at Toynbee Hall, a very famous institution just about at the border between the City and the East End of London. Communal life at Toynbee had many resemblances to life at a college; even the architecture and the small individual bed‑sitting rooms conveyed that impression. In the evenings the residents would sit down to dinner at a long table in a dining hall, at one end of which there were a few comfortable chairs and a cheerful coal fire. It was in one of these chairs that I would sit after dinner reading the latest work of fiction I had borrowed from the "Times" Lending Library. This wasn't really quite the done thing. I should have been up and about the Lord's work. University graduates were there to take their share in the social work of the neighbourhood, and to do their best to bring one kind of a light or another into the lives of the vast arrays of the underprivileged which swarmed around us to north, east, and south.
It was brought home to me that I must do my bit; and the first suggestion mad to me was that I should help to run one of the several boys' clubs associated with Toynbee. This would only mean spending one or two evenings a week in the company of rather rough boys at a club a mile or so from the Hall in, admittedly, a squalid neighbourhood. This was at a time when such clubs ran quite easily, and encountered no disagreeable attentions from hooligans as has been the case in recent years. Nevertheless I was terrified. I would not have the least idea how to communicate with such persons. I imagine I had a suspicion that, as soon as they would become aware of me as a foreign body, a gang of them would set on me and beat me up. But what held me back was not so much a physical fear as a mental one; the torturing shyness I suffered from at this time effectively cut me off from practically everyone but my old friends and fellow medical students.
Running a boys' club would have been a very soft option in comparison with what I chose. This was to give a course of lectures to prisoners in Pentonville Gaol; my subject, English literature. This meant a long tram‑drive at night, through a dreary neighbourhood, entering through the frowning gates of the prison, being conducted by a warder to a room in which some thirty prisoners were awaiting me. Once into the room, I heard the door clang to behind me and the lock slammed, leaving me alone with my pupils. What followed was frightful. I would endeavour to make my voice heard above the hum of conversation on all sides, and make pathetic attempts to keep order. What the men were there for was to have the chance of a gossip, and I was pretty well ignored except, I remember, by one sycophantic clerkly fellow who seemed to listen and want to draw me out. I knew that I was making a fool of myself, and that if this was what social work was then it was not for me. I put in an application to the Warden and Residents' Committee to be permitted to regard my work at the bedsides of the poor and sick and dying as a sufficiency of social work, and this specious plea was actually allowed though I think with a poor grace. I was not well regarded after that; and when the residents at their dining table heard my fits of laughter (over Gerhardi's Polyglots, I remember) and saw me at ease in front of the fire, my image suffered further damage. Some years later an exresident wrote a history of Toynbee Hall, in which as an appendix there was a complete nominal roll of all the residents up to that date ‑ complete, that is to say, but for my name, which had been omitted like that of a criminal.
About this time I developed a craze for gambling. There were about four or five of us who indulged this taste at Toynbee, and we would meet in the most spacious of our bed‑sitting rooms at least once or twice a week. Bridge was soon thought too slow, poker followed, and then the nakedly gambling games like crown and anchor and roulette. It was at this game that I learned a lesson which stayed with me ever after. Typically of my nature, I was trying to get the better of the odds; instead of taking the slim chance of a big win, I wanted the maximum chance, certainty indeed if attainable, of some win, however small. In pursuit of this, starting with a small stake on an even chance, say red or black, I doubled it every time I lost until at the end I should have recovered the initial stake plus its equivalent. Unfortunately with this cautious technique, a long run of ill luck can be murderous. Sweating, I was finding I had bet all the money I had and was now venturing my next month's allowance; what would happen if that went I did not even envisage. Fortunately, the last bet won and I only found myself out of pocket by that small amount occasioned by rounding off when passing by doubles from pennies into shillings and shillings into pounds.
I was not entirely cured of the itch to gamble, but after this confined myself to games with an element of skill (particularly poker, when I was a resident at St. George's). In post‑graduate years in London I also played a good deal of bridge; and in general I fancied myself at games of skill. Here too I have been taught lessons of humility. I gave up poker after a game in the emergency hospital I was seconded to in the war years; at this there was one good player, who took the money of all the rest of us and gave me the clearest demonstration of my incapacities. I have had exactly the same experience at bridge, and indeed from the same man, a well‑known ear surgeon; but here I was more put off the game by playing with a married couple who bickered through the evening and were so passionate in their addiction to that there could be no interval for conversation or even for refreshments which had to be consumed at table. Most instructive of all was when I met someone very much my master at chess, in a postal game in which one had all the time one needed for reflection and calculation. This was a bewildering experience. After the opening development, in which my opponent chose almost from the start a little‑played and unorthodox line, I found myself becoming more and more unclear about what his intentions were. Time and again, the reply I expected was not made, perhaps indeed one different from all the possibilities I had considered plausible. On the other handm, each of the possibilities I considered for my own play disclosed itself as having objections and weaknesses. Eventually I had entangled myself into a cramped position in which instead of developing my own game I was restricted to holding off the enemy attack. It came, indeed, from an unexpected quarter; the gap in the armour was exposed and the knife came through.
Somewhere in his recollections Bertrand Russell has spoken of what it was like to meet on the intellectual level someone considerably more able than oneself, in his case Maynard Keynes. In my chess game I felt as if I was living in a thick darkness out of which cobwebs were descending on me, always thickening the dark and hampering my movements. My opponent, I knew, was in the light. The impression one gets at a scientific meeting is not quite like that. More than once I have heard J. B. S. Haldane enter the discussion of a paper presented by myself (and others too, of course) and shine like some kind of firework. Squibs are let off in all directions, exploding among one's cherished ideas, and one thinks again and again "how dull of me not to have thought of that." But I fear we can learn only from our intellectual equals or near equals; and those to whom we are as mental defectives can neither instil us with any of their brilliance nor even give us perhaps the line that we in our inferiority should choose in which to go on with our work. I certainly learnt no chess lesson from my victor and I fear that in the course of my connection with genetics I never learned much from Haldane.
In my day it was possible to qualify after only 21 months of hospital practice with the "Conjoint" examination; the university diploma of M.B. required one more year. I succeeded in getting my qualification in minimum time, but once again it was not without a smile from fortune. One such came to me in the written examination in medicine. There before me stood the question, demanding that I should te examiners what I knew about "dementia praecox." I looked at it aghast. I had heard of this disease. After some hesitation I went up to the invigilating exal and asked "Please, sir, is this another name for G.P.I.?," to which he replied can't very well expect me to answer that question, can you?" I retired to my for another think. Clearly this could not be another name for G.P.I., since if i been a rarely used synonym, he would surely have told me. It was then some different, apparently a dementia and coming on in young people. I sat down and wrote. I threw in everything I had ever heard of. The disease was commonly insidious and progressive but could be interrupted with acute attacks, mania, melancholia, delusions, hallucinations, confusion, homicidal and suicidal outbursts, remissions that did not last, a tendency to relentless deterioration of mind and character. The pathology, I wrote, was unknown (it had to be, since I had never heard of it); some thought that it belonged to the group of progressive disorders for which Gowers had advanced his hypothesis of abiotrophy. I feel sure that on this question I scored at least a pass. I dare say that the examiners themselves, necessarily none of them psychiatrists, knew no more than I had invented. Clear proof of widespread ignorance was given me a few years later when I tried to look up the subject in a well known textbook of medicine. I was a neurological house physician at the time, and I was trying to find what might be the matter with a very odd patient, who showed nothing abnormal neurologically, who seemed sometimes to be bright and at other times answered so oddly that you might take him to be mentally deficient. After a thorough study of the chapter on psychological medicine, I came to the conclusion that my patient might be suffering either from schizophrenia or from dementia praecox. The two disorders seemed to have much in common, but they were distinct since each had its own section, with a number of pages separating them (1930).
After qualifying I had a brief experience of general practice. A G.P., ex‑St. George's, who must have had an extraordinarily confiding disposition, let the School secretary know that he wanted a holiday locum for about ten days. I went out to see him, in a nice house in a pleasant leafy residential part of Bucks, about twenty‑five miles from the centre of London in the Oxford direction. The experience should have been idyllic. I was living in the doctor's house, waited on by his domestic staff, driven around by his gardener‑chauffeur. It was hell. I was called to patients who had something the matter with them, pains in the tummy, unexplained fevers, a sprained (or was it fractured?) ankle, which I was usually unable to diagnose, and if able to diagnose did not know how to treat. The only patient of all those I visited whom I could recognise as suffering from a familiar syndrome, was an emaciated young man in a poor cottage with lumps all over his belly to be felt through the thin abdominal wall. That I had seen in the wards at St. George's, and knew it for tuberculous peritonitis.
The doctor had warned me that there was one baby case coming up, in a young primipara and no complications to be expected; if there were, I could call in his partner who lived a couple of miles away. I regarded this prospect with sinking sensations, since despite all the regulations I had only delivered one baby, and that in the wards and under supervision. My hopes that the baby would be delayed were disappointed, and in due course I was sent for. There at the cottage was the district midwife, who should have been able to manage the whole affair without my help. I asked her whether she had examined the patient and what was the lie of the baby's head. She said yes, and it was one of the two normal positions with the baby's occiput to the front, either right or left. In the course of my examination I thought it was an occipito‑posterior presentation, but thought that I must be wrong as I was so inexperienced. To cut a horrid story short, it was an occipito‑posterior and it never corrected itself. All that day the patient continued in labour, without advancing. I came and saw her, and went away, and came again, and walked about in the doctor's garden in the delicious early summer weather, sweating and groaning and wishing I were anywhere but there. It would be too impossibly bad luck to have my first delivery an abnormal one! In the end I was injecting pituitrin in a kind of panic, and did not have the courage or the cold common sense to call in the partner until the early hours of the following morning. He was most kind, and accepted this abysmal conduct as just a manifestation of the natural irrationality of mankind. He found the baby's head stuck, applied forceps, and dragged it out face to pubes, dead.
General practice would not be for me, and I should have to work for some time with the shadow of the hospital's authority behind me. I was lucky in getting my year of hospital appointments at my teaching hospital, and for four months in turn was casualty officer, house surgeon, and house physician. My period as house surgeon was spent with Mr. (later Sir) Claude Frankau, who rapidly became allergic to me. I do not know quite what it was about this long, gangling (189 cm, 70 kilo), ham‑handed youth that put him off; I always imagined that it was because he sensed some lack of respect when, in the course of those long bed‑side discussions on the Surgeon's round, I edged my behind onto the corner of a locker, instead of standing dutifully fully erect, to save some of my blood from sinking into my belly. Every house surgeon regarded it as one of his rights to be allowed to perform one operation on an inguinal hernia and one operation on a quiescent appendix under the supervision of his chief. In the last week of my tenancy of the appointment, Mr. Frankau placed the knife in my hand and indicated where I was to make the skin incision. However, no sooner had I taken hold of it than he exclaimed: "That isn't the way to hold a scalpel! Here, let me show you!" With that he took the knife back again, and completed the operation himself.
My period as a House Physician with Hugh Gainsborough was much more rewarding. I was still capable of failing miserably to carry out an air‑replacement of a pleural effusion (to the confusion of the Registrar's class of students in the afternoon who all mistook the "hyperresonant" chest for a "dull" one); but I enjoyed the sustained excitement of working through the night to save the life of a patient in diabetic coma, and of demonstrating by my own preparation the pneumococci in a sample of cerebrospinal fluid I had taken. I don't know quite how good or bad I was. Gainsborough advised me not to try to take the Membership of the Royal College of Physicians, which would be the portal of entry for a career as a specialist.
My year came to an end. I was enjoying life so much in the "Cottage" (the residents' quarters) that I could not bear to leave. I applied for and got six months as resident anaesthetist. I should think I must have been the worst ever. My predecessor was an extremely able man, and he had been practically the first at St. George's to use gas‑oxygen machines and introduced the technique of intubation (passing a catheter into the trachea). I tried to follow in his footsteps, but would have been better advised to do just what all the Hospital's senior anaesthetists did ‑ just pour the mixture of chloroform and ether onto an open mask.
After that they threw me out, and what was I to do now? Hospital it had to be. I thought first of paediatrics and then of neurology. I was turned down for the paediatric job I applied for but got the neurological one, and so became junior house physician at the West End Hospital for Nervous Diseases, and resident in the small in‑patient department in a converted mansion in its own grounds in the very substance of Regent's Park probably the most delightful quarters of any hospital in London. I had been attracted to neurology by the clinical demonstrations of James Collier, with all the elegance that neurologists, the prima donnas of the medical profession, aspire to and so frequently attain. Now, in practice, I found that neurology suited me well, although my lack of feeling for anatomy would have been a serious handicap if I had proceeded with it.
During my year at the West End I succeeded, despite Hugh Gainsborough's opinion, in passing the examination for the Membership of the Royal College of Physicians. This was then a ferocious ordeal in which at three successive stages one had to report to receive an envelope in which there would either be a notice of dismissal or a request to present oneself for further examination. I failed at the first hurdle on the first attempt, and on the second went through all stages up to the final terrifying oral in which one faced not only the four Censors but the President of the College himself, in his robes of office. The strangest stories circulated among candidates about the out of the way, or ironic, or utterly bizarre questions that had been asked and might be asked. My toughest nut was a question about psittacosis, an infection then current which had been passed to mankind from parrots. All I knew about it was that it somewhat resembled typhoid fever. In the vaguest terms I dared I described, as the symptoms of psittacosis, the leading symptoms of typhoid. My questioner grumbled "Sounds rather like typhoid to me," but fortunately did not cross‑examine me further.
After this, my ambitions revived somewhat and I determined to try to get to Queen Square. At that time there were three neurological hospitals in London, of which the National Hospital at Queen Square was sublime, the one at Maida Vale respectable, and the West End despised. The reason for the contempt in which it was held lay in the fact that, very sensibly, it had psychiatrists on its staff to help with the large numbers of psychiatric patients which, then as now, are attracted to neurological clinics; and a neurologist, who allows himself to associate with such borderline citizens, must be badly in need of a hospital appointment. In due course a vacancy for a house physician at Queen Square was advertised. I made my application, and went the rounds of the doors in Harley Street, Wimpole Street, and Queen Anne Street calling on the demigods who had my fate in their hands. My reception was every bit as forbidding as I could have feared. Both Kinnier Wilson and Gordon Holmes (names that were glittering with fame, in that little world) implied that it was really rather impudence on my part to be applying for such a wonderful job, and Gordon Holmes told me it was a senior appointment for which I was quite insufficiently prepared. However, I heard later that I had been a second choice when it came to the decision, the man who got the job having worked at Queen Square in a voluntary capacity for some months. I meant, then, to have another shot, and considered how I might prepare myself better for it.
Now, for the first time, it seemed to me that I ought to know something about psychiatry. Everyone knew that the neurologists drew most of their income from consulting on psychiatric patients, and it would be well then to have some understanding of them. I wrote to Edward Mapother and asked him whether he would be able to take me on at the Maudsley. This time the response was encouraging. He asked me to come over to see him, and at the end of the interview told me he would like to take me on but that there was no vacancy now or for some time to come. Looking through the advertisements in the Lancet, I next saw a vacancy for an Assistant Medical Officer at Derby County Mental Hospital, residence and £350 per annum. I applied for it, was summoned north (a hundred and thirty miles) for an interview with the assembled committee of the local authority and the medical superintendent, and was appointed. I had been the only applicant.
There now began an extraordinary interlude in my career. The hospital was shut off from the world in its own extensive grounds by a high stone wall, through which the main egress was by a great pair of iron gates, fronted by a weighbridge, at the side of a lodge. Foot‑passengers went through the lodge; cars, vans and lorries through the gates which were specially opened for them. Now the great stone wall has disappeared, and the patients are made at home in villas instead of those long halls, lined by shuttered side‑rooms, that housed them in my day.
Most of the patients who were allowed some liberty were restricted to ground parole, but there were a few who were allowed at times to go down to the village, and execute small commissions for fellow patients. The little world inside was governed by the medical superintendent, and the medical assistance, at the time I was there, consisted of the deputy medical superintendent whose wife practised as a general practitioner in the neighbourhood, an elderly bachelor "locum," and myself. It was difficult to find someone to make contact with, but I did get some human companionship from the dispenser.
The day's routine consisted of rising at 9.30, in time to put in an appearance at the superintendent's "office" at 9.45. Here we three doctors stood lounging in front of the desk, at which sat the superintendent, his clerk at his side, while the morning's mail was opened. Answers, mainly about patients to questions from their relatives, were dictated to the clerk, on information provided by the doctors. The affair was over by 10, when I went upstairs again to eat the breakfast still lying rather coldly on the table and read the paper. At 10.30 I would start on the morning round, which was confined to male chronic wards. The acute reception centre was looked after by the super himself, the female wards (notoriously more difficult than male wards as well as having a heavier case load) by the deputy and the locum. My round consisted in walking briskly from one ward to another, initialling a diet sheet put before me by the charge nurse, asking him whether there was anything else, and moving on. Sometimes an annual clinical note was required, and sometimes a statutory recertification. The annual note would be written by me, the charge nurse standing at my elbow telling me what to say: "He is very melancholic and depressed, sir, and believes his insides are being eaten up by lice. He is extremely dependent and devoid of initiative, and still in need of hospital care". The recertification was too responsible a job for a beginner, and the patient would be sent to the office for one of the two seniors to do it. There were also periodical physical examinations, and the visit of the ward for the sick and bedridden. The whole thing, though it involved perhaps three quarters of a mile of walking, would be over by 11.30 to 11.45, when would come my visit to the hospital dispensary, a cup of coffee, and a gossip with the dispenser. On four afternoons a week I would be off duty, and so able to take a bus into Derby, where my principal errand was to go to the Boots lending library and change my book. The two half‑days on which I was on duty, most of the time would be spent, when the season advanced, in playing tennis. Two week‑ends out of three I was off, and would have been able to go away on a visit, if Derby had not hccn, as it seemed to me, lost in the unknown northern parts of the country, and an unmanageable sum in travel money from the genial south.
It could not be said that the clinical work demanded of a junior psychiatrist in the chronic wards was of a stimulating or educative kind. There was nothing that one could do for the chronic patients; and when from time to time, in the course of wiiting the required six‑monthly notes, I settled down to a talk with the patient, and found that he was much saner, happier and healthier than one might gather from his records, my efforts to get him considered for discharge were not well received. My seniors relied in the main on a security argument; the man might seem to have recovered, but underneath he would show some residuum of his old illness, let us say lingering belief in the reality of delusional experiences of the past, or a degree of emotional lability and a liability to get down‑hearted. Such men were not safe.
Practically always, of course, the relatives of these patients had long reconstituted their family lives without him and would not be over‑enthusiastic about his return. In quite a few cases, the patient himself had become happily adapted to hospital life. I remember particularly the groundsman who loved the cricket pitch as if it had been his own lawn, and though long since recovered from a single attack of an affective psychosis, was reluctant to face the insecurities of the outside world.
In due course, another vacancy for a house physician at the National Hospital was advertised, and I applied. I might have spared my effort. It was for nothing that I invested in a short black jacket and waistcoat and pinstripe trousers, came up to London, and went from door to door in the Harley Street area. I had touched pitch and had now become defiled. I imagine that I was quite written off, and did not receive even that degree of consideration which had met my first application.
My position now was extremely discouraging. I could not bear the life I was leading, and I even thought of applying for a post as a ship's doctor, in order to see some of the world before I settled down to whatever fate I should have to meet in the end. However, even in my state then, I could not voluntarily enter such a blind alley as that. I had heard nothing from Mapother, but clearly could lose nothing by writing to him again. I did so, and poured out my heart. Work in the mental hospital, I wrote, was completely stultifying. One was not even a doctor who could try to help his patients, but only a custodian. Any clinical discussion of the strange and ununderstandable case material was out of the question, since my colleagues were not interested. As for the possibility of research ‑ !
This last point may have been made more because I knew that research work was highly regarded at the Maudsley than because I myself felt any strong spontaneous urge. In fact, I did not have the least idea what research was. None of my clinical teachers had been research workers and few, very few, had made any original contribution to medical knowledge. This instinctive appeal, however, did touch Mapother on a soft spot. He replied, almost by return, that there would be a vacancy for a locum to do holiday duty, if I liked to come south and try it, without any guarantee for the future. I remember still the last journey by train from Derby, on a Sunday evening in the beginning of October 1931, giving myself the treat of a dinner in the restaurant car, and hugging myself all the way with joy.