Part 2 of a 3 part series
The asylum as curative
Asylums themselves were, at least initially, deemed curative. For some years, there were no specific ‘psychiatric’ treatments given to the patients, other than opium, which in Essex was used ‘freely’ for melancholia. Medical conditions were still being treated with blisters, leeches and blood letting. It also appears that bleeding had been used to exhaust agitated patients prior to asylum admissions, but fortunately, this practice was ‘now being discouraged’.
Initially, mechanical restraint was employed for agitated patients in Essex. It was ‘usual for patients to be brought in chains, straight jackets or handcuffs, whether necessary or not’, and ‘straight waistcoats and locked gloves’ were used on ‘the determinedly suicidal’.
In common with other asylums, the use of restraint declined, and was rare by 1900. The granting of increased autonomy to patients followed from the the ideas of French revolution, via Pinel’s efforts in Paris. The Essex asylum records describe how restraint came to be viewed with ‘pious horror’.
Recreational activities were ‘well used’ at the asylum. These included chores and occupational therapy (in the original, literal use of the term), although the patients also had the use of cricket equipment, a skittle shed, bowls, quoits, lawn billiards, and from 1857, a library. There were regular dances, entertainment from musicians and ventriloquists, and walks and picnics in local landowners’ estates. Such activities were thought of as a mainstay of treatment.
Sedatives and stimulants
1870 brought the first mention of a specific treatment other than opium at the asylum. These medications were thought of, at the time, as falling into one of two groups: stimulants or sedatives.
New sedatives included chloral hydrate (later infamous as the date-rape drug ‘Mickey Finn’), croton-chloral, and Indian hemp. The latter is also known as cannabis indica, which has predominantly sedative effects, as compared to cannabis sativa, which produces a ‘high’. Kush, named after the Hindu Kush mountain range in Asia, is a strain of cannabis indica.
Nux vomica was another newly introduced medicine. A product of the strychnine tree, native to southeast Asia, nux vomica continues to be marketed as a homeopathic remedy for nausea and indigestion.
New stimulants included amyl nitrate, which can induce euphoria and dissociation, and today is used recreationally in the form of ‘poppers’.
In 1876, the calabar bean was introduced to Essex as a treatment for General Paralysis of the Insane (GPI), a result of chronic syphilis infection. The bean is the seed of an African plant, and because it contains physostigmine, which acts in the same way as a nerve gas by disrupting nerve-muscles communication, it is toxic to humans at high doses.
The spread of syphilis
Before antibiotic treatment for syphilis were discovered, many patients at the Essex asylum were diagnosed with GPI. Syphilis is a sexually transmitted infection, which usually starts with a painless genital ulcer. If untreated over many years the infection can spread to other parts of the body, including the heart and brain. Infection of the brain leads to a variety of progressive neurological and psychiatric symptoms, including poor memory, exaggerated reflexes, delusions of grandeur, and clouding of consciousness.
GPI is an interesting early example of a diagnostic term that was expanded to include, in the words of the Bethlem Asylum Superintendent Theo Hyslop: ‘nearly every possible abnormal mental manifestation’. It seems to have proved tempting to alienists to attribute any unexplained symptom and sign of mental illness to this known diagnosis, perhaps as today’s psychiatrists do with expanding labels like Bipolar Affective Disorder. A biological (infective) cause of syphilis was eventually revealed, a feat that modern psychiatry continues to attempt to repeat with our modern day myriad of maladies, with little success.
From alienists to modern psychiatry
The late 19th century marked a shift in the perception of madness in society, and the birth of modern psychiatry.
Michel Foucault, in ‘Folie et Deraison’ (Madness and Civilisation), notes how the idea of madness evolved from the supernatural beliefs of the middle ages, where it was viewed as socially significant and even divine, via being seen as unreason and the antipathy of the 18th century Enlightenment, to being thought of as a moral failing and becoming medicalised in the 19th century.
Asylums had been founded as places where individuals went to be cured, but, as historian Rhodri Hayward notes, they gradually took on the role of saving the human race, in a time when insanity was seen in Darwinian terms. From offering asylum to the mentally troubled, they became warehouses for vagrants, prostitutes, and the senile. In doing so, they removed the toxic cells damaging Herbert Spencer’s ‘social organism’, or ‘body politic’, in which society was seen as a functioning organism, for example workers as the muscles, and the government as the nervous system.
Mental illness was seen as hereditary, the result of bad breeding, related to moral degeneracy. This was a eugenic approach to mental illness, subscribed to both by Maudsley, and Emil Kraepelin, the father of modern psychiatry.
Kraepelin was the first to classify psychiatric diseases based on patterns of symptoms over time, and distinguished dementia praecox (schizophrenia) from manic depressive psychosis (which included melancholia and manic depression). He was sure that a biological cause of madness existed. His ideas caught on, and with increasing patient numbers, asylums became laboratories filled with cases for Kraepelin’s followers to study. Madness had been medicalised.
In the Essex asylum records, the nascent stages of this era are marked by the introduction of a questionnaire with which to take patient histories in 1862, the use of the word hospital for the first time in 1874, and the start of training for attendants, with a skeleton sometimes hired for lectures. Investigations into organic structural abnormalities as a cause of insanity were started in Essex from 1910.
There are interesting notes of early experiments with coloured glass in treating patients, with violet for excited patients, and rose for melancholics. Unfortunately, the results are not documented. These experiments have some parallels with more modern research on colours and the placebo effect, which has shown that anxiety symptoms respond best to green placebo tablets, whilst depressive symptoms respond best when the tablets are yellow.
The search for biological causes and effective remedies continued unsuccessfully for some years, fostering a growing sense of therapeutic nihilism within the psychiatric profession. The available treatments were viewed as non specific, and a major emphasis remained on fresh air (outdoor relief) and a healthy environment, distinctly unglamorous interventions compared to the technological advances being made in medicine.
Next time – Part 3: Psychiatry’s Melancholia Lifts