In our final instalment of the ‘Surgery in the Asylum’ series, I want to consider the possible effects of surgery on patients – not necessarily those in the asylum, but hospital patients more generally. Towards the end of the 19th century, concerns were growing about cases in which surgeries of various kinds appeared to have caused insanity.
To take one example, a 48 year old woman was admitted to hospital in February 1883 after suffering from an ovarian tumour for some years:
‘Ovariotomy was performed … The progress of the case for the first six days was satisfactory enough; she was cheerful, anxious to get well, and slept and ate normally. On the sixth day her physical condition was satisfactory, but her expression had entirely altered. She still recognized her husband and those of us who were immediately concerned with her care, but her mind was full of delusions varying in their nature, but all to her of an alarming character. She was very restless in bed. On the eighth day she was in a condition of acute mania. She recognized no one, attempted to injure those about her, and was very violent. … My friend Dr. Savage was kind enough to see the patient with me, and looked upon it as an ordinary case of acute mania. The wound was dressed on the eighth day [where it was found] she had torn the edges apart in her struggles … During the next eight-and-forty hours the mania continued with undiminished intensity. Her physical condition became weaker, and the greatest difficulty was experienced in getting her to take any food. She died exhausted on the eleventh day.’
At post-mortem, it was reported that nothing could be found that explained the woman’s rapid mental decline. What had caused such a marked change in her character after the operation?
One possibility was simply the disturbing experience of undergoing an operation. The dread and fearful anticipation experienced by patients before surgery was recognised by C.T. Dent, who reminded the readers of ‘Insanity following Surgical Operations’ that almost everyone felt somewhat emotional before such procedures. If a person was especially nervous, he said, it was ‘no uncommon thing to see [them] in a deeply hysterical state, continuing for days, after [for example] the extraction of a tooth, where no anaesthetic was administered.’
Administering anaesthetic, however, was no sure-fire way around the problem. An oft-cited explanation for post-operative insanity was the use of anaesthetics and antiseptics during surgery. The use of chloroform or ether to sedate the patient, and of iodoform or carbolic acid to prevent infection, were increasingly implicated in post-operative issues – and sometimes death. ‘Chloroform deaths’ attracted significant press attention in the late 1800s, where doctors were often depicted recklessly administering chloroform to helpless patients. It wouldn’t be surprising if such a perilous chemical could also bring about insanity. Too much chloroform or iodoform absorbed into the body was suggested by some to have a toxic effect on the brain causing mental disturbance, much like excess alcohol. (Conversely, some writers posited that alcoholic patients might become temporarily insane as a result of the enforced drying-out period in hospital before and after an operation.)
Variations between cases, though, made it difficult to pin down any particular cause with confidence (what about cases of insanity where anaesthesia hadn’t been given?) and it was here that the patient’s predisposition was appealed to. In inherently ‘unstable’ individuals, an operation might – like an accident or traumatic event – act as a catalyst. S. Weir Mitchell put this forcefully in a speech to the College of Physicians of Philadelphia in 1910: ‘We must consider the patient as a loaded gun, and that the surgeon merely pulls the trigger.’ Not all agreed about this hereditary influence, noting that the main point of interest in many cases of post-operative insanity was the pronounced lack of family insanity or previous attacks. It was precisely this absence of hereditary taint that made cases of post-operative insanity so interesting.
A vocal critic of hereditary theory was Henry Cotton, who – in an interesting reversal of the operations = insanity equation – advocated surgical intervention to cure (and sometimes prevent) mental disturbances. In their quest to tackle the somatic origins of insanity, Cotton and his colleagues removed thyroid glands, ovaries, teeth, tonsils, and sections of intestine (an undertaking chronicled in Andrew Scull’s Madhouse).
Cotton’s solution to insanity was an alarmingly simplistic one that had predictably dire results: post-operative infection, sometimes resulting in death, and relapses of mental illness. His endeavours demonstrated precisely what his predecessors had worried about: in examining the links between surgery and insanity they had been cautious in assigning mental disturbance to a single cause like infected teeth or tonsils. Within discussions of post-operative insanity several factors might be cited to explain the phenomenon – often in collaboration – and the fact that it could affect people with no apparent hereditary predisposition somewhat blurred the boundary between ‘sanity’ and ‘insanity’. Identifying the definitive cause of mental illness is an enduringly attractive prospect, seen today in the hunt for a ‘schizophrenia gene’ for example. Just how far biology can provide a complete explanation, however, is a question equally enduring.
On chloroform deaths, see Ian Burney, Bodies of Evidence: Medicine and the Politics of the English Inquest, 1830 – 1926 (Baltimore: Johns Hopkins University Press, 2000).
A.C. Butler-Smythe, ‘Acute mania following rupture of the rectum by enema thirteen days after ovariotomy. Recovery‘, Journal of Mental Science (Jul. 1893).
William Noyes, Review of Folie post-opératoire by Prof. Mairet, The American Journal of Psychology 4 (Dec. 1891).
J. Christian Simpson, ‘On post-operative insanity, with notes of a case occurring three weeks after laparotomy‘, Journal of Mental Science (Jan. 1897).