Tag Archives: general paralysis of the insane

Medical technology in the asylum – and plans for the blog

With the Science in the Asylum conference completed, we’re excited to begin a more regular blog schedule, with posts each Monday from myself, Mike, and guest contributors. Submissions are strongly encouraged – the conference brought us into contact with several people working on the history of science and medicine in relation to the asylum, and we’d love to find more of you! Please get in touch here.

This is the first of our Monday blogs, and takes up a theme we plan to revisit in some future posts: the use of medical technologies within the asylum.

By the 19th century, as doctors increasingly focused on bodily lesions as the site of disease, there was hope that disturbances of the mind might also have somatic origins. It was commonsensical, for example, that the activity of the brain depended upon its blood supply; thus, blood vessels were often identified as the starting point of disease. Daniel Hack Tuke’s Dictionary of Psychological Medicine noted that ‘capillary disorder could lead to a wide variety of dysfunctions’, and suggested that circulatory issues were the cause of many mental diseases. Indeed, during microscopical and post-mortem investigations, the poor state of patient’s blood vessels was often noted.

How could such bodily change be examined in the living patient though? In Medicine and the Reign of Technology, Stanley Reiser lists the new pulse-recording instruments that appeared in the 19thcentury. Among these, Étienne-Jules Marey’s sphygmograph of 1860 was crucial. By resting one end of a piece of metal on a pulsating artery, and attaching a pen to the other, the pulse could be made visible as each movement was traced onto a strip of paper.

Marey’s sphygmograph. © Wellcome Images

By the 1880s, Marey’s device had been eclipsed by Robert Ellis Dudgeon’s ‘pocket sphygmograph’, a smaller device that was especially useful for the asylum physician who dealt with restless or excitable patients.

Dudgeon’s less cumbersome ‘pocket’ sphygmograph. © Wellcome Images

Sphygmographs had their problems: each model might produce a slightly different result, or be further affected by the technique of the person using it. Nevertheless, George Thompson at Bristol Asylum said that he ‘implicitly trusted [the] instrument as a means of discovering at least one form of brain-disease’. He applied the sphygmograph to almost every form of mental disease found in the asylum, but found the most striking results in general paralysis (now understood to refer to neurosyphilis).

In the West Riding Medical Reports in 1871,Thompson described his experiments on the pulse of general paralytic patients at the West Riding asylum. He presented two tracings, one from his own research and one from W.B. Carpenter’s Principles of Human Physiology. They bore a remarkable resemblance. Whilst Thompson’s example represented the pulse of a general paralytic, Carpenter’s showed the pulse of a healthy person in a state of chill.

Thompson’s pulse tracing of a general paralytic patient.

…And Carpenter’s tracing of a healthy individual suffering from ‘chill’.

To Thompson, it was evident that in both cases a contraction of the vessels was being recorded. He concluded that general paralysis was ‘a disease … owing to a considerable extent to persistent spasm of the vessels’.

Could halting this spasm also halt the degenerative process that was characteristic of general paralysis? James Crichton-Browne was one of several alienists who used Calabar bean for this purpose. Calabar is a poisonous seed from an African plant, lethal if ingested in anything more than minute quantities. It was put to a number of uses in the 19th century due to its ability to paralyse muscle, and proved to be the first effective drug treatment for glaucoma. It was suggested that Calabar could lead to an improvement in general paralytic patients such as ‘S.M.’:

‘When admitted to the West Riding Asylum he had exalted ideas; there [was] inequality of the pupils, tremor of the lips, and awkwardness of gait. … [After three months of treatment with Calabar bean] there was such marked improvement in his condition that the use of the extract was discontinued.’

Calabar beans. © Wellcome Images

Calabar’s relative scarcity in the historical record suggests it was seen as an occasional palliative measure rather than cure, however. Writers on the subject were at pains to point out that they knew of no authenticated cases of cure; those patients who recovered enough to be discharged were often re-admitted later, any improvement proving only temporary.

These experiments with the sphygmograph in the Victorian asylum are interesting for a number of reasons. Many historians have emphasised how new medical technologies in the 19th century served to remove the patient’s subjective experiences from the picture, with doctors relying on supposedly ‘objective’ mechanical data. In the case of the sphygmograph, data didn’t necessarily eclipse the patient, with the tool employed alongside established methods of clinical examination including consideration of the patient’s own testimony.

Looking at the use of such technology in an asylum context can also expand our understanding of the asylum’s place within contemporary medical landscapes. Christopher Lawrence describes the sphygmograph as a tool with limited usage, partly because experimental physiology only developed as a specialty in the 1870s. The use of it in the asylum suggests that researchers there were drawing inspiration from a wide variety of medical disciplines – a spirit of innovation also evident in the invention of instruments and post-mortem tools by members of the alienist community.

Examining such research can also problematise wider assumptions about the development of the medical profession and the resulting impact on patients. As described above, post-mortem findings could raise questions that were investigated further in the laboratory, the findings of which then informed clinical intervention. The notion of an easy split between the laboratory and clinical contexts, then, is perhaps less applicable to the asylum at this time.

Forgotten episodes within the history of asylum research are often forgotten because they don’t involve a breakthrough discovery, a success story, or a bizarre intervention that raises our anxieties about patient care. Yet they can also be places where we might find alternative viewpoints to the pictures presented in broader histories of medicine. Perhaps then, unusual endeavours such as Thompson’s should grab our attention not as side projects in the historiography, but as narratives with wider historical significance.

Further reading

William Bevan Lewis, ‘Teachings of the Sphygmograph in General Paralysis of the Insane’, Journal of Mental Science 27 (1881).

T. Duncan Greenlees, ‘Observations with the Sphygmograph on Asylum Patients’, Journal of Mental Science 32 (1887).

Christopher Lawrence, ‘Physiological Apparatus in the Wellcome Museum. 1. The Marey Sphygmograph’, Medical History 22 (1978).

Christopher Lawrence, ‘Physiological Apparatus in the Wellcome Museum. 2. The Dudgeon Sphygmograph and its Descendants’, Medical History 23 (1979).

Alex Proudfoot, ‘The Early Toxicology of Physostigmine: A Tale of Beans, Great Men and Egos’, Toxicological Reviews 25 (2006).

Stanley Joel Reiser, Medicine and the Reign of Technology (Cambridge: CUP, 1978).

George Thompson, ‘On the Physiology of General Paralysis of the Insane and of Epilepsy’, Journal of Mental Science 20 (1875).

George Thompson, ‘The Sphygmograph in Lunatic Asylum Practice’, West Riding Lunatic Asylum Medical Reports 1 (London: J & A Churchill, 1871).

Keith Wailoo, Drawing Blood: Technology and Disease Identity in Twentieth-Century America (Baltimore: Johns Hopkins University Press, 1997).

– Jennifer Wallis

Forgotten histories of psychosurgery, and facing our fears

In 1890, T. Claye Shaw and Harrison Cripps related the case of a male patient at Banstead asylum who was suffering from general paralysis of the insane – a diagnosis now believed to refer to neurosyphilis. Post-mortem examinations of these patients often found large amounts of cerebro-spinal fluid (CSF) in the skull, and it was findings like these that could be used to inform treatment of the living patient. Under Cripps’s care, it was suggested that the patient had excess fluid in the skull that ‘was exercising considerable pressure’ and causing excruciating headaches. As a means of relieving this intra-cranial pressure, trepanation was performed – the removal of a small piece (or pieces) of bone from the skull.

A Bronze Age skull showing the marks of trepanation. © Wellcome Images.

In the historiography of psychosurgery, the use of trepanation in general paralysis is frequently absent. Searching index entries for ‘Psychosurgery’ often instructs one to ‘See Lobotomy’, reflecting our modern view of psychosurgery as those infamous methods instituted by Egas Moniz and Walter Freeman. Many accounts of psychosurgery’s development jump from ancient practices of trepanation to the early twentieth-century interventions of Moniz and Freeman, sometimes interrupted by reference to the work of Swiss alienist Gottlieb Burckhardt in the late nineteenth century. Burckhardt is then credited with the ‘discovery of psychosurgery’ – by his almost contemporaries and pioneers of lobotomy, Walter Freeman and James Watts, for example.

There was significant interest in the topic before Burckhardt’s work, however: Paul Broca examined a Peruvian skull that bore the marks of trepanation sent to him by an anthropologist acquaintance. That such findings would occasion a rejuvenation of interest in the topic amongst the alienist community appears an almost foregone conclusion, yet there are few references to the Shaw episode – or similar undertakings – within histories of psychiatry and psychosurgery. An exception is German Berrios’s work – in 150 Years of British Psychiatry (volume 1, 1991) and his 1997 article, ‘The Origins of Psychosurgery: Shaw, Burckhardt and Moniz’. Berrios places the work of Shaw alongside that of Burckhardt, and also addresses the moral implications of such invasive treatments. Though there is little evidence that it was a particularly common intervention, looking back on trepanation within the asylum appeals to our worst fears about the patient as experimental object. Berrios shows, though, that the use of trepanation in cases of general paralysis was not presented unproblematically by asylum doctors, and that its proponents ‘were aware of the potentially serious consequences of their treatment, and of the fact that they needed scientific, ethical and social warrants’.

Though logical considering contemporary understandings of the disease, Shaw’s surgical solution to general paralysis was not without controversy. In the British Medical Journal during the late 1880s and early 1890s, a number of articles and letters debated the appropriateness of trepanation for the asylum patient. Shaw and Cripps were enthusiastic about the operation, appealing to data that demonstrated the ‘increased arterial tension’ in the early stages of general paralysis. It was a surgical response that depended on early diagnosis, said Shaw and Cripps: they were convinced that the benefit for the patient was clear if trepanation was performed as soon as possible. One such case was presented as a resounding success: ‘The present state of the patient is a great improvement upon what it was; in fact he is no longer insane, and I propose to discharge him’, Shaw related triumphantly. The patient from Banstead, however, fared less well: though initially discharged when his headaches and delusions disappeared, his wife later wrote to say that he had been unable to retain his job and had become increasingly irritable. To Shaw and Cripps, the operation still had its merits, as the ‘painful urgent symptoms’ had been relieved.

Trephination set, 1771 – 1800. © Wellcome Images.

Trepanation was of course an extreme response to the symptoms of mental disease. For some commentators, the intractable nature of general paralysis merited such measures. Others displayed contempt for the practice. Prestwich Asylum’s George Revington wrote to the British Medical Journal in 1890, criticising Shaw: ‘I may mention the practical point’, he said, ‘that general paralytics are quite sufficiently apt to injure themselves, and to be injured by others without the additional facilities which a trephine hole in the skull would afford’.

Ultimately, trepanation could not cure general paralysis. In Berrios’s analysis, it was symptoms rather than cure that were foremost in contemporary doctors’ minds: Shaw and Burckhardt were able ‘to target individual (troublesome) mental symptoms without committing themselves to having to treat the entire disease’. Just how far doctors saw themselves as relieving symptoms – rather than precipitating cure – is unclear, however. At the time, the cause (or causes) of general paralysis remained obscure, so that any anomalies – such as the abundance of fluid on the brain – might hold out the promise of a solution.

Last week, a friend posted a link on Facebook to the Science in the Asylum conference. The first comment on the link read ‘It was terrible what they used to do people back then’. But as well as what was done, shouldn’t we also be asking why it was done? It’s very easy to look back at medical treatments of 100 years ago with horror from our present viewpoint, and to assume that interventions were doled out by sadistic doctors based on little more than poorly-informed medical speculation. The reality, however, was rarely so clearcut, and debates between doctors much richer and varied than we often give credit for, as demonstrated by the correspondence around the Shaw affair. Whilst we should never lose the patient from the history of psychiatry, we must take care not to lose the doctor too.

 – Jennifer Wallis

Further reading

Joel Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century (Berkeley: University of California Press, 1997).

Stanley Finger et al, Trepanation: History, Discovery, Theory (Lisse: Swets & Zeitlinger, 2003).

Walter Freeman and James W. Watts, Psychosurgery: Intelligence, Emotion and Social Behavior following Prefrontal Lobotomy for Mental Disorders (Springfield, Illinois: Charles C. Thomas, 1942).

John Macpherson and David Wallace, ‘Remarks on the Surgical Treatment of General Paralysis of the Insane’, BMJ (23 Jul. 1892).

George A. Mashour et al, ‘Psychosurgery: Past, Present, and Future’, Brain Research Reviews 48 (2005).

Andrew Scull, ‘Somatic Treatments and the Historiography of Psychiatry’, History of Psychiatry 5 (1994).

T. Claye Shaw, ‘The Surgical Treatment of General Paralysis’, BMJ (16 Nov. 1889).