Tag Archives: history of surgery

Surgery in the asylum III: Post-operative insanity

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.’

V0017053 An unconscious naked man

Man attacked by demons armed with surgical instruments, symbolising the effects of chloroform on the human body. Watercolour by R. Cooper.
© Wellcome Library, London

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.

L0011590 Une laparotomie (a l'hopital Broca), by J. Heuse.

Doctors at a Parisian hospital perform abdominal surgery.
© Wellcome Library, London

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.

Further reading

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).

Surgery in the asylum I: Which way to the operating theatre?

On our lunch break a few weeks back, fellow postgraduate student Emily Andrews and I started to compare notes about post-mortem procedures in asylums (these are the kind of conversations you get into as historians of medicine – to our fellow diners, I can only apologise). Whilst both of us had uncovered quite detailed reports about the appearances of bodies at post-mortem, we had less information about the spaces in which post-mortems were performed. This led us to consider other medico-surgical spaces within the asylum.

There are many accounts in both archival and secondary literature of operations being performed on asylum patients. Alongside narratives of psychosurgery (covered previously on this blog) are tales of other types of operation: for cataracts, for removing foreign bodies ingested or inserted by patients, or for the excision of tumours. Rarely, though, are the practicalities of these operations mentioned. Where did they take place? Who performed them? Who benefitted (and who didn’t)?

The operating theatre of London's Metropolitan Hospital in 1896. © Wellcome Images

The operating theatre of London’s Metropolitan Hospital in 1896. © Wellcome Images. Is this perhaps what many asylum operating rooms looked like?

The need for surgical intervention within the asylum was graphically highlighted in an 1858 article by D.F. Tyerman, Colney Hatch Superintendent, in which he described various emergency situations involving suicide attempts by patients. In 1834, he had prevented the death of a male patient who cut his throat with a knife during dinner. Arriving at the scene, Tyerman ‘introduced into the wound [his] fore finger’ before plugging the wound with lint and tying the carotid artery. He was also called to attend situations in the immediate area beyond the asylum, including a man who had cut his throat in a nearby hotel. As institutions typically placed some distance from urban centres, Tyerman’s anecdote showed how basic medical skills possessed by asylum staff might be called upon by neighbours in an emergency.

This distance could be problematic for the asylum, however, especially if an institution lacked staff who were able undertake such heroic measures. J.H. Sproat, in 1899, related four cases of surgical intervention that had necessitated calling in outside help because staff at the Somerset and Bath Asylum lacked the necessary skills. In some cases, local doctors proved difficult to convince, being reluctant to operate in institutions lacking the usual facilities and no doubt fearing any ensuing coroner’s inquests. In large asylums, then, it was crucial to have, if not the staff, then at least the facilities to deal with medical emergencies, as well as to perform more routine operations. (Many asylum staff were able to perform minor procedures, though it appeared less common for them to undertake things such as amputation, as William Dudley had at the West Riding Asylum in the 1890s.) R.H. Steen, writing on asylum architecture, included an operating theatre in his plans of a model asylum; it should be located close to the wards and ‘centrally placed’.

Victor Horsley operating at Queen Square in the early 1900s. © Wellcome Images

Victor Horsley operating at Queen Square in 1906. © Wellcome Images

The importance of such facilities can be seen in accounts of the construction of Cardiff Lunatic Asylum, which opened in 1908 under the Superintendency of Edwin Goodall. Speaking at a meeting of the Medico-Psychological Association in 1908, he explained how ‘the object had been to give the Institution as much a hospital character as possible’ (indeed, he also considered the possibility of employing the term ‘mental hospital’ rather than ‘asylum’ – a change that did take place a few years later). In the original plans for Cardiff, an operating room was included at a cost of £600, then reconfigured to be accommodated within existing rooms for the lower cost of £500. A loan to cover the cost had been refused by the Commissioners in Lunacy, but ‘as the buildings were nearly completed at that time they went on with them, [reasoning that] the cost would have to be borne out of the rates’. The Commissioners, defending their refusal to provide the funds, ‘said the operations [undertaken in asylums] were few’ and ‘that operations were often done in private bedrooms’. Goodall countered by producing a telegram from Dr Bond at Long Grove Asylum ‘saying that he had an operating room, so that such had recently been allowed [by the Commissioners]’. Debates with the Commissioners aside, Goodall proudly reported that Cardiff now had a well-equipped operating room with ‘about £360 worth of … instruments’.

Though Cardiff still relied on outside expertise where necessary, the benefit of on-site facilities was soon evident: within two weeks of opening their operating room, ‘their Night Sister sustained a fracture of the base of the skull and … was operated upon [there]’. Evidently, then, staff as well as patients might be treated within the asylum. Many operations were described as urgent measures – to treat an injury or remove a life-threatening tumour – but for patients in particular, surgery might also be viewed as a route to improved quality of life. Robert Picqué in France considered this in a 1907 article ‘Ce que Doit Être à notre Époque La Chirurgie des Aliénés’ [‘The Needs of our Time in Respect of the Surgical Treatment of Insane Patients’]. As a review of his work related, Picqué suggested that ‘restoring the use of a limb [for example], may exercise an indisputable, though indirect, action towards the restoration of mental health’ by allowing the patient to resume a more active life.

All was not well, however. At the same time, doctors were increasingly expressing their concern about the often hasty recourse to surgery on asylum patients. A worrying faith in craniectomy as a ‘cure’ for idiocy was identified, as well as the phenomenon of post-operative insanity – insanity caused or exacerbated by surgery. Both of these though, will be stories for future posts…

- Jennifer Wallis

If you’ve found any information on surgical practices in an asylum you’re researching, we’d love to hear from you!