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.
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.
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
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).