Tag Archives: neurosyphilis

A ‘new’ disease?

At the November and December meetings of the London Clinical Society in 1884, an interesting debate unfolded: was a ‘new’ disease appearing in England? A number of patients had been seen in hospitals and asylums in the preceding years who exhibited unusual joint affections. It was a sudden phenomenon, characterised by severely swollen but usually painless joints. Though any joints of the body might be affected, knees and ankles tended to fare worst. The lack of pain and generally dulled sensations that were experienced impacted on the everyday actions of sufferers, who dropped objects, frequently fell, or had difficulty walking. Other bodily manifestations appeared in the form of ulcers, often on the feet. Many patients also reported that they suffered from ‘neuralgia’, ‘flying gout’, and gastric crises.

Deformity of the knee in Charcot's disease. © Wellcome Images/St Bartholomew's Hospital Archives & Museum.

Deformity of the knee in Charcot’s disease.
© Wellcome Images/St Bartholomew’s Hospital Archives & Museum.

The condition was first properly identified by neurologist Jean-Martin Charcot in 1868, earning it the moniker ‘Charcot’s joint’ (Charcot noted that the condition had also received attention from J.K. Mitchell in the 1830s). In 1880s England, though, according to W. Hale White of Guy’s Hospital, ‘discussion about Charcot’s joint [had] waxed very warm’. Alienist interest in the condition stemmed from its appearance in tabes dorsalis (nerve degeneration in the spinal cord due to untreated syphilis) patients, who were often seen in asylums before the incidence of syphilis was vastly reduced with the use of penicillin in the 20th century. Charcot said he had only ever seen the condition in tabes dorsalis patients, and other asylum doctors related similar cases. Conolly Norman at Dublin’s Richmond Asylum hosted a meeting of the Irish division of the Medico-Psychological Association in 1896 at which delegates viewed two cases of Charcot’s joints on Richmond’s wards, both occurring in general paralytic (neurosyphilitic) patients. In syphilitic conditions, nerve degeneration impaired patients’ reflexes and sensations whilst muscle wastage reduced the natural protection around the joints. The result was that patients became increasingly vulnerable to injury (discussions of the disease often noted spontaneous fractures), or their bones literally ‘wore away’ as they ground together.

L0061441 Dissected knee joint, the subject of marked locomotor ataxy

Dissected knee joint exhibiting Charcot’s disease.
© Wellcome Images/St Bartholomew’s Hospital Archive & Museum.

Alongside syphilis, physical injuries were also cited by some as an immediate, exciting cause. (Whilst syphilis was the condition most commonly associated with Charcot’s disease by nineteenth-century doctors, it was gradually recognised as a condition with much wider aetiological factors. It may be present in diabetic neuropathies, for example, where nerve damage affects the weight-bearing joints.) J. Wallace Anderson related the case of a patient at Glasgow Royal Infirmary. Admitted to the hospital due to his difficulty in walking, the 45 year old gardener ‘ascribe[d] his complaint to a stroke of lightning … twelve years ago’, following which he began to experience ‘tingling’ pains and weakness in the hips, until finally his right hip “went out”. Though he was discharged from the hospital able to walk with the aid of sticks, he remained prone to ‘unusual variations in his general condition’. Charcot’s disease was, ultimately, untreatable, and little could be done for patients other than try to assist their mobility in various ways.

N0008052 Charcot's knee

X-ray of a Charcot’s knee.
© Wellcome Images.

Ascertaining if Charcot’s disease was indeed novel to the late nineteenth century was difficult. One stumbling block was the apparent lack of such specimens in pathological museums: if it wasn’t a new disease, why were there no samples from previous years? At the London Clinical Society meeting, Sir James Paget suggested that museum curators – even if they were able to secure a specimen of a comparatively rare condition – tended to collect normal rather than abnormal specimens for teaching purposes. Interpretations of the disease ranged from osteo-arthritis to ‘modified’ chronic rheumatic arthritis, though such diagnoses were complicated by the sudden onset of the joint affection.

Although W. Hale White said that discussion about the disease had ‘waxed very warm’ and ‘everyone [had] had an opportunity of expressing his opinion’, he doubted if ‘exact knowledge of the subject [had] been much advanced’. At a point in time when doctors were increasingly keen to pinpoint the physical lesions of disease, Charcot’s joint seemed a perfect opportunity to trace a visible physical deformity to minute changes in the nerves. This was complicated by its resemblance to other conditions, however: was it just a form of rheumatism? Was it a ‘new’ disease? Or a ‘new compound of diseases’? These were – and are – fascinating questions that bring to mind current historical debates about retrospective diagnoses, the ‘framing’ of disease, and how we assess medical knowledge of the past: giving a condition a name didn’t necessarily mean that its identity was static, or signal a ‘pinnacle’ of understanding.

Further reading

D. Ferrier, On Tabes Dorsalis: the Lumelian Lectures, delivered before the Royal College of Physicians, London, March, 1906 (London: John Bale, son & Danielsson, 1906).

W.J.M.A. Maloney, Locomotor Ataxia (Tabes Dorsalis): An Introduction to the Study and Treatment of Nervous Diseases, for Students and Practitioners (London: D, Appleton, 1918).

L.C. Rogers et al, ‘The Charcot Foot in Diabetes‘, Diabetes Care 34 (2011).

L.J. Sanders, ‘Jean-Martin Charcot (1825 – 1893): The Man Behind the Joint Disease‘, Journal of the American Podiatric Medical Association 92 (Jul./Aug. 2002).

H. Waldo, ‘A Case of Charcot’s Joint Disease, with Perforating Ulcer of the Foot in a Tabetic Patient‘, BMJ (1 Dec. 1894).

R. Waterhouse, ‘Remarks on the Arthropathies of Acquired Syphilis‘, BMJ (10 Oct. 1908).

Muscle and mind in the asylum

The bodies of the insane held a particular fascination for the 19th-century asylum doctor. Actions might betray a person’s psychological state in the most striking ways, with bodies subjected to tics and spasms, and facial expressions revealing the deepest thoughts and feelings.

The late 1800s was a climate in which the relationship between body and mind was being ever more meticulously refined. In the 1890s, for example, Charles Sherrington discovered a feedback mechanism in muscles that was important for the regulation of posture and movement. Sherrington’s work suggested that bodily attitudes – such as seated posture, or how a person ‘carried’ themselves – could indicate inner psychology.

L0057988 Dynamometer, France, 1890-1910

A dynamometer, just one of a range of tests that might be used to assess patients’ bodies upon admission. © Wellcome Images

This was an idea that had obvious application within the asylum. At admission, patients were physically assessed, a process that often included testing of the reflexes and bodily strength using contraptions such as the dynamometer (to measure the grasping power of the hands). Thus, a doctor might note something like this: ‘Patellar tendon reflex absent in each limb, no cremasteric reflex. Tactile sensibility of lower limb is diminished.’ For this patient, his mental state was also found wanting; he showed ‘great obtuseness in understanding what [was] said to him’ and was characterised throughout his case notes as dull, unresponsive, and generally ‘diminished’. In a seamless melding of body and mind, both were in a state of decline. It was the body that succeeded in speaking for the patient, his appearance compensating for his difficulties with verbal communication (his articulation was ‘thick and indistinct’).

N0006653 Tabes dorsalis

Demyelination seen in tabes dorsalis. © Wellcome Images

Apart from indicating a general deterioration in a patient’s condition, the state of muscles and reflexes might also indicate the seat of a problem with surprising specificity. David Ferrier noted that the knee jerk was a crucial indicator of disease – it was absent in cases of tabes dorsalis, for example. (Tabes dorsalis is a neurosyphilitic condition characterised by nerve degeneration.) The importance of the muscular sense in health and disease was clear in many physiological and psychiatric tracts. ‘That the muscles possess a sensibility of their own’, wrote Ferrier in The Functions of the Brain, ‘…is proved beyond all doubt by their nervous supply and by physiological and clinical research’. He described a hierarchically-organised community of muscles, varying in strength, ‘thus the powerful extensors of the back, and muscles of the thighs keep the body arched backwards and the legs rigid’. Guillaume Benjamin Amand Duchenne de Boulogne (phew!) had also credited the muscular system with an independent intelligence, reasoning that coordination required a harmonious relationship between different muscle groups. The use of the term ‘muscular sense’ by many physiologists gave muscular tissue an almost anthropomorphic character – muscles were independent entities capable of action and reaction in response to external influences.

L0033543 Spasms in hysterical patients

Muscular spasms in ‘hysterical’ patients. © Wellcome Images

It was up to the patient, then, to keep their muscles in check. The will, an elusive but enduring concept in alienist science, was most forcefully expressed – or most notably absent – in the movements of the body. The view that only the will stood between order and chaos, as Roger Smith tells us, ‘translated easily to physiological descriptions of the economy and hierarchical arrangement of the nervous system’. Loss of control over bodily movements was viewed as a ‘de-education’, or erasure of learned automaticity, seen for example, in the tottery but energetic gait of tabes dorsalis patients.

The central explanations for such loss of control, by emphasising the co-existence of reflex action and the will, allowed mental science to move closer towards natural, biological science without discarding that essence of being human that marked men apart from other animals. Thus, as Stephen Jacyna points out, bodily actions could be explained in a mechanistic way, but also as a consequence of manipulation by the soul. If a person lost their powers of control, the body could descend into a state of chaos. In this way, the patient’s movements and attitudes frequently served as a diagnostic tool in the asylum, particularly if the patient’s own verbal testimony was unreliable or impossible.

Further reading

W.F. Bynum and F. Clifford Rose (eds.), Historical Aspects of the Neurosciences: A Festschrift for Macdonald Critchley (New York: Raven Press, 1982)

David Ferrier, The Functions of the Brain (London: Smith, Elder & Co., 1876)

L.S. Jacyna, ‘Somatic theories of mind and the interests of medicine in Britain, 1850–1879’, Medical History 26 (1982).

Roger Smith, Inhibition: History and Meaning in the Sciences of Mind and Brain (London: Free Association Books, 1992).

– 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).