A History of Medical Psychology Part II ASYLUM

A History of Medical Psychology, Part II: ASYLUM Douglas Lehrer, M.D. Director of Medical Education Twin Valley Behavioral Healthcare “Since there is nothing in the world more excellent than man, nor in man than his mind, particular attention should be given to the welfare of the mind; and it should be considered a highest service if we either restore the minds of others to sanity or keep them sane and rational ... Juan Luis Vives “One ought to feel great compassion for so great a disaster to the health of the human mind, and it is of utmost importance that the treatment be such that insanity be not nourished and increased, as may result from mocking, exciting or irritating madmen …” Juan Luis Vives Asylum • Prior to the mid/late-18th century, where was the mentally ill person? • Beggars wandering the roads • “Village idiot” • Burden on family • Often kept in horrible conditions “There is nothing so shocking as madness in the cabin of the Irish peasant… When a strong man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin, not high enough for the person to stand up in, with a crib over it to prevent his getting up. This hole is about five feet deep, and they give this wretched being his food there, and there he generally dies.” House of Commons, 1817 “A youth of sixteen, who for years had lain in a pigpen in the hut of his father, a shepherd, had so lost the use of his limbs and his mind that he would lap the food from his bowl with his mouth just like an animal.” Anton Muller, Chief of Psychiatry, Royal Julius Hospital, Wurzberg, c. 1800 “In our rural areas, where people are still imbued with absurd prejudices, public opinion sees having madness in a family as shameful and will not send the person to an asylum. This is the principle reason that motivates our peasants to keep such poor, afflicted individuals at home. If the insane person is peaceful, people generally let him run loose. But if he becomes raging or troublesome, he’s chained down in a corner of the stable or in an isolated room, where his food is brought to him daily…” Louis Calderac, Brittany, 1860 The Custodial Asylum • Had existed since Middle Ages • Conditions poor, befitting beasts whose animal natures must be subdued • Mixture of MI, MR, criminals, misfits, orphans, epileptics, physically ill, etc… • Restraint, cruelty, beatings, “spouting” • Few physicians to be found Priory of St. Mary of Bethlehem (1247) Thomas Willis (1621-1675) “The primary object is naturally curative… discipline, threats, fetters and blows are needed as much as medical treatment...Truly nothing is more necessary and more effective for the recovery of these people than forcing them to respect and fear intimidation. Thomas Willis (1621-1675) “By this method, the mind, held back by restraint, is induced to give up its arrogance and wild ideas and it soon becomes meek and orderly. This is why maniacs often recover much sooner if they are treated with torture and torments in a hovel instead of with medicaments.” 17th Century: The Dawn …of a world governed by rational order 17th Century: The Dawn • • • • • Influence of church on the wane Travels of the 16th century Rise of lay philosophers Invention of scientific tools Scientific societies 17th Century: The Dawn • Medical ideas re. MI were reductionistic applications of contemporary medical thinking, physiologic/anatomic study • MI beyond reach of tools; speculative • 17th C physicians drawn to bedside, library, dissecting room not to dungeon, prison, scaffold, or the other domains of the MI 17th Century: The Dawn • “Psychiatry without psychology” • Laid the foundations for a scientific psychiatry • Spread of the custodial asylum Therapeutic Asylum • 18th century: The Enlightenment • Ascendancy of individual rights, personal dignity, compassion • Medicine followed suit • Concern with reform, public health, proper care of MI • Hospital organization, teaching Therapeutic Asylum: The Early Pioneers • William Battie: St. Luke’s Hospital, London, 1751 – Wrote Treatise on Madness (1758): First extensive text solely devoted to MI • Vincenzio Chiarugi (1759-1820), Florence – Insanity due to "impairment of the physical structure of the brain” – First to address “moral treatment” and psychotherapy in the asylum Vincenzio Chiarugi (1759-1820) • Proposed new psychiatric hospital in Florence: the Bonifazio (1785) • Autopsied patients • Insanity due to "impairment of the physical structure of the brain" The York Retreat • 1796: William Tuke, tea merchant, founded Retreat for Quakers in mental distress • Not established as medical institution • Popularized term “moral treatment” • Still in business Phillipe Pinel (1745-1826) • Physician-in-Chief at Bicetre, then Salpetriere • Served under the Revolution, the “Terror,” Napolean, and the restored Bourbons • Almost influenced by Ben Franklin to go to colonies Phillipe Pinel (1745-1826) • Had chains removed at Bicetre, 1793 • Daily rounds • Introduced modern recordkeeping Phillipe Pinel (1745-1826) • Prioritized medical and psychiatric education • Landmark textbook in 1801 • Classification: mania, melancholia, dementia, idiocy • Also described hysteria, anorexia, bulimia, hypochondriasis, OCD (folie du doute) Phillipe Pinel (1745-1826) • Espoused moral treatment (“institution morale”) in the asylum • Opposed to bloodletting, “ducking,” indiscriminant drug use J. E. D. Esquirol (1772-1840) • Started clinical teaching at Salpetriere, 1817 • Statistical methods • Monumental teacher • Precipitating factors • Coined term “hallucination” • Monomanias Johann Reil (1759-1813) • Neuroanatomist, internist, psychiatrist • Rhapsodies in the Application of the Psychological Method of Cure in Mental Alienation (1803) • Believed institutions superior to family for care (baths, open spaces, etc.) • Concentrated scarce doctors • Concept of “irritability” Johann Reil (1759-1813) • • • • • • • Elaborate treatment regime physical therapy psychotherapy; theater “non injurious torture” firing cannons, throwing pt. into water prostitutes (male patients, of course) Coined the term, “psychiatry” Therapeutic Asylum • • • • • • Common Elements Purgatives, emetics, enemas Bloodletting Medications +/- Restraints Baths, hydrotherapy Sorting by prognosis, diagnosis Therapeutic Asylum • • • • • Common Elements Activities, work, exercise Music, arts Cleanliness, fresh air, open spaces Kindness Doctor-patient relationship as therapeutic agent The Colonies • Like Europe, family responsible for MI members • 1729: Boston Almshouse: First psychiatric ward to separate MI from other inhabitants The Colonies • Pennsylvania Hospital established in Philadelphia (1751) • 1773: First U.S. psychiatric hospital established in Williamsburg Benjamin Rush (1745-1813) • “Father of American Psychiatry” (APA, 1965) • Signed Declaration of Independence • Attending physician at Pennsylvania Hospital Benjamin Rush (1745-1813) • 1791: 1st course in psychiatry, U. Penn • 1812: Medical inquiries and Observations upon the Diseases of the Mind: 1st U.S. psychiatric textbook Benjamin Rush (1745-1813) • Alternatives to restraints – tranquilizing chair, gyrating chair • Devotee of purging, bloodletting • Listened to his patients; humane treatment Early U.S. Asylums • 1817: Frankford Retreat • 1818: Boston Asylum, later McLean Asylum • 1824: Retreat at Hartford, later Institute For Living Early U.S. Asylums • By 1840’s, numerous asylums built • Overcrowding becoming a problem • Hopes of reformers threatened Early U.S. Asylums • By 1840’s, numerous asylums built • 1843: William Awl (Ohio): announced 100% cure rate • 1844: First meeting of Association of Medical Superintendents of American Institutions for the Insane Dorothea Dix (1802-1887) • Appalled by conditions in jails, almshouses, etc • Pts/prisoners locked together • Dark, unheated, filthy rooms • No regard for gender or age Dorothea Dix (1802-1887) • Convinced 15 state legislatures, Canada, and Italy to improve conditions • 1848: Report to U.S. Congress • Civil War: Superintendent of army nurses. Early U.S. Asylums • 1850’s: 6 asylums established in Ohio • By 1860’s: 63 U.S. asylums in 28/33 states • 1875: 1st meeting of American Neurological Association Voted to bar membership to Asylum superintendents Asylums: The Fading Light • By 1880’s, asylums regressed from rehabilitation back to custodianship • Therapeutic asylum overwhelmed by sheer numbers • What were the reasons for the burgeoning numbers? Causes for Overcrowding Redistribution: • Family to asylum • Prisons, workhouses to asylum Changing rates of mental illnesses: • Neurosyphilis • Alcoholic psychoses • Schizophrenia Neurosyphilis • General Paralysis of the Insane (GPI) • Dementia Paralytica • General Paresis • By mid-late 19th C 5-20% had syphilis infection • 6% w/ neurosyphilis Neurosyphilis • • • • • Mania Dysarthria Dementia Paralysis Pupillary Changes • Ptosis • Tabes Dorsalis, ie, gait changes, lancinating abdominal pains • Invariably lethal Alcoholic Disease •  alcohol consumption in 19th C • 1881: Carl Wernicke described acute confusion, gait disorder, ophthalmic signs • 1887: Sergei Korsakoff described chronic psychosis and memory loss Schizophrenia • Not clearly described in literature before late 18th century (contrast to mania and melancholia) Recent disease? The Asylum • By 1900, 150,000 patients in U.S. asylums • Similar trend in Europe • Asylum: “Good intentions gone bad”