Confronting chaos: today we view early psychiatric treatments as inhumane, but during their time they were state-of-the-art.
Below we discuss some early interventions (arranged alphabetically) that demonstrate the wide range of "treatments" used between 1700 and 1950, between the time of the dawn of American psychiatry to the introduction of antipsychotics. Although many of these "treatments" are recognized now as cruel and ineffective, they were considered state-of-the-art for their times and were developed and promoted in a sincere effort to help people struggling with serious mental illness.
Bloodletting. Bloodletting, either by leeches or by incision, was a common 18th-century practice for a variety of ailments. Benjamin Rush (1745-1813), recognized as the father of American psychiatry, used bloodletting in treating people with mental illness. (1) Bloodletting involved taking copious amounts of blood from the patient, leaving him depleted, exhausted, and obviously anemic. It was indicated for patients with an agitated psychosis in which such treatments caused a drop in blood pressure with resultant sedation. (2) In 1854, Pliny Earle published An Examination of the Practice of Bloodletting in Mental Disorders. (3) Blood transfusion also was attempted as a treatment, sometimes using animal blood. (4)
Chains. Restrictive chains, shackles, and fetters were popular interventions in the 18th and 19th centuries, although their use dates back much earlier. Chains were a primitive method of containing aggressive individuals. Aulus Cornelius Celsus (25 BC-50 AD), who chronicled treatments for mental illness available in his day, reported on the use of chains. Jacques-Rene Ten-on (1724-1816), a reformer who surveyed 18th-century hospitals and advocated for their improvement, recommended chains as part of his therapeutic vision. (4) Rush, on the other hand, advocated for the removal of chains from most patients with mental illness in the Pine Building of the Pennsylvania Hospital, as well as advising the removal of patients from the building's unheated basement. (1)
Hollow wheels. In the late 18th century, German psychiatrist Johann Reil (1758-1813) invented a therapeutic hollow wheel (figure 1). The patient was placed inside and could either remain stationary or run forward or backward. Theoretically, this activity would engender goal-directed behavior, with the hope that such forced activity on the patient's part would take him out of his hallucination-filled world and into reality:
[FIGURE 1 OMITTED]
Freed at times to satisfy his physical needs, the patient could spend generally 36-48 hours in the wheel and would then be 'either tractable and obedient as a result of the wheel' or so fatigued by the constant pace that he presented little if any management problem. (5)
Sadly, staff occasionally found it entertaining to watch a patient wear himself down during a 36-hour period in the wheel.
Needle cabinets. Needle cabinets were steel boxes designed to hold a patient in a standing position. High-pressure water then was pumped directly onto the skin. (6) (Since needle cabinets could be viewed as a form of hydrotherapy, they are discussed below.)
Purging. Many, including Rush, employed purging as a treatment. Rush believed that purging could cure mental illness by expelling noxious elements from the body. The patient was given an emetic in the hope that the ensuing vomiting would expel any offending substances from the body. (1)
Straitjackets/waist restraints. The straitjacket has a long history, and all too frequently its use has been depicted in movies dealing with psychiatric hospitals. The straitjacket was used to contain and control violent patients. As Rush wrote in 1812, "These [straitjackets] will sometimes be necessary in order to prevent their destroying clothes and the furniture of their cells, as well as to punish outrages on their keepers and each other." (7) A waist restraint was a different form of a straitjacket; Rush used the term "strait waistcoat." Again, the rationale was to prevent injury and to curb destructive actions. (6)
Terror. One of the earliest psychiatric "treatment" approaches was simply to terrorize patients to restore them to sanity. This was clear in Reil's immersion methods. He advocated dunking the patient into water while at the same time cannons were fired. (4)
Tranquilizer chair/sensory deprivation chair. Rush devised the tranquilizer chair (figure 2). (6) A patient was strapped into the chair, and his arms and legs were immobilized with straps before a wooden hood was placed over his head. The goal was to calm the patient by restricting his sensory input. (5) The tranquilizer chair also was known as the sensory deprivation chair.
Twirling chairs and their variations: The Gyrator and O'Halloran's swing. The twirling chair could spin a person rapidly about his own axis. The hypothesis was that twirling would serve to separate the various "humors" within the brain. (6) The humors were thought to govern both body and mind. Hippocrates argued that illness was due to an excess of one of the four humors: yellow bile, black bile, phlegm, or blood.
Rush developed a variation of this spinning approach called the Gyrator, a horizontal board on which torpid patients were strapped and spun to stimulate blood circulation. (1) An Irish physician developed his own version of this twirling device: O'Halloran's swing (figure 3). Patients were rotated up to 100 times a minute in it. The centrifugal force drove blood to the brain, theoretically treating mental illness and gaining patient obedience. (5)
Utica crib. This bedlike restraining device was associated with the Utica Lunatic Asylum in New York (figure 4). Its origin actually is attributed to a French physician who brought it to the United States in 1845. In 1846, it became known as the Utica crib and gained wide use in the later part of the 19th century. The patient was placed face up in it and could not turn over. (5)
Water treatments (hydrotherapy). Hydrotherapy is an ancient treatment approach and was very popular in the 19th and early 20th centuries, widely employed in many public and private psychiatric hospitals in the United States. Hydrotherapy provided a method to alter circulation (e.g., hot water improved capillary flow and thereby affected neural functions).
Hermann Boerhaave (1668-1738), the renowned medical teacher of Leiden (The Netherlands), said, "The greatest Remedy for it [mental illness] is to throw the Patient unwarily into the Sea, and to keep him under Water as long as he can possibly bear without being quite stifled." (4) Reil advocated throwing patients into water while at the same time firing cannons to restore them to their senses. He saw such treatment as a legitimate "psychological" method of treatment. (4)
Later refinements included running cool water over patients' wrists and ankles to reduce their metabolic rate. (6) Certain conditions such as mania are associated with increased metabolism. Hence, people thought application of cold water would decrease metabolism and therefore agitation. Other conditions such as hypothyroidism are associated with decreased metabolism and lead to problems such as "myxedema madness" (psychosis caused by a low-functioning thyroid).
Over time hydrotherapy approaches became gentler, more organized, and more precisely administered. Wright defined hydrotherapy as "the remedial use of water in any of its forms--ice, liquid or vapor, internally or externally." (8) Wright cataloged a wide variety of douche treatments:
[FIGURE 2 OMITTED]
[FIGURE 3 OMITTED]
* Needle spray, in which multiple horizontal small sprays of water were applied to a standing person
* Fan douche, in which a hose sprayed water over a standing person
* Jet douche, in which a medium-pressure hose applied water only to a standing person's back
* Scotch douche, in which water alternating between hot and cold was applied to a small area of skin
* Vapor douche, in which a stream of vapor was applied to a small area
* Rain douche, essentially a shower
* Pail douche, in which a series of pails of water at three different temperatures were poured over the person
* Perineal douche, which was applied to a seated person's perineum
* Whirlpool bath
* Wet sheet packs with cold water
* Tub shampoo
* Electric light bath (the person was bathed in the glow of electric lights similar to a sunbath)
* Revulsion, in which alternating hot and cold applications were applied to a small area
The ultimate rationale for this popular form of therapy was, as Baruch stated, "Of all remedial agents in use since the dawn of medicine, water is the one all the vicissitudes of doctrines [rely on]." (9) Wright noted, "The physical properties of water render it capable of producing thermic and mechanical impressions upon the skin and mucous membrane." (8)
Despite the cruel, bizarre, and inhumane nature of the above "treatments," there were a number of rationales for them.
Biologic explanation. The theory that mental illness has a biologic etiology has been one cornerstone of psychiatry throughout the ages, and this was reflected in the Greek idea of humors. Galen argued that the brain was the seat of mental illness. (4)
In the same vein, Rush, who believed the seat of mental illness was in the mind, designed the twirling chair to separate the humors of the brain. (6) Hydrotherapy was based on the idea that it affected the flow of capillary blood, in turn improving circulation to the nervous system and improving their condition. (8) Ice water treatment offered a way to decrease metabolism. (10) The Gyrator was designed as a method to relieve "brain congestion." (10) And the tranquilizer chair provided an approach directed at reducing the flow of stimulating blood to the brain. (1)
Reverse irrationality. One common hypothesis behind these treatment approaches was that patients were irrational and, therefore, any method employed to restore rationality was laudable. The key was to bring patients back to their senses and return them to normalcy. (4) This was the ostensible justification for frightening patients by cannon firings and water immersion, as well as the hollow wheel.
Control violence to self, others, and property. Because many patients were violent, straitjackets, chains, and manacles provided containment for prevention of self-injury, assaults, property destruction, and suicide.
Possession. In this view, either gods or demons possessed patients. Homer considered mental illness the result of gods taking away the minds of people. (11) Aeschylus viewed mental illness as a product of demonic possession and recommended exorcism. (11)
Many cultures have viewed people with mental illness as being possessed by demons or spirits. Whether due to possession by gods or demons, the goal of therapy was to reduce suffering and drive out negative influencers. Some believed that the seriousness of the mental illness justified the use of violent approaches to terminate demonic possession, such as exorcism. (4)
Patients as wild beings. Some viewed people with mental illness as not being human. They saw this population as animals. Therefore, the aim of treatment was to tame these "animal like beasts." (12) "Treatments" such as isolation, shackles, and confinement were the order of the day.
Punishment. Hospital staff often saw their patients as people that must be controlled and contained by maintaining order. Staff dealt with perceived infractions of the rules by punishment, and disorderly conduct was grounds for punitive restrictions. Chains, cribs, and spinning chairs provided methods to enforce a hospital's policies and regulations.
Fear. The community was fearful of people with mental illness and felt threatened by their supposed unpredictability and violence. As a result they removed and isolated patients with mental illness, using chains as a method to make caregivers, the public, and patients feel safe.
Calls for Change
Although these practices were widespread in the 18th, 19th, and early 20th centuries, some were calling for change.
Parisian Philippe Pinel believed that "goodness is the most effective of remedies, and justice the most impressive of authorities." (6) Pinel became the head of the insane asylum at Bicetre in 1793. According to Zilboorg, "Pinel asserted that it was impossible to determine whether mental symptoms resulted from mental disease or from the effects of chains." (4) As a result he developed "moral treatment" in which he immediately removed the inmates' chains, eliminated physical punishment, and made the living conditions better. Pinel emphasized kindness in his treatment with attention to patients' work and play. (13)
[FIGURE 4 OMITTED]
In 1841, Dorothea Dix (1802-1887) began her moral treatment crusade. She railed against the criminal treatment of people with mental illness. She offered compassion and care rather than containment and restraint. (4) Dix is credited by many for major reforms in America. She challenged the notion that people with mental illness were incurable and provided such practical amenities as heat and clothing in the living quarters of mental patients. She was instrumental in the creation of 32 mental hospitals, as well as schools for the "feeble minded" and training programs for nurses. (4)
In addition, scientific advances precluded these early treatment approaches. And eventually people with mental illness were recognized as human beings with medical problems.
In the 1950s, the National Mental Health Association (NMHA) asked asylums across the United States for their discarded chains and shackles. In April 1956 they were melted and recast into the Mental Health Bell, inscribed, "Cast from shackles which bound them, this bell shall ring out hope for the mentally ill and victory over mental illness." (14)
We gratefully acknowledge the work of Sarah M. Elder, Curator of Collections, the St. Joseph Museums, Inc., St. Joseph, Missouri, in securing material and images for this article.
Stephen M. Soreff, MD, is President of Education Initiatives in Nottingham, New Hampshire, and is associated with the Metropolitan College at Boston University, Fisher College, Worcester State College, and Southern New Hampshire University. He also works in the School Health Section of the New Hampshire Department of Education.
Patricia H. Bazemore, MD, is an Associate Professor in the departments of Family Medicine, Community Medicine, and Psychiatry at the University of Massachusetts Medical School in Worcester. She is also Chief of Medicine at Worcester State Hospital. To send comments to the authors and editors, e-mail email@example.com.
1. University of Pennsylvania Health System. History of Pennsylvania Hospital. Psychiatry. Available at: www.uphs.upenn.edu/paharc/collections/exhibits/psych.
2. Collect Medical Antiques. Bleeding by psychiatrists. Available at: www.collectmedicalantiques.com/blood letting2.html.
3. Earle P. An Examination of the Practice of Bloodletting in Mental Disorders. New York: Samuel S. and William Wood, Publishers; 1854.
4. Zilboorg G. A History of Medical Psychology. New York: Norton; 1941.
5. St. Joseph Museums, Inc. Glore Psychiatric Museum. 3406 Frederick St., St. Joseph, MO 64508; firstname.lastname@example.org; (800) 530-8866.
6. History of Fulton State Hospital. Available at: www.dmh.missouri.gov/fulton/history.htm.
7. Rush B. Medical Inquiries and Observations, Upon the Diseases of the Mind. Philadelphia: Kimber & Richardson; 1812:181. Available at: http://dcila.dickinson.edu/theirownwords/title/0034.htm.
8. Wright R. Hydrotherapy in Hospitals for Mental Diseases. Boston: Tudor Press; 1932.
9. Baruch S. An Epitome of Hydrotherapy. Philadelphia: WB Saunders; 1920.
10. Alexander FG, Selesnick ST. The History of Psychiatry: An Evaluation of Psychiatric Thought and Practice from Prehistoric Times to the Present. New York: Harper & Row; 1966.
11. Diamond SA. Anger, Madness, and the Daimonic: The Psychological Genesis of Violence, Evil, and Creativity. Albany, N.Y.: State University of New York Press; 1996.
12. Valenstein ES. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books; 1986.
13. Weitz R. The Sociology of Health, Illness, and Health Care. 3rd ed. Wadsworth; 2004.
14. National Mental Health Association. The NMHA Bell Story. Available at: www.nmha.org/about/bellstory.cfm.
BY STEPHEN M. SOREFF, MD, AND PATRICIA H. BAZEMORE, MD
IN THIS DEPARTMENT
we take a look at some of yesterday's treatment, reimbursement, and technology trends--and where they stand now.
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|Title Annotation:||IN RETROSPECT|
|Author:||Soreff, Stephen M.; Bazemore, Patricia H.|
|Date:||Jun 1, 2006|
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