The European Reform
In 1793 Philippe Pinel took charge of the Salpetriere and Becetre asylums in Paris, the turning point of method in the management of inmates. Pinel found that if inmates were not neglected and brutalized they behaved normally. Pinel discovered “that insanity was curable in many instances, by mildness of treatment and attention to the state of the mind exclusively…” Thus Pinel resorted to “the management of the mind” by talking to his patients and listening to their complaints. He got to know them and appreciate them, saying “I have never met, except in romances, with fonder husbands, more affectionate parents, more impassioned lovers, more pure and exalted patriots, than in the lunatic asylum, during their intervals of calmness and reason.”
In his 1801 book, Traite Medico-Philosophic sur l’alienation mentale, Pinel envisioned building a helpful asylum for the mad, serviced by medics schooled in using methods suitable for managing five different “species” of madness, during the day keeping the inmates busy doing useful and pleasurable tasks.
The first asylum of this kind was opened in America by Quakers in 1817. Though the change was radical it was heartedly embraced, fitting the democratic ideals of Americans. Soon other privately funded asylums appeared, these followed by a publicly funded asylum so that by 1841 there were sixteen asylums altogether promising humane management of the inmates. Each asylum claimed good results.
Medics were losing out, so Connecticut State Medical Society lobbied for finances to build a local asylum with government assurance that the superintendent would be a medic. Other states followed, asylum medicine becoming its own specialty, so that by 1844 thirteen asylums formed the American Association of Medical Institutions for the Insane. Thenceforth medics took over the management of inmates and have never let go of it.
Until the 20th century the practice was mainly that of torturing inmates to force them to stop acting-as-if-mad. They stopped. Why? Because they were so weak and terrified they were unable to continue.
Phineas Gage survived an accident in which a large iron rod was driven completely through his head, destroying much of his brain’s left frontal lobe, and is remembered for that injury’s reported effects on his personality and behavior. It was his apparent recovery of the ability to use words and tools that alerted medics to guess that madness was somehow due to defect in the frontal lobes of the cerebral cortex. Hence lobotomy—the surgical destruction of the frontal lobes.
Lobotomy consists of cutting the connections to and from the prefrontal cortex, the anterior part of the frontal lobes of the brain. While the procedure has been controversial since its inception in 1935, it was a mainstream procedure for more than two decades—this despite general recognition of frequent and serious side-effects. The heyday of its usage was from the early 1940s until the mid-1950s. By 1951 almost 20,000 lobotomies had been performed in the United States. The decline of the procedure was gradual rather than precipitous. In Ottawa’s asylums, for instance, the 153 lobotomies performed in 1953 were reduced to 58 by 1961, after the arrival in Canada of the drug chlorpromazine in 1954. Anxiety, introspection, feelings of inadequacy, and self-consciousness are reported lessened. Post-operative apathy, blunting, childishness, distractibility, facetiousness, incontinence, and irresponsibility are the rule rather than the exception. The practice proved to be a godsend to neurosurgeons who at the time were earning only $5000 per year owing to a shortage of patients. Learning of the methods of destroying the prefrontal lobes of the cerebral cortex they increased their income five-fold besides being praised for their remarkable service to those seeking relief from their distress. The cost was far greater than the benefit, it being permanent apathy, blunting, and the rest.
required trained staff. Usually injections were administered six days a week for about two months. The daily insulin dose was gradually increased to 100-150 units until comas were produced, at which point the dose would be leveled out. Occasionally doses of up 450 units were used. After about 50 or 60 comas the dose of insulin was rapidly reduced before treatment was stopped. Courses of up to 2 years have been documented. After the insulin injection patients would experience various symptoms of decreased blood glucose: flushing, pallor, perspiration, salivation, drowsiness or restlessness. Each coma would last for up to an hour and be terminated by intravenous glucose. Seizures sometimes occurred before or during the coma. Many would be tossing, rolling, moaning, twitching, spasm-ing, or thrashing around. Patients were sometimes also given electrical convulsive shocks or metrazol convulsive shocks during the coma, or on the day of the week when they didn’t have insulin treatment. Patients required continuous supervision as there was a danger of hypoglycemic aftershocks after the coma.
So called “ECT” produces seizures by electrical shock. It was first introduced in the 1930s and gained widespread use in the 1940s and 1950s. In the 21st century an estimated 1 million people worldwide receive ECT every year, usually in a course of 6–12 treatments administered 2 or 3 times a week. ECT can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and positive outcomes. After treatment, drugs are usually continued, and some patients receive continued electrical shock. Involuntary treatment is uncommon in the United States and is typically only used in cases in which the medic knows nothing else to do.
By the way, as a student of clinical psychology in 1949 I interned in a small private asylum for the insane. At the time I was doing case studies of inmates using responsive interviewing and projective personality tests, methods I’d been using for over two years in the university clinic and in homes of persons afflicted with essential hypertension, who’s personalities I was studying. Each Saturday all 50 inmates were subjected to electroshock, one at a time, the rest waiting in dread of their turn for the terrifying and horrifying experience. It was during those months of internship that I learned how ignorant the three “psychiatrists” attending the asylum were of both madness (“psychopathology”) and its management (“psychotherapy”). None of them studied any of the inmates, leaving that to us two psychologists. The inmates received their weekly shocks of disability while I received my weekly shocks of disbelief that some medics could be so incredibly ignorant and incompetent.