ABSTRACT | PDF
GUEST GALLERY
The story of psychiatry (part III)
Uddip Talukdar
Registrar of Psychiatry
Fakhruddin Ali Ahmed Medical College and Hospital, Barpeta, Assam
[Emergence of asylums as therapeutic institutions, Emil Kraepelin, Socio-cultural influence of asylums.]
In the last part we discussed the emergence of psychiatry as a branch of medicine and how the first concepts of mental illness were beginning to form. Reil and Esquirol brought psychiatry under the purview of medical science and universities began to offer courses on psychiatry. Studies in psychiatry began and more students came to study psychiatry.
Universities used asylums as areas of practice for psychiatry and used to play a major part in administering the asylums. The number of asylums grew tremendously. In the beginning of 19th century there were few hundred individuals in asylums, but at the turn of the century the number was several thousands. In 1904, 150,000 individuals were in asylums and in Germany alone there were more than 400 asylums. The reasons for this skyrocketing increase of patients in the asylums are still debated.
German Universities were the first to devote increasingly to the study of psychiatry and consequently, scores of psychiatrists began working in the asylums of Germany and the country became a world leader in Psychiatric studies.
The increasing number of inmates in the asylums brought in problems as there was no regulatory authorities either in Germany or in any other country. France was the first country to pass law in 1838 to regulate admission and treatment in the asylums. By 1840s most of the European countries and America had their treating asylums.
The most influential law introduced in England and Wales that changed the status of mentally ill individuals was The Lunacy Act 1845 (8 and 9 Vict., c. 100) and the County Asylums Act 1845, which formed mental health law in England and Wales from 1845 to 1890. The Lunacy Act's most important provision was a change in the status of mentally ill people to patients; previously they were prosecuted and usually treated as prisoners.
We hope to discuss more about the changing view of laws in a separate section later.
These asylums provided the population for study to the psychiatrists and the new ideas and concepts brought forth a wide-spread view that mental illnesses soon would be easily treatable. However, it did not take long to come crushing. The asylum inmates did not show the improvement that all psychiatrists dearly wanted.
The overcrowding in the asylums for whatever the cause cast a heavy spell on the treatment of those patients and gradually they became custodian organizations more than treatment centers. The new and promising science of psychiatry failed measurably to live up to the expectation and its reputation came crushing down.
But that was in the beginning of the 20th century. Before the dream failed a lot had happened in psychiatry and some of those were the founding pillars of modern psychiatry. So, we set aside for sometime the disturbing story of the asylums and travel a century backwards where an idea changed the course of science forever.
Carl Linnæus (Latinized as Carolus Linnæus, 23 May, 1707 – 10 January, 1778) was a Swedish botanist, physician, and zoologist, who laid the foundations for the modern scheme of binomial nomenclature. He is known as the father of modern taxonomy, and is also considered one of the fathers of modern ecology. A proven system of classification is the beginning point of any science. Psychiatry too needed classification for further advancement. The direction was already shown by Pinel by his emphasis on observational methods.
However, the botanical taxonomic approach was abandoned in the 19th century, in favor of an anatomical-clinical approach that became increasingly descriptive.
Karl Ludwig Kahlbaum (December 28, 1828, Driesen - April 15, 1899), a German psychiatrist realized that attempting to classify psychiatric patients in terms of outward symptoms was futile and so, along with his associate Ewald Hecker (1843-1909) at Görlitz, introduced a classification system that used descriptive terms such as dysthymia, cyclothymia, catatonia, paraphrenia and hebephrenia. They were pioneers in the application of modern clinical practices in the study of mental health and some of them are still followed. By general, Kahlbaum is considered to introduce the ‘catatonia’ and Hecker, the ‘hebephrenia’, but it be best to remember that Kahlbaum’s description of ‘catatonia’ was significantly different from what we understand today.
Their work influenced another young German psychiatrist, Emil Kraepelin (15 February 1856 – 7 October 1926). Emil Kraepelin was one of the most influential psychiatrists and more so in today’s biologically oriented psychiatry. A quick mention of his name in today’s text-books under the schizophrenia chapter fails to show the deep impact this man has on today’s psychiatry. So, I would like to devote a paragraph or two to this great thinker.
H.J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic malfunction. His theories dominated psychiatry at the start of the twentieth century and, in today’s psychiatry his theories are proving to be more deep rooted than Freud’s.
Kraepelin was a student of Wilhelm Wundt, and he had life long interest in experimental psychology. For 20 years, he worked on ‘language disorders of dreams’, on the basis of dream-psychosis analogy. But, he abandoned psychology when it came to understanding the causes of mental illnesses. On the contrary he believed that mental illnesses are caused by lesions in the brain. This theory was probably rooted from his working on Alzheimer’s disease.
He co-worked with Alois Alzheimer on Alzheimer’s disease, and it was in Kraepelin’s laboratory that the pathological basis of Alzheime’s disease was discovered. Probably as a consequence of this, his belief that all psychiatric disease has a definable pathology grew stronger.
Beyond ideas and theories, his major contribution was classifying still prevalent concept unitary psychosis into two major classes, dementia praecox and manic depressive illness. Originally dementia praecox was a separate group of disease from hebephreania and catatonia, but in sixth edition of Lehrbuch der Psychiatrie, published in 1899, he stated that all three were different manifestations of the same disease.
Another cardinal principle of his method of classification was that it was not that manic-depressive and dementia praecox cannot share symptoms, it was rather the pattern of symptoms what was more important for the classification.
These ideas of Kraepelin are so relevant that both ICD and DSM still follow them, and probably we have to follow them till we derive aetiological classification. Kraepelin's contributions were to a good extent marginalized throughout a good part of the twentieth century, during the success of Freudian aetiological theories. His observations, ground-breaking ideas and theories provided the frame-work for modern psychiatry to follow and advance beyond him.
Advancing upon his theories, Paul Eugen Bleuler (April 30, 1857 – July 15, 1939), a Swiss psychiatrist, realized that dementia praecox was neither a dementia, nor did it always occur in young people (praecox meaning early) and so gave the condition the purportedly less stigmatising but still controversial name from the Greek roots schizein ("to split") and phrēn, phren- ("mind"), schizophrenia.
Kraepelin showed a route to follow and understand psychosis, but the main question of how to treat them remained unanswered and meanwhile number of individuals grew rapidly in the asylums, as the diagnoses could be made but there was no effective treatment to offer.
We will pause the discussion about psychosis here for two reasons, one that though Kraepelin’s ideas brought a revolution in thinking about psychosis, there was almost nothing to offer as treatment and so, we have to wait till middle of the 20th century.
Second and more important reason, is that, another maverick thinker entered the field of psychiatry who started from a very different view-point and showed that understanding the mind may have a different path altogether and he not only introduced new ideas about diseases but also ways to treat them. He started with neurosis and tried to answer some of the fundamental questions of mind, and in doing so, he changed the mind-set of the whole civilization. In the next part, we shall discuss about this man.
But, before we wind up, we must discuss a bit more about asylums which we stopped halfway above. It is necessary to restart the discussion because, though asylums helped to understand and apply psychiatry in a systematic way, it also earned ill-fame for psychiatry. Asylums were not only places to keep the insane, but also institutions of significant cultural impact on the human understanding about rights, responsibilities and obligations of the civilization.
I would like to skip the very beginning of the history of asylums, as we have mentioned those in the initial chapters. Truly speaking, history of psychiatry when viewed from the point of view of general population is the history of asylums itself. From the asylums, psychiatry grew and developed and later on changed the very concept of asylums. We have earlier mentioned that at the very beginning asylums were places to house the mentally ill patients and the main reason was to protect the public from the insane. Thus, they were nothing else but prisons and that should give the reader an idea about what could be the conditions of such an institution.
However, not every person considered asylums as prisons. As early as in 1758, Englishman William Battie, ‘the leading mad doctor of the day’ wrote in his ‘Treatise on Madness’ that management do much more than medicine and he emphasized on confinement. He strongly believed that mental illness can be cured by confinement, but his confinement was not a form of torture, as he wrote—‘such unhappy objects (patients) ought by no means abandoned, much less shut up in loathsome prisons, as criminals or nuisances to the society.’
Please note the year in which the book was published, because Pinel brought ‘moral treatment’ almost half a century later in 1795. Here is another important cultural influence that is important to remember here. Philip Pinel was a product of French Revolution, one of the major socio-cultural influences of Europe.
Pinel’s influence and regulations imposed by the state, changed the status of asylums from ‘madhouses’ (prison for mentally ill) to therapeutic institutions. Physicians studies patients there and drew up theories about mental illnesses. But, the biggest question was still unanswered. How to treat the patients?
The situation in those asylums was pathetic. Patients were kept in small cells, without proper food and hygiene, and were subjected to treatment methods that had no validity, and worse, some of those treatments were nothing but various forms of torture. Some of the ‘notorious’ (from the view of general population) treatment methods of asylums were malarial therapy, deep sleep therapy, insulin coma therapy, electro-shock therapy, and lobotomy.
The inside environment of asylums, and the treatments practiced there caused social stirs time to time. Some influential journals, books and movies flamed these public reactions. These reactions lead to widespread change in the regulations about mental health, particularly maintaining the asylums.
The two World Wars and their impact on the human thinking made great changes in the perception of psychiatry. Psychiatry was even used as a political tool. These topics we would like to discuss in a bit detail later.
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