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Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 298-302

Psychiatric treatment in the preneuroleptic era

Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka, India

Date of Submission25-Nov-2019
Date of Decision01-Dec-2019
Date of Acceptance02-Dec-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Dr. Avinash Joe
Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_159_19

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Throughout history there were many attempts to understand the mind and to derive treatment options based on the presumed causes. This often resulted in many of the controversial and outlandish practices. In this article we have tried to emphasize on some of such practices, some more unusual than other, that have been used in the pre – neuroleptic era. Advancement in the field of science has changed the way we look at psychiatric disorders and brought transformation in the way we treat psychiatric patients.

Keywords: History of psychiatry, pre-neuroleptic era, psychiatric treatment

How to cite this article:
Rasquinha SL, Joe A, Safeekh A T. Psychiatric treatment in the preneuroleptic era. Arch Med Health Sci 2019;7:298-302

How to cite this URL:
Rasquinha SL, Joe A, Safeekh A T. Psychiatric treatment in the preneuroleptic era. Arch Med Health Sci [serial online] 2019 [cited 2022 Jun 28];7:298-302. Available from: https://www.amhsjournal.org/text.asp?2019/7/2/298/273063

The manifestations of the maladies of the mind have evoked from the human race a myriad of reactions ranging from mild curiosity and mirth, ridicule and pity, to fear of the ununderstandable and the unexpected. Throughout the ages, man has attempted to reason out the cause of “madness” to base its treatment on. The last half-century has seen monumental discoveries and advances in the field of psychiatry.[1] The introduction of chlorpromazine in 1952 brought a revolutionary change in management and understanding of psychiatric disorders. However, the history of the treatment of psychiatric disorders before the age of neuroleptics and manualized psychotherapies was fraught with controversial and outlandish practices (which in some cases have paved the way to modern treatment systems). In this article, we bring to light some of the treatment methods, some more unusual than others, that have been used in the times gone by, with particular emphasis on somatic and physical therapies.

Since antiquity, diseases have been attributed to the supernatural.[2] One of the oldest psychosurgical methods was perhaps trepanation – the procedure of penetrating the skull with an instrument, with the intent of removing a piece of bone to create an opening [Figure 1]. Archaeological evidence suggests that this procedure dates back to the Mesolithic era and the first written mention of it was in the 5th BC, in Hippocrates's book “On Injuries of the Head.” Although the exact purpose of our ancestors in performing trepanation may be unknown, the procedure was widely used through the Middle Ages and the Renaissance to allow evil spirits to escape through the opening in the skull.[3],[4]
Figure 1: Johannes Scultetus (1655) showing how trepanation was performed (Source: Costandi M. An illustrated history of trepanation. 2007;16(7):7641)

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The humoral theory was central to the teachings of the ancient Greek physicians, Hippocrates (460–370 BC) and Galen (130–210 AD). According to this theory, illnesses occurred when there was an imbalance in the humors within the body. A multitude of treatment approaches were developed to bring about the balance between these humors – bloodletting, vomiting, and purging – most of which long outlived the theories that justified them.[1]

A similar notion to the humoral theory was the concept of Doshas held in the ayurvedic teachings. The medical system of Ayurveda has advocated the tradition of using “dhara” (externally applied medicated liquids) to balance the Doshas (biological humors). In particular, Shirodhara, a type of dhara, where oil drips onto the forehead in a steady stream is practiced widely. It has been shown to alleviate stress, improve anxiety and insomnia, and to potentiate the immune system through sympatholytic effects. Details of administration of Shirodhara are addressed in classical texts such as “Dharakalpah.[5],[6]

Meanwhile in the Arab world, Muhammad ibn Zakariya al-Razi (Ibn Rhaez) of Baghdad rejected Galenic notions and believed that a healthy mind was the precursor to a healthy body. He was one of the first physicians to consider mental illness as a medical disorder and assigned hospital wards exclusively for the care of the mentally ill. His treatment included dietary changes, occupational therapy, aromatherapy, baths, and music therapy. He also developed an early form of psychotherapy for obsessive thoughts. At discharge, his patients were given some money to help with their integration back into society – an example of the first psychiatric aftercare system.[7] Avraham Abulafia of Saragossa was a Jewish mystic who evolved the k'fitzah, a practice by which an individual trained themselves to skip from one thought to another. This was to later influence Freud in the development of free association.[8]

The medieval ages saw the reemergence of the hypothesis of the supernatural causation. Under the influence of the Christian philosophies, mental and neurological illnesses were once again attributed to the devil and to evil spirits. This concept was further strengthened during the Great Plague (1347–1348). Exorcism (a specific form of prayer that is used to drive out demons or evil spirits from those who have been possessed), the killing of cats (considered to be the incarnation of the devil), confessions to a priest, and the singling out of women as witches and their subsequent torture were commonplace in the medieval times and continued into the Renaissance. Even to this day, the practice of exorcism continues and is hugely popularized by the films that capitalize on the public's continued fascination with it.[9]

Bloodletting was used by the ancient Greeks and the Arabs, much before it gained prominence in the west (where it was in use up till the 19th century), and was expected to cure melancholia by the removal of an excess of black bile. Bloodletting was performed either through the more commonly used venesection, or through the attachment of leeches, or by dry cupping (which involved the application of a warmed cup to the shaven head to draw blood away from the internal parts to lessen congestion), or wet cupping (where the skin under the cup was removed to allow the escape of blood).[2]

The 16th century marked the beginnings of modern psychiatry and the debunking of witchcraft in causing mental illnesses. Felix Plater (1536–1614), a Swiss physician, coined the term alienation to allude to mental illness. He recommended the use of purgatives as he believed that this would rid the body of an excess of black bile, thus in keeping with the still widely held humoral theory. And although the humoral theory still persisted, the 17th century saw the slow rise of rationalism and empiricism. Richard Burton's “Anatomy of Melancholy” was published in 1621, in which he advocated in addition to dietary measures, vacations in the country, and various herbal remedies, a psychotherapeutic approach to melancholy – involving revealing one's troubles to a trusted friend. Contrastingly, Thomas Willis (1621–1675) recommended much harsher treatment modalities – beatings, bloodlettings, and restraints.[1],[10]

The practice of aromatherapy has gained popularity over the past few years and claims to heal a wide variety of both physical and mental afflictions.[11] In the 17th century, herbal remedies as advocated by Burton including chrysanthemums, lemon balm, saffron crocus, the day lily, rosewater. Periwinkle rosemary, and marigold were used to ward off the bad humors, while Valerian in a tincture with potassium bromide was used for anxiety and hysteria (to bring back the wandering uterus to its original anatomical location).[2]

Along similar lines, Homam is a sacred ritual practiced in Hinduism, Buddhism, and Jainism where mantras are chanted while offering grains, fruits, herbs, ghee, and twigs into the fire. Fumigation and vaporization of these substances produce ash, which is said to have medicinal properties. They act as cerebral stimulants and are said to help patients with breathing difficulties and mental disorders. This atmosphere claimed to provide relaxed, peaceful, and destressing experiences.[12]

Regardless of the spread of rationalism and empiricism during the 17th century, the people's belief in the healing power of miracles continued to be strong. Valentine Greatraks (1628–1683) took particular advantage of this and believed himself to possess the power to cure ailments and did so by the stroking of the affected body part. Thousands flocked to him, and it is reported that he cured many with hysterical paresis (though he prudently avoided the organic lesions) and perhaps his legacy pays tribute to the powers of suggestion and placebo.[13]

The 18th century, though thought of as the Age of Enlightenment, did not see much improvement in the conditions of the institutionalized mentally ill nor much change in the treatment methods of choice, with bloodletting, emetics, and purges still widely practiced. In the early 1700s, Franz Friedrich Anton Mesmer (1734–1815), a graduate from Vienna, believed that diseases stemmed in the imbalance of “universal magnetic fluids” in the body, which he called “animal magnetism,” which could be cured by the application of magnets and metallic conductors. He later claimed that his hands themselves possessed magnetic healing powers and with flamboyance had claimed to heal many an illness, including hysterical blindness. His work was discredited when King Louis XVI put together a royal commission (which included Benjamin Franklin) and found no support for this theory. His theory unfortunately became more acceptable when he showcased that a wand was not needed but that it was enough to rely on the power of suggestion, the essence of which formed the basis for Charcot's hypnosis.[1],[2]

A notable and progressive change was brought about by Philippe Pinel [Figure 2], a French physician through his “traitement moral” (moral treatment). He rejected the humoral theory and believed that mental ill individuals regardless of their diagnosis should be treated with dignity and as human beings. The mentally ill in institutions were unshackled and barred from public display for the purposes of entertainment.[1]
Figure 2:Dr. Philippe Pinel at the Salpêtrière, 1795. Pinel ordering the removal of chains from patients at the Paris Asylum for insane women (Source: Guevara JE. History of psychiatry. Nicar Med 1961;17:281-6)

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The term psychiatry as we now understand was first coined in 1808 by Johann Reil (1759–1813), who among his various contributions to the field, was one of the pioneers of occupational therapy, in addition to music and drama therapy, as a means of enhancing coping in patients.[1] The pseudoscience of phrenology [Figure 3], though first described in the last decade of the 18th century by the works of theViennese physician Franz Joseph Gall (1758–1828) and publicized by Caspar Spurzhiem, gained credence during the first half of the 19th century. This fallacy in modern psychiatry believed in the ability of gleaning one's character and mental faculties from the shape of one's head. Although initially harmlessly quaint, it took an ugly turn when used to establish the superiority of certain races, like in the case of Charles Cadwell from Kentucky used it to misproclaim native American Indians as an inferior race.[14]
Figure 3: Phrenology by William A. F. Browne: Measures the bumps in the skull to predict mental traits (Source: Guevara JE. History of psychiatry. Nicar Med 1961;17:281-6)

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A school of thought that existed from antiquity was the exposing of the mentally ill to a sudden sharp shock, either to drive out demons or the evil humors. A bizarre treatment mode in the 19th century was the Rotational Therapy. First proposed by Erasmus Darwin [Figure 4], it was believed that this would lessen “brain congestion.” Dr. Joseph Mason Cox (1762–1822), a Scottish physician, developed a novel rotating chair designed to rapidly swing the patient and frighten them, which purported to drive out worrying ideas and emotions. This spread to a few countries and was perhaps a rudimentary initial description of the biomedical effects of g-force.[15],[16]
Figure 4: Erasmus Darwin (1731–1802) (left). Hallaran's circulating swings used in rotational therapy to drive out demons (right) (Source: Wade NJ. The original spin doctors-the meeting of perception and insanity. Perception 2005;34:253-60)

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By the 20th century, syphilis (or the great imitator, as it was accurately named) was widespread and its neuropsychiatric manifestations were widely recognized. The Austrian psychiatrist Julius Wagner-Jauregg (1857–1940) had observed that the inmates of his asylum suffering from syphilis, when in an acute febrile state, had a resolution of their psychiatric symptoms. Working with this observation, he tested various methods to induce a fever in his patients. In 1917, he received the Nobel Prize for treating psychiatric symptoms in patients by inoculating malaria in them. His contribution to the field of psychiatry lay in the fact that he was able to provide a biological basis for psychiatric disorders, something which had eluded alienists till date.[17],[18]

In the early 20th century, four major “somatotherapies” were developed: insulin coma therapy, chemical convulsive therapy, psychosurgery, and electroconvulsive therapy (ECT). Inducing a coma to treat schizophrenia may seem outlandish in this century but was a standard treatment practice in the 1930s. Developed by the German physician Manfred

Sakel (1900–1957), insulin coma therapy encompassed the treatment of schizophrenia by administering high doses of insulin, rendering the patient stuporous, and therefore, appearing calmer and more compliant. The mortality rates with this procedure ranged from 1% to a worrisome 10%.[2],[19]

The notion that convulsions attenuate psychiatric symptoms has existed for centuries. The Swiss alchemist Paracelsus (1493–1541) induced convulsions using camphor in 16th century to cure lunacy. Centuries later, in 1934, a Hungarian neuropsychiatrist Ladislas J Meduna (1896–1964) researched the hypothetical antagonistic relation between seizures and schizophrenia based on the possible lack of glial cells in schizophrenia and overgrowth of these in epilepsy in neuropathological studies.[20] By injecting camphor oil, he induced a series of seizures to treat catatonic schizophrenia. Camphor was later replaced with metrazol which was more soluble and acted faster. In 1938, Ugo Cerletti (1877–1963) and Lucio Bini (1908–1964) used electricity as an alternative for inducing brief seizures to overcome the unpleasant effects of chemical convulsions. Although ECT is still an important and relevant mode of treatment for severe mental disorders, it continues to be tinged with stigma and fear, unfortunately propagated through popular media.[21]

Among therapies that are considered dubious, orgone therapy stands out. A recent Delphi poll, ranking treatments in the order of most to least discredited, puts it at third place. The orgone box, devised by an erstwhile star pupil of Freud, Wilhelm Reich (1897–1957) (who by the time of his death was considered an outcast by the scientific community), claimed to be able to harness the orgone energy (a sexual force present throughout the universe) of individuals and heal them of all ailments [Figure 5]. Needless to say, this was not condoned by psychiatrists worldwide.[22]
Figure 5:Orgone box: Psychiatrist Wilhelm Reich declared the existence of a universal healing and revitalizing force, called orgone, and created devices to capture and administer it (Source: Healing Devices (FDA 138). Available from: https://www.flickr.com/photos/fdaphotos/8224052279/)

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Faith-based mental asylums were institutions where people were kept for long periods of time with the purpose of curing them through divine intervention. These asylums used inhuman treatments on the mentally ill. “Patients” were chained, beaten to drive away evil spirits, and tied to trees while waiting for a divine command to set them free. An accidental fire in one such asylum in the village of Ervadi of Tamil Nadu, India on August 6, 2001, claimed the lives of 28 inmates who were chained to the beds.[23] The Mental Healthcare Act of India, 2017 now prohibits such asylums.

Many countries have by and large abandoned witchcraft and the occult for treating mental illness; however, developing countries like India still struggle with it due to poverty, ignorance, and superstition. Even though, from the current perspective, some of the treatments discussed above appear odd or even barbaric, it is imperative to bear in mind that they were based on the belief systems and etiological models prevailing at that time, with the goal of controlling the symptoms and segregating patients. The treatment of mental illnesses has evolved over the years into modern day practices based on our understanding of neuroscience, aiming at functional recovery and rehabilitation. Decades down the line, science will hopefully enable us to further demystify mental illness by deepening our understanding of the etiopathogenic processes at work and help to develop more effective, and more humane, treatment modalities.

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