Anaesthesia and psychiatry by Quentin Smith
From the ancient 'lunatic asylums' to modern day
(Published in Today’s Anaesthetist 2010 Vol 25[3])
Anaesthesia’s role in the treatment of mentally ill patients over the centuries has been limited, but today it is an integral part of a very commonly employed psychiatric treatment modality.
Institutions to house the mentally ill were first introduced because urbanised communities could no longer cope with the demands of these individuals. As such early asylums served simply to remove the mentally ill from society, functioning more like prisons than hospitals. Of course the wealthy could afford to have their mentally ill taken away, but the poor had no such facility.
The first known asylum in Europe was Bethlem Royal Hospital, known as “Bedlam”, founded in 1547 in London. It is now the Imperial War Museum. Visitors could pay for entry to watch the lunatics incarcerated inside as a form of popular entertainment, and this continued until as recently as the 19th Century. Only in the 1700’s did the term patient finally replace the word lunatic.
Society in general viewed mental illness somewhat unsympathetically, regarding it as a punishment for sinful living. This may in part be due to the fact that, following the introduction into Europe of syphilis in the 1490’s, the neuropsychiatric complications of advanced syphilis were not understood for over 400 years until the early part of the 20th century.
Unfortunately most early lunatic asylums were rather inhumane in their treatment of incarcerated lunatics. So called therapy administered to patients included bleeding, purging with leeches, mustard plasters, muzzles and shackles, and being spun around rapidly (100revs/min).
Although Persian physicians had tried psychological and physiological explanations to treat mentally ill patients as early as the 10th century, it was not until Phillipe Pinel in 1793 and later Carl Jung in the early 1900’s, that attempts to categorise and understand mental illness reached Europe. Pinel was among the very first to remove patient restraints together with William Tuke, a Quaker who established the more humane York Retreat. Here the traditional medical treatments of the day were abandoned in favour of understanding, hope, moral responsibility, and occupational therapy.
In England, Parliament introduced the Madhouse Act in 1828 which permitted the construction of purpose built asylums for treating the mentally ill. Amongst these the West Riding Pauper Lunatic Asylum was one of the very first to introduce supervised site employment as a means of making patients better.
Over the years many ineffective and cruel treatments were tried and popularised, more often as “quick fixes” rather than cures. Eugenic compulsory sterilisation programs were introduced in most American states and in Germany, the rationale being that mental illness was a “defect”, and most likely a hereditary one. Therefore sterilisation was introduced to cleanse society more so than to help the patients. *
There are some very controversial accounts of the misuse of lunatic asylums in certain countries, often for stifling political dissidence. One example is the T-4 Euthanasia Program implemented in Nazi Germany in the 1930’s which was used to kill tens of thousands of mentally ill patients in state asylums. There is disturbing evidence that Dr Hans Asperger, the paediatrician responsible for describing what we today know as “Asperger’s Syndrome”, was involved in the T-4 Euthanasia Program in the run up to the Holocaust. * [note: see Huber's Tattoo]
With the advent of the 20th century a series of radical and innovative psychiatric treatments were introduced to try and break the culture of institutionalising the mentally ill in asylums. These radical and somewhat invasive therapies included malaria therapy for general paresis of the insane (1917), barbiturate sleep therapy (1920’s), and insulin shock therapy (1930’s).
Electroconvulsive shock therapy (ECT) was introduced in 1938 and was performed without anaesthesia for about 30 years. Of course without anaesthesia patients undergoing ECT required substantial restraint to prevent terrible injuries including oral lacerations, fractures of long bones, and other skeletal injuries from occurring. Restraint was not always successful in its goal.
ECT was even used as a form of anaesthesia to enable other forms of invasive psychiatric treatments. The most notorious of these was frontal lobotomy, or leucotomy. Introduced in 1935 this procedure involved surgically severing the neuronal connections to and from the pre-frontal cortex. Controversial from inception it had a wide range of indications, from delusional psychoses to schizophrenia, paranoia to chronic pain conditions. The side effects, as one can imagine, were many, and some quite devastating.
Some lobotomies were performed under ether anaesthesia, others during the post-ictal state induced by ECT. Egaz Moniz, the man who described the trans-orbital lobotomy which could be performed in just seconds under local anaesthetic, was controversially awarded the Nobel Prize for Physiology and Medicine in 1949 for his work in this field. Frontal lobotomy was so successful in some aggressive and excitable patients that it enabled them to be discharged to their homes, preferable of course to long term institutionalisation. It became a mainstream procedure until about 1951 during which time tens of thousands were performed in the USA alone.
The single greatest advance in psychiatric care came in 1950 when chlorpromazine was introduced. As the first effective chemical psychotropic drug it revolutionised psychiatric care. Gradually insulin shock therapy and especially lobotomies were humanely superseded, and scores of patients were freed from institutions.
Of all the early and often controversial treatments used in asylums only ECT survives to this day, and it remains a popular treatment for severe depression. In the USA more ECT’s under general anaesthesia are performed annually than CABG, appendicectomy and herniorrhaphy combined !
And are lobotomies a thing of the past? Actually not. Today general anaesthesia still plays a role in the performance of stereotactic psychosurgery including subcaudate leucotomy, anterior capsulotomy, and anterior cingulotomy. Because of the significant side effects of many psychotropic drugs some professionals pursued new and improved techniques of targeted psychosurgery as an alternative. Institutions in Cardiff and Dundee have performed upward of a 100 psychosurgical procedures under general anaesthesia over the past decade. In the USA over 500 psychosurgical operations were performed to treat obsessive compulsive disorders over the same period.
When one considers that worldwide many called for Egaz Moniz’s 1949 Nobel Prize to be withdrawn in the wake of the countless lives ruined through lobotomy, it appears that a once crude and barbaric surgical procedure may have spawned a massive opportunity for treating millions of psychiatric patients through the modern application of advanced brain science.
From the ancient 'lunatic asylums' to modern day
(Published in Today’s Anaesthetist 2010 Vol 25[3])
Anaesthesia’s role in the treatment of mentally ill patients over the centuries has been limited, but today it is an integral part of a very commonly employed psychiatric treatment modality.
Institutions to house the mentally ill were first introduced because urbanised communities could no longer cope with the demands of these individuals. As such early asylums served simply to remove the mentally ill from society, functioning more like prisons than hospitals. Of course the wealthy could afford to have their mentally ill taken away, but the poor had no such facility.
The first known asylum in Europe was Bethlem Royal Hospital, known as “Bedlam”, founded in 1547 in London. It is now the Imperial War Museum. Visitors could pay for entry to watch the lunatics incarcerated inside as a form of popular entertainment, and this continued until as recently as the 19th Century. Only in the 1700’s did the term patient finally replace the word lunatic.
Society in general viewed mental illness somewhat unsympathetically, regarding it as a punishment for sinful living. This may in part be due to the fact that, following the introduction into Europe of syphilis in the 1490’s, the neuropsychiatric complications of advanced syphilis were not understood for over 400 years until the early part of the 20th century.
Unfortunately most early lunatic asylums were rather inhumane in their treatment of incarcerated lunatics. So called therapy administered to patients included bleeding, purging with leeches, mustard plasters, muzzles and shackles, and being spun around rapidly (100revs/min).
Although Persian physicians had tried psychological and physiological explanations to treat mentally ill patients as early as the 10th century, it was not until Phillipe Pinel in 1793 and later Carl Jung in the early 1900’s, that attempts to categorise and understand mental illness reached Europe. Pinel was among the very first to remove patient restraints together with William Tuke, a Quaker who established the more humane York Retreat. Here the traditional medical treatments of the day were abandoned in favour of understanding, hope, moral responsibility, and occupational therapy.
In England, Parliament introduced the Madhouse Act in 1828 which permitted the construction of purpose built asylums for treating the mentally ill. Amongst these the West Riding Pauper Lunatic Asylum was one of the very first to introduce supervised site employment as a means of making patients better.
Over the years many ineffective and cruel treatments were tried and popularised, more often as “quick fixes” rather than cures. Eugenic compulsory sterilisation programs were introduced in most American states and in Germany, the rationale being that mental illness was a “defect”, and most likely a hereditary one. Therefore sterilisation was introduced to cleanse society more so than to help the patients. *
There are some very controversial accounts of the misuse of lunatic asylums in certain countries, often for stifling political dissidence. One example is the T-4 Euthanasia Program implemented in Nazi Germany in the 1930’s which was used to kill tens of thousands of mentally ill patients in state asylums. There is disturbing evidence that Dr Hans Asperger, the paediatrician responsible for describing what we today know as “Asperger’s Syndrome”, was involved in the T-4 Euthanasia Program in the run up to the Holocaust. * [note: see Huber's Tattoo]
With the advent of the 20th century a series of radical and innovative psychiatric treatments were introduced to try and break the culture of institutionalising the mentally ill in asylums. These radical and somewhat invasive therapies included malaria therapy for general paresis of the insane (1917), barbiturate sleep therapy (1920’s), and insulin shock therapy (1930’s).
Electroconvulsive shock therapy (ECT) was introduced in 1938 and was performed without anaesthesia for about 30 years. Of course without anaesthesia patients undergoing ECT required substantial restraint to prevent terrible injuries including oral lacerations, fractures of long bones, and other skeletal injuries from occurring. Restraint was not always successful in its goal.
ECT was even used as a form of anaesthesia to enable other forms of invasive psychiatric treatments. The most notorious of these was frontal lobotomy, or leucotomy. Introduced in 1935 this procedure involved surgically severing the neuronal connections to and from the pre-frontal cortex. Controversial from inception it had a wide range of indications, from delusional psychoses to schizophrenia, paranoia to chronic pain conditions. The side effects, as one can imagine, were many, and some quite devastating.
Some lobotomies were performed under ether anaesthesia, others during the post-ictal state induced by ECT. Egaz Moniz, the man who described the trans-orbital lobotomy which could be performed in just seconds under local anaesthetic, was controversially awarded the Nobel Prize for Physiology and Medicine in 1949 for his work in this field. Frontal lobotomy was so successful in some aggressive and excitable patients that it enabled them to be discharged to their homes, preferable of course to long term institutionalisation. It became a mainstream procedure until about 1951 during which time tens of thousands were performed in the USA alone.
The single greatest advance in psychiatric care came in 1950 when chlorpromazine was introduced. As the first effective chemical psychotropic drug it revolutionised psychiatric care. Gradually insulin shock therapy and especially lobotomies were humanely superseded, and scores of patients were freed from institutions.
Of all the early and often controversial treatments used in asylums only ECT survives to this day, and it remains a popular treatment for severe depression. In the USA more ECT’s under general anaesthesia are performed annually than CABG, appendicectomy and herniorrhaphy combined !
And are lobotomies a thing of the past? Actually not. Today general anaesthesia still plays a role in the performance of stereotactic psychosurgery including subcaudate leucotomy, anterior capsulotomy, and anterior cingulotomy. Because of the significant side effects of many psychotropic drugs some professionals pursued new and improved techniques of targeted psychosurgery as an alternative. Institutions in Cardiff and Dundee have performed upward of a 100 psychosurgical procedures under general anaesthesia over the past decade. In the USA over 500 psychosurgical operations were performed to treat obsessive compulsive disorders over the same period.
When one considers that worldwide many called for Egaz Moniz’s 1949 Nobel Prize to be withdrawn in the wake of the countless lives ruined through lobotomy, it appears that a once crude and barbaric surgical procedure may have spawned a massive opportunity for treating millions of psychiatric patients through the modern application of advanced brain science.
