|LOST HOSPITALS OF LONDON|
A brief history of healthcare provision in London
TREATMENTS PROVIDED IN MENTAL HOSPITALS
The early asylums for mental patients were basically prisons for the insane, not offering treatment but incarceration and restraint. Patients who were violent to themselves or to others, or destroyed property, were caged, shackled or put into strait jackets. However, new ideas about the treatment of the mentally ill were introduced in the mid 19th century - restraints were viewed as cruel and unnecesary - and conditions for the patients began to improve. Over time, diagnosis became more accurate and the range of treatments expanded, as suggested in the following sketches.
Ergotherapy (occupational therapy)
Most patients would have been skilled in a trade, and work was encouraged in the asylum, where a routine was implemented comparable to one that they would have experienced outside it. The patients' labour also contributed to the self-sufficiency of the asylum, reducing costs. The work was segregated by gender: men worked on the asylum farm or market garden, in the workshops or helped to maintain the fabric of the institution, while women worked in the laundry, the kitchens, the sewing rooms or did cleaning. This later changed and women were also allowed to work outdoors.
By the beginning of the 20th century hydrotherapy had become a popular treatment. The most common forms were continuous baths, packs, showers, needle sprays, sitz baths and Scotch douches (alternating jets of hot and cold water). Each was held to have particular advantages in different types of cases.
Continuous bath: fresh water at approximate body temperature was constantly poured into the bath, while the old water drained away. This had a calming effect and was used for patients with insomnia, or those who were agitated or suicidal.
The patient was placed in a canvas hammock arranged on a metal frame in the bath, which was then covered with a canvas sheet which had a hole in it for the patient's head. The patient was immersed up to the chin with his head resting on a rubber pillow.
Continuous baths could last for several hours or even days. Prolonged exposure to warm water kept the skin in good condition and prevented abrasions and the development of bed sores.
Cold water at a temperature of 48-70oF was used to treat patients with manic-depressive psychoses.
Packs of sheets dipped in varying temperatures of water were wrapped around the patient from head to foot, who remained in this condition for several hours. The technique allowed excited patients to get some rest.
Dry sheets or blankets were used when wet packs were unadviseable.
Showers and needle sprays (multiple horizontal small sprays of water applied to the standing patient) used either warm or cold water, or both alternately (Scotch douches).
In 1917 Julius Wagner-Jauregg (1857-1940), an Austrian physician, had inoculated patients suffering from generalised paralysis of the insane (neurosyphilis) with the malarial parasite to induce malarial fever. The patients either became well or showed signs of improvement or, at the least, progress of the disease was arrested.
A Malarial Therapy Unit was established at Horton Hospital.
Following the introduction of penicillin for the treatment of syphilis, cases of neurosyphilis greatly diminished and the treatment became redundant.
Insulin coma (insulin shock treatment)
Developed by the Polish researcher Manfred Sakel (1900-1957) in 1927, it was derived from the observation that schizophrenic patients who were also diabetic improved psychologically after a coma.
Coma was induced by the injection of a large amount of insulin, but the methods of administering the treatment varied and there was no agreed way of doing it. Epileptic seizures occurred during the early stages of the treatment, about 45-100 minutes after injection, before the onset of coma. The procedure was terminated after the patient had been in a comatose state after about an hour, by an intravenous injection of glucose.
The treatment was used especially for schizophrenic patients, but was only useful in the early stages of the disorder. Some 30-40 treatments were given, after which the patient often appeared much improved.
Modified insulin treatment, in which lower (sub-coma) doses of insulin were given, was employed in patients suffering from physical debility and loss of weight associated with tension states, generally of a neurotic character.
Insulin treatment was gradually replaced by tranquilising drugs. It was finally abandoned in the mid 1960s.
In 1934 Ladilas Meduna (1896-1964) in Budapest injected mental patients with cardiazol (a cardiac stimulant), which induced fits of an epileptic type. The drug resulted in a remarkable improvement in patients with certain mental disorders, especially depression.
Bexley Hospital was amongst the first in the UK to use this treatment. Cardiazol was given at 10 times the usual dosage until the patient had seizures.
This technique was replaced by electroconvulsive treatment (ECT).
Electroconvulsive treatment (ECT)
This treatment was devised by the Italian neurologist Prof. Ugo Cerletti (1877-1963) in 1938. He had visited the Rome abattoir and observed that pigs were rendered comatose by electric shock prior to slaughter, but not actually killed by the current passing through their heads.
ECT was first used in the UK in 1939. Electrodes were placed on both sides of the patient's head (or on one side only) and a dose of 70-150 volts was usually given for 0.1-0.5 seconds. Patients were held down by a team of four nurses as convulsions happened, to prevent broken long bones or joint dislocation due to muscle pull. The entire procedure lasted about 30 minutes.
Patients with depression usually required 6 to 12 treatments, usually given every other day, three times a week. The total number of treatments varied and depended on many factors, for example, age, diagnosis and medical history.
Later, from the 1950s, a muscle relaxant and intravenous anaesthesia were given beforehand. This was known as modified ECT.
By the mid 1970s the technique had fallen into disrepute. Although it is used occasionally today for patients with depression, catatonic or manic excitement, paranoid reactions, hebephrenia and schizophrenia, it has been mainly replaced by powerful new drugs.
Prolonged sleep treatment (deep narcosis)
This was used particularly for manic or very agitated patients. Sleep was induced for 7-14 days. The main drug used was sodium amytal (amobarbital), with or without paraldehyde.
The patient's sleep needed to be monitored and any changes recorded, so required a lot of nursing care. Bronchopneumonia was an outstanding complication of the technique.
Psychosurgery, particularly lobotomy (leucotomy), became popular during the 1930s, perhaps because it was regarded as a solution to the overcrowded and understaffed conditions in mental hospitals. Early operations were performed using surgical knives, electrodes, suction or ice picks to sever or disable areas of the brain in order to trigger a change in the patient's erratic behaviour. By the 1940s each mental hospital was equipped with an operating theatre.
Prefrontal lobotomy had been developed by Egas Moniz (1874-1955) in Portugal in 1935. A small piece of the frontal lobe was removed or damaged. It was performed on patients with certain chronic obsessional disorders, chronic depression and some forms of schizophrenia. Side-effects from the surgery included a reduced capacity to learn and an inability to deal with situations requiring quick or alternative planning.
Transorbital lobotomy (ice-pick lobotomy) - in which an ice-pick was inserted through the orbit above the eyeball and manouevered to cut brain fibres - had been developed as a quicker and less invasive method by the American neurologist, Dr Walter Freeman (1895-1972). It was abandoned in the 1940s because of the uncertainty of this method.
Lobotomy was gradually replaced by the introduction of anti-psychotic drugs, notably Largactil (Thorazine), in the mid 1950s.
Cingulotomy, a more limited and controlled procedure, was introduced in 1952 as an alternative to lobotomy. It is performed on patients with mental disorders that have failed to respond to other treatments. Bilateral cingulotomies can also be used to alleviate chronic pain in cancer patients.
Psychiatry and allied therapies
Psychiatry. The term psychiatry was coined by the German physician Johann Christian Reil in 1808. It describes the medical specialty devoted to the study and treatment of mental illness, including various affective, behavioural, cognitive and perceptual disorders.
Mental disorders are conventionally divided into three loose categories - mental illness, learning disability and personality disorder.
Psychiatrists are qualified physicians and can prescribe drugs and other treatments for their patients, including psychotherapy, psychoanalysis and cognitive behavioural therapy.
Psychotherapy. The term was first used in 1890. The technique is used to help people overcome stress, emotional or relationship problems or troublesome habits. It is sometimes regarded as counselling.
Most forms of psychotherapy use conversation ('talking therapy'), either between an individual and a therapist, or as a couple, a family or a group, but other forms of communication can be employed - the written word, art, drama. story-telling and music.
Abreaction therapy, a type of psychotherapy, is used to help patients suffering from post-traumatic stress disorders by re-living their experiences in a controlled environment.
Psychotherapists need not be medically qualified and may be unlicensed practitioners (there are currently no laws in the United Kingdom regarding counselling and psychotherapy).
Psychoanalysis. The Austrian neurologist Sigmund Freud (1856-1939) developed the idea of psychoanalysis, a form of psychotherapy, in Vienna during the 1890s as a way of finding an effective treatment for patients with neurosis or hysteria. Following his death in 1939 other psychoanalysts, for example Carl Jung, Alfred Adler and Melanie Klein, continued his work. Psychoanalysis became popular in the post-war period.
A psychoanalyst must complete training at an analytic institute.
Psychology is all-embracing term for the scientific and academic study of the mind
It is concerned with all aspects of behaviour and the thoughts, feelings and motivations realised in behaviour. A practitioner in this field also explores underlying physiological and neurological processes. Many types of psychology exist, for example, clinical, biological, cognitive, and counselling.
Classified as a social or behavioural scientist, a psychologist will have qualified with a Ph.D. in psychology.
Paraldehyde was introduced into clinical practice in the United Kingdom in 1882 by the Sicilian physician Vincenzo Cervello (1854-1919). It was soon found to be an effective anticonvulsant, hypnotic (sleep-inducing) and sedative drug. One of the safer drugs, it was given to patients in mental and geriatric hospitals at bedtime to induce sleep. It was the main drug of choice until new medications were developed at the beginning of the 1950s.
Sedatives and tranquilisers. The first barbiturate drug, barbital, was synthesized in 1902 in Germany. Several related drugs had been developed by 1904. Phenobarbital (Luminal) was marketed in 1912 and was a popularly prescribed sedative-hypnotic until the development of benzodiazepines (see below). It was discovered that Luminal was also effective as a treatment for epilepsy (the only available drug for the condition had been bromide, which was of limited efficacy and had unpleasant side-effects). Between 1934 and 1945, during the Nazi regime in Germany, Luminal was used to painlessly kill children with congenital mental or physical handicap.
Sodium amytal (amobarbital), a barbiturate derivative, was first synthesized in 1923 in Germany. It was used by the United States Army in WW2 to get shell-shocked troops back to the frontline during the Battle of the Bulge in December 1944-January 1945. The drug enjoyed a brief reputation as being a 'truth drug'.
Meprobamate (Miltown, Equanil, Meprospan), launched in 1955, was the best-selling tranquiliser of its time. It was also found to be useful in the treatment of alcoholism. However, it was discovered to cause physical and psychological dependence and, by 1970, was listed as a controlled substance.
In 1960 chlordiazepoxide (Librium) was the first benzodiazepine introduced in the United States. Another benzodiazepine, diazepam (Valium) was marketed in the United Kingdom in 1963 as a sedative drug to treat anxiety disorders.
Anti-psychotic drugs. Chlorpromazine (Largactil, Thorazine), the first of the anti-psychotic phenothiazines introduced around 1954, relieved the worst symptoms of psychotic illness. While phenothiazines controlled symptoms without the sedative effects of the previous drugs, they were sometimes known as 'chemical strait jackets' or 'chemical lobotomy'. American psychiatrists dubbed the feet-dragging of patients the 'thorazine shuffle'. The effects were often permanent, even though treatment was discontinued, indicating brain damage.
The use of phenothiazines made community care for mental patients a possibility. The first long-acting anti-psychotic phenothiazine, fluphenazine (Modecate), was introduced in 1969. Given as an injection every two to five weeks, it is used in the treatment of schizophrenia and other paranoid psychoses.
Atypical anti-psychotics became available in the 1990s; clozapine (Clozaril) in 1990, risperidone (Risperdal) in 1993, and sertindole (Serdolect) and olanzapine (Zyprexa) in 1996. It is claimed they have less debilitating side-effects than chlorpromazine.
Anti-depressive drugs. The first anti-depressive - a monoamine oxidase inhibitor, ipronazid (Marsalid), was introduced in 1958. Originally intended as a treatment for tuberculosis, its anti-depressant properties were noted to make TB patients 'inappropriately happy'. It was later withdrawn as it was found to be hepatoxic (patients had developed jaundice) and replaced by isocarboxazid (Marplan), phenelzine (Nardil) and tranylcypromine (Parnate).
Since the 1990s many more drugs, too many to mention here, have been introduced for the treatment of mental disorders. This progressive introduction of new sedatives, tranquilisers, anti-psychotics and anti-depressives have reduced the pressure on hospital accommodation and facilititated 'care in the community' approaches.
LCC MENTAL HOSPITALS IN 1948
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(Author unstated) 1949 The LCC Hospitals. A Retrospect. London, LCC.
Scull A 2005 The Most Solitary of Afflictions: Madness and Society in Britain 1700-1900. London, Yale University Press.
Selesnick A 1967 The History of Psychiatry. London, George Allen & Unwin.
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