Every year we focus on the 12 months that passed. A longer time horizon can provide a better focus, perhaps, about insights that have stood the test of time, not just for one new year but for many many years. In this article, PL analyzes a Top Five list of insights from the history of psychiatry.
PL Note: Julius von Wagner-Jauregg was a medical school classmate and for a time a research colleague of Sigmund Freud. While Freud struggled in private practice, Wagner-Jauregg rose quickly in academic stature to become chairman of the department of psychiatry at the University of Vienna. In later years, though they opposed each other on many occasions (including in court), they had qualified respect for each other, exchanging birthday greetings yearly. Throughout his life, Freud hoped to obtain the Nobel Prize, for which he was nominated but rejected. Wagner-Jauregg, now forgotten, obtained the prize for malaria therapy for neurosyphilis, a treatment that seems odd to us now, but had, in fact, an important historical impact on psychiatry, mostly for the better. Historian Edward Shorter (A History of Psychiatry, pp 194-196) tells this story:
In 1883, during his residency at the asylum, Wagner-Jauregg noted that a female patient who had contracted erysipelas, a streptococcal infection, experienced a remission of her psychosis. This piqued his interest in the relationship between fever and madness, which had long been a subject of medical inquiry. In 1887, Wagner-Jauregg wrote an article speculating that it might be possible to treat psychosis through the use of fever. He mentioned neurosyphilis as being potentially treatable….
In 1890 the German microbiologist Robert Koch developed a vaccine, tuberculin, that was supposedly effective against tuberculosis. Wagner-Jauregg injected tuberculin into several patients whose psychotic symptoms were caused by neurosyphilis, with the aim of giving them a tuberculous fever. (It was thought that fever itself arrested the progress of neurosyphilis on the ground that the syphilis spirochetes are heat-sensitive). By 1909 he was regularly obtaining long-term remissions of the symptoms of neurosyphilis through the use of tuberculin. Yet he discontinued his experiments with tuberculin because it was considered to be toxic.
Wagner-Jauregg then returned to the possibility of giving paretics a fever with malaria, which, unlike other possible infections, had the advantage of being controllable with quinine. In June 1917, he learned that one of his patients, a soldier sent back from the Macedonian front with shell-shock, seemed to have malaria. An assistant physician asked Wagner if the patient should be given quinine. No, said Wagner, who decided upon the spot to inject some of the soldier’s blood into his neurosyphilitics.
In May 1917, a 37 year-old actor with the initials T.M. had been readmitted to the clinic with the now advanced symptoms of neurosyphilis, including weakness of memory, fits, and pupils that were unequal in size and unresponsive to light, a clinical picture that customarily amounted to a death sentence. There being nothing to lose…Wagner-Jauregg inoculated T.M. with malaria. Three weeks later, the patient had his first febrile attack, and after nine such attacks was given quinine.
Astonishingly, after the sixth malaria attack, the syphilitic fits came to an end. [Wagner-Jauregg later wrote]: ’In the course of the following months, there was gradual improvement to the point of abolition of all of the patient’s symptoms…’ A year later Wagner-Jauregg gave the first report of his work, describing the effect of the malaria-cure upon a total of nine patients. This was an epochal moment…Wagner-Jauregg’s fever “cure” (it did not cure but it did restore an almost normal life to patients who otherwise would have died demented) broke the therapeutic nihilism that had dominated psychiatry in previous generations. If one could halt the neurosyphilitic psychoses, perhaps psychotic illness from other causes was treatable as well. Wagner-Jauregg received the Nobel Prize for this work in 1927.
PL Note: The most widely read psychiatric textbook of the mid 20th century was Clinical Psychiatry, written by three British psychiatric academic leaders, two of whom were of Continental origin. Willy Mayer-Gross from Germany and Martin Roth from Austria (both influenced by the great German psychiatrist Karl Jaspers) had emigrated and worked in the UK for most of their adult lives. Together with Eliot Slater, they produced, in the opinion of the PL editor and others, the most comprehensive and clear-headed psychiatric textbook of the last 50 years. The last edition, published in 1969, predates most of the new medications, which would lead later generations to forget about this treasure trove of psychiatric wisdom. This excerpt (p 36) gives a taste of their insights into the psychiatric interview:
Only in the course of time can the psychiatrist develop the art of eliciting by tactful questioning all he has to know. Long training is needed to learn how to overcome the patient’s resistance, to be aware of where his tale is biased, where information has been withheld and where it has been coloured by an emotional attitude. The beginner is inclined to take every statement the patient makes at its face value. In this he has been encouraged by psychoanalytic teaching that fabrications and even deliberate falsifications have their value as symptoms. He must, however, beware of an uncritical credulity. It is the objective world in which we live and to which the subjective world must pay deference. It is even more important to know what the facts are than to know what the patient makes of them.
PL Note: For two millennia, almost all physicians agreed that bleeding was an appropriate treatment for almost all conditions, including insanity. This was based on widespread acceptance of the four humor theory of disease. Here we have a good description of the state of the art in the mid 19th century, written by Esquirol, a successor to the great Philippe Pinel of Paris, founder of the moral therapy approach to insanity which led to removal of chains. Pinel’s humanism was based on a biological theory of insanity being a disease of the brain, and thus he taught skepticism about the widespread bleeding which was the accepted mainstream standard of care of two thousand years. Yet even in his circle, bleeding and other evacuations predominated, as described in Esquirol’s textbook, Mental Maladies (pp 404-405). As you read about these treatments, widely accepted by the most advanced clinicians of that era, think about what treatments these days are accepted widely and yet may prove to be mere beliefs as opposed to scientific facts:
Administration of medicines…calls for careful reflection…So easy it is for us to permit ourselves to be imposed upon by the violence of symptoms. The same medicines should not be ordered indiscriminately to all maniacs and during all periods of the malady…..
At the outset of mania, during its first symptoms, if gastric symptoms are present…we may employ emetics….If indications of plethora are present, we employ and repeat blood-letting. We apply leeches behind the ears, or upon the temples; cupping glasses to the back of the neck; and frequently a small number of leeches to the anus…..
We must be cautious respecting sanguine evacuations. By enfeebling maniacs, we run the risk of throwing them into dementia. ‘Bleeding,’ says Pinel, ‘ is an unusual evacuation….How numerous are the maniacs who have never lost blood, and been cured; how many have been bled, but still remain incurable!’
We employ tepid baths, and continue them for two, three, and four hours; repeating them two and three times a day, by giving a bath every time that the delirium and fury is renewed, if the subject is of a dry and irritable temperament. While the patient is in the bath, we apply cold water constantly to the head…We insist upon the use of cold, diluent and slightly laxative drinks. Lastly, we unload the large intestine by enemata, at first emollient, then purgative. The diet should be cautiously restricted.
PL Note: Daniel Tuke was a British physician whose treatise on mental illness, Insanity in Ancient and Modern Life, is full of insights that still ring true today. Here he describes the importance of paying attention to mild mood symptoms, especially hypomanic ones. These days, many clinicians use the term “hypomania” as a way to minimize the importance of manic-depressive disease, as if manic symptoms only matter when they are severe. Tuke reminds us that mild manic symptoms are important to diagnose:
Warnings of danger are very frequently, if not always, associated with the inability to sleep. The foe is insidious, and, true to his character, loves to assail us in the dark. He comes upon us in the night….
Emotional warnings there are also, which are of grave import, and ought to be regarded with suspicion by those to whom they occur. Among these may be enumerated slight depression of spirits, especially if this alternates with a sense of exaltation and buoyancy….The buoyancy of spirits…is less likely to excite apprehension among friends than despondency; but it is most important to remember that exuberant spirits, mental exhilaration, loquacity, when unusual to the individual, are fully as serious indications as are the opposite states of mind….
Unfortunately, when action is taken, mistakes in business have been made, or legal documents have been signed which involve serious consequence, family disputes have been occasioned, friendships have been broken, and a great deal of misery caused in various ways, all of which might have been prevented by arresting the symptoms by timely treatment, or failing this, arresting the patient himself and sending him to an asylum in an early stage of the disorder….
PL Note: The historian of psychoanalysis, Paul Roazen, had made it his business to identify and interview all of Freud’s living ex-patients in the 1960s and 1970s. In his book, How Freud Worked, Roazen brings Freud the clinician to life, and reveals some astonishing facts about what he believed and how he practiced. Here is an excerpt of the experience of one of Freud’s ex-patients, herself a psychoanalyst, as interviewed by Roazen in 1966 (pp 167-187):
Dr Irmarita Putnam…struck me as one of the most unusually detached and brainy of all the former patients of Freud’s that I ever met….Although Dr. Putnam had once been a practicing analyst in Boston, by the time I had met her she was 71 years old and living in a quietly elegant New York City apartment….In 1925 Dr. Putnam spent not quite a year in analysis with Jung…Thinking back on her contact with both Jung and Freud, Dr. Putnam thought that ‘one could not have imagined any two people more different.’
[By 1930 she had arranged therapy with Freud himself]. She felt Freud was very attentive, as if she were his ‘first patient.’ While she was in treatment with Jung, he had wanted to talk primarily about what he was interested in….Freud was ‘different’; he talked about ‘everything under the sun’ - but he ‘analyzed’ her ‘too’….Although the analysis was never lost sight of, a great deal else came into the picture. He spoke about Communism and opera, for instance….Yet the analysis was undertaken in the ‘strictest’ fashion; there was nothing ‘social’ about it, and only what was relevant got introduced….
Dr. Putnam knew that Freud had been disillusioned with his early analyses, which had once looked so successful but had turned out not to be. He talked about having become skeptical himself, especially about the therapeutic value of psychoanalysis….When something happened in Dr. Putnam’s analysis that was ‘classical’, he would say, “Didn’t I tell you that psychoanalysis was a fine thing for normal people,’ and he would laugh…
Dr. Putnam felt in the course of her own analysis that everything was her own responsibility, and she did not resent what Freud expected of her. Before she saw Freud it had never occurred to her not to ‘project like other people,’ seeing in others her own weak points. The lesson she took away from her psychoanalysis with Freud was that you should not find faults elsewhere, but rather be preoccupied with what you yourself are doing. Even if the other person was in the wrong, what counts is what you are able to do with the situation. She had the healthy-minded conviction that ‘anything can be made somewhat better or worse….’
I asked Dr. Putnam if she thought she had been helped by her therapy with Freud, and her answer was unequivocal: ‘Definitely.’ He had considered her ‘normal,’ but she of course, like everybody, had ‘problems.’