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Friday, July 19, 2019

Blood-letting as a cure for madness. An East Anglian account.

We tend to forget the terrible state of knowledge amongst clinicians about the many forms of 'lunacy' or 'insanity', and its treatment before the first World War.  In fact, in the nineteenth century society was still in the grip of theories that had been discredited since the start of the nineteenth century. The public felt cheated if the insane weren't subject to 'blood-letting'. They still held to the theories of the 'Humours' and the phlogiston Theory'. Clinicians may have held fancy idea but it was commonsense to the general public that insanity was caused by too much hot blood, and the cure was a poor diet of plain fibrous food, and the periodic draining of blood. Doctors too often gave in to pressure and advised blood-letting as a general treatment for insanity, almost always making the problem worse.

East Anglia had a few Lunatic Asylums, in response to the County Asylums Act of 1845. the Lunacy Act required every county to have a Lunatic Asylum, with treatment to be provided by Medical Superintendents. Their regime was devised as a radical alternative to the rudimentary care offered by the workhouse. In some cases, the the patients admitted to these institution had been so harmed by the treatment already applied under the instruction of their doctors, that they became difficult to cure. Because diagnosis was almost entirely random, and patient records almost entirely absent, the effects of ignorant and appalling treatment of  insanity weren't obvious at the time. It was a bad time to go mad.

Dr D. C. Campbell, the first Medical Superintendent of the  Essex Lunatic Asylum at Warley, gave, in the annual report of the asylum, an interesting account in 1867, fifteen years after the establishment was opened, of his frustrations about the use of bloodletting, and the frustrating lack of clinical records or accurate diagnosis.

"THIS asylum contains 573 patients, of whom 250 are males and 323 females. Dr. Campbell, in his report, remarks, inter alia, that, in a number of the patients brought to the asylum, a practice not infrequent in cases of acute mania had been resorted to, viz. bloodletting; and he goes on to write
"Throughout all ranks of society, an opinion is pretty generally diffused that insanity is a disease of a very inflammatory nature, and that strong antiphlogistic means must be used to allay the excitement. Accordingly, low diet, powerful purgatives, and bloodletting, are had recourse to, and it frequently happens in those cases in which they are most detrimental. 
"That low diet in certain cases may be beneficial is not to be denied; great discretion, however, even in this is required, for a furious state of excitement may coincide with real debility, and may be best subdued by generous diet: nay, even in some cases, stimulants may be required to secure repose. 
Of all misapplied remedies, however, the worst is bloodletting, and yet in some districts it is frequently resorted to. So strong is the impression that insanity is of an inflammatory nature, that it often requires the authority of an experienced practitioner to persuade the nearest relatives that bleeding is unnecessary, if he cannot convince them that it is absolutely prejudicial. 
 It is not, therefore, to be wondered at that some surgeons who are not likely to see many cases of the disease should fall into the same error, and by doing what they consider to be useful, or at all events innocuous, gratify those around them. Surrounded with difficulties, struggling with the patient, destitute of proper means of control, worried by friends, and overwhelmed with suggestions, they perform what they deem a very simple operation. Blood is extracted, the patient for the time becomes quiet, or rather exhausted, and the surgeon congratulates himself, and is applauded by the bystanders ; but in a very short time the scene is changed: the patient becomes as furious or as incoherent as ever, and, if the plan be persevered in, soon sinks. Should, however, the want of success prove the inutility of depletion, the unfortunate patient is then sent to an asylum, and the medical officers have to contend, not only with the original malady, but with an aggravation so well known in lunatic asylums that such cases are looked upon as very doubtful, and in six cases out of ten, if the patient survives, he sinks into a state of incurable dementia."
No less true are the following remarks, made by Dr. Campbell, respecting the statistics annually presented with the reports of lunatic asylums : 
" The statistical tables,which I yearly lay before you contain such abundant and various information as to make any general commentary on the forms of disease admitted, the causes of the malady, or of the chances of recovery afforded, unnecessary. These tables are compiled from the records kept of each case, and, although every endeavour is made to obtain information that may be relied upon, I can never present such tables to you without stating the extreme difficulty of avoiding errors. In some cases I regret to say that no dependence whatever can be placed on the information sent with a patient on admission, and in others no information can be obtained. These remarks especially apply to the returns made of the duration and the causes of the malady."


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