Biological Therapies before the Introduction of Modern Psychotropic Drugs

Psychiatrists of the early twenty-first century have little comprehension of the therapies employed prior to the advent of the modern psychotropic era, which was heralded by lithium in 1949. Most would have some awareness of the primitive forms of restraint used, but few have knowledge of the wide range of medicinal agents, hydrotherapies, bloodletting and other techniques that were still in day-to-day use in asylum practice at least up to the end of the nineteenth century, and for some treatments until the 1930s and 1940s. Those techniques introduced in the first half of the twentieth century, i.e., fever therapy, insulin coma and the early convulsive therapies, are also only vaguely familiar to modern eyes.

There appear to have been at least four determining principles for the choice of these therapies. The first (and oldest) was expunging the body of the evil spirits or forces that were believed to cause these disturbances in behavior. An early example of this was the use in ancient Greece of the purgative plant extract hellebore. In Greek mythology, this was reputed to have cured the daughters of Proteus who had been visited with madness after insulting the goddess Hera. The second principle was the need to rid the body of postulated poisons or toxins. The third was the concept of "shock and commotion." This was based on three sets of clinical observations: (i) systemic illnesses were often terminated favorably by crisis; (ii) insanity often improved after intercurrent physical illness or injury; and (iii) patients with hydrophobia (presumably due to rabies) had been reported to be cured by the shock of having been thrown into the water on several occasions. This led to treatnents designed to reproduce natural crises, such as gastrointestinal irritants (emetics and purgatives such as hellebore and camphor), large bleedings and fever. Another intent of these shock treatments was to cause a "revulsion of the system" severe enough to alter the patient's mind. The aim was to act either directly on the brain, or work indirectly to cause apathy or forgetfulness concerning the abnormal ideas or feelings. Examples of such shocks were the "bath of surprise" or the circular swing. The fourth principle is more easily comprehensible to modern medical minds, and was that of symptomatic management, be that purgatives to treat "costiveness" (constipation), or sedatives or warm baths to calm the overactive "manic" (the term referred to any overactive or excited psychotic patient). It should be noted though, that, for a number of writers of the era, such treatments were considered curative rather than merely symptomatic.

This chapter will focus upon medicinals and other physical treatments used prior to the twentieth century, electrical and convulsive therapies, fever therapy, insulin coma therapy, and surgical procedures.