History of Medicines used in Psychiatry

A Short History of the Use of Drugs for Medicinal Purposes

Human beings have used preparations ‘medicinally’ to reduce or control mood, behaviour, perceptions, thinking and feeling and to reduce human experience of distress the world over in all cultures and at all times in history. Most often these substances have been naturally occurring or easily synthesised, though from the early twentieth century more complex compounds have been applied. Many of these have been applied accidentally and desired effects have been discovered by coincidence, rather than by design. More recently as some of the complex chemical mechanisms of the brain have become slightly better understood, compounds have been developed deliberately to intervene in those processes.

The main aspiration of those who have administered these preparations has been to produce feelings and experiences of well-being and tranquillity without producing torpor, and to remove distressing experiences. Historically little regard or understanding have been given to the dangers of dependence or the side effects of these medicines. Indeed it is not until the twentieth century that a concept of addiction was even postulated. Psychotropic medicines (from the Greek ‘psyche’ meaning mind and ‘tropos’ meaning change) have for the very greatest part been applied 'empirically'. That is, they are administered to the patient and after observation of their ‘positive’ effects simply applied again, and also to others with same condition. Understanding of the means of their action is not necessary. Medicine has a strong tradition of empirical method and its application in psychiatry is entirely consistent with physical medicine. In more recent times our ability to investigate complex inter-relating physiological processes that are associated with thought, mood, perception and behaviour has increased. Though there are many who consider the present state of our understanding to be that of solving a thousand piece jigsaw, with all white pieces - and we have eight pieces, three with straight edges!

Historically, all sorts of beliefs were proposed to explain the action of remedies - to correct the imbalance of the 'humours’, to release ‘evil spirits’ and to shock the system for instance. And those people regarded as distressed or disturbed, the so-called 'mad', have been housed in institutions – workhouses, madhouses, asylums, mental hospitals and psychiatric units. They have formed a captive and controllable group on whom to try and test newly discovered or synthesised chemicals. Drugs of all sorts have been administered in these institutions and some have been seen to have an effect, quite coincidentally, on the patients’ distresses. As a result, all manner of medications originally tested for use in physical conditions such as bladder infections, came to be identified as drugs useful to psychiatry. For the mass of people apocetharies were in any case the main source of medicines, rather than doctors, physicians or surgeons. The ‘top position’ in terms of power, status and reward though became the doctors rather than any other professional group. There were some moves to provide remedies based on non-medical ideas. Moral management around the turn of the nineteenth century was one such approach. The people who promoted Moral Management set about achieving recovery by treating people with respect, providing work, and a pleasing environmen in which to thrive and grow. The provision of such experiences and the culture of humanity fell short however of what then was needed to constitute the foundations of a ‘profession’ and Moral management whithered.

Doctors themselves were involved in ‘the madness trade’ principally because of their social position and general education, rather than any real knowledge about controlling or curing distress. The responsibility for the prescription of medicines and the discovery of more applicable medicines in the twentieth century, was the main reason for medical psychiatry's dominant position in the mental health system. It is easy to take for granted this is almost ‘the natural order of things’ - mental distress an illness, doctors treat illnesses, the remedies are chemical, so nothing wrong here(?) This certainly was not always the case. In the early post 1stWorld War period, for example, many doctors in physical medicine were actively discouraging their colleagues from their involvement in psychiatry, on the grounds that it was bringing the whole profession into disrepute. There were editorials written to such effect in the Lancet and 'distressing' cases of doctors being successfully sued for wrongful incarcaration of their patients.

For the mostpart then there were no cures only warehousing, well into the twentieth century. And worse still, the patients were incarcerated without hope (and often ‘illegally’) and in many cases subject to horrendous abuses. The advent of ‘respectable’ physical and chemical treatments that seemed to offer some hope of ‘cure’ changed this in the 1930s. These looked high-tech compared with the old days and in keeping with advances in physical medicine. Electroconvulsive therapy, insulin coma therapy and the uses of the convulsant metrozol for instance, together with barbiturates changed this and medical dominance of theory and practice grew vigorously from the 1930s onwards on the back of these developments.

There has been a wide choice of 'medicines' used by prescribing practitioners throughout history............

ALCOHOL

Alcohol has been used as a medicine since the year dot. Taken "for medicinal purposes", is still a good excuse for a drink.

In 1792 Buchanan’s Medical textbook recommends the use of alcohol in the treatment of nervous diseases:

“Take of Peruvian bark an ounce, gentian-root, orange peel, and coriander, of each an ounce; let these ingredients be all bruised in a mortar, and infused in a bottle of brandy or rum, for the spaces of five or six days. A table spoonful of the strained liquor may be taken in half a glass of water, an hour before breakfast, dinner, and supper.”

It is likely that the remedy was frequently applied in excess of the stipulated dose! In the mid-19th century the renowned Professor Todd found reason to give: “….twenty or thirty ounces of brandy a day to young patients'”! (The Lancet 1865) - consider that this could have been over three quarters of a bottle.

Alcohol addiction was, as one can imagine, widespread in the nineteenth but conceptions of addiction did not at that time exist. Doctors explained the condition of patients, who were not able to stop drinking alcohol as being as a result of ‘lack of will power’ or, worse, ‘an attraction to pleasure seeking’.

Later Darwinian thinking was applied to this problem. The major factor in alcohol addiction was considered to be 'a peculiar weakness of the nervous system, which is inherited.’ It didn't occur to the medical men of the time (there were no women) that the action or nature of their medicines was a factor. Cushney's authoritative book (1928) set the scene for the widespread use of alcohol as a therapeutic intervention in the Second World War, and alcohol was used in much the same way as so called tranquillizers are used today. Copious quantities of alcohol were available to soldiers and often available free to the officer ranks. It has been reported anecdotally that in some engagements, the officers were quite drunk and engaged in battle as if they were going to a party. Cushney noted that “it is difficult to prove that the moderate use of alcohol is injurious” and that “alcoholism is probably due to a mental defect”.

Medicinal alcohol was still widely prescribed into the mid-80s in tonics and has been available over the counter until relatively recently in infant preparations such as 'GripeWater'. It is currently estimated that over 20% of the adult male population drinks more than the stated safe limit of alcohol in each week.

MARIJUANA

Marijuana is a plant that has been used medicinally for thousands of years. It was introduced into this country probably about the time of Henry VIII, together with other types of hemp, in response to the need for rope for the navy. Liverpool had an enormous rope making industry, situated behind Bold Street on the hill down to the Bluecoat Chambers – now called Ropewalks. Marijuana was commonly used throughout the seventeenth and eighteenth centuries as a medicine, though probably mostly by the 'peasant and working classes' as it was cheap and easily produced. Queen Victoria herself is said to have used it, particularly, she claimed, for relief from menstrual discomfort and pain. It produced tranquillity and feelings of well being. A legal stop was placed on its use as a non-prescribed medicine and for 'pleasure' in 1928, after an international conference on drugs was persuaded by the Egyptian delegate to outlaw its use.

Evidently the British Government of the time considered the matter to be of no major consequence either way, so agreed to its prohibition, to keep good relations with the Egyptian Government. Today, its use medicinally and recreationally in still subject of debate both in the medical profession and in parliament.

OPIUM

Opium was very popular in the U.K. up to the 1850s. It was regarded as a herb or spice rather than a drug and was available at the grocers, purchased with the biscuits and the ginger beer. Later in the century it was sold by apothecaries, the forerunner of the chemist's shop. Opium was considered to be a safe effective and non-addictive drug, which produced tranquillity. The use of opium was rarely considered a problem as people rarely complained of withdrawal problems. The drug was so widely available and ‘useful’ that few considered it necessary to try to give up (in much the same way cigarettes were viewed in the mid-decades of the 20th century). Opium was soaked in alcohol for particularly potent relief. It then became known as 'laudanum'. As addiction became more noticeable, a cure for this and a means of treating original symptoms had to be found. The substitute was called morphine.

CHLORAL HYDRATE

When chloral hydrate was introduced in 1869 it was heralded as a 'wonder drug' and 'a sensational medicine’. It was considered to be safe, effective and non-addictive. Its action was sedative-hypnotic and it was used as a treatment for variety of mental disorders. It was also used to treat alcohol, opium, morphine and later cocaine addiction. Doctors preferred it because it was marginally less dangerous in overdose and was unpopular in suicide. Chloral taking became a widespread habit. People under the influence of chloral appeared permanently drunk and dependence easily resulted. Used medicinally it had the major disadvantage that its effects were unpredictable and varied from person to person and required individual management by a physician. This degree of personal attention was unlikely to have been the general experience of patients.

COCAINE

After several thousands of years use in South America, cocaine was first used in Western medicine in the 1860s 'for young persons afflicted with timidity in society’. It was introduced into Europe in the 1880s as a cure for alcohol, morphine and opium addiction and was considered to be safe, effective and non-addictive. Freud used it and called it 'a magical drug' and gave it his enthusiastic endorsement. Parke Davis, the American drug company declared… 'Cocaine will be indeed the most important therapeutic discovery of the age, the benefit to humanity will be incalculable'

MORPHINE

Morphine was a more refined derivative of opium. It was considered to be a safe, effective and non-addictive drug. It was considered to be a suitable replacement for opium, as only a small amount of it was required to achieve the same effect as a larger quantity of opium, (the same logic might indicate that a double whiskey is less dangerous that a pint of beer!)

Morphine was used as a remedy for chronic alcohol and opium intoxication, which was widespread. The popularisation of the syringe in the mid nineteenth century vastly encouraged morphine taking, which became a socially accepted, even a desirable habit, with little syringes and artistically made bottles to be taken out at parties and the opera. Addiction to both substances was a considerable problem but the 'authorities' seemed unconcerned and energy to do anything about the problem was low. The Royal Commission of 1895 concluded that ’moderate use of the drug was not attended by any injurious consequences'. At this time Tax Revenue from the opium/morphine trade netted the Treasury enough to pay for half the cost of the Civil Service each year.

The medical profession did by and large soon acknowledge the addictive quality of the drug, though Freud himself stayed in its favour, probably because he himself found great difficulty in managing it himself or giving up taking it. Addiction was attributed to the personality of the taker or his/her unconscious mind - not to the nature of the substance itself or quantity taken.

These types of beliefs persist and even today people who have become dependent on benzodiazepines (minor tranquillisers) have been labelled as 'drug dependency prone people' by drug producers.

DIAMORPHINE

Diamorphine was a further refinement of opium which was popularly introduced to have an effect on alcohol, opium, and morphine addiction, all of which had surprisingly? been discovered to be a problem. It was also used for the treatment of childhood and infant management problems. It was marketed under its trade name 'Heroin'.

CORN FLAKES

Corn Flakes were introduced as an anti-masturbation food in 1898, as part of a general fitness regime, which included regular enemas, exercise and cold baths. The strategy has been popularly presented in a film about the sanatorium in which Dr Kellogg worked (Battle Creek, Michigan) – ‘The Road to Wellville’. Masturbation was not only a sin it seems. It was believed by some that allowing the fingers to wander could cause physical conditions such as blindness and moral degeneration, which led ultimately to mental illnesses and dementia.

Dr Kellogg’s' initial marketing strategy does not appear to have caught the world's imagination however, for some unaccountable reason, and it is now merely one of our favourite breakfasts, with no claimed psychotherapeutic effects.

BROMIDES

Potassium bromide was first recommended as a sexual inhibitant by the aptly named Sir Charles Lowcock. Thereafter the large number of synthesised bromides was applied to every kind of distressed or disturbed state of mind. They were applied particularly 'whenever there is excitement'.

Apart from sexual excitement, they were particularly used when 'excitement' became available to a whole generation of men in the First World War. Here they were used on a massive scale to treat 'malingering reactions' at the front. The use of these drugs was considered much more effective than shooting deserters.

Many have said they suspected its continued use in NAAFI tea in the Second World War and into National Service, though the suspicions may have as much to do with the taste of the tea rather that any observed effect on the sexual appetite of conscripts. The use of bromides brought on intoxication, increased restlessness, disorientation, paranoid trends, hallucinations and apprehension. The imaginative cure for these alarming drug-induced symptoms was, you guessed right - more bromide! Many occupants of mental hospitals in the 20s,30s and 40s were found to be suffering from no 'clinical condition' but simply from bromide poisoning.

BARBITURATES

Barbiturates were first synthesised by Von Baeyer in 1862 but did not become a more widely used drug until the burgeoning of the big drug companies in the 1930s, by which time there were some 2,500 different barbiturate compounds available. They were advertised as ’absolutely safe and without toxic effects’. They were used to sedate. All of them had much the same effects but were aggressively sold to doctors on the basis of their own particular, idiosyncratic (and illusory) advantages. They were highly addictive, had severe withdrawal symptoms (which could include death) and were particularly 'effective' in suicide. The massive prescription of barbiturates up to the 1950s contributed to the start of the ongoing national debate about the use of such drugs as a vehicle for social control. It also focused on the role of the state in creating drug dependence and addiction by the prescription of medication by medical practitioners. That debate seemed temporarily to disappear then re-emerge with the advent of the wonder drugs that heralded the 'drug revolution' of the 1950s and 60s. Chemicals, it appeared, were at last about to really clear up all human ills!

BENZODIAZEPINES (so-called minor tranquillisers)

A chemist named Leo Sternbach - a Polish American working in university in the U.S.A. - synthesised a number of compounds in his laboratory in 1955, following work he had done but not followed through some 20 years earlier. Synthesising chemicals was his job. The story goes that Sternbach, not a tidy man in his laboratory, was instructed to clean up. He asked an assistant to help. As it happened, chlordiazepoxide had lain undisturbed in the laboratory for 2 years since he had last worked on it. The assistant came upon this chemical and asked if it should be thrown away or be sent for screening. Sternbach thought for a moment and said it should be submitted to the pharmacological research laboratory at Roche for further evaluation rather than simply throw it in the refuse bin. And so it happened.

The chemical appeared to produce a number of effects on animals in laboratory tests - muscle-relaxing, sedative and anti-aggressive. It calmed the animals down. Because the action of the drug seemed so powerful, general excitement at its properties was created. Films were made to illustrate its amazing powers. A particularly bad-tempered lion was filmed making close friends with a little lamb, after a good big dose. Benzodiazepines were then tried on to human beings and presented as 'the wonder drug', a universal panacea for human ills, such as anxiety and aggression. It was anticipated the women would happily return to their domestic duties, men would return to repetitive jobs, the prisons would empty and all humankind would be wearing a smile. They were marketed as 'minor tranquillisers'. Some would say however that they are not minor at all, and nor are the conditions they were used to treat.

They did however work! They were seen to have powerful effects on anxiety in particular. Dependence was not seen to be a problem either. We now know that the probability of dependence is extremely high. Ironically this class of medicines – tranquillisers – has come to be typified as much by the agitation of withdrawal than by the initial tranquillity they produce.

In the early days of their use, they were not considered to be addictive- in fact in the first 20 years of their use only under 30 cases of ‘addiction’ were officially noted through the ‘yellow card’ system in the U.K. These cases were dismissed as best explained by the fact that the patients were clearly 'dependency prone people'. In fact it is conservatively estimated that there are currently in excess of 2 million people in the U.K. who are experiencing (or who would experience) considerable withdrawal problems, as a result of taking these drugs. A patient information leaflet given with Valium in 1992 however stated that 'little is known about the long term effects of this preparation’. They have been in use now for nearly forty years, during which time much anxiety has been relieved but millions of people have suffered dependence problems.

ANTIPSYCHOTIC MEDICATION (NEUROLEPTICS/MAJORTRANQUILLISERS).

Phenothiazines from which the early antipsychotic chlorpromazine were derived were first synthesised as compounds in 1883 and used for a variety of purposes – in the dyeing process as an insecticide and later in the treatment of parasitic worms and a bladder antiseptic. In 1952 Henri Laborit, a French doctor, was looking for a way to reduce surgical shock in his patients, caused by anaesthesia. He was struck by the effect on his patients of a drug called chlorpromazine.

He noticed that after being given the drug they didn't seem anxious about their upcoming surgery. Laborit thought the drug must have some use in psychiatry. But at that time, "no one in his right mind in psychiatry was working with drugs. Better to use shock or various psychotherapies". Dr. Heinz Lehmann, a fellow surgeon, passed the word on about chlorpromazine to his brother-in-law, the psychiatrist Pierre Deniker. Deniker's ordered some chlorpromazine to try on his most agitated, uncontrollable patients. The results were impressive. Patients who had stood in one spot without moving for weeks and patients who had to be restrained because of violent behaviour, could now make contact with others and be left without supervision.

Another psychiatrist reported, "For the first time we could see that they were sick individuals to whom we could now talk." They became known as antipsychotics (or neuroleptics – a rather unhelpful term that refers to the medicines range of neurological side effects rather than their wanted actions).

Of all psychotropic medicines, the use of typical antipsychotics has given psychiatry its recent dominant position the professional hierarchy in relation to human distress/mental illness. Their perceived benefits, in terms of the achievement of tranquillity and reducing or eliminating disturbing experiences, gave way to an examination of the human costs of taking these drugs long term. Conditions such as tardive dyskinesia may result, even after short periods and low dosages. They have been used blatantly for social control purposes on people with learning disabilities, older people and children, all of whom could be considered by some to present 'management problems', particularly in institutional settings. The new range of 'atypical' antipsychotics, with far less disturbing side effects is now available and offers a realistic hope that some of the more distressing experiences reported by those with severe mental health problems can be significantly reduced. As important are the opinions, researches and guidance to prescribing produced by the National Institute for Clinical Excellence, which are now published and available to everyone. Though the cautionary note that ‘little is known about the long term use of these drugs’ used in relation to benzodiazepines a generation ago should always promote our vigilance, when taking powerful chemicals into our bodies.

Bob Knowles

Memories of St Catherines Hospital Tranmere

St Catherine’s Hospital – A few personal reflections

Prior to l86l, Birkenhead formed part of the Wirral Union of Workhouses. After that date a separate authority was formed, administered by the ‘Guardians of the Poor of the Birkenhead Union,’ comprising the parishes of Birkenhead, Bidston-cum-Ford, Noctorum and the whole of what later became the County Borough of Wallasey, but excluding Moreton.

One of the new Union's duties, as with all Unions of Parishes, was the erection of a workhouse and for this purpose, the existing site in Church Road, boundaried by Elm Road and Derby Road (then Yolk of Egg Lane) was purchased. It is of interest to note that the purchase also included what is now the site of St. Catherine's Church, but shortly afterwards this was sold to the Ecclesiastical Authorities.

When the new workhouse was practically completed, but before the official opening, an ‘immigrant ship’ sailed into the Birkenhead Docks with an outbreak of cholera on board. The infected cases were removed to the Livingstone St. (later Birkenhead General) Hospital, and the rest of the crew and passengers, all of whom were contacts, were removed to the new workhouse buildings in Tranmere.

The Birkenhead Union Workhouse was officially opened in 1865 after ( it is hoped) thorough disinfection. Some few years later a new nurse was required on the staff. Hitherto it had always been the practice to appoint some able bodied trusted “inmate” of the workhouse to a vacancy of this kind, but this time a heated argument arose at the Board of Guardians' Meeting as to whether a certain woman should be appointed, or whether one of those "new fangled" Nightingale trained nurses" from Liverpool should succeed to the vacancy. After a very narrow victory the first properly trained nurse was appointed at a very small salary, but plus one of the usual emoluments of those times "one pint of beer per diem".

A very large part of the “education” afforded in the workhouse consisted of boot and shoe making for the boys and domestic work and laundry work. for the girls. The large dining room in the Annex doubled as a workroom and a classroom. The Royal Coat of Arms had its place over the fireplace and the school master's stood at the other end of the room. The Workhouse School continued in operation until at least 1908. At that time many changes

were being made, the children were being removed to “Children's Scattered Homes”, usually consisting of a dozen or so children together with a foster mother, in houses throughout Birkenhead and Wallasey. Children who were members of the Church of England would then attend ordinary elementary schools near their house of residence, whereas Roman Catholic girls were sent to St. Clare's Convent, Pantasph, Holywell, and Roman Catholic boys to various other residential Catholic homes.

In 1911, the Boarding Out Order became operative, permitting children to live with private foster parents, similar to the practice of today. As a consequence of the removal of the children and the closing of the Workhouse School, it became possible to re-organize the accommodation. Further new buildings were erected on the Elm Road side of the site, and in 1911, the final separation from the Union Infirmary was completed, and placed under the separate administration of a Steward. The Workhouse Master was then completely in charge of what became St. Catherine's Annexe. This latter portion of the buildings then contained the ordinary accommodation for “the indigent poor, the able-bodied, the chronic sick, the nursery for children under three years of age, and

mental cases”.

“Tramp wards” were also maintained, these having now been converted into workshops for such people. They consisted of a long, one-storied building along Derby Road with sleeping cells on one side of the corridor, and work cells on the other, separated by a metal grill. The “inmates” were provided with a block of granite, a stool, a sledgehammer and a small hammer. When the granite block had been reduced to the necessary small dimensions, and all passed through the grill, the male tramp's task was completed, the reward was shelter and a meal. Those not of a sufficient physique were engaged in making bundles of firewood, and the women put to work ward cleaning and in the laundry.

The Annex consisted of the original Workhouse School, which became the “mental block”. Other buildings were gradually added, incorporating all the front entrance and the wards to the left of the Office, with the Master's quarters above. It can still be seen that there is a round piece of stone in the small tower facing the entrance lodge which was intended to contain a clock.

During the 19l4-19l8 War, considerable use was made of the workhouse for general hospital patients, as a considerable portion of the Birkenhead Union Infirmary was placed at the disposal of the War Office, for the treatment of wounded soldiers. The ambulances were kept in the garages, near the Nurses Home, until the nineteen thirties. The first motor ambulance (as opposed to horse-drawn) was purchased in 1914. It was a “Minerva" - a Belgian make, and was reputed to be the last chassis to leave as the Germans entered Antwerp.

In 1928 the approximate accommodation in the Birkenhead Institution consisted of 635 beds, and that of the adjoining Birkenhead Infirmary 550 beds. The Board of Guardians, always in the forefront of ‘enlightened opinion’, decided that the aged able-bodied inmates should not ,spend their declining years in workhouse surroundings, and purchased "Eastham House", Eastham, a country mansion in 48 or so acres of farm and parklands, and transferred eighty of the aged to these delightful surroundings, with freedom to enter and leave as they wished – an unusual relaxing of restrictions which had applied in the very mixed institution from which they came.

By the passing of the Local Government Act in 1929, the Birkenhead Union Institution and the Birkenhead Union Infirmary, together with all other property of the Birkenhead Board of Guardians, was transferred to the Birkenhead Council for administration. In 1936 a group of the new State Registered Nurses was recruited to complement the existing group of assistant nurses and nursing assistants. The practice of hygiene was rudimentary by modern standards. Sterilization of such items as syringes and small instruments was carried out on a small old fashioned gas stove situated in what was known as the "serving room", so named because all meals were delivered to this focal point of the building. Ward kitchens did not exist. Until the provision of ward trolleys, which were made by the hospital joiners and were said to resemble Chieftain tanks, all food was transported to the wards manually, up and down flights of steps in urns, pans and on trays.

During the last War, the kitchens at the Birkenhead Institution were used for the preparation of meals for Emergency Rest Centres, as well as continuing to provide catering for the patients. These kitchens were severely damaged by enemy action, as were other parts of the buildings. For the disposal of swill, ‘pig bins’ were situated close to the tennis courts until about 1956 when this kind of waste was taken to Eastham House Farm.

The entire wartime staff of every grade were dedicated. Sixteen continual hours of duty was commonplace. During prolonged air-raids, night nurses were prevented from reporting for duty, so day staff remained until relief came. Bereavement and loss of homes affected many of the staff too, but their dedication persisted. When war broke out, among other precautionary measures taken, was the provision of a very large storage tank for fresh water in case of the interruption of the main supply. This was achieved by the providential finding of a huge rainwater tank, under the square outside the laundry buildings. This had apparently been made and used a good century ago for the main supply, when a piped water supply was not available.

In 1952, the administration of the Infirmary was undertaken by the Health Committee but administration of the Birkenhead Institution continued to be undertaken by the Public Assistance Committee. In 1948 all Hospitals were transferred to the Regional Hospitals Board, and thus removed from municipal control, by the National Health Service Act.