THE HISTORY of GENERAL PARALYSIS of the INSANE in BRITAiN, 1830 to 1950 A thesis presented by Juliet D Hum for the Degree of Doctor of Philosophy in the University of London March 1998 Abstract of Thesis Juliet D Hum, The History of General Paral ysis of the Insane in Britain, 1830 to 1950 This thesis explores the history of ideas about, and responses to, general paralysis of the insane (GPI) - specifically in the context of the developing profession of psychiatry in Britain. It considers GPI as an objective disease entity whose subjective definition was nevertheless open to negotiation; for example, in deciding how central was overt insanity, or how GPI should be differentiated from the allied disease of tabes dorsalis. It explores how psychiatrists' interest in organicism and the science of medicine - and their attempts to raise the status of their specialty - both informed their understanding of GPI, and allowed them to promote it as a flagship disease for their profession. Nevertheless it draws attention to the gap between such claims and concrete practical advances which the disease fostered. The thesis considers changing causal explanations for GPI: first, in relation to the evolving image of the typical general paralytic patient; and second, in relation to the credence attached to different forms of causal evidence such as pathology, statistics, and laboratory medicine. It suggests how assessment of this evidence might have been informed both by professional aspirations and by pervasive cultural concerns such as fear of syphilis and degeneration theory. The thesis studies the use of malaria therapy to treat GPI in Britain, and uses this episode to explore a number of themes: early twentieth century ethical attitudes to heroic treatments; perceptions of 'cure'; and the change in emphasis from asylum care to community care. Finally, it considers ideas about the epidemiological history of the illness - from early twentieth-century theories about the evolution of infections, to Edward Hare's hypothesis of a neurotropic epidemic; and considers how the views of disease as objective entity, and disease as cultural construct, might be reconciled in the context of GPI. I would like to thank the numerous library staff who orientated me during my research, particularly those at the Welicome Institute, the Greater London Record Office, and the Public Record Office at Kew. I am particularly grateful to those individuals who helped me to locate and use the more elusive archives of Horton and Claybury asylums. Thank you to those colleagues at the Weilcome who have offered practical advice over the past three years, to my 'office-mates' who have shared numerous laughs and cups of hot chocolate, and above all to my supervisor, Bill Bynum, for his ever-patient support, his constructive suggestions, and for his enthusiasm. Finally, my family and a number of close friends have been very important to me - particularly during the rather frustrating last stages of the thesis. I would like to thank them very much for their constant encouragement and for their kindness. CONTENTS Page number Introduction 6 Ch 1: The Making of 'General Paralysis of the Insane' 27 Introduction 27 The Arrival of GPI 31 Creating 'GPI' 37 GPI and the Insanity Defence 47 GPI and the Science of Mental Disease 52 Ch 2: Masculinity, Immorality, and Syphilis: The Causes of GPI 69 Introduction 69 'Disease of Manhood' 75 'Guilty of Excess' 85 GPI as Tertiary Syphilis 92 Foumier and Venereology: Domains of Syphilis 96 'Parasyphilis' and the Power of Statistics 107 Accepting the Link in Britain: 1880 - 1910 113 'The Apotheosis of Selfishness': GPI as Degeneration 119 Into the Twentieth Century: 'Syphilisation and Civilisation' 129 Ch 3: 'GPI' Becomes 'Neurosyphilis' 135 Introduction 135 'A Thoroughly Wassermannized Profession': The Test Enters Medicine 141 The Test Enters Psychiatry: Neurosyphilis Confirmed 158 The Wassermann Test Diagnoses GPI 167 The Wassermann Test and Early GPI 174 Stretching the Boundaries of GPI 185 Contents cntd Ch 4: 'Desperate Ills Demand Desperate Remedies': Malaria Therapy in Britain, 1920 to 1950 192 Introduction 192 The Background to Malaria Therapy: Julius Wagner-Jauregg 196 Malaria Therapy Comes to Britain 202 Ministry, Board, and the Horton Treatment Centre 206 The Benefits of Malaria 211 218 The Dangers of Malaria Surgeon Rear-Admiral Meagher's Report 229 Into the 1930's: Psychiatry and Malariology 234 Before the Asylum: Early Treatment of Neurosyphilis 240 After the Asylum: General Paralytics Enter the Community 251 The Impact of Malaria Therapy 259 Ch 5: The Rise and Fall of GPI 268 268 Introduction The Rise of GPI 269 GPI After the First World War 280 Hare's Hypothesis 284 Alternatives to Hare 292 Conclusion 301 Bibliography 308 INTRODUCTION In 1859 the medical superintendent of Bethnal House Asylum wrote a vivid description of a patient's descent into insanity and death: 'A person who is insane ... [shows] slight tremors of the lips ... and feeble, straddling, or devious [gait] ... He is full of all manner of schemes ... and talks of the wealth he fancies his projects have brought him ... The whirl of the spirits increases Arrived at this pitch, everything becomes invested with immensity, grandeur, or beauty. Common pebbles are transformed into gems ... [Thereafter] incessantly talking and restless, violent and destructive, tearing everything tearable to shreds ... he lies on his bed ... or on the padded floor of his room in a dream of happiness and splendour, which contrasts horribly with his hollow features and emaciated, squalid body. Happily death is at hand - exhaustion or paralytic coma soon closes the scene.'1 The patient in question was suffering from general paralysis of the insane (GPI), a disease which had captured the imagination of British doctors through a number of striking features. First, it was a form of insanity which had sprung to prominence only since the 1820's - appearing first in the mental hospitals of Paris and thereafter being recognised increasingly within English asylums. During the nineteenth century it would rise inexorably, so that by the end of the 1880's it would '1 J Austin, A Practical Account of General Paralysis, its Mental and Ph ysical Symptoms, Statistics, Causes, Seat, and Treatment (London: Churchill, 1859); extract reproduced in R Hunter and 7 account for roughly 15% of annual male asylum admissions.2 Although this was not a startling proportion, its clinical course and invariable fatality meant that it accounted for a far larger percentage of asylum deaths, and demanded intensive and exhausting nursing care. Furthermore, since it attacked predominantly middle-aged men, it was regarded as having particularly important socio-economic implications. Second, it followed a peculiarly grotesque and degrading clinical course. Although the emphasis attached to different symptoms would vary over time, the above portrayal was a typical one, contrasting as it did florid delusions of grandeur - in which the patient typically believed he owned everything around him - with a sordid physical decline ending in total paralysis, gangrene, and death. Third, notwithstanding the powerlessness of alienists to influence its course, GPI threw interesting light upon some of the most important intellectual and professional problems of mental medicine. Considering its importance to nineteenth and early twentieth-century psychiatrists - not to mention the men and women afflicted by it - GPI has attracted surprisingly little attention amongst historians. Accounts of the disease have predominantly been in the triumphalist tradition, and have been short, even passing, references placed in the context of the march of medicine or psychiatry as a whole.3 I Macalpine, Three Hundred Years of Psychiatry 1535 - 1860 (London: Oxford University Press, 1963), pp 1053-7; on p 1056. 2 The figures, for example, for 1887 were 1062 male admissions (compared with 7086 admissions as a whole); and 238 female admissions (compared with 7250 admissions as a whole). Here, and in future references, I use the term 'triumphalism' to mean a style of history-writing in which it is assumed that scientific progress can be charted through the approach towards an objective scientific truth. Such history-writing tends to be retrospective: present-day knowledge is taken as the goal towards which past generations have been striving. It also tends to be judgmental: praising the work of those perceived to have aided progress; and dismissing the work of those perceived to have hindered it. Although such triumphalism has been largely eschewed by historically-trained writers 8 Henry and Zilboorg, Ackerknecht, and Hunter and Macalpine, for example, have produced more or less detailed histories of this kind, chronologically tracing the discovery and clarification of the disorder by the scientific process. 4 Key points are emphasised in such accounts: the French alienist Bayle' s first clear description of GPI, published in 1822; the elaboration of its clinical and pathological features; the French venereologist Fournier's championing of its syphilitic aetiology during the late nineteenth century; and the work of the laboratory scientists Noguchi and Moore who identified the syphilitic organism in the brains of general paralytics - thus vindicating Fournier' s earlier arguments. Malaria therapy, used to combat the disease from the 1920's, has attracted some interest - although again far less than it deserves. This interest has again been primarily in the triuinphalist