The most deadly disease of asylumdom: general paralysis of the insane and Scottish psychiatry, c.1840–1940

Abstract

General paralysis of the insane (GPI) was one of the most devastating diseases observed in British psychiatry during the century after 1840, in terms of the high number and type of patients diagnosed, the severity of its symptoms and, above all, its utterly hopeless prognosis. With particular reference to the physicians and patients of the Royal Edinburgh Asylum, this article explores the diagnostic process and the social and medical significance of the 'death sentence' that accompanied the GPI diagnosis.KeywoRdS General paralysis of the insane, mortality, diagnosis, prognosis, postmortem, Royal Edinburgh Asylum deClARATionS of inTeReSTS No conflicts of interest declared. General paralysis of the insane (GPI) emerged as a new and devastating form of insanity during the early nineteenth century. Its identification as a distinct disease category has been credited as the achievement of a small group of French psychiatrists, or alienists, as this profession was commonly known during the nineteenth century. G Davis1 The disease was not recognised in Scotland until around 1839, 2 though clinicians on both sides of the English Channel questioned whether this was simply because British alienists had not yet 'learned to see' the disease. 3,4 There was also considerable confusion as to the causation of GPI. Although the possibility of syphilis had been suggested as early as 1857, this was not generally accepted in the nineteenth century, when the disease was thought to be multi-causal, relating largely to the destructive influences of the urban environment and in particular to the excesses of alcohol, tobacco and sex. Not until the early twentieth century did the 'syphilitic hypothesis' begin to achieve widespread acceptance, with the Japanese bacteriologist Hideyo Noguchi's demonstration of the presence of the organism, then called Spirochaete pallida, in the brain of a patient who had died of GPI.5 However, even then, Scottish asylum physicians continued to ascribe GPI to factors as diverse as 'bereavement', 'kick from a horse', and 'unknown origin '. 6 There was, however, broad agreement on the disease's symptomatology and prognosis. It was widely perceived as the most deadly disease of psychiatry. The course of GPI was one of steady and progressive mental and physical deterioration ending in death. The disease inflicted degenerative dementia upon its sufferers in tandem with the development of muscular incoordination and paralysis, hence the disease's pseudonym 'dementia paralytica'. Most of those diagnosed were middle-aged males in the prime of their working lives; the socioeconomic implications of the disease were therefore a source of significant concern. Worst of all, there appeared to be no cure, the diagnosis conferring an almost certain death sentence upon its sufferers. As a result of the type of patient diagnosed, the severity of the symptoms and the hopeless prognosis, the eminent Scottish alienist Thomas Clouston described GPI as the 'most terrible of all brain diseases '. 7 Nor was this ...

Clinical Presentation of General Paralysis of the Insane in a Dutch Psychiatric Hospital, 1924-1954

“…Most patients were referred to the VvGI because of behavioral problems that were too difficult to manage at home or at a general hospital ward, that is, aggression and challenging behavior. The majority of patients were middle-aged men, an observation also made by other investigators [5,6,14,17,18] . The finding that all patients were from the lower working class is in accordance with the results of the study by Slijkhuis and Oosterhuis [14] on GPI patients in Dutch psychiatric hospitals in the period 1870-1920.…”

“…Although exact figures are unknown, asylums throughout the world reported, in the first decades of the 20th century, an increase in admission rates up to 20% [2,13] . At the Royal Edinburgh Asylum, Scotland's largest asylum, up to 17% of admissions and 34% of deaths concerned the patients with GPI [6] . Death from GPI in all Scottish asylums increased from 8.9 to 12.5 per 1,000 resident patients [5] .…”

“…In the 19th century, GPI was described by Clouston, a Scottish 'alienist' (as physicians specialized in the treatment of mental illness were referred to at that time [4] ) and superintendent of the Royal Edinburgh Asylum between 1873 and 1908, as the 'most terrible of all brain diseases' [5,6] . About 2 decades after an untreated syphilitic infection, GPI presented with progressive mental and physical decline in 3-5% of the patients.…”

Syphilis and psychiatry at the Mysore Government Mental Hospital (NIMHANS) in the early 20thcentury

“…The course of GPI was one of steady, progressive mental and physical deterioration, ending in death. The disease resulted in muscular incoordination and paralysis along with the development of degenerative dementia; hence, the disease's pseudonym “dementia paralytica.”[ 3 ] It was only in the early twentieth century that the “syphilitic hypothesis” began to achieve widespread acceptance, when, in 1913, Hideyo Noguchi demonstrated the presence of the organism, then called Spirochaete pallida , in the brain of a patient who had died of GPI. [ 4 ]…”

Desórdenes psiquiátricos de los inmigrantes chinos del siglo XIX. Segunda parte: Condiciones de vida y salud mental de los inmigrantes chinos entre 1865 y 1900

“…Davis (24) informa que la PGP constituía el 17% de los ingresos al Royal Edinburg Asylum (Escocia) a fines del siglo XIX.…”