The continuing growth of the asylum compromised treatment provided to the insane and the brevity of case note entries make it difficult for researchers to delve into this area. Through all these years G.’s case notes tell us very little about his treatment except that he was employed on the hospital farm. Treatment options were still limited, but employment of patients seemed to benefit the hospital as much as the patients themselves who were enabled to learn new skills. Medical Superintendents’ reports up to 1900 list the various kinds of employment available to male and female patients, but also show that only about 50% of the resident population was actively employed. Male patients were mainly employed on cleaning duties as well as out-door activities on the farm and hospital gardens. Female patients were given fewer options. Apart from assisting with domestic duties, they could engage in needlework as well as work in the laundry and kitchen. Patient labour was productive, as the lists of articles of clothing and bedding produced in the hospital reveal (Medical Superintendent’s Annual Report 1900).
Pharmacological intervention was well-established at the DCLA by the late 19th and early 20th centuries – consent to treatment from the patient or a relative was still not required.
Annual reports also provide evidence of research into various treatments starting in the 1870s and reaching far into the 20th century. Early research was stimulated by two aims. Firstly, continuing debates about the use and efficacy (Cameron, 1881) of sedatives required justification. Secondly, psychiatry at the end of the 19th century had little to show for itself, and the development of the institution provided an ‘infrastructure within which a specialised profession could develop’ (Scull, MacKenzie & Hervey, 1996). In order to offer medical treatment ‘in proximity with the ever-advancing steps of Medical Sciences’ (Medical Superintendent’s Annual Report, 1854), Bucknill and his successors were prepared to trial hair-raising methods such as relieving epilepsy through tracheotomy and extreme excitement through the inhalation of chloroform. In the spirit of ‘put[ting] to the test of clinical experience’ medical treatments used in general hospitals and discovering ‘remedies which appear to possess any advantage over those formerly in use’ (Medical Superintendent’s Annual Report, 1870), in 1870 the Medical Superintendent opined that ‘no medicine deserves a fuller trial than chloral hydrate’ [a sedative], admitting that ‘its merits have been freely and fairly tested in this Asylum’ (Medical Superintendent’s Annual Report, 1870). Despite all good intentions, research in the DCLA was flawed from various angles. Firstly, it was usually stimulated by a serendipitous discovery rather than a well thought-out research agenda. Secondly, myriad methodologies and ways of selecting the study groups compromised the comparability of results and, finally, research was carried out without consent.
The 1920s saw what was perceived as a major breakthrough in psychiatric treatment. The discovery of the cause of syphilis in the first decade of the 20thcentury raised hopes to cure patients suffering from ‘general paralysis of the insane’ (GPI), the terminal stages of syphilis. GPI was a common diagnosis in the DCLA, particularly in male patients and probably exacerbated by the Plymouth naval base. The early mercurial treatments failed to cure the illness, but the Austrian Julius Wagner-Jauregg, building on ancient associations of fever in infectious diseases with curative effects on psychoses, injected such patients with malaria-infected blood (Whitrow, 1990).
Malaria therapy started in Devon in 1924, and patients were infected by either mosquitoes or blood, while special care was taken to avoid infecting other patients (Medical Superintendent’s Annual Report, 1932). Although the Devon case notes attest to the occasional temporary remission and the patient’s discharge from the hospital, this treatment failed to live up to the ambitious hopes, and the advent of antibiotics eventually confined malaria treatment to history. It did however strengthen the notion that ‘affecting the body and maybe the brain in some way could be curative’ (Healy, 2002), an approach nearly all later treatments built on. Malaria treatment was still performed in the DCLA in the 1940s (Visitor’s Handbook 1945), but on occasions curtailed by limitations in space.
It was not before the introduction of such hazardous treatments that the hospital asked family members for their written consent for the treatment – still leaving the patient without a choice about accepting or rejecting the treatment. The early standard consent forms did not usually mention a diagnosis – possibly due to the label of syphilis. They also reassured relatives that the hospital is ‘anxious to adopt the latest method of treatment […] as […] done in the majority of cases […] admitted in the last five years’ (Correspondence regarding EG). Information about the exact treatment remained limited to ‘the treatment involves the infecting of the patient with Malaria [sic] and superimposing this on [his / her] existing condition’. Other forms merely referred to ‘special treatments’ (Correspondence regarding EH). Risks were not mentioned on the form. The wording of the form was both hopeful and assuming compliance: ‘[…] up to the present this is the only treatment that gives any prospects of any improvement of the nervous complaint your […] is suffering from and I therefore trust you will not hesitate to give us permission to give [him / her] the benefit of this course’. Indeed, most relatives gave permission to ‘carry out any treatment [the Medical Superintendent] might think necessary to aid in the recovery’.
Malaria treatment provided another avenue for the DCLA to secure its flag on the research map, trialling quinine, atebrin and a new synthetic preparation, phenoquine, to compare their efficacy in the prevention of malaria (James, 1933). Results of these trials were sent to the League of Nations. Patient’s case notes do not contain any evidence that relatives were informed about these trials or that patients were in any way aware of them.