David Roth completed an MA(Hons) at ANU on Claremont Hospital for the Insane in Perth 1909-1919 in 2015. He began study for a PhD at ANU in 2016
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From the early nineeteenth century, mental asylums worldwide began to move away from policies of harsh, effectively permanent, confinement and grim physical restraint to a system of ‘moral management’. Patients were to be treated kindly, employed in useful activities, and enjoy a regulated lifestyle in a protective and pleasing environment. There was a new therapeutic optimism: patients could be cured, re-educated and returned to their families and occupations. At NSW Hospitals for the Insane, attendants and nurses were strictly enjoined against unnecessary roughness or taunting: they were required to amuse the depressed, calm the excited, and entertain or occupy the bored or idle. A regular regime of exercise, sports, religious services, useful employment and social events was set up.
F. Norton Manning, Inspector of the Insane from 1876 (Inspector General from 1879), until his retirement in 1898, was a firm advocate of moral management. Manning personally supervised the architecture, siting and facilities of Callan Park (constructed 1876-1877), ensuring that they conformed to his policies. While Manning and his successor Eric Sinclair, who took over in 1898 on Manning’s retirement, deprecated physical constraint, they understood that it was essential to prevent violent, suicidal or excited patients from harming themselves or others. Physical restraints, such as straitjackets, had a number of disadvantages. They were highly visible to the Inspector General, Official Visitors and visiting families and friends. Moreover, sensationalist newspapers were always ready to seize upon and misrepresent asylum incidents, inspiring unwelcome criticisms in Parliament ‘Smashed Patient’ .
Another disadvantage of physical restraint was the additional workhours required to care for resistive patients, in a climate of constant staff shortages. Restrained patients had to be released, toileted, cleaned, dressed and undressed, often forcibly. As a large number of patients were incontinent of faeces or urine, the restraining apparatus had to be often replaced by clean equipment. At least two staff members were required to be present when stronger patients were restrained or released from restraint. Some idea of the impracticability of the additional workload can be given by the following thought experiment. If each physically restrained patient required the labour of two attendants one extra hour a day (optimistically), this would have meant an additional 300 workhours a day in the year 1900, assuming that a third of the asylum patients in that year required restraint at any one time. The total theoretical maximum available attendant workpower per day in 1900 was 480 manhours (from 48 attendants).
I would go on to suggest that the rapid growth of asylums internationally at this period was only possible via the labour-saving and cheap device of chemical restraint. Opium tincture could be bought at ‘twenty five drops to a penny’ in the 1850s. Chloral hydrate was mass produced in the 1880s, far beyond the production of any other sedative, indicating a similarly low price. At Callan Park, about half the patients were sedated for extended periods at some time during their stay. Women were 30 per cent more likely to be chemically restrained than men. This disparity arose on ideological grounds. In this era, the use of physical force against women in institutions under the public eye was frowned on in official and ‘respectable’ circles.
The most popular sedative was opium. Opiates were the first widely used therapeutically effective drugs to manage mental illness, used since the time of the Pharaohs. The evidence suggests that opium was also used in some cases to ‘smooth the pillow’ of the dying. Yet at Callan Park doctors ignored the medical guidelines of their day, by poor documentation, by not adjusting dosages by weight or sex, or by prescribing opium for a pregnant woman near term. The second most used sedative was chloral hydrate. At this time there were numerous mentions of suicide, addiction, misadventure, overdose or murder in connection with chloral hydrate in the press or in medical journals. It was a truly dangerous medication and the evidence suggests that chloral hydrate and opium shortened lives at Callan Park.
The two most significant harms from sedation, particularly among the fragile and aged, were probably choking at mealtimes resulting in asphyxiation, and broken bones from falls. We can see a modern echo of these adverse consequences in current controversies over the claimed excessive use of Selective Serotonin Uptake Inhibitors (SSRIs) and other hypnotics in aged and mental health care – Falls Dysphagia Overuse of SSRIs. Broken bones in the aged or fragile can often lead to prolonged morbidity and death, while choking may lead to fatal pneumonia arising from retained food in the lungs. This article provides further insight into addressing current misfortunes in aged and mental health care, where the incautious overuse of chemical behaviour modifiers, in order to achieve financial goals, eclipses non-medication approaches.
As a (very) mature age student, David completed an MA(Hons) at ANU on Claremont Hospital for the Insane in Perth 1909-1919 in 2015. He began study for a PhD at ANU in 2016. His thesis topic is :‘Life, death and Deliverance at Callan Park Hospital for the Insane 1877 to 1923’. He presented a paper on ‘Chemical Restraints at Callan Park before 1900’ at the July 2017 Conference of the Australian and New Zealand Society for the History of Medicine. He is currently preparing an extended version of this presentation for submission to an academic journal. He has been invited to present a paper on General Paralysis of the Insane to the local branch of the Society in October 2017. Before starting this latest round of study, David had a long career in IT work.
Citation: David Roth. Chemical Restraint at Callan Park Hospital for the Insane before 1900. Australian Policy and History. November 2017.
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