In his last column for The Irish Times, MAURICE NELIGANconsiders psychiatry's long route to the mainstream
I WAS not cut out to be a psychiatrist. The surgical vocation requires clearer diagnoses and treatment pathways in so far as are possible. My early and indeed woefully short exposure to psychiatry was the mandated course before we faced final medical exams. This consisted of a series of lectures and visits to a clinical setting. In my case this was to Grangegorman, which later became St Brendan’s Hospital.
I have always had the impression that changing the name of a hospital is often an attempt to leave negative connotations behind. In my time, psychiatry was a Cinderella specialty, overshadowed by the cutting edge disciplines of medicine and surgery. I learned enough of the subject to pass my exams, but I now think far more tuition and experience would have stood me in good stead in later practice.
There was a tendency to quickly refer such patients to the appropriate colleague lest the order of your practice was dislocated and your beds occupied by problems deeper than those cured by the knife. Walter Lincoln Palmer, distinguished physician, adjured colleagues, “Don’t send a patient to a psychiatrist as if you were telling him to go to hell.” There was, and to some degree remains, an “out of sight, out of mind” approach to such patients. The medical student’s superficial conclusion that the subject concerned the “care of the id by the odd” was not conducive to considering the very real issues involved.
In medicine, luckily, there are always bigger and better minds than your own. The great pioneering surgeon John Hunter wrote, “Perhaps there is nothing in nature more pleasing than the study of the human mind.” More tellingly, the equally distinguished physician Sir William Osler, in his classic Principles and Practice of Medicine, said, “Everywhere the old order changes and happy they are who can change with it.” There was a lot to change in the treatment of those with diseases of the mind; there remains a lot to improve.
It has been a long and arduous road to the incorporation of psychiatry fully into the body of mainstream medicine. Such illnesses are like most others – a mixture of genetic, social, biological and psychological functions. The genesis of many psychiatric conditions is as yet poorly understood, but we must ensure that the treatment of those with such conditions is not allowed to be dealt with once more on the “out of sight, out of mind principle”. Society has for too long turned its back on these patients.
In earlier days, some patients with epilepsy and other neurological and psychiatric conditions were associated with demonic possession and witchcraft, and many perished cruelly because of our fears of the unknown. Others were banished from society or incarcerated so that the rest of us could remain secure in our ignorance.
The Bethlehem or Bedlam Hospital established in London in 1330 is a case in point. There were held a mixture of the “mentally disabled, the criminally insane, epileptics and indigent poor” and one might be tempted to add “other inconvenient persons”.
The Pitié-Salpêtrière Hospital in Paris served the same function and also was a prison for the flotsam and jetsam of the lower classes. It was stormed during the French Revolution and while incarcerated prostitutes were freed by the mob, many shackled “lunatics” were murdered in cold blood. With the dawn of enlightenment, this great hospital grew into the world class institution it is today.
Pierre Janet, writing about the Paris of the time, pointed out the class distinctions of psychiatric practice: “If a patient is poor, he is committed to a public hospital as ‘psychotic’, if he can afford the luxury of a private sanatorium, he is diagnosed as ‘neurasthenic’, if he can afford to be nursed at home with attending physicians, the diagnosis is ‘eccentric’. In some respects, plus ça change.
In our little island, the great Dean Swift wrote of his own death:
“He gave the little wealth he had
To build a house for fools and mad,
And showed by one satiric touch
No nation needed it so much”
Now we talk the talk with our Vision of Change document for the mental health services here. Will we walk the walk, or will these vulnerable patients be sacrificed with so many more of our people for the failures of others?
Maurice Neligan:
May 15th, 1937 - October 8th, 2010