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A 45-year-old, right-handed man was electively admitted to a London hospital following an illness of at least 7 years' duration. On admission, he was described as exhibiting ‘unusual’ behaviour, but was not thought to be a risk to himself or others. He was prone to walking round ‘screaming’ and complained of auditory hallucinations. His admission was prompted by social concerns, as he was unable to manage his activities of daily living. The clinicians performed no tests, recorded no treatments in his case notes, and he died within 2 years of admission. It was 1912 and Abraham Raphael had general paralysis of the insane (GPI).
Abraham Raphael's case notes are recorded in the male casebook held in the Bethlem Royal Hospital archive. He had been admitted with ‘dementia of the general paralytic’ (GPI) and ‘ideas of a widely exaggerated nature’ to Bethlem (figure 1) while it was in St George's Fields, Lambeth, having been transferred in February 1910 from Camberwell House, a private asylum in Peckham. Although Bethlem's alter ego Bedlam is notorious, at the time of Raphael's admission the hospital was compared to the best London hotels, an image in sharp contrast to the common representations of Edwardian asylums as dark, forbidding Gothic institutions. Since the mid-19th century, Bethlem had gone through a period of reform: the wards had been improved and a convalescent home had been opened in Surrey. Now largely removed from the public eye after the scandals of the early 19th century, Bethlem in 1910 was a semi-private institution to which middle-class patients like Raphael, a headmaster at a Jewish orphanage, could be admitted for a modest charge to one of its 200 beds. Neither dangerous nor suicidal, like many patients Raphael found his way into an asylum because he had become too difficult to manage within a domestic setting at a time when no treatments were available for GPI beyond institutional care. For a man of Raphael's standing, being a private patient in Bethlem offered his wife a less stigmatising alternative to a country asylum, which mainly received pauper patients, and a less expensive solution than care in a private institution.
Reading the patient
What should we make of Raphael? He was not a writer or philosopher. He was unremarkable and his case was not published. Nor was his clinical history unusual for the period. Although Raphael had long had depression, the onset of his ‘unusual’ behaviour had begun to arouse concern in 1905 and, notwithstanding his denials, he was admitted with obvious signs of GPI 5 years later. Contemporary psychiatrists—referred to as alienists at the time—had found that the new antisyphilitic Salvarsan had no effect with GPI. Salvarsan had been discovered in 1909: an organo-arsenic compound derived from atoxyl, which proved toxic to the spirochaetes, it was administered orally by dissolving the drug in distilled sterile water and was hailed as the first ‘magic bullet’. If Salvarsan offered no cure for GPI, nor did the mainstays of treatments commonly used in Edwardian asylums. These often focused on sedation, exercise or supportive treatments, and offered only a temporary, symptomatic effect on patients with GPI. With no specific treatment available, Raphael was recorded to be ‘steadily going down hill’ in April 1911. By October 1912, he became bedridden and ‘weak minded’, having shown some improvement in his mental if not physical state, and by December had begun to have seizures and become ‘quite helpless’. The clinical features of Raphael's decline illustrate the typical progression of GPI from florid delusions to paroxysms with seizures leading to paralysis. With no cure available until the 1920s, death inevitably occurred within 3 years.
The important fact about Raphael's case is that it is unremarkable. Patients with GPI were admitted to countless private and public asylums during the period and Raphael is just one such example. Such ignored cases can tell us much about the normal practice of care for such ordinary patients, but they can also be revealing in other ways. Although the case notes offer only one voice from a multiple set of conversations, it is possible to uncover the social and cultural ideologies that pertain to the patient's position and which make each case unique. Additionally, something of the perspective of the patient can also be unearthed from the descriptive language of the clinicians who document the symptomology.
It may be a surprise for a medical audience to read a case history with a named patient. Patient records remain closed for a 100 years to protect the patient and their relatives, but they are used by historians in an attempt to think about patients' experiences. Psychiatric case notes have been read in a number of ways. They have been used to recapture the patient's voice to illuminate the ‘inner world’ of mental illness or to show how patients were controlled or abused. Raphael's case provides a valuable narrative of his delusions illustrating both the common symptoms of GPI and throwing light upon their historical situation.
Through his case notes we hear how the clever and moody Raphael ‘will give millions to all he comes into contact with’; how he could ‘drink a million bottles of wine’, would ‘live 200 years’, and had cured everyone at Camberwell House. We hear how Raphael had ‘prevented a great many unmarried women from becoming pregnant by passing a lancet & an electric lamp in the rectum & then removing the uterus, ovaries and fallopian tunes’; how he had not only provided ‘1000 lbs of bacon & more than 1000 eggs for his school children’ but had also fed them ‘continually per rectum with rubber tubes’, notably at night. Unsurprisingly, such stories had provoked worried comments from the governors of his school and his behaviour had caused them virtually to force him to see a doctor. As was common with GPI, Raphael imagined himself an ‘independent gentleman, very wealthy & lives in Paris’; going on to explain how in a café in Italy he had ‘drunk 1 000 000 bottles of wine’ and how in Ireland he could buy pigs and elephants ‘for nothing’ because ‘they simply run into your arms’. What is also evident is the stigma associated with syphilis, which at the time was held partly responsible for national degeneration. Unsurprisingly, Raphael initially denied having syphilis: it was not until his physical condition deteriorated that he admitted to ‘being treated for it for some time’. Although no mention was made of his prior treatment, injection, inhalation or ingestion of preparations with mercury were still the main form of treatment used by Edwardian medical practitioners.
Nowhere does Raphael tell his own story: his experiences of GPI are filtered through the words of the house physicians. Unless published, case notes were private documents intended only for the institution's medical officers. While patients often drew upon medicalised language in recounting their experiences, like many contemporary cases notes, those of Raphael use familiar medical terms, such as subcutaneous haemorrhages, along with shorthand to point to ‘Tertiary σ ς’ (sigma for syphilis) or ‘P.R. only’. They talk not in the first person but about ‘he’ and the ‘Pat.’. Raphael's case notes are not then a patient narrative but a medicalised account. Raphael and his experiences became a medical construct shaped by the categories, perception and language of medicine.
If Raphael was silent, his case notes demonstrate how mental illness and GPI were framed in Edwardian Britain. The link between GPI and syphilis had been suspected in the 1860s, but it was only by the 1890s that clinicians accepted syphilis as the primary cause and not until 1905 that the exact cause—the bacterium Treponema pallidum—was discovered. While it was obvious from the start that Raphael had GPI, it was believed that increased work and responsibility had prompted his deterioration. This reflected contemporary concerns about the dangers of urban living, but also distanced Raphael from the common connections made between syphilis and a poor or degenerate lifestyle. Raphael's physical condition was carefully recorded and so was his family history. Edwardian psychiatrists were particularly interested in organic interpretations of mental illness and in ideas of heredity. Hence, when examining Raphael, the house physicians looked for what they believed were the obvious signs of degeneration, such as tuberculosis and alcoholism.
Although subtle, his racial and religious background as a Jew does register in the notes, in particularly interesting ways. First, Jewishness was quietly pathologised as a symptom of the patient's grand delusions. Raphael's belief that, as a Jew, he was ‘the chosen of God and therefore a perfect man’ may be overstating the tenets of Judaism, but that does not necessarily make his claims part of the ‘exalted ideas’ regarded as signs of his insanity, as his doctors claimed. Secondly, Raphael himself drew attention, perhaps unconsciously, to an infamous moment in London's own history of multiculturalism. His claim to have violated a number of women in order to bring an end to their reproductive capabilities has eerie echoes of the Whitechapel Murders of 1888 (which took place when Raphael was aged 33 years). (figure 2) As London's detectives sought for clues to the identity of Jack the Ripper, many speculated that the murders were being perpetrated by a Jewish immigrant with some form of mental delusion.
Similarly, despite existing only as a medicalised account of the patient from the perspective of the medical staff, the notes do suggest something of his efforts to resist the onset and acute spread of GPI. It is clear, for example, that Raphael's insanity presented as a series of mathematical or numerical delusions (the 1000 eggs or 1 000 000 bottles of wine), which may owe their imaginative structure to his career as a schoolteacher. As Raphael's condition deteriorated he made an effort to exert control over his own mind and body via comparable logical systems. He became ‘argumentative in a very logical way’ and boasted of his ability to ‘drill’ his former pupils to the same level as the British Army. There is pathos in these comments (even if reported second-hand) as it is possible to recognise an individual using the safety of familiar patterns to assuage personal anxieties and fears that are not explicitly documented by the house physicians compiling his notes.
Syphilis, like gout or tuberculosis, appears superficially rakish and has echoes of a distant medical past; to the point that one can be surprised that those conditions are still so common. There is a poorly understood unconscious ranking of the stigma associated with certain medical conditions, best described by Album and Westin when they ranked the prestige of certain disorders and certain medical specialties.1 Incurable modern sexually transmitted AIDS was obviously ranked as heavily stigmatising, whereas less ‘prestigious’ were all the psychiatric and addiction disorders—anorexia, schizophrenia, depressive neurosis, alcoholic cirrhosis, anxiety neurosis and fibromyalgia. Furthermore, the second least prestigious medical specialty in their study was (syphilis's own) dermatovenerology. It has been speculated that much of epilepsy's perceived stigma has more to do with its association with neurosyphilis in Western Europe than it has to do with witchcraft and belief in devils. Not only is GPI sexual transmitted, but it produced a myriad of psychiatric and neurological symptoms that were recognised as incurable, even with the introduction of malaria treatment in the 1920s which, by artificially infecting patients with malaria, appeared to halt the patient's inevitable degeneration.
It was in modern-day metropolises like Raphael's London that the foci of the UK boom in syphilis were found. In the 21st century, co-infection with HIV is driving the inflation in syphilis cases that previously had dipped in the second half of the 20th century. Indeed, in this era of easy access to antimicrobial agents, it is sobering that in HIV-positive patients with untreated late-latent syphilis, the prevalence of neurosyphilis may be as high as 24%.2 A low CD4 count (<350 cells/ml) and male sex are risks for developing neurosyphilis in those with primary syphilis who are HIV positive. The neurological manifestations have also changed (meningeal and vascular forms occur more frequently), and syphilis is once more considered part of the differential diagnosis in a young person with stroke. Of course, Raphael had tertiary syphilis where symptoms and signs develop 10–50 years after primary infection. Neurosyphilis may not necessarily be tertiary—indeed, personality change is a common sign of late syphilis. Syphilis is not as common as in Raphael's time, when an estimated 10% of the UK may have been infected. The ‘epidemic’, widely feared, was a common cause of pregnancy loss and of infant mortality.
In contrast to the traditional case report (demonstrating the easily overlooked, or the ‘atypically atypical’ case), we present a common, treatable and reassuringly ordinary case. However, even an ordinary case can shed light on the social and cultural influences at work in hospital medicine. The language of case notes, even written from a single perspective and tending to silence the patient, can be read ‘against the grain’ to reveal something of the patient's experiences. Clinicians, like historians, must attend to the patient's narrative and analyse a variety of sources to produce an account of the collection of signs presented. Despite functional imaging, genomics and monoclonal antibodies, much of a modern clinician's daily work would be familiar to Bethlem's doctors of 1912, because the conditions we may encounter have changed little and our attempts to alter their effects have been limited. However, the personal interactions between clinician and patient in an Edwardian asylum may seem a world away from those in a modern centre of excellence. Yet a historical case offers an insight into the social and cultural world of patients and helps us to understand how mental illness and GPI have been framed, offering a glimpse into the inner world of the patient and of the institution.
General paralysis of the insane (GPI) or paralytic dementia is a neuropsychiatric disorder affecting the brain and central nervous system caused by syphilis infection. Originally considered a psychiatric disorder—19th-century patients often presented with psychotic symptoms—GPI has a gradual onset after the secondary stage of syphilis with depression as the initial main symptom. Progressive memory and intellectual impairment follow. As the frontal lobes are particularly involved, GPI is characterised by sudden personality changes with disinhibition and development of extravagant and grandiose behaviour. Early physical symptoms include slurred speech, a tremor of the lips and tongue, and possibly Argyll Robertson pupils. The clinical picture then appears to level out but is followed by a progressive dementing illness, paroxysms with seizures and increased leg weakness leading to spastic paralysis. Eventually the patient becomes completely incapacitated and dies, the process taking on average 3 years.
The authors thank Colin Gale at the Bethlem Royal Hospital Archives and Museum Services for his help and support, and the editor of Practical Neurology for his encouragement. The paper was reviewed by Dr Gerald Stern, London, UK.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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