1.

The so-called ‘chemical revolution’Footnote ¹ in psychiatry has given rise to much scholarship over the past sixty years.Footnote ² The introduction of the first antipsychotic (chlorpromazine) in the first half of the 1950s and the first antidepressant (imipramine) in the late 1950s is said to have profoundly changed practices and to have permanently integrated psychiatry into the field of modern medicine. Physicians, sociologists, anthropologists and historians have since engaged in a debate on the purported ‘revolutionary’ nature of these chemical agentsFootnote ³ and on the consequences of their introduction, focusing, in particular, on the following four questions. Was de-institutionalisation, as observed in many western countries, the cause or the consequence of this therapeutic change?Footnote ⁴ What was the role of pharmaceutical companies in changing definitions of psychiatric nosology?Footnote ⁵ How have neuroleptics transformed understanding of mental illness?Footnote ⁶ And, finally, have scientific methods in psychiatry (for example, double-blind randomised controlled trials, MRI and medical files) been modified based on the above developments?Footnote ⁷

These discussions have resulted in a vast historiographical output. Specific studies exist for several European countries, tracing the arrival of these drugs on the market and in hospitals.Footnote ⁸ Over the past fifteen years, an interest in this issue has developed alongside new questions emerging from the fields of science and technology studies (STS) and the history of medicine. Among the lines of research influenced by STS, we find drug trajectories,Footnote ⁹ the standardisation of pills and syrupsFootnote ¹⁰ and the formation of Denkgemeinschaften (Ludwig Fleck), which enable us to analyse the reception of scientific ideas. This probably explains why patients remain absent from narratives, both as key players involved in the discovery of certain chemicals’ neuroleptic effects and as objects of their use. Patients have never been at the centre of STS, although they represented a classic topic for social history in the 1970s and 1980s (a stance notably defended by Roy Porter in his seminal article, ‘The Patient’s View. Doing Medical History from Below’).Footnote ¹¹ Yet the social history of medicine has shown little interest in the second half of the twentieth century, focusing largely on early modern times and the nineteenth century.Footnote ¹²

Based on the patient recordsFootnote ¹³ of the Institut de Psychiatrie (Brussels), this paper retraces the use of medication in the 1950s, a time when neuroleptics and antidepressants became an integral part of the therapeutic arsenal. It studies these developments through transcriptions left in patient letters, physician records and nurse notes.Footnote ¹⁴ The paper thus contributes to the history of psychiatry from below but also participates in the following two important debates. How can the history of the patient’s view enrich classical historical accounts? And how did patients narrate the so-called ‘chemical revolution’?

More generally, this article qualifies the Foucauldian concept of the ‘medical gaze’. The sources of the Institut provide unique access to patient agency, since patients’ letters come close to a ‘direct’ voice that has not been edited by nurses and psychiatrists. These materials reveal that the early users of neuroleptics employed varied and complex tactics to retain control over their experience. At the same time, these patients remained in an institutional order, a medical logic and a pharmaceutical–industrial commodity market, all of which affected their area of agency. Also, this piece highlights the importance of integrating previously neglected players into this historiographical narrative. Since Porter’s seminal article, historians have sought to paint a far richer picture, no longer describing psychiatry in terms of the classic asylum–psychiatrists–patient trinity. Typically focused on the nineteenth century, they argue that there was no single response to treatments and practices, but rather a multiplicity of them.Footnote ¹⁵ Analysis of the unedited patient records of the Institut de Psychiatrie during the 1950s shows the importance of staff, outpatients, family members and therapeutic technologies in shaping these clinical encounters. It reveals that the patient–physician relationships are more complex than usually portrayed when it comes to post World War II contexts.

2. The Introduction of Drugs at the Institut de Psychiatrie

Drugs were not new to asylums in the 1950s. While opium and morphine have long been used in psychiatry, the second half of the nineteenth century witnessed the emergence of a large number of other substances considered more effective and less dangerous, such as chloral and bromides. After the success of these sedatives in the second half of the nineteenth century, the early 1890s saw the rise of barbiturates. These were considered more active and were seen as having fewer side effects than their predecessors,Footnote ¹⁶ although concerns were regularly voiced about their addictive properties.Footnote ¹⁷

The use of therapeutic drugs was widespread within the Institut ever since its foundation in the early 1930s. In 1931, at least 55 per cent of patients received some drugs during their stay, the most prominent being Luminal, a barbiturate distributed by Bayer. In 1935, this percentage dropped to around 40 per cent; in 1940, it rose to around 80 per cent; in 1945, approximately 50 per cent of patients were medicated; and by 1950, two thirds of them were on some form of medication. Despite the significant variations due to its rather small size, this sample shows that, before the introduction of neuroleptics, more than half of the patients at the Institut consumed therapeutic drugs. Well before the 1950s, drugs thus rhythmically structured the daily lives of patients at this institution; and, indeed, the users were well aware of the material nature of these medications. Their distribution – whether in the form of pills or injections – took place two or three times a day and represented a moment of negotiation between patients and caregivers. The doctor prescribed the framework within which the drugs were administered (frequency and maximum amount), but every day it was the nurses who decided on these parameters and negotiated the actual taking of the drugs with the residents.

By the time psychotropics entered psychiatric wards, the body language and timing of their distribution had already been codified. The first neuroleptic was introduced into French psychiatry in 1952 under its generic name chlorpromazine; it was sold under the name Largactil. But only in 1954 did the psychiatric field begin to consider the drug as a breakthrough, and its use in most western-European countries began to transcend the experimental framework. That same year, Largactil was administered to the first patients at the Institut. At this point, it had been marketed for about a year in Belgian medical journals by Specia, the pharmaceutical branch of Rhône-Poulenc and the Belgian distributor of Largactil. The first accounts of its use appeared in Belgian scientific journals published in 1954. At first, Largactil was not sold exclusively as a psychiatric drug, but also as a treatment for surgery and obstetrics. The emphasis was placed more on ‘symptomatic treatment’ than on any ‘pathogenic specificity’, that is, on the drug’s effect on symptoms rather than actual healing.Footnote ¹⁸ Over the years, Largactil was more specifically defined as a psychiatric drug, although the indications for use still remained very broad: ‘psychomotor agitation, confusion, anxiety, depression, obsessions, cenestopathy, intractable insomnia, sleep therapy, neuralgia, various pains, dysautonomia’.Footnote ¹⁹ In the second half of 1954, Largactil was classified as category A by the Belgian National Health and Disability Insurance Fund (Fonds National d’Assurance Maladie-Invalidité). This classification offered patients in Belgium a refund of 70 per cent of the drug’s cost,Footnote ²⁰ providing an important argument for its use given the high cost. It should be mentioned that the introduction of neuroleptics happened in a context of collective enthusiasm for medical drugs. Since the triumphant march of penicillin in the mid-1940s, the medical community seemed to find a new miracle cure every year: for example, the first anti-TB medicine (late 1940) and extended spectrum antibiotics. As a symbol of ‘postmodern medicine’,Footnote ²¹ the doctor no longer merely affixed a diagnosis, but also healed organic diseases. Neuroleptics allowed psychiatry to participate in this boundless enthusiasm.

In parallel with these discussions at national and international levels and across different arenas – medicine, pharmaceutics and welfare state – neuroleptics also made their way into asylums at a local level. At the Institut, Largactil was used very broadly to treat schizophrenia as well as anxiety and delirium tremens. Within ten years, treatment patterns went through some major changes, as indicated in the table below.

Table 1: Psychotropic drugs and electroconvulsive therapy at the Institut de Psychiatrie de Brugmann (Percentage of patients receiving treatment).

While Electroconvulsive therapy (ECT) was still the ‘cure’ used most frequently in the late 1940s, it saw a significant and sustained decrease from the second half of the next decade. At the same time, the growing and widening diffusion of psychotropic medication allows for two conclusions. First, never in the history of psychiatry had any treatment experienced such a widespread use; in the late 1960s, nearly nine out of ten patients received psychotropic drugs. Second, their use led to the virtual disappearance of all other biological therapies such as cardiazol and insulin shock therapy. Only ECT retained a negligible share in treatments. These developments had an impact on patient experience as well as on the dynamics among members of the Institut.

3. Medical Notes, Records and Patient Narratives

The detailed nursing notes, taken three times a day, as well as the letters kept in patient records, can be used to gain insight into how patients perceived the change in medication practice during the 1950s. This topic appears in many files. In two thirds of them, a nurse or psychiatrist has noted down the patient’s reaction to the medication. Patient response is extremely heterogeneous and a far cry from clichéd images (depictions of ‘inmates’ being force-fed drugs by doctors on the pay list of pharmaceutical companies or, in stark opposition, the introduction of neuroleptics as a universally hailed innovation).

To be sure, many patients were opposed to taking drugs during their stay. Refusing them sometimes became a tactic of resistance to counter perceived ‘negative power’ of the physicians. The administration of medication – usually at 8am, 2pm and 8pm – was a daily ritual. Since the patients were left to themselves most of the time, this was also one of the few moments when they interacted with the staff. Indeed, administering drugs not only structured the day as an obligatory meeting with the caregivers, but it also represented a moment when an opposition to hospitalisation could be expressed – especially at a time when this still happened mostly without the patient’s consent.

The reasons for this refusal are not always clearly indicated. In 1958, a certain Mill M. entered the Institut for the third time in his life.Footnote ²² A 65-year-old retired officer of the Belgian army, he was not given a very precise diagnosis and the reasons for his admittance cannot be found in his medical records. At no point did the staff take any detailed notes on his consuming any drugs. The word ‘medicine’ appears in one single instance within a more general comment:

In this note, only the patient’s general refusal is mentioned. In a broader sense however, he also rejected most rules in his ward. Mill M. showed a characteristic stance. Not taking one’s medication was a way to show a general opposition to one’s stay in the hospital, in the same way as a refusal to eat or urinate properly.

For many patients, disease, medication and healing formed a closely interlaced triangle. Taking medication implied that one was ill. It would be interesting to study whether administering drugs helped psychiatrists convince patients of their illness. At the same time, receiving medication offered patients some hope for their approaching remission. Nevertheless, it was generally a powerful indicator that there was a problem. Refusing drugs was thus a way to tell the physician that one did not (any longer) consider oneself sick.

Some patients resisted psychotropics specifically. Joseph R., for example, was a German worker in his forties. In February 1958, twenty years after leaving Germany, he was interned at the Institut for the first time. Diagnosed as ‘paranoid’, he received his first dose of Largactil after two weeks. Over the following two weeks his daily dose was quadrupled from three administrations of 50mg to three administrations of 200mg. Although Joseph R. had no access to his file, he realised that the dose was increasing. It thus became progressively more difficult to convince him to take his pills: ‘wants to leave but wonders how on earth he can, considering his medication was increased.’ A few days later: ‘Unhappy – wants to go home if his medication is not reduced.’Footnote ²⁴ For this patient who was convinced that he was not ill, the administration of drugs reminded him daily that he would not soon be leaving the Institut. The dosage increase was interpreted as a sign of his deteriorating condition, and implied that his stay would be prolonged.

Another frequent complaint for Joseph R. – and others – concerned the unwanted physical reactions of the drugs. Indeed, the first neuroleptics produced quite serious side effects, affecting both patients (who developed tremors similar to Parkinson’s disease) and nurses (who developed skin rashes). The medical records regularly mention secondary symptoms commonly attributed to psychotropic drugs from the 1950s and 1960s. These include stomach aches, headaches and sleep problems. Since physicians were not in regular contact with the drugs, at first they paid little attention to these side effects. Before the Thalidomide scandal, which broke out in West Germany and Austria in the early 1960s and then spread throughout Europe, this issue was hardly debated in the public space, and its ethical implications were not discussed among medical doctors.Footnote ²⁵

At the Institut a first sign of concern about side effects appears in a patient record of 1962. After complaining repeatedly about tremors caused by Haloperidol, a neuroleptic that had been produced in Belgium since 1958, Dirk M. caused the head physician to reduce the prescribed dose used by the attending psychiatrist. This earned the physician letters of thanks:

Dirk M. is not the only patient who linked his medication to physical problems. In February 1955, Karine O. went to the Institut for the sixth time with a diagnosis of ‘depression’. She had repeatedly received psychotropics before:

It is perhaps not surprising, therefore, that patients should make up various strategies to escape what some of them saw as ‘poison’:Footnote ²⁸

[Patient] is to be monitored for taking pills, tries to throw them or hide them between his fingers, under his tongue; basically tries every possible trick, even spitting them into a cup so as to throw them out at the slightest inattention.Footnote ²⁹

These strategies were not uniformly adopted by all residents. Thirty-one-year-old Christian D. was admitted to the Institut in June 1958. The scion of a bourgeois family from Brussels, he had attended university and worked as an artist. The initial diagnosis, ‘delirium’, seemed to signal a short stay. Very quickly he challenged the authority of the psychiatrist and opposed his forced hospitalisation by writing letters to family members and friends who held influential positions in Brussels’ society. In a call to a relative (who also happened to be a physician), he wrote:

It was not only the Institut’s medication practices that Christian complained about. Nursing notes are filled with the questions he raised about his drugs: the reasons for their use, their dosage, their frequency, the point of the treatment, and so on. ‘Often enough requests explanations about medications treatment, etc.; would prefer not having to take medication and leave from here.’Footnote ³¹

Christian D. remained one of the few patients who voiced specific questions about the use of drugs and the reasons for their use. This is certainly related to his social origin. Stemming from the liberal bourgeoisie of the Belgian capital, he challenged doctors’ prescriptions. These sceptical questionings had little to do with his ‘mental illness’; rather, they are evidence of a social milieu that saw its relationship with the medical world not only paradigmatically as patients, but also as customers. The nurses he had to face throughout the day were not part of his social class in the outside world, and Christian D. seems to have had particular difficulty recognising their authority.

As seen above, patient opposition to the medication also gave rise to a whole range of rusesFootnote ³² to escape treatment. But these tactics of resistance, in turn, encouraged the nurses to develop tactics of their own: a form of knowledge that was obviously not included in their textbooks. To be sure, the records show that patient complaints were often ignored by the medical staff. Nursing notes such as the one below (about An S., who was admitted to the psychiatric ward after an ‘acute psychotic state’)Footnote ³³ are common:

It is therefore not surprising that, for some patients, taking drugs became a symbol of the physicians’ ‘negative power’. Yet refusing medication did not mean escaping medication. Even within the voluntary service, not taking drugs was not an option.

Interestingly, however, a first refusal was not automatically penalised by forced administration (a measure that is nowhere mentioned in this sample).Footnote ³⁵ When patients acted in a non-compliant manner, the nurses showed flexibility. The case of Gilles S. is typical in this respect. Convinced of suffering from Joubert syndrome, he was admitted to the Institut for the first time in November 1954 at the age of forty-three. After a week, he began to be opposed to taking drugs: ‘very suspicious, constantly asking why he has to take medication, at first does not want to take them, took them finally, does not sleep yet, calm.’Footnote ³⁶ These notes are found in several reports. Sometimes nurses were even willing to accept that patients reject their drugs if they remained calm, as shown in the example of Nordin F., diagnosed as ‘senile demented’: ‘Evening refuses his medication [25mg of Largactil] – falls asleep nonetheless.’ But these instances remain exceptional, even for Nordin F. Indeed, the following day he refused his neuroleptic once again: ‘Did not want to take his larg [Largactil] $+$ phen [Phenergan]. Received 1 amp[oule]. Larg[actil] at 21 o’clock.’Footnote ³⁷

The nurses’ notes remain silent on the means of persuasion used at the Institut. Did they explain the effects of the drug? Did they exert some pressure? Were pills easier to administer than ampoules? The records say close to nothing on the strategies and persuasive techniques of nursing and medical staff. They do, however, suggest that, sometimes, the administration of neuroleptics in 1950s psychiatric clinics was due to administrative or practical reasons. In a later file, dating from 1960, a letter from a patient to the League of Human Rights makes explicit the possible strategies for constraint used by medical officers. These included the (more painful) threat of administering the drug intravenously in case a patient refused to swallow the pill:

Despite these tensions, records show that not all patients perceived the introduction of these drugs in solely negative terms. For some, being given medication was actually a sign of care. Karine O. (discussed above) was admitted to the Institut for the fourth time in September 1954. Until then, the only treatment she had received was electroconvulsive therapy; but this time, the psychiatrist decided to have her try a new drug that had just been released: chlorpromazine. Karine O. welcomed the cure with great enthusiasm. A letter to a friend shows her delight:

In this case, receiving drugs was taken as a sign that the disease was being dealt with.Footnote ⁴⁰ For Karine O. it acted as a synonym for ‘good treatment’ and it was closely linked to the hope of healing. The introduction of new medication therapies and their widespread use in psychiatric hospitals, therefore, not only led to new hopes within the medical field, but also among patients.

Many of them actually insisted that their physicians prescribe them drugs. We still lack studies on their consumption in private during the 1950s and 1960s, but several patients of the Institut did regularly take medication at home. Thus Anne-Marie C. expressed from the first day her desire to receive drugs:

In this example, the patient no longer appears as a passive subject who merely waits for the psychiatrist’s instructions. Instead, she turns into what we might now consider a psychiatric ‘user’. One can even wonder if these attitudes have not become more widespread since the 1980s, when patients came to be represented not simply as objects without agency, but, indeed, as active customers.

Anne-Marie C. was not the only person who had very specific ideas about the therapies that suited her best. In the admission report of Gilles S., suffering from ‘oligophrenia’ [Joubert syndrome], we find similar comments:

Gilles S. had already been interned in psychiatric hospitals by the time he arrived in the Institut. During short stays in other asylums, he had experienced and witnessed restraint. But he also gained practice with taking (psychiatric) medicine. As soon as he was admitted, he required a sedative; and to give more weight to his demand, he mentioned his experience at another hospital. For him, taking medication was a way to escape internment: ‘Give me a tranquilliser and let me leave.’ He was aware of being agitated, but knew that his agitation could be stopped with medication. The administration of the drug was thus perceived, instead, as a possibility for escaping the hold of the psychiatric hospital. Compared to other psychiatric treatments of the time, such as ECT, taking drugs was an act that paradoxically served to weaken the medical grip; this was a therapy that could be administered outside the hospital walls.

For medical staff, there also remained the issue of finding out how much access patients had to drugs prior to their hospitalisation at the Institut. The case of Francis C. is a vivid illustration of this phenomenon. His first encounter with psychiatry happened through the consultation service. A few days after his first appointment in December 1953, he was admitted to the Institut in January 1954 with a diagnosis of depression. Since he was particularly agitated, Francis was administered hyoscine, a sedative, almost every night. But the drug did not have the desired effect. In fact, for two consecutive nights he destroyed the sheet in which he was wrapped. The attending psychiatrist then prescribed bromide and chloral, two other sedatives, but Francis C. remained very disturbed until his release on 8 February 1954. The two drugs were administered to calm him down and he received five electroshocks. During that first stay, his record remains silent as to how he perceived the medication. During a conversation with his wife, however, it emerged that he had taken Largactil even before coming to Brugmann.Footnote ⁴³ The case of Francis C. therefore not only poses the question of how many patients had been on medication before entering the Institut, but also whether (and how widely) Largactil was distributed outside asylums before being used in those institutions. In fact, the records lack enough detail to provide a precise answer, but they do reveal practices that have hardly been addressed by historians until now: namely, the use of medications outside hospital.

Six months later, Francis C. went back to the Institut, this time without a precise diagnosis. His admission was justified on the basis of some very general symptoms: ‘anxious states of melancholia. Suicidal ideations. Insomnia. Mental disorders, dangerous to himself.’ The man now seemed used to taking medication. Upon admission, he asked for an injection to help him sleep, a request that was denied by the nurse on duty. The following night, he received two tablespoons of Largactil. In late August, after thirteen days, he left the hospital. He came back three years later. The physician made the following diagnosis: ‘old agitation, tendency to depression and suicide. Insomnia.’ This was the first time he received neuroleptics on a regular basis and after ten days he started to complain. The nurses noted that he ‘spends much time resting on his bed’.Footnote ⁴⁴ The next day the psychiatrist wrote: ‘remembers having had ECT in ‘54 and “it was better than the pills”.’ The same day, the nurse recorded in the morning: ‘Seems a little depressed today, never agrees with what he is given as a medicine – thinks it’s too much, also complains of headache.’ And at night: ‘Around 6pm received 1 Cibalgine – did not want to take (suspicious), said he will be dead tomorrow. Very depressed – cries – falls asleep afterwards.’ The next day:

During his third stay and a few days after he had asked several questions about drugs, Francis C. received his first electroshock. From that moment his attitude towards neuroleptics changed radically. Instead of opposing them, he now asked for them:

The above indicates that, at a time when therapies were not explained to patients, they could actually appropriate a part of medical knowledge. It is particularly striking, in this respect, that patients often referred to drugs by their names – sometimes even their industrial names, for example, R1625 for Haloperidol. These regularly appear in the files, generally with a more or less correct pronunciation and spelling. (It is to be noted, however, that patients did not describe drugs through their effects: the terms antipsychotics,’ ‘neuroleptics’ and ‘antidepressants’ do not appear in patient writings.Footnote ⁴⁷) Some even declared themselves psychiatric specialists inside their family circles by virtue of their stay at the Institut. Pia M., a young servant girl diagnosed as ‘depressed’ who stayed thrice at Brugmann while several of her family members also suffered from mental illnesses, once wrote to her grandmother: ‘What I was especially happy about is that C[.] and you Granny both take $1/2$ a Seresta; which seems to do you well because I found you all 4 very well.’Footnote ⁴⁸

More generally, these records highlight the varied and complex tactics employed by the various protagonists in this story. Neuroleptics were administered for a number of reasons – reasons that sometimes went beyond strictly medical motives. The nurses were interested in keeping their wards calm or had other practical interests. As for patients, they had some power of compliance or non-compliance, and integrated these drugs into their daily lives and into different understandings of healing. This affected their area of agency. Naturally, elements such as social class often played a role on the degree to which their demands were met by medical staff. In any event, the vast majority of patients who asked for some medication received it. In 200 cases studied in detail, all such requests were responded to positively by the caregivers.Footnote ⁴⁹