Mending minds

IN late 1939, a rich man of thirty from Madras (now Chennai) called Anand (name changed), a research scholar in science, was admitted to the Mysore Government Mental Hospital in Bangalore (now Bengaluru). At the time of his admission he was described as asthenic, which meant that he was weak and poorly built, barely weighing 45 kilograms. Anand was hallucinating, delusional and restive. He also had suicidal tendencies and complained of sleeplessness. According to case notes accompanying his admission, Anand had begun to evince interest in the affairs of a certain female student in 1933. The case report pithily stated: “There does not seem to be any mutual love between them. He was anxious to marry her but she refused him. His brother reports that the patient is addicted to masturbation.” On being asked his date of birth at admission, Anand responded: “You may refer to the High Court.”

His final diagnosis stated that he was “suffering from a mental disorder called Schizophrenia of the Paranoid Type, or as it is sometimes termed, Dementia Praecox.” A doctor who was supervising his case had noted: “Patient is confined to his house, which is in a noisy place and scarcely gets out. He is dirty, untidy, restless and sleepless. He is constantly hearing voices. He takes no interest in anything and does not even read papers or journals. He spends most of his time lying down in bed. He is occasionally destructive. He is suspicious that his property and papers are being tampered with, if his wish of being left alone is not acceded to, he becomes [space] and aggressive. Coaxing him to do things has not helped him in any way.” The case notes do not stop here but provide copious details for the next 20 pages. Results from a range of physiological and psychological tests are also appended.

He remained at the hospital, now known as the National Institute of Mental Health and Neurosciences (NIMHANS), for a few years.

Such detailed case records became the norm only after Dr Frank Noronha returned from training at Maudsley Hospital in London in 1921 and took charge as the first Indian psychiatric superintendent of the mental hospital. He was the one who started the practice of maintaining case records that documented personal and clinical histories in detail.

Any serious researcher of the history of mental illness in India will find Anand’s case record fascinating for the amount of detail it contains. His file can now be accessed at the recently established archive of NIMHANS, which forms part of a new museum located on the premises of this premier institute of national importance.

The vast archive contains two kinds of material: registers and case records. Registers contain brief social and clinical details of admitted patients and are available from 1893. Case records began to be maintained at NIMHANS from 1923 and are much more exhaustive in recording information relevant for psychiatric care. The archive contains registers of 4,345 patients and case records of 5,475 patients until 1947.

Enviable reputation

By 1939, the mental hospital had built up an enviable reputation for the treatment of mental disorders in the subcontinent. A few years earlier, it had even impressed Edward Mapother, Medical Superintendent of the Maudsley Hospital in London. Mapother was the world’s leading psychiatrist at the time and described the hospital as “a monument to the vision and wisdom of all those responsible for the mental defectives in the East. The institution is almost unique among mental hospitals in India… it is quite evident that modern methods of diagnosis and treatment are available and freely used.”

The eminent psychiatrist, who toured seven hospitals across British India during his visit, was mostly disappointed with the state of psychiatric care in the rest of the country. He began his report by stating: “It would be difficult for the most jingoistic to affirm that, in the matter of provision for mental disorder in India, the British ‘bearing of the white man’s burden’ has been quite adequate.” This assessment was not wrong, as at the time of his visit, India had only 9,608 beds dedicated to psychiatric care for a population of 276 million. (The comparative figure for London was 22,000 beds for a population of 4.4 million.)

The only thing that one can quibble about in Mapother’s statement is the sentiment behind the phrase “white man’s burden” as it is no longer valid. (The economic gains made from colonies are well documented now and it is an established fact that the “burden” borne by the white man was not as altruistic as it was made out to be.)

That apart, colonies like India benefited from advancements in medical science made in Europe that were gradually, and partially, transposed to realms that the British colonised.

Dr Sanjeev Jain, psychiatrist and historian of mental illness, NIMHANS, says: “Modern psychiatry in India owes a lot to the British. They established mental hospitals wherever they went and this is true of their colonies in India, Africa and other parts of the world as well.”

Prof. James Mills of the University of Strathclyde in Glasgow identifies four distinct periods in the growth of modern psychiatry in India in a paper. The first period, he writes, is between 1795 and 1857 when the institutions set up for Indians were little more than refuges while the European patients were repatriated to the United Kingdom.

The second period lasted from 1858 to 1914 when the foundation of the modern psychiatric system was laid and an institutional and legal framework was built. The asylum populations during this period were drawn from the poorest sections of society, such as peasants, servants and beggars.

In the third period, from 1914 to 1947, the two World Wars had their impact on the discipline of psychiatry as well victims of shell shock and the need for more space for their treatment. This period also saw the rise of a generation of Indian psychiatrists and wider acceptance of psychiatric institutions among Indians. There was also a system of prognosis and diagnosis and greater use of drugs during this period. The profile of patients also changed, with wealthy Indians now being admitted. The fourth phase, from 1947 to the 1990s, has seen the discipline follow the patterns established during the colonial period.

The beginning

The Bangalore Lunatic Asylum was established in 1850 when Mysore was being governed directly by the British (the kingdom reverted to the royal family of Mysore only in 1881). The asylum evolved from the Hospital for Soldiers, Peons and Paupers begun in 1833 by Dr Charles Irving Smith, a British medical practitioner, whose diary provides the earliest case notes of psychiatric ailments in South Asia. Dr Smith wrote in one instance: “Abuse of some form of stimulants such as spirits or bhang (cannabis), venery, and exposure to the sun were common causes of mania, according to him [patient].” In 1879, cannabis was identified as a cause in 75 per cent of the admissions, although this declined significantly in the 20th century.

By the end of the 19th century, the asylum recorded patients from a variety of nationalities, including Armenians, European Catholics, Italians, Irish, the English and people from all parts of India, testimony to the cosmopolitan character of Bangalore even at that time. The occupations of the “lunatics” were also very diverse. An 1878 report describes the professions of patients as labourer, dyer, ryot , goldsmith, oil monger, siledar , sepoy, fisherman, cook, daffedar , printer, butcher, saddler, baker, merchant, Brahman, priest, scavenger, watch repairer, hakim , beggar, and ayah. At the time, this was the only mental asylum in any princely state in South Asia.

An early census revealed that the princely state of Mysore had a higher share of people with psychiatric problems than other parts of India. This led Census Officer B.L. Rice to speculate that large and rapid demographic changes in Bangalore caused by migrations from the Maratha, Hyderabad, Madras and Malabar regions had given rise to a very “vagrant and bohemian lifestyle”, increasing abnormal behaviour that led to the high prevalence of psychiatric problems in Mysore.

Opening of asylums

By 1893, when the asylum in Bangalore began to maintain a systematic record of patients, the Indian government had begun to recognise mental illness as a separate category. The British had already demonstrated a clear commitment to building hospitals for the mentally ill, with each institution being headed by a British doctor drawn from the Indian Medical Service.

The Lucknow Lunatic Asylum was opened in 1859, and over the next few decades several asylums were set up across British India. In 1875, asylums in Bengal Presidency had 1,147 patients. By 1900, 26 asylums operated in the presidencies of British India. Mental illness was recognised in the first census of 1871 itself, with a category called “insane and idiots”. Some 67,000 people were included in this category in the first census.

Many Indians admitted to asylums in the second half of the 19th century were said to be suffering from mania or were classified as “criminal lunatics”. The methods of psychiatric care were European in origin, and consisted of moral therapy, which included a “non-restraint atmosphere”, medicines, and the development of a comprehensive work regimen. Electroconvulsive therapy, or shock therapy, was also practised in Indian asylums by the end of the 19th century. Things changed substantially in the 20th century as psychiatry developed as a discipline. At the mental hospital in Bangalore, by 1914 no further expansion of the hospital was possible, with its strength stabilising at about 200 patients. By the 1920s, the asylum was an important part of the medical establishment in India and there were more than 100 admissions every year. The Bangalore Lunatic Asylum changed its name to Mental Hospital after the First World War and moved to its current spacious location in late 1937 from its cramped quarters in the city.

The hospital benefited from the financial largesse and support of Krishnaraja Wadiyar IV, the monarch of Mysore, who ruled from 1902 until his death in 1940. Apart from Dr Frank Noronha, another prominent Indian psychiatrist was Dr M.V. Govindaswamy, who joined the hospital in 1932 and played a pivotal role in enhancing the hospital’s reputation.

Changing notions of madness

Anand was one of the patients to benefit from the much larger space and modern facilities that were offered on the new premises of the hospital. Under a heading called “significant mental findings” in his case record, the remarks read: “Stubborn and a general tendency to be always nasty in his remarks and keeping idle. Has an exaggerated sense of well being and of his own importance. Suspicious with a feeling that others are trying [to] ruin and rob him. Educated, good comprehensive acuity but makes mole of a mountain (sic)… There is gross disturbance in the higher faculties of sentiment, judgement and reasoning.”

This made him a perfect candidate for prefrontal leucotomy, a form of psychosurgery that was introduced in the hospital in 1942. Patients who had been ill for several years and who had not responded to other treatment were selected. The surgery, which involved cutting connections to the frontal lobe of the brain, was performed on Anand as well. His post-operative medical record stated: “Bilateral anterior prefrontal leucotomy done under chloroform anaesthetic. Patient was easily under and there was no stage of excitement.”

Those who have read Ken Kesey’s acclaimed novel, One Flew Over the Cuckoo’s Nest , on the psychiatric facilities in the United States during the 1950s (later made into an Academy Award-winning film starring Jack Nicholson) will remember leucotomy, also known as lobotomy. It is performed on the feisty Randle McMurphy after he challenges the authority of Nurse Ratched in a most spectacular way. The procedure reduces him to a vegetable-like state.

Dr B. Rao and Dr Govindaswamy of the mental hospital also published a note on “Prefontal Leucotomy” in the Indian Medical Gazette , 1944. They wrote: “On the psychological side, in many, if not all, there is a profound change, even from the day of the operation. Patients who were violent are subdued; the bellicose are more modest, they have lost their hallucinations, take a more intelligent interest in the surroundings and in conversation, the voices that used to talk to them are no longer heard and the patients appeared to be calm and placid. The improvement has been progressive and maintained.”

Insulin coma therapy, another procedure that is no longer used in psychiatric treatment, was also introduced in the hospital. In this, a patient is given high doses of insulin to induce seizures. Such details can be found while perusing the records available at the archive.

The archive is tremendously useful as it chronicles the changing notions of madness. It shows how the British, with their fetish for control, tried to rein in chaos in society by building asylums for the “insane”.

Dr Sanjeev Jain, who along with a team of dedicated researchers has been instrumental in making this archive a reality, said: “The practice of modern psychiatry, though introduced during the period of colonial rule, became immensely popular and its use was widespread. The provision of care, reliable interventions and participation in the progress of medical services by the local trained professionals helped evolve a psychiatric facility that was valued by the community it served, and helped establish academic psychiatry in India.”

Valuable data

While the archive is valuable for researchers on mental illness for studying treatment methods and the development of psychiatric care over a long period, its records will also be useful for social scientists as they contain brief social profiles of all cases. The colonial attitude and response to matters of gender, caste and religion can be discerned from the material. Questions on differential responses of treatment of Indian and British patients can be answered from the data, adding value to research on the broader theme of the relationship between the coloniser and the colonised. Data on occupations are also available, allowing for inferences to be made on questions of class. Case records, which record the voices of the patients, are also a useful resource for the subaltern historian as the “mad”, whichever class they belonged to, were denied their own voice and agency in history.

The archive is part of the NIMHANS History Museum, which is interesting in its own right for material chronicling the institute’s history. It is slated to be inaugurated soon and has a variety of material on display, including devices that were used to conduct psychiatric tests in the past, such as the “Stanford Binet Test”, the “Goldstein Schereer Wool Skeins Test” and the “Kohs Block Design Test”.

(Material for this article has been drawn from the archives of NIMHANS and from Mindscape and Landscape: An Illustrated History of NIMHANS, 1850-2014 , authored by P. Radhika, Pratima Murthy and Sanjeev Jain, all of whom work at the institute’s Department of Psychiatry.)