REVIEW ARTICLE Current topical and systemic approaches to treatment of rosacea HC Korting,* C Schöllmann Department of Dermatology and Allergology, Ludwig-Maximilians-Universität, Munich, Germany *Correspondence: HC Korting. E-mail: [email protected] Abstract Rosacea is a common, often overlooked, chronic facial dermatosis characterized by intermittent periods of exacerbation and remission. Clinical subtypes and grading of the disease have been defined in the literature. On the basis of a genetic predisposition, there are several intrinsic and extrinsic factors possibly correlating with the phenotypic expression of the disease. Although rosacea cannot be cured, there are several recommended treatment strategies appropriate to control the corresponding symptoms/signs. In addition to adequate skin care, these include topical and systemic medications particularly suitable for the papulopustular subtype of rosacea with moderate to severe intensity. The most commonly used and most established therapeutic regimens are topical metronidazole and topical azelaic acid as well as oral doxycycline. Conventionally, 100–200 mg per day have been used. Today also a controlled release formulation is available, delivering 40 mg per day using non-antibiotic, anti-inflammatory activities of the drug. Anti-inflammatory dose doxycycline in particular allows for a safe and effective short- and long-term therapy of rosacea. Topical metronidazole and topical azelaic acid also appear to be safe and effective for short-term use. There are indications that a combined therapy of anti-inflammatory dose doxycycline and topical metronidazole could possibly have synergy effects. Further interesting therapy options for the short- and long-term therapy of rosacea could be low-dose minocycline and isotretinoin; however, too little data are available with regard to the effectiveness, safety, optimal dosage and appropriate length of treatment for these medications to draw final conclusions. Received: 21 December 2007; Accepted 9 December 2008
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Making Sense of the ‘Chemical Revolution'. Patients' Voices on the Introduction of
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Patients' Voices on the Introduction of Neuroleptics BENOˆIT MAJERUS Institut d'Histoire, University of Luxembourg, L-4360 Esch-Alzette, Luxembourg The so-called chemical revolution has produced a vast historiographical corpus. Yet the patient's voice remains surprisinglyabsent from these stories. Based on the archives of the Institut dePsychiatrie (Brussels), this paper traces the introduction of Largactilas recounted in patient letters, physician records and nurse notes.
The paper thus contributes to the history of therapies from below,but also participates in the historiographical debate about whether theintroduction of neuroleptics can indeed be considered a revolution.
Chemical Revolution, Institut de Psychiatrie de Brugmann, Brussels, 1950s, Neuroleptics, Largactil The so-called ‘chemical revin psychiatry has given rise to much scholarship overthe past sixty The introduction of the first antipsychotic (chlorpromazine) in thefirst half of the 1950s and the first antidepressant (imipramine) in the late 1950s is saidto have profoundly changed practices and to have permanently integrated psychiatry intothe field of modern medicine. Physicians, sociologists, anthropologists and historians havesince engaged in a debate on the purported ‘revolutionary' nature of these chemical and on the consequences of their introduction, focusing, in particular, on the following fourquestions. Was de-institutionalisation, as observed in many western countries, the causeor the consequence of this therapeutic What was the role of pharmaceuticalcompanies in changing definitions of psychiatric How have neuroleptics * Email address for correspondence: 1 Roy Porter, Madness: A Brief History (Oxford: Oxford University Press, 2002), 205.
2 To cite just three exemplary works that correspond to three particular moments in the debate: Judith P.
Swazey, Chlorpromazine in Psychiatry (Cambridge, MA: MIT Press, 1974); David Healy, The Antidepressant Era (Cambridge, MA: Harvard University Press, 1997); Joanna Moncrieff, The Myth of the Chemical Cure: a Critique of Psychiatric Drug Treatment (Basingstoke and New York: Palgrave Macmillan, 2008).
3 Nicolas Henckes, ‘Magic Bullet in the Head? Psychiatric Revolutions and their Aftermath", in Jeremy Greene, Flurin Condrau and Elizabeth S. Watkins (eds), Therapeutic Revolutions: Pharmaceutical and Social Change in the Twentieth Century (Chicago: University of Chicago Press) forthcoming.
4 Gerald N. Grob, From Asylum to Community. Mental Health Policy in Modern America (Princeton: Princeton University Press, 1991).
5 David Healy, Let Them Eat Prozac: the Unhealthy Relationship between the Pharmaceutical Industry and Depression (New York: New York University Press, 2004).
Patients' Voices on the Introduction of Neuroleptics in the 1950s transformed understanding of mental And, finally, have scientific methods inpsychiatry (for example, double-blind randomised controlled trials, MRI and medical files)been modified based on the above dev 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 inOver the past fifteen years, an interest in this issue has developed alongside newquestions emerging from the fields of science and technology studies (STS) and the historyof medicine. Among the lines of research influenced by STS, we find drug thestandardisation of pills and and the formation of Denkgemeinschaften (LudwigFleck), which enable us to analyse the reception of scientific ideas. This probably explainswhy patients remain absent from narratives, both as key players involved in the discoveryof certain chemicals' neuroleptic effects and as objects of their use. Patients have neverbeen at the centre of STS, although they represented a classic topic for social history inthe 1970s and 1980s (a stance notably defended by Roy Porter in his seminal article, ‘ThePatient's View. Doing Medical History from BeloYet the social history of medicinehas shown little interest in the second half of the twentieth century, focusing largely onearly modern times and the nineteenth century Based on the patient of the Institut de Psychiatrie (Brussels), this paper retraces the use of medication in the 1950s, a time when neuroleptics and antidepressantsbecame an integral part of the therapeutic arsenal. It studies these developments throughtranscriptions left in patient letters, physician records and nurse The paper thuscontributes to the history of psychiatry from below but also participates in the following 6 Alan A. Baumeister, ‘The Chlorpromazine Enigma', Journal of the History of the Neurosciences, 22, 1 (2013), 7 Viola Balz, ‘Die Geburt der Stammkarte. Zur Genese eines Epistems der neuroleptischen Wirksamkeit in der fr¨uhen Psychopharmakaforschung in der BRD', Medizinhistorisches Journal, 43 (2008), 56–86.
8 On Belgium and the Netherlands: Toine Pieters and Benoˆıt Majerus, ‘The Introduction of Chlorpromazine in Belgium and the Netherlands (1951–68). Tango between Old and New Treatment Features', Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences, 42, 4 (2011), 443–52. On Switzerland: Katharina Brandenberger, Psychiatrie und Psychopharmaka Therapien und klinische Forschung mit Psychopharmaka in zwei psychiatrischen Kliniken der Schweiz, 1950–80 (Zurich, 2012). On France: S´everine Massat-Bourrat, ‘Des ph´enothiazines a la chlorpromazine: les destin´ees multiples d'un colorant sans couleur' (PhD thesis, University of Strasbourg, 2004). On Germany: Viola Balz, Zwischen Wirkung und Erfahrung. Eine Geschichte der Psychopharmaka Neuroleptika in der Bundesrepublik Deutschland, 1950–80 (Bielefeld: transcript, 2010). The only ‘Eastern' country to have been studied so far is the GDR: Volker Hess, ‘Psychochemicals crossing the wall. Die Einf¨uhrung der Psychopharmaka in der DDR aus der Perspektive der neueren Arzneimittelgeschichte', Medizinhistorisches Journal, 42, 1 (2007), 61–84.
9 J.P. Gaudilli ere, ‘Introduction: Drug Trajectories', Studies in History and Philosophy of Biological and Biomedical Sciences, 36, 4 (2005), 603.
10 Christian Bonah, Christophe Masutti, Anne Rasmussen and Jonathan Simon, (eds) Harmonizing Drugs.
Standards in 20th-Century Pharmaceutical History (Paris: Editions Glyphe, 2009).
11 Roy Porter, ‘The Patient's View. Doing Medical History from Below', Theory and Society, 14, 2 (1985), 12 Flurin Condrau, ‘The Patient's View Meets the Clinical Gaze', Social History of Medicine, 20, 3 (2007), 530.
13 At the Institut de Psychiatrie de Brugmann (Brussels), the entirety of nurses' notes taken three times a day on each patient have been kept in the patient records. On the history of this institute and the composition of the sample (every tenth patient record has been taken into account), see Benoˆıt Majerus, Parmi les fous. Une histoire de la psychiatrie au 20e si ecle (Rennes: PUR, 2013). To facilitate reading, I will henceforth simply use ‘the Institut' when referring to the Institut de Psychiatrie de Brugmann in Brussels, which was created in 1931 within a general hospital that had been in operation since 1923.
14 Until now this point has only been addressed by the historiographical school of the Charit´e (Berlin) that offers an interesting historiographical blend of classic social history of medicine and the STS approach. Viola Balz's book is the most successful example: Viola Balz, Zwischen Wirkung und Erfahrung, op. cit. (note 8).
Benoˆıt Majerus two important debates. How can the history of the patient's view enrich classical historicalaccounts? 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' letterscome close to a ‘direct' voice that has not been edited by nurses and psychiatrists. Thesematerials reveal that the early users of neuroleptics employed varied and complex tacticsto retain control over their experience. At the same time, these patients remained in aninstitutional order, a medical logic and a pharmaceutical–industrial commodity market,all of which affected their area of agency. Also, this piece highlights the importance ofintegrating previously neglected players into this historiographical narrative. Since Porter'sseminal article, historians have sought to paint a far richer picture, no longer describingpsychiatry in terms of the classic asylum–psychiatrists–patient trinity. Typically focusedon the nineteenth century, they argue that there was no single response to treatments andpractices, but rather a multiplicity of Analysis of the unedited patient records of theInstitut de Psychiatrie during the 1950s shows the importance of staff, outpatients, familymembers and therapeutic technologies in shaping these clinical encounters. It revealsthat the patient–physician relationships are more complex than usually portrayed whenit comes to post World War II contexts.
The Introduction of Drugs at the Institut de Psychiatrie Drugs were not new to asylums in the 1950s. While opium and morphine have long beenused in psychiatry, the second half of the nineteenth century witnessed the emergence ofa large number of other substances considered more effective and less dangerous, suchas chloral and bromides. After the success of these sedatives in the second half of thenineteenth century, the early 1890s saw the rise of barbiturates. These were consideredmore active and were seen as having fewer side effects than their althoughconcerns were regularly voiced about their addictive 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 theirstay, the most prominent being Luminal, a barbiturate distributed by Bayer. In 1935, thispercentage 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 themwere on some form of medication. Despite the significant variations due to its rather smallsize, this sample shows that, before the introduction of neuroleptics, more than half ofthe patients at the Institut consumed therapeutic drugs. Well before the 1950s, drugs thusrhythmically structured the daily lives of patients at this institution; and, indeed, the userswere well aware of the material nature of these medications. Their distribution – whetherin the form of pills or injections – took place two or three times a day and represented 15 For some characteristic examples, see, eg., Peter Barlett and David Wright (eds), Outside the Walls of the Asylum: The History of Care in the Community 1750–2000 (London: Athlone Press, 1999); Akihito Suzuki, Madness at Home: The Psychiatrist, the Patient, and the Family in England, 1820–60 (Berkeley: University of California Press, 2006); Hilary Marland, Dangerous Motherhood: Insanity and Childbirth in Victorian Britain (Houndmills: Palgrave Macmillan, 2004); and Sabine Braunschweig, Zwischen Aufsicht und Betreuung.
Berufsbildung und Arbeitsalltag der Psychiatriepflege am Beispiel der Basler Heil- und Pflegeanstalt Friedmatt, 1886–1960 (Z¨urich: Chronos, 2013).
16 Stephen Snelders, Charles Kaplan and Toine Pieters, ‘On Cannabis, Chloral Hydrate, and Career Cycles of Psychotrophic Drugs in Medicine', Bulletin of the History of Medicine, 80, 1 (2006), 95–114.
17 Henri Hoven, ‘A propos des intoxications par les hypnotiques. Deux cas d'intoxication par le sulfonal', Journal belge de Neurologie et de Psychiatrie, 31, 2 (1931), 67–9.
Patients' Voices on the Introduction of Neuroleptics in the 1950s a moment of negotiation between patients and caregivers. The doctor prescribed theframework 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 actualtaking 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 intoFrench psychiatry in 1952 under its generic name chlorpromazine; it was sold under thename Largactil. But only in 1954 did the psychiatric field begin to consider the drug asa breakthrough, and its use in most western-European countries began to transcend theexperimental framework. That same year, Largactil was administered to the first patients atthe Institut. At this point, it had been marketed for about a year in Belgian medical journalsby Specia, the pharmaceutical branch of Rhˆone-Poulenc and the Belgian distributor ofLargactil. The first accounts of its use appeared in Belgian scientific journals publishedin 1954. At first, Largactil was not sold exclusively as a psychiatric drug, but also asa treatment for surgery and obstetrics. The emphasis was placed more on ‘symptomatictreatment' than on any ‘pathogenic specificity', that is, on the drug's effect on symptomsrather than actual Over the years, Largactil was more specifically defined as apsychiatric drug, although the indications for use still remained very broad: ‘psychomotoragitation, confusion, anxiety, depression, obsessions, cenestopathy, intractable insomnia,sleep therapy, neuralgia, various pains, In the second half of 1954,Largactil was classified as category A by the Belgian National Health and DisabilityInsurance Fund (Fonds National d'Assurance Maladie-Invalidit´e). This classificationoffered patients in Belgium a refund of 70 per cent of the drug's providing animportant argument for its use given the high cost. It should be mentioned that theintroduction of neuroleptics happened in a context of collective enthusiasm for medicaldrugs. Since the triumphant march of penicillin in the mid-1940s, the medical communityseemed to find a new miracle cure every year: for example, the first anti-TB medicine (late1940) and extended spectrum antibiotics. As a symbol of ‘postmodern thedoctor no longer merely affixed a diagnosis, but also healed organic diseases. Neurolepticsallowed 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 wayinto asylums at a local level. At the Institut, Largactil was used very broadly to treatschizophrenia as well as anxiety and delirium tremens. Within ten years, treatment patternswent through some major changes, as indicated in the table below.
18 Christian Bonah and S´everine Massat-Bourrat, ‘Les "agents th´erapeutiques"', in Christian Bonah and Anne Rasmussen (eds), Paradoxes et ambigu¨ıt´es d'une histoire des rem edes aux XIXe et XXe si ecles Histoire et m´edicament aux XIXe et XXe si ecles, (Paris: Glyphe, 2005), 51.
19 Advertisement published, inter alia, in several 1954 issues of the Acta Neurologica et Psychiatrica Belgica.
This process of first defining a drug broadly and then using it more specifically had an exact parallel in the medical field. Although chlorpromazine was first discussed in obstetrics journals as well as in journals of internal medicine or psychiatry, the scientific community gradually established it as a drug intended only for psychiatric patients. This process of specialisation and standardisation took place in an international market and within a transnational scientific community, but it also had particular national characteristics linked to the mechanisms of the different welfare states.
20 Fonds National d'Assurance Maladie-Invalidit´e, Rapport g´en´eral sur l'Ann´ee Sociale 1955. 2e Partie. Rapport du service m´edical (Brussels: Minist ere du Travail et de la Pr´evoyance Sociale, 1955), 71.
21 Edward Shorter, Doctors and Their Patients: A Social History (New Brunswick: Transaction Publishers, 1991), Benoˆıt Majerus 1950–54 (n = 46) 1955–59 (n = 87) 1960–64 (n = 318) 1965–69 (n = 284) 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 nextdecade. At the same time, the growing and widening diffusion of psychotropic medicationallows for two conclusions. First, never in the history of psychiatry had any treatmentexperienced such a widespread use; in the late 1960s, nearly nine out of ten patientsreceived psychotropic drugs. Second, their use led to the virtual disappearance of all otherbiological therapies such as cardiazol and insulin shock therapy. Only ECT retained anegligible share in treatments. These developments had an impact on patient experience aswell as on the dynamics among members of the Institut.
Medical Notes, Records and Patient Narratives The detailed nursing notes, taken three times a day, as well as the letters kept in patientrecords, can be used to gain insight into how patients perceived the change in medicationpractice during the 1950s. This topic appears in many files. In two thirds of them, a nurseor psychiatrist has noted down the patient's reaction to the medication. Patient responseis extremely heterogeneous and a far cry from clich´ed images (depictions of ‘inmates'being force-fed drugs by doctors on the pay list of pharmaceutical companies or, in starkopposition, 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 thephysicians. The administration of medication – usually at 8am, 2pm and 8pm – was a dailyritual. Since the patients were left to themselves most of the time, this was also one of thefew moments when they interacted with the staff. Indeed, administering drugs not onlystructured the day as an obligatory meeting with the caregivers, but it also represented amoment when an opposition to hospitalisation could be expressed – especially at a timewhen 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 A 65-year-old retired officer of theBelgian army, he was not given a very precise diagnosis and the reasons for his admittancecannot be found in his medical records. At no point did the staff take any detailed noteson his consuming any drugs. The word ‘medicine' appears in one single instance within amore general comment:The patient refused all food and medicine. [?] Active – bites his fingers – refuses to urinate in toilets. [?] on the hands – claims he has a headache ever since he got here. After the injection at noon, rests on the bed, in a theatrical position, feigns total 22 All patient names have been anonymised. I am grateful to my family and friends who have lent theirs to ‘my' 23 Hˆopital Brugmann, Institut de Psychiatrie (HBIP), Ancienne s´erie (AS), no. 10 455, nursing notes (17 July Patients' Voices on the Introduction of Neuroleptics in the 1950s 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 takingone's medication was a way to show a general opposition to one's stay in the hospital, inthe 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 whetheradministering drugs helped psychiatrists convince patients of their illness. At the sametime, receiving medication offered patients some hope for their approaching remission.
Nevertheless, it was generally a powerful indicator that there was a problem. Refusingdrugs was thus a way to tell the physician that one did not (any longer) consider oneselfsick.
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 wasinterned at the Institut for the first time. Diagnosed as ‘paranoid', he received his first doseof Largactil after two weeks. Over the following two weeks his daily dose was quadrupledfrom three administrations of 50mg to three administrations of 200mg. Although JosephR. had no access to his file, he realised that the dose was increasing. It thus becameprogressively more difficult to convince him to take his pills: ‘wants to leave but wondershow on earth he can, considering his medication was increased.' A few days later:‘Unhappy – wants to go home if his medication is not reduced.For this patient whowas convinced that he was not ill, the administration of drugs reminded him daily that hewould not soon be leaving the Institut. The dosage increase was interpreted as a sign of hisdeteriorating 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 sideeffects, affecting both patients (who developed tremors similar to Parkinson's disease) andnurses (who developed skin rashes). The medical records regularly mention secondarysymptoms commonly attributed to psychotropic drugs from the 1950s and 1960s. Theseinclude stomach aches, headaches and sleep problems. Since physicians were not inregular contact with the drugs, at first they paid little attention to these side effects. Beforethe Thalidomide scandal, which broke out in West Germany and Austria in the early 1960sand then spread throughout Europe, this issue was hardly debated in the public space, andits ethical implications were not discussed among medical 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 neurolepticthat had been produced in Belgium since 1958, Dirk M. caused the head physician toreduce the prescribed dose used by the attending psychiatrist. This earned the physicianletters of thanks:Dear Madam, thank you for your lovely visit and for your fortunate intervention as well as for the Cogentin, crucial in stopping internal and external tremors – the side effects of R1625 [which produced in me a purely 24 HBIP, AS, no. 12 225, nursing notes (29 March and 8 April 1958).
25 Following this scandal, a law on medical drugs was voted in Belgium in March 1964.
26 HBIP, AS, no. 7971, letter to ‘Madame Cosijns, M´edecin chef de l'institut de Psychiatrie' (3 February 1962), for the parts in between brackets: letter to Duret-Cosijns (6 January 1962). Cited in Val´erie Leclercq, ‘Le stylo- bille et l'entonnoir. Ecrits et ecriture des patients de l'Institut de psychiatrie Brugmann (1931–80)' (MA thesis, Universit´e Libre de Bruxelles, 2009), 94–5.
Benoˆıt Majerus 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:There is just one thing that is unpleasant about my health; I sleep very well, but every morning I wake up with a crazy headache. And there is no way to get rid of it even though I dine at 6pm and I go to bed at 10 or 11pm the latest. Lately Dr Dewale prescribed me quatane but with these tablets I only managed to wake up completely at 10 o'clock. While I was working, I always became tired with these drugs and the headaches did not go away It is perhaps not surprising, therefore, that patients should make up various strategies to escape what some of them saw as [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 acup so as to throw them out at the slightest 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 familyfrom 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 thepsychiatrist and opposed his forced hospitalisation by writing letters to family membersand friends who held influential positions in Brussels' society. In a call to a relative (whoalso happened to be a physician), he wrote:I apologise [for this unstructured letter] - they gave me, I should say fed me, "Largasil" [Largactil], a revolting pill that makes it difficult to follow up on two ideas. Since you're a doctor, I hope you can intervene and demand explanations from the doctors of the 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 theiruse, their dosage, their frequency, the point of the treatment, and so on. ‘Often enoughrequests explanations about medications treatment, etc.; would prefer not having to takemedication and leave from here.
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 worldnot only paradigmatically as patients, but also as customers. The nurses he had to facethroughout 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 to escape treatment. But these tactics of resistance, in turn, encouraged the nursesto develop tactics of their own: a form of knowledge that was obviously not included intheir textbooks. To be sure, the records show that patient complaints were often ignored 27 HBIP, AS, no. 10 547, letter by Karine O. to a friend (13 September 1954).
28 HBIP, AS, no. 10 624, nursing notes (9 February 1954).
29 HBIP, NS, no. 6460, nursing notes (19 February 1966). Cited in Julie De Ganck, ‘Les antid´epresseurs a l'hˆopital Brugmann' (Seminar paper, Universit´e Libre de Bruxelles, 2008), 28.
30 HBIP, AS, no. 13 515, letter by Christian D. to a friend (23 July 1958).
31 HBIP, AS, no. 13 515, nursing notes (28 July 1958).
32 Michel de Certeau, L'invention du quotidien. 1. Arts de faire (Paris: Gallimard, 1990), 89.
Patients' Voices on the Introduction of Neuroleptics in the 1950s by the medical staff. Nursing notes such as the one below (about An S., who was admittedto the psychiatric ward after an ‘acute psychotic are common:[Patient] has just complained to the nurse because must take Agarol [Largactil] at night, said it makes her ill, afterwards came complaining that she passes no stool and that it has been lasting all day. Just bored everyone with her supposed 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 sWhen patientsacted in a non-compliant manner, the nurses showed flexibility. The case of Gilles S. istypical in this respect. Convinced of suffering from Joubert syndrome, he was admitted tothe Institut for the first time in November 1954 at the age of forty-three. After a week, hebegan to be opposed to taking drugs: ‘very suspicious, constantly asking why he has totake medication, at first does not want to take them, took them finally, does not sleep yet,calm.These notes are found in several reports. Sometimes nurses were even willing toaccept that patients reject their drugs if they remained calm, as shown in the exampleof Nordin F., diagnosed as ‘senile demented': ‘Evening refuses his medication [25mgof Largactil] – falls asleep nonetheless.' But these instances remain exceptional, evenfor Nordin F. Indeed, the following day he refused his neuroleptic once again: ‘Did notwant to take his larg [Largactil] + phen [Phenergan]. Received 1 amp[oule]. Larg[actil] at21 o'clock.
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 easierto administer than ampoules? The records say close to nothing on the strategies andpersuasive techniques of nursing and medical staff. They do, however, suggest that,sometimes, the administration of neuroleptics in 1950s psychiatric clinics was due toadministrative or practical reasons. In a later file, dating from 1960, a letter from a patientto the League of Human Rights makes explicit the possible strategies for constraint usedby medical officers. These included the (more painful) threat of administering the drugintravenously in case a patient refused to swallow the pill:they wanted me to take a drug called Haloperidol (1625), which they had wanted me to take before and to which I am opposed . . if you do not take your drug or drugs they make you take them as an injection . . however, in recent days, they make me take Largactif [Largactil] in large doses. Upon my refusal to take the drug again comes the threat of 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 asign of care. Karine O. (discussed above) was admitted to the Institut for the fourth timein September 1954. Until then, the only treatment she had received was electroconvulsive 33 HBIP, AS, no. 13 500, medical report (9 May 1957).
34 HBIP, AS, no. 13 500, nursing notes (19 April 1957).
35 Even if there was no written convention stating that coercion measures needed to be noted in patient files, it seems that such an unwritten rule did exist at the Institut. Thus the use of straightjackets and force-feeding were noted systematically. It is very likely that the forced administration of drugs was also noted down.
36 HBIP, AS, no. 11 055, nursing notes (22 November 1954).
37 HBIP, AS, no. 12 855, nursing notes (6 and 7 December 1958).
38 HPIB, NS, no. 7980, letter to ‘Monsieur le Pr´esident de la Ligue des droits de l'homme' (24 June 1966); cited in Leclercq, op. cit. (note 26), 90.
Benoˆıt Majerus therapy; but this time, the psychiatrist decided to have her try a new drug that had just beenreleased: chlorpromazine. Karine O. welcomed the cure with great enthusiasm. A letter toa friend shows her delight:Since Saturday, as I've said, I have a new treatment with Lacartine [Largactil] 6 per day and from tomorrow Wednesday I get an additional injection in the morning to calm me because I can only sleep from 9pm until 2 or 3am; thus I stay awake in my bed, it's long (. . ) I'll tell you about the treatment that they give me. The morning some Beladomme at about 9am 1 cup protecum + 2 promenal + 2 lacartine [Largactil] +3am: 2 promenal, 2 lacartine [Largactil], 1 cup protenum 6am: 2 promenal, 2 lacartine [Largactil] 8pm: 1 f´energant [Phenergan] 9am 1 injection + 1 in the morning So you see that I am cared for and that I am treated very well. That way I'll leave the hospital completely In this case, receiving drugs was taken as a sign that the disease was being dealt For Karine O. it acted as a synonym for ‘good treatment' and it was closely linked to thehope of healing. The introduction of new medication therapies and their widespread usein psychiatric hospitals, therefore, not only led to new hopes within the medical field, butalso 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 patientsof the Institut did regularly take medication at home. Thus Anne-Marie C. expressed fromthe first day her desire to receive drugs:Sick, came in at noon, clean. Would like a room, does not like to talk to other patients. Says she is too tired.
Requests a pill because of great stomach pain – cannot be healed. . Insists on taking something to sleep, received one pill of [vitamin] B complex at 8pm. Not asleep yet, but calms down at 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 considera psychiatric ‘user'. One can even wonder if these attitudes have not become morewidespread since the 1980s, when patients came to be represented not simply as objectswithout 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:Pat[ient] well oriented in time and space, extremely agitated and anxious, constantly gets up from his bed, despite all the injunctions, asks plaintively for sedatives, or inquires about his release date . . The examination is constantly interrupted by anxious questions, always the same: "You're surely not restraining me with the belt, I was wrapped like rotten fish . . give me a tranquilliser and let me out tell doctors" . . Several times to consultations at the hospital of Etterbeek where one would have given him 1 bottle and 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 witnessedrestraint. But he also gained practice with taking (psychiatric) medicine. As soon as he wasadmitted, he required a sedative; and to give more weight to his demand, he mentioned his 39 HBIP, AS, no. 10 547, letter by Karine O. to a friend (30 November 1954).
40 The cooperative taking of medication can be a sign to the psychiatrist that a patient accepts a treatment, and thus that he or she is on the road to remission.
41 HBIP, AS, no. 1575, nursing notes (22 March 1954).
42 HBIP, AS, no. 11 055, doctor's report (16 November 1954).
Patients' Voices on the Introduction of Neuroleptics in the 1950s 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 knewthat his agitation could be stopped with medication. The administration of the drug wasthus 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 anact that paradoxically served to weaken the medical grip; this was a therapy that could beadministered 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 vividillustration of this phenomenon. His first encounter with psychiatry happened through theconsultation service. A few days after his first appointment in December 1953, he wasadmitted to the Institut in January 1954 with a diagnosis of depression. Since he wasparticularly 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 destroyedthe sheet in which he was wrapped. The attending psychiatrist then prescribed bromideand chloral, two other sedatives, but Francis C. remained very disturbed until his releaseon 8 February 1954. The two drugs were administered to calm him down and he receivedfive electroshocks. During that first stay, his record remains silent as to how he perceivedthe medication. During a conversation with his wife, however, it emerged that he hadtaken Largactil even before coming to The case of Francis C. therefore notonly poses the question of how many patients had been on medication before enteringthe Institut, but also whether (and how widely) Largactil was distributed outside asylumsbefore being used in those institutions. In fact, the records lack enough detail to provide aprecise answer, but they do reveal practices that have hardly been addressed by historiansuntil 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, dangerousto himself.' The man now seemed used to taking medication. Upon admission, he asked foran injection to help him sleep, a request that was denied by the nurse on duty. The followingnight, he received two tablespoons of Largactil. In late August, after thirteen days, he leftthe 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 hereceived neuroleptics on a regular basis and after ten days he started to complain. Thenurses noted that he ‘spends much time resting on his The next day the psychiatristwrote: ‘remembers having had ECT in ‘54 and "it was better than the pills".' The sameday, the nurse recorded in the morning: ‘Seems a little depressed today, never agrees withwhat he is given as a medicine – thinks it's too much, also complains of headache.' And atnight: ‘Around 6pm received 1 Cibalgine – did not want to take (suspicious), said he willbe dead tomorrow. Very depressed – cries – falls asleep afterwards.' The next day:Same behaviour – Rests a lot. The patient is sad and a little anxious. Wonders if he still needs to take his medication for long. Said the doctor had promised him another 43 HBIP, AS, no. 10 382, conversation with the wife of Francis C. (28 December 1953).
44 HBIP, AS, no. 10 382, nursing notes (26 July 1958).
45 HBIP, AS, no.10 382, nursing notes (27 and 28 July 1958).
Benoˆıt Majerus 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:Very anxious after E. Schock. Remains a little confused in the afternoon. Constantly asks for his injection in evening. Says he cannot sleep without something. Not yet sleeping at about 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 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.
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 caregiv This article has aimed to follow the proposition made in 2007 by Flurin Condrau in hisrather pessimistic assessment of the historiography of patients. If historians want to havea voice, he noted, they must ‘engage with debates that have raged elsewhere and to claimintellectual, empirical and theoretical importance in the field.The few pages of thiscontribution raise questions linked to four broader debates: the bias due to observingthe sufferer solely through the institutional archive, the multiplicity of players in thehospital setting, the critical and often ‘anti-psychiatric' genealogy of scholars interested inpsychiatric history and the question of whether a historical investigation ‘can only revealwhat is heard, not what is 46 HBIP, AS, no. 10 382, nursing notes (9 January 1954).
47 De Ganck, op. cit. (note 36), 28.
48 HBIP, NS, no. 9720, letter to ‘Ma tr es ch ere petite Mamy' (11 February 1968), cited in Leclercq, op. cit.
(note 26), 100.
49 Thus Lilly C., a seamstress diagnosed with ‘paranoid schizophrenia' who was moved from a general ward to psychiatry, requested drugs very often when she started to feel agitated. ‘The patient is really impertinent. Caused tears and tantrums . . Recognises that she is much agitated and asked for her injection, which she received at 9pm.' (HBIP, AS, no. 10 505, nursing notes, 11 October 1954).
50 Condrau, op. cit. (note 12), 435.
51 David Armstrong, ‘The Patient's View', Social Science & Medicine, 18, 9 (1984), 737.
Patients' Voices on the Introduction of Neuroleptics in the 1950s I would like to return to Roy Porter's seminal article, ‘The Patient's View. Doing Medical History from Below'. In this piece the author did not really lay his cards onthe table. Indeed, his was far from a plea to consider the patient only within the hospital.
Porter aimed further, by also addressing aspects beyond the patient – that is, the suffereroutside the hospital. Herein lie also the limits of this article. The wealth of informationin the Institut's archives allows one to appreciate patient narratives, not only because ofthe medical reports, nursing notes, and so on that were recorded, but also because of theInstitut's tendency to archive documents produced directly by patients. These files containthe direct voices of these key players through therapy-related material (for example,drawings and results of writing workshops), but there are also traces that were illegallypreserved such as letters that the hospital management decided never to send. Yet ourknowledge remains extremely limited on the use of antipsychotics and antidepressants innon-hospital settings, since these practices do not necessarily give rise to archival material.
As such, the patient records provide a few small glimpses into what appears to be a highconsumption of these new drugs outside the institution.
On a purely empirical level, the integration of the patient's voice into a history of psychiatric medication expands the characters that ought to appear in this narrative. Thatthese now include patients seems obvious, as evidenced by the theme of this special issuededicated to Porter's seminal article. But the same applies to caregivers, whose central rolein patients' accounts should now be clear. In the past three decades, historians of psychiatryhave sought to integrate the patient into the classic narrative but still often present itas a dance for twIt is time to recognise the multiplicity of roles within psychiatricinstitutions and to include, in particular, the heterogeneous figure of the ‘nurse' (forexample, guardians, servants, caregivers and nurses). After World War II, when these newdrugs spread through the asylum, there was a proliferation of new professions in psychiatry(for example, social workers, psychologists and occupational therapists) who changed thepatients' experiences of their stay in psychiatric institutions. If, for the nineteenth century,Roy Porter could still claim that ‘it takes two for a medical this is definitelynot the case for the twentieth century – especially since this period witnessed the move ofmedical encounters and healthcare from patients' private houses to hospitals.
The change in scale that often goes along with an interest in patients' attempts to ‘make sense' also takes this story to the ‘ground levThis change of perspective moves awayfrom a medical history that is embedded (as is so often the case) in a sterile and moralisingopposition between, on the one hand, a narrative that focuses on the remarkable progressof medicine, and, on the other hand, one that only sees a history of ‘rulers and ruled'. Thisparticular historiographical understanding of the past is particularly strong in psychiatryThe humanities remain strongly marked by this anti-psychiatric genealogy, even more thansixty years after the publication of the two great classical critical studies: Erving Goffman'sAsylums and Michel Foucault's Madness and Civilisation. Integrating the patient as a keyplayer and not just as an object of the medical gaze renders narratives less linear and morecomplex. The psychiatric ward of the 1950s was certainly marked by an asymmetry of 52 For exceptions, see note 15 (above).
53 Porter, op. cit. (note 11), 175.
54 Jacques Revel, ‘L'histoire au ras du sol', in Giovanni Levi (ed.), Le pouvoir au village. Histoire d'un exorciste dans le Pi´emont du XVIIe si ecle (Paris: Gallimard, 1989), i-xxxiii.
55 See, eg., the contrary analyses of Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York: John Wiley & Sons, 1997) and Healy, op. cit. (note 5).
Benoˆıt Majerus structuring power. By choosing to focus on daily life, however, we perceive the marginsof interpretation and manoeuvring for all those involved: patients, nurses, doctors andfamilies.
This article also questions a particularly strong current among sociologists who emphasise two phenomena: first, that the patient supposedly exists only through medicine,or, in the words of Michel Foucault, through the ‘medical gaze.' From this perspective,the patient's experience is only transmitted by ‘a technique demanded by Second, they argue that, over the last hundred years, the voice of the patient has largelydisappeared from the medical field, whose representatives no longer rely exclusively on thepatient to establish a diagnosis but use other techniques to ‘hear' the disease without thepurported patient bias. However, this story – at least in psychiatry – is more complicated.
Psychiatrists still depend largely on the patient's word to determine the efficacy ofpsychiatric therapies, particularly with regard to psychoactive drugs, because their effectcannot be fully measured by bodily reactions. Despite the development of tools supposedto decipher mental illness – first electroencephalograms (EEG), then computerised axialtomography (CAT) and magnetic resonance imaging (MRI) scans – this voice from belowremains essential for gaining insight into various forms of disease experience and itsmanagement and representation.
56 Armstrong, op. cit. (note 51), 739.
Noste 2010 Montagne come sentieri di benessere e di salute Che per noi la montagna rappresenti un richiamo irrinunciabile è evidente, ma che la nostra passione possa contagiare chi sembra esserne immune è l'obiettivo che ci ha condotti a