INTRODUCTION:

In the whole range of social history there is no sadder chapter than of the treatment of the insane. To write about “psychiatric nursing” before 1800, would be almost a contradiction in terms, since up to the nineteenth century, with a few notable exceptions, sufferers from mental illness received no “nursing” beyond harshness and restraint. The explanation of this fact is that the nature and causes of their malady were totally misunderstood. Mental derangement was regarded as a judgment of heaven or as possession by the devil- in no sense an illness, but a manifestation of inherited guilt or of a moral taint; sometimes indeed the insane were supposed to be witches.¹

Early AD condition of lunatics:

On the whole these unfortunates were treated in classical times with far more humane intelligence that many centuries later. The Greek physicians recognized various forms of insanity. They recommended individualized management for each insane condition and gave special importance to Diet in each treatment. Hippocrates said that the milder type of lunatics to be given exercise, vapor baths, and emetics.Rufus (c. 100 A.D.) also recommended the same and emphasized the importance of good food, mild bleeding, and purgatives, and the necessity of distracting the invalid’s thoughts. Oribasius (4^th century A.D.) advises the treatment regime to be initiated from the onset of illness. In the Latin Celsus (c.30 A.D.) mentions of coercion stating that those suffering from mental disease to be treated by gentle massage, careful diet, bleeding and purging and use of narcotics for sleep induction., It further mentions use of music, reading stories and games to keep the real melancholic amused and calm. Praising the patient in front of them was also found useful in treatment however they also emphasized the use of restrains for violent person.²

As per Roman law agreement the inanes were to kept either with relatives or in prisons for violent behaviour. Under this system the mentally deranged if their disease was of a mild and harmless type lived unmolested and many communities even in the Middle Ages labelled them with village idiots and stayed in family premises only.³ But the situation worsened for those with acuter forms of mania⁴, were labelled as the unhappy madman of medieval and were subjected to so called curative measures to “drive out the evil spirit such as flagellations, exorcism, duckings in cold water.⁵

Role of churches and possession image of lunatics:

Shrines or churches played crucial role in this evil spirit removal treatment of insane in earlier times. Breughel has mentioned about the church of St. Willibald near Luxemburg where annual pilgrimage of epileptics and use of well and pool was witnessed as retreat or treatment option for insane up to 1793.⁶ Such magical treatment by saints were believed to be effective and popular as many art works represented saints in the act of “driving out a devil”- seen as emerging from the patient’s mouth. But the bitter reality was that when none of the magical things work the insane were either imprisoned or left alone to roam like a wild beast. King Lear (Act IV) has mentioned leaving insane on streets and 1807 Sir G.O. Peele had written to the Home Secretary regarding condition on insane in England as “unfortunate creatures” who are “left to ramble half naked or starved through the streets or highways, teased by the scoff and jest of all that is vulgar, ignorant and unfeeling.⁷

Apart from possessions ideas, very strange ideas were prevalent regarding their confinement and treatment. Confinement chaining areas in bitter cold of England were usually cold outhouses or cellars as they believed insane were insensible to temperature variations. Medical treatment if given was confined to bleeding and to violent purgatives or emetics supposed to dispel the “black bile.” In 1783 Dr. T. MOnro (of Bethlehem Hospital) had mentioned mentally ill patients were ordered to be bled in latter part of May and then subjected to purging. He further mentioned this treatment legacy was being transferred to physicians from earlier generations and still being continued. ⁸

Early hospitals and nursing for care of lunatics:

Mentally diseased were hardly admitted in hospitals and even segregation of them from general patients was the last striking thought. The lunatics were kept indiscriminately in hospitals (those who admitted them) or in jails and later in almshouses or workhouses. Only a few to be named hospitals existed exclusively for the insane.⁹

One to be mentioned in Europe was St. Mary of Bethlehem was founded in 1247, admission of lunatics started from 1377. The treatment followed was same use of chain bolts and bars. The hospital reported an inventory ^of 1398, “4 pairs of manacles, 11 chains of iron, 6 locks and keys, 2 pairs of stocks”, which was most probably used for inhuman features of the incarceration of madmen.The lunatic’s tower was built in Vienna in 1784. St. Luke’s Hospital in London came with the change of not putting lunatic’ s in general public view.Visitors were only admitted by ticket and saw the inmate in the presence of an attendant by 1700 in Bethlehem. ¹⁰

In America the earliest hospital for the insane only was the Eastern Lunatic Asylum at Williamburg, Virginia, founded 1773; this was followed by the Bloomingdale Asylum, New York, in 1809, the Pennsylvania hospital, founded at Philadelphia in 1751 and the Society of Friends (Quakers) erected near there an asylum at Frankford in 1871.¹¹

There was hardly any designated person made responsible as attendants for looking after insane and the use of nurses for the above was seldom,Edward Tyson, physician 168-1708, appointed ¹²the first nurse to look after any among the patients who might be suffering from physical disease. But theses nurses were doubtless rough and ignorant like those in the orthodox general hospital. An order of 1646 states that “That no officer or servant shall give any blows or ill language to any of the mad folks on pain of dismissal.” To prevent rough handling of insane. Difficulty in getting suitable asylum attendants or attendants and use of prisoners for working in asylums has been reported by Dr. Jacobi, 1841, in Germany. In 1810 it was suggested to have by Dr. Benjamin Rush of Philadelphia to have a man and women for taking care of the lunatics although he did not mention about training system hence it could not be implemented¹³.

The era of reforms for lunatics:

The reform movements started simultaneously in England and in France at the end of the eighteenth century. In France Philippe Pinel (1745-1826), director of the famous Bicetre Hospital in Paris requested permission from the Commune to take the chains off the patients. This moment marks the beginning of the scientific application of humane treatment to the insane. He carried out similar reforms in 1795 mental hospital in Paris, the Salpetriere, by changing all the women at-tendants²³ and similar reforms were followed by other physicians.¹⁴

In England after the death of a woman friend, under suspicious circumstances in the York Asylum (opened 1772), William Tuke (1732-1822), whose was a merchant and member of the society of Friends at York, suggested the founding of a small private establishment for the reception of Friends with mental illnesses. It started with a small house setting and under the idea of retreat for patients with mental illness. Harshness and confinement were substituted with sympathy and gentleness, no use of restrains and women caretakers for taking care of female patients found results beyond exceptions. Based on Tukes Evidence before a committee of Enquiry on lunatic asylums at the House of Commons, in 1828 a bill was passed regulating the treatment of the insane and establishing fifteen commissioners in Lunacywith extensive powers. And followed by the Act of 1845, the Lunacy Act “Magna Charta of the Insane.” was passed, making more stringent the provisions of the Act of 1828 barristers; its wise provisions gained for it the title of the¹⁵ “Magna Charta of the Insane.”

No restrain system was the next significant change in many asylums. In 1820 Dr. Charlesworth greatly diminished the use of coercion there untill all restraint was finally given up. similar changes were seen in Middlesex asylum in 1839 ¹⁶.

In America the, Dorothea Lynde Dix in 1841 advocated for reforms for lunatics against in human social status for them.she conducted an enquiry into living conditions of insane in jails and workhouses through out massachuttes and she found out that they were “confined in cages, closets, cellars, stalls, pens, chained, naked, beaten with rods and lashed into obedience.” She visited 18 State penitentiaries, 300 county Jails and houses of correction, besides hospitals and houses of refuge. Her efforts proved fruitful with establishment of six hospitals for the insane, several county poor-houses and several jails on a reformed plan however she could not highlight how the insane could be nursed in special manner. Other mental asylums she bought changes through advocacy included Scotland, france and Italy and could influence the higher position men like Pope Pius and creation of royal commissions for various enquiries for insane living conditions in Europe.¹⁷

Nurse in disguise of female attendant for care of mentally ill:

The training of attendants was another reform which gained mention among prominent stakeholders of insane care after 1854. Conolly in his valuable book On the Construction and Management of Lunatic Asylums (1847) suggests regarding training the male and female "attendants" in their duties. The pioneer training was arranged in 1854 by Dr. W. A. F. Browne at the Crichton Institution at Dumfries, Scotland, but his example was not widely followed for many years. It was advocated to hold a systematic professional training for attendants in our large asylums along with good pay and pension,¹⁸In 1854, Mrs. Jameson drew attention, in her "Sisters of Charity," to the need of good feminine influence for insane men as well as insane women. "As to the use of trained women in lunatic asylums, “Lunacy Commissioners in England recommended dismissal of large numbers of the old attendants and nurses. However nothing was done towards instituting a system of training. The Commissioners in their 11th Report, 1855, recommended the appointment of head attendants of a superior class, to be responsible for the conduct of the other attendants. An experiment was also tried of placing educated ladies in some of the asylums as "companions to female patients of the upper classes" ¹⁹.

Training planning for psychiatric specialized nursing:

In the United States also until early 1870, at Michigan Asylum for the Insane no systematic or thoroughgoing instruction in nursing was thought of. The first organized course of lectures and training in mental nursing was given at the McLean Hospital, Boston, in 1882, and in Germany the Institute at Arnsdorf in Saxony started training attendants in 1884. In 1885, D. H. Tuke had mentioned that "skilled nurses" had been introduced into an asylum at Norristown near Philadelphia. Yet for many years to come trained personnel was far from universal. Indeed as late as 1897 at a meeting of the German Society of Psychiatry, three well known German alienists demanded a systematic training for attendants with an examination and a certificate. The (British) Royal Medico Psychological Association, founded 1841, did not examine for its certificate till 1891, and the Netherlands Society for Psychiatry and Neurology first gave theirs in 1903²⁰.

The treatment in bed with no restrains, like a general patients, in case of lunatics when started to be followed, made skilled care all the more necessary and has been mentioned in earlier historic books. In the ‘eighties the "family" treatment was experimented and nurses were more involved. It was practised at Gheel in Belgium, where mental patients were boarded out with "foster-parents" often for many months under the supervision of a qualified (male) mental nurse who inspects periodically. This system of treatment was also introduced in Finland in 1887; in Sweden there were boarding colonies connected with four mental hospitals. Still countries like China, Greece, and Bulgaria had attendants in mental hospitals mostly untrained contradictory to what America and Europe was practising¹⁴. There were two systems for giving training in psychiatric nursing in earlier times. The first was where the nurse (man or woman) was trained in a mental hospital in psychiatric nursing alone, and receives little or no training in general nursing; the second where some mental training is included in the basic curriculum of general nursing or was taken as a postgraduate course²¹.

Under the first system nurses receive in a mental hospital a training of one, two, or three years which ends in a qualifying examination. In Great Britain, Holland, New Zealand, Switzerland, etc., the course was three years, in Finland two years, in Germany usually two years, and in Denmark and Sweden two years for the subsidiary group who work under the fully trained (i.e., general plus mental trained) nurses. In Hanover the ordinary attendants have an examination after one year, and the supervisors at the end of two years. This mental training equiped the personnel for service in mental hospitals only; their educational and social level was often not high and they do not automatically rise to the executive posts. These, in countries where nursing in mental hospitals is of an advanced type, was usually filled by persons whose training has been both general and psychiatric ²².

In Germany there existed state examinations for mental health nurses in Baden, Hamburg and Lübeck (since February, 1930), a state diploma was also given in Saxon mental hospitals after one and a half year's training with validity only in Saxony. The English Registration Act provides for a supplementary register of mental nurses; both men and women take, after eighteen months' training, the same preliminary examination as general nurses and, at the end of three years, a special examination supervised by the General Nursing Council. The Royal Medico-Psychological Association, however, holds examinations of its own. In Switzerland the three year training culminates with an examination held since 1927 under the Swiss Association for Psychiatry. Some states like Bavaria and Hesse allowed mental nurses without further training to take the state examination in general nursing. In Sweden, Finland and Norway four or six months' psychiatric training (both theoretical and practical, ending in an examination) in a mental hospital forms part of the general course. Psychiatric training of varying length was given to all pupil nurses in France and in certain nursing schools of the United States, Austria, Japan, Switzerland, etc. contradictory the above in those times still in . Great Britain and New Zealand, nurses during their general course get no psychiatric training at all. In Danish council of nursing all graduate nurses took a six months' postgraduate course in mental. Nursing and was indeed compulsory for all private duty nurses who wish to get employment. German graduate nurses took a course of one year is given at the Nervenklinik in Kiel, the only course of its kind in Germany. Many refresher courses in psychiatric nursing and mental hygiene were held around the globe ²³.

Psychiatric nurses in working situation:

Mean while in England The first systematic attempt to train asylum nurses began within the Council of the Medico-Psychological Association, II, Chandos Street. Sir James Crichton Browne's continued efforts for improving the education and status of asylum nurses are well known. Education did not spread rapidly amongst asylum nurses, there were nurses in the wards who could not read the directions on the medicine bottles, and had to get the lunatics to help them. Sir James had one hundred and fifty nurses under his charge, drawn from the lower domestic class, and when he raised the wages of the under-nurses from twelve pounds to fourteen pounds per. annum, the ladies of the district laid a complaint before the committee of the asylum, saying that their kitchenmaids were being taken away to be made into nurses. Employment of women in the male sick asylum wards by night as well as by day was given by Dr. Robertson's. More than half of the staff was replaced by mental health trained female nurses for taking care of male patients in asylum. The aged and infirm male lunatics are nursed by women in a special infirmary ward. The result was that bed sores are abolished, the imbecile and feeble folk are more carefully and patiently tended, and the male patients prove more amenable. There were no scandals to bereport, nor any assault. Male attendants are employed for some offices, such as bathing and dressing and undressing the male patients. Miss Wise, the matron, for the manner was appreciated for the way in which she has administered the asylum under these novel conditions ²⁴.

Future role of psychiatric nurses as planned:

Psychiatric nursing was on the threshold of a further development with active participation in that prevention and early treatment of mental disease. Two amplifications of training was felt to be necessarily. First, all nurses to have some psychiatric training as a desirable qualification, and to include this in the syllabus of every school of general nursing. ." Psychiatric were in favour of opening a psychiatric department in every general hospital were interested in the idea of having the mentally ill nursed there like other sick persons. Great emphasis was laid on after care, and nurses being more and more employed in the "follow up" schemes of the social service departments of mental hospitals; like in the United States and, in Belgium. Another extension of their sphere concerns abnormal or defective children consisting of intensive study of such patients to assist diagnosis, as at the children's hospital of the University of Vienna," and in home investigation of defective children, as in New Zealand ²⁵.

The second future development targeted was public health nurses; for them psychiatric training (whether obtained in the basic course or postgraduate) was considered not merely desirable but essential. They had to see cases of mental disease in its very earliest stages and influenc public. The importance of public health nurses in the mental health movement, called "one of the greatest medical movements of modern times, was at the Brussels Congress of French speaking alienists in 1924 strongly stressed by Dr. Ernest de Craene, General Secretary of the Belgian National League of Mental Hygiene, who said, "All those who are interested in mental hygiene know how great is the importance of the collaboration of nurses who have been specially trained." On the whole the existing provision of postgraduate mental training was inadequate and considerable expansion was demanded ^26,27. The evolution of need of women care takers let the creation of psychiatric nurse although it was still in preliminary stages with bleak view about syllabus and credentials required to be psychiatric nurse²⁸.

REFERENCES:

1. Willhite CC. UN! Vebsjty Of Utah Libraries (Doctoral Dissertation, University of Utah).

2. Kleisiaris CF, Sfakianakis C, Papathanasiou IV. Health care practices in ancient Greece: The Hippocratic ideal. Journal of Medical Ethics and History of Medicine. 2014;7.

3. Sampoornam W. A Study to Assess the Knowledge on Mental Illness. Asian Journal of Nursing Education and Research. 2019;9(2):263-4.

4. Iskandar AZ. An attempted reconstruction of the late Alexandrian medical curriculum. Medical History. 1976 Jul;20(3):235-58.

5. Kaur D, Pareek B, Sujata N. Revolving Door Phenomena and its Associated Factors among Patients with Psychiatric Illnesses. International Journal of Advances in Nursing Management. 2016;4(3):283-8.

6. Singh GP. Ethical and legal issues in Psychiatric Nursing. International Journal of Advances in Nursing Management. 2021;9(1):91-3.

7. Manju T, Augustine MM, Mini TK, Jose P, Mathew P, Bhattacharya C, Mathew R. Knowledge on early warning Signs and home care Management of mental Illness among care givers of People with Mental Illness in A Selected Hospital at Mangalore, Karnataka. Asian Journal of Nursing Education and Research. 2018;8(3):389-94.

8. Farreras IG. History of mental illness. General psychology: required reading. 2019.

9. Thakur P, Sharma S. A descriptive study to assess the knowledge and attitude regarding selected complementary and alternative system of medicine in mental illness among adults in selected areas of district Mohali, Punjab with a view to develop an information booklet. Asian Journal of Nursing Education and Research. 2020;10(2):130-6.

10. DelCogliano M. Basil of Caesarea's anti-Eunomian theory of names: Christian theology and late-antique philosophy in the fourth century trinitarian controversy. Brill; 2010 Jul 12.

11. Pindoria S, Sinha N. Effects of age on the quality of life of caregivers of patients with mental illness. Research Journal of Humanities and Social Sciences. 2019;10(2):629-34.

12. Gracia JJ, Noone TB, editors. A companion to philosophy in the Middle Ages. John Wiley & Sons; 2008 Apr 15.

13. Coutinho L, Caeira MW, de Paola L, Walusinski O, Cardoso FE, de Lima PM, Teive HA. Les démoniaques dans l'art: Charcot and the “hysterical saints”. Arquivos de Neuro-Psiquiatria. 2022 Nov;80(11):1178-81.

14. Nagesh, V.A. and Kola, D.A., 2016. A Study to Determine the Level of Perception towards the Mental Illnes among Peoples in Selected Rural Field Practices Area of Dharwad district. Asian Journal of Nursing Education and Research. 6(4), pp.454-456.

15. Balasubramanian, N., 2012. Effectiveness of Self Instructional Module (SIM) Regarding Early Detection and Management of Mental Illness Among Peripheral Level Nurses in a Selected Rural Area, Tirupur District, Tamil Nadu. Asian J. Nursing Edu. and Research. 2(4), pp.177-180.

16. Parel JT, Khakha DC, Balhara YP. Do psychiatric nurses have favourable knowledge and attitude towards tobacco prevention among their patients? A cross-sectional study from national capital of India. Asian Journal of Nursing Education and Research. 2018;8(1):1-4.

17. Britto JG. Relapse prevention among caregivers of patients with schizophrenia. Asian Journal of Nursing Education and Research. 2014;4(1):140-4.

18. Tuke DH. Chapters in the History of the Insane in the British Isles. BoD–Books on Demand; 2018 Apr 4.

19. Greenberg B, Rothenberg A. William Shakespeare (1564-1616) Medico-Psychological and Psychoanalytic Studies on his Life and Works: A Bibliography. International Review of Psycho-Analysis. 1974;1:245-54.

20. Farreras IG. History of mental illness. General psychology: required reading. 2019.

21. Tuke DH. Insanity in Ancient and Modern Life: With Chapters on Its Prevention. London: Macmillan; 1878. P:79.

22. Lecky WE. History of European morals, from Augustus to Charlemagne v. 1. D. Appleton & Company; 1897.

23. Glick TF. The naked science: Psychoanalysis in Spain, 1914–1948. Comparative Studies in Society and History. 1982 Oct;24(4):533-71.

24. Porter R. Madness: A brief history. OUP Oxford; 2003 Mar 13.

25. Patricia D’Antonio. History of psychiatric nursing. Available from: https://www.nursing.upenn.edu/nhhc/nurses-institutions-caring/history-of-psychiatric-hospitals/

26. Harvey AM. Henry Mills Hurd: the first superintendent of the Johns Hopkins Hospital and the first professor of psychiatry. The Johns Hopkins Medical Journal. 1981 Mar;148(3):135-48.

27. Lord JR. Nursing Mental and Nervous Diseases: From the View-point of Biology, Psychology and Neurology. A Text-book for Use in Schools for the Training of Nurses. By Albert Coulson Buckley, MD London: JB Lippincott Company, 1927. Demy 8vo. Pp. 312. 57 illustrations. Price 12s. 6d. Journal of Mental Science. 1928 Oct;74(307):789-90.

28. Quarterly Journal for Chinese Nurses, July, 1929, "The Need for Mental Disease Hospitals and Nurses in China."

Received on 23.03.2023 Modified on 05.05.2023

Int. J. of Advances in Nur. Management. 2023; 11(3):160-164.

DOI: 10.52711/2454-2652.2023.00037