Psychological symptoms and medical responses in nineteenth-century India

Introduction

An organized European medical service, run by the East India Company, was in place in India by the late eighteenth century. Subsequently, descriptions and discussions about diseases and their correlates were recorded in detail (Arnold, 1993; Pati and Harrison, 2001, 2009). Formal academic interest was further enhanced with the publication of the Indian Medical Gazette (started in 1866), which described itself as ‘A Monthly Record of Medicine, Surgery, Obstetrics, Jurisprudence, and the Collateral Sciences; and of General Medical Intelligence, Indian and European’. It had been preceded by a number of ‘local’ medical journals in Bombay and Madras, but the Gazette attempted to cover health-related issues on an all-India perspective. In the mid-1870s, the Gazette’s subtitle further included ‘hygiene’ and in the mid-1880s, ‘public health’, while jurisprudence and obstetrics were removed.

The purpose of the Indian Medical Gazette was to document the breadth of medical science and practice – specialized and general – across the vast continent of India. The medical reports published in the journal came from dispensaries in far corners of British India, e.g. Fort Lockhart, Samana (North West India on the border with Afghanistan); Jhang (Pakistan Punjab); Arrah (Bihar); Bhuggocool in Dacca district (Bangladesh); and Noakhilah in Bogra district (Bangladesh). Reports were submitted by both Indian and European doctors, including officers of the Indian Medical Services (IMS) and civilian employees of the Government.

In an early issue, editors C. Macnamara and K. McLeod (1873) put out a call to medical officers to report local socio-medical practices. Their concern was the reluctance of the Indian populace to access ‘Western’ medicine, and their preference for ‘primitive’ medicine that was locally available. The editors reflect that it would be useful to know ‘why a dispensary is not well attended … because of a kobiraj, pir, fukeer or other pretender’, and record two such dispensary reports, one from Noakhilah dispensary (present-day Bangladesh) where a ‘godman’ (religious guru) Shumboo Thakur conducted what they called an Adalut (court) where he promised to remove all kinds of ailments and, when he died, many more Shumboo Thakurs arose from among his followers. The second report was from Bhuggocool dispensary, Dacca district, where a man called Kally Coomer Chuckerbutty administered the dust of his feet as a panacea for all illnesses. Such documentation was important for British administration and the medical establishment, to ensure the spread of ‘scientific’ medicine, a process not merely occurring in the colonies but also ‘back home’ in Britain. The journal editors condemn native superstition, wherein dengue fever is chased away from a South Indian village through drumming, but also add that England itself is ‘not foreign to similar cults’ (Macnamara and McLeod, 1873: 299). This suggests that at least in the mid-nineteenth century, there were no assumptions being made about essential differences between Indian and British society in the credulousness of the populace, or public acceptance of ‘Western’ medicine.

In this paper, we focus on descriptions of and discussions about psychological symptoms in medical accounts in nineteenth-century India. By this time, doctors seeking employment in the East India Company were expected to familiarize themselves with the principles of mental health care by working in one of the asylums in the UK for at least three months (Crawford, 1914). These medical accounts help us understand the travel of ideas about mental syndromes between Europe and India.

Phenomenology of psychological medicine: investigation and treatment

Many papers in the Indian Medical Gazette present detailed clinical descriptions of mental illness and its treatment. One of the earliest descriptions of hysteria is provided by Pandurang and colleagues in a note on ‘Hysteria’; this discusses a 12-year-old girl H. who suffered from loss of speech and twitching of lower and upper extremities after seeing a reptile. The doctor concludes that she is afflicted with hysteria based on the abrupt onset of choreiform movement, and its disappearance after the use of chlorodyne mixture, within three days (Pandurang et al., 1869).

An article by a civil surgeon from the Dacca asylum, now in Bangladesh, lists the various delusions and provides a fascinating and detailed description of phenomenology. The delusions recorded include the following: one patient described being gifted a tea garden by Queen Victoria, another of possessing three lakhs (300,000) rupees in England and trading in goods, a third deifying herself as the daughter of agni (fire), and a fourth feeling persecuted by those who ‘blew his body with wind’ (Smith, 1875: 207–8). Patients in India were thus incorporating British institutions into their delusions.

P.W. O’Gorman from the sub-medical department presents ‘A case of acute mania’ in a 29-year-old European soldier admitted to the Agra station hospital for 14 days in December 1881. The author reports the patient’s symptoms and treatment, and detailed descriptions of his behaviour – staring eyes, clenching teeth, tearing clothes and sheets, his delusions of being ‘Jesus Christ’ and ‘Blessed Virgin’. The patient’s food intake, sleep, urine and stool patterns, grasping and response ability, and people’s attitude towards him, are also discussed by O’Gorman (1882).

There are also reports of effective treatments. Indian doctors were publishing their findings as early as 1867, a year after the Indian Medical Gazette began. Ram Chunder Mitter, of the Arrah charitable dispensary, discusses ‘A case of mania treated successfully’. R., a 14-year-old married girl who suddenly showed signs of illness, is described as being quiet, not listening to relatives, singing and talking nonsense all day, and not eating well since the beginning of her illness. She is successfully treated over a week by the application of a blister over the top of her head, along with purgatives, cold bath, tartar emetic and morphia (Mitter, 1867).

JN and MM (1867) – who preferred these abbreviated names – present details about their use of ‘Bromide of potassium in insanity’. They show its effectiveness in inducing sleep and calming a person through two case studies: a father and son with incipient and confirmed insanity, respectively. They list favourable effects of the salt, along with other substances that they have administered: kamila troches (kamila rubbed up with confection of roses), painting the lumbar region of the spine with the linimentum cantharides of the British Pharmacopoeia, a dose of laxative of rhubarb, aloes and taraxacum, and a dose of ‘potassii bromidi, ammon: carb:, extract: chirett fluid and aquae ad’ (JN and MM, 1867). The doctors mention having later learnt of potassium bromide being endorsed by ‘high authority’ in the Edinburgh Monthly Journal.

This coincides with the introduction of bromides in the 1860s in Britain and Europe. As Healy (2000: 396) points out: ‘their use was initially in hospital settings where, combined with henbane, digitalis or cannabis, they proved effective sedatives. By the turn of the century bromides had migrated into private care.’ JN and MM’s study appeared within a decade of Charles Locock (1857: 528) describing the use of potassium bromide in hysterical epilepsy and hysteria.

We also find elaborate descriptions of psychopathology in the asylum reports of the mid- to late-nineteenth century. The 1871–72 report of the Punjab asylum records:

The common form of insanity from Indian hemp is dementia, with or without melancholia, where the patient is totally indifferent to persons and things, and to what is passing around him. He seems to hold no intercourse with the world, has a stupid stare, is very quiet, sleeps well, and has a voracious appetite … A less frequent form from the incautious use of hemp shows itself in excitement and paroxysms of violence with intervals of quiet. They talk loudly, are authoritative and commanding, and most irritable. This state will last for a day or two, and the patient becomes more tractable; but he is never safe. (Punjab Lunatic Asylum, 1872: 5)

In the Delhi report for 1875, the following is recorded for Ashraff Khan, a criminal lunatic:

On one occasion, in the hot weather, he refused to leave his sleeping ward until he had seen me, and I found the reason was that he thought he had been cheated of his proper quantity of food by the jamadar [junior official], whom he still looks upon as his enemy, and who he believes wishes to kill him. He first asked me the weight of the bread and dal which he ought to get, and on being told this he brought out the whole of his previous day’s rations, which he had hidden away in a corner untouched, and he requested that it might be weighed there and then. Fortunately both the bread and the dal, although they had been kept so long, were rather over the prescribed weight. He was a little crestfallen at the result, but apparently satisfied, and I have heard no more complaints since. I mention the circumstance to show what unfounded suspicions occasionally come across the man’s mind; and during these there can be no doubt that he is prepared for any deed of violence, for, while questioning me about his rations, his whole manner was most excited. (Delhi Lunatic Asylum, 1876: 18)

There are other reports in the Delhi asylum records: an Irish soldier converting to Islam and mobilizing all Muslims to help the Russians fight the English (Delhi Lunatic Asylum, 1877) and a Sikh ‘sirbhangi’ (‘head full of cannabis’) guerrilla soldier being discharged as not insane, though he was admitted for eating the body of a dead child in 1883 (Jain, 2003: 279).

The asylum reports during the mid- to late-nineteenth century were debating diagnoses and also presenting psychological reasons for insanity. The 1872 Punjab report states:

The classification of the forms of madness as manifested in natives is, in my opinion susceptible of a more simple arrangement than that laid down in Return 12, in which we have acute and chronic mania, and also acute and chronic dementia. Instead of these four heads, I would make two great forms of mental derangement, one characterised by visible excitement, the other by depression. Melancholia, when the mind is engrossed in some painful sentiment, with perhaps propensity to suicide or homicidal impulse, may complicate almost every form of derangement of mind, but it is always dependent on delusion expressed or not, and, therefore, is correctly made a separate disorder. (Punjab Lunatic Asylum, 1872: 3)

Psychological causes for mental illness were being acknowledged in many patients. Grief is cited as one of ‘the chief causes for insanity’ (Delhi Lunatic Asylum, 1874: 3; 1875: 10). It was a predominant cause among 23 physical causes and 18 moral causes, as it was found in 13 cases vis-à-vis 8 cases caused by ganja, i.e. hemp/cannabis (Delhi Lunatic Asylum, 1875: 10).

Thus, the following are all evident in reports from India: concepts of hysteria, classification of insanity into few or several categories, content and nature of delusions, and hereditary and exogenous causes of mental illness (biological, such as cannabis, or psychological such as grief). These issues are congruent with preoccupations in Britain, Europe and the USA at that period, and do not seem to suggest any attempt at using a different framework for defining psychological symptoms in India (Altschule, 1976; Berrios, 1999; Shorter, 1996). Clearly, similar issues are still being discussed: somatic symptoms (hysteria) in the Third World/LAMIC countries; the use of DSM-5 vs. ICD-11; the role of drugs of abuse; and social adversity in mental illness.

Biomedical or physiological approaches

Advances in anatomical and physiological understanding of brain function, and attempts to correlate it with various diseases through phrenology, impulse theories, degeneration theories, etc., were evident throughout the nineteenth century in Europe, and were used in discussions about mental illness in India too.

McLeod (1883) discusses the limitations of phrenology in mapping mental functions to localized parts of the brain, but emphasizes its strengths in attempting to build an ‘objective method of observation’ and making a necessary connection between the brain and mind, thus making the study of mind a study of biology (p. 4). By this time phrenology had become discredited in Britain and Europe after the initial popularity it enjoyed between 1810 and 1840 (Shorter, 1996), though many have suggested that the current preoccupation with imaging and its correlates with mental phenomena may be an extension of this anatomical inquiry (Uttal, 2001).

Another lecture given by R.J. Macnamara, at the 1894 annual session of the Indian Medical Congress, presents a study of head measurements of the insane in comparison with the sane, and also discusses how a given personality trait could be determined by measuring the area of the skull that overlies the corresponding area of the brain. The lecture, later reproduced in the Indian Medical Gazette (Macnamara, 1896), asserts that the mentally ill and lunatics have a smaller brain size than normal people. It suggests that their deficient intelligence is the cause for criminal behaviour and their inability to assess right and wrong. Macnamara thus argues for the law to be liberal with criminal lunatics. Macnamara’s study followed Samuel George Morton’s major monographs on craniometry, Crania Americana (1839) and An Inquiry into the Distinctive Characteristics of the Aboriginal Race of America and Crania Aegyptiaca (1844), which claimed that intellectual capacity is directly proportional to cranial capacity (Shorter, 1996). The topic of racial and temperamental differences in cranium size had again been made popular by Morton and others (Le Bon, 1879), and Macnamara’s paper suggests considerable familiarity with these ideas. The work of McLeod and Macnamara is indicative of the biomedical gaze in mental science at the end of nineteenth century in India.

Indian doctors were also reporting on ‘bio-markers’ of mental illness. A note on melancholia points out: ‘From my experience of this disease I find that in several cases the urine of melancholic persons is loaded with a dark substance, and is strongly acidic in reaction’ (Shah, 1882). Urine changes during melancholia had been described in traditional Ayurvedic and Unani medicine, as well as European medicine (Broumand, 2011; Glas, 2003; Klibansky, Panofsky and Saxl, 1964). This shared semiology makes it difficult to determine whether Shah’s ideas were derived from adherence to prevalent traditions in India, or by what he would have learned at British medical school (which in any case derived their knowledge from similar sources: Galen and Avicenna).

Debates on genetic causes and family histories that started in the eighteenth century continued into the nineteenth. In his report on mania, Mitter (1867) opines that the patient has ‘no family history’. JN and MM (1867), looking at mania across three generations of patients (son, father and grandfather), assert that ‘there could be no doubt of the hereditary tendency’. The clustering of mental illness in families was thus well recognized.

Treatments included experiments with drugs, both native and European. W.B. O’Shaughnessy of Calcutta presented the first evidence of the medical use of cannabis indica in treating illnesses such as rheumatism, cholera and delirium tremens in 1839 (O’Shaughnessy, 1838–40). Subsequently, during the annual meeting of the Association of Medical Superintendents of American Institutions for the Insane, Dr John P. Gray, Superintendent, New York State Lunatic Asylum, Utica, read a paper ‘On the use of cannabis indica in the treatment of insanity’, which is recorded in the proceedings of the meeting. Gray states that there had been a renewed interest in the last three to four years in the use of cannabis indica in treating insanity. Its most marked effect was in acute mania and was least effective in melancholia. Other doctors present at the meeting concurred with Gray on hemp’s usefulness in reducing delusions, controlling hysterical dispositions and producing a soporific effect in the treatment of mania. If the substance had failed at all, they attributed it to the preparation used rather than to the qualities of hemp (Shrady, 1859: 83–9). This shows that ideas about treatment were not merely travelling from the West to India, but also in the other direction. The Indian Medical Gazette also recorded the use of drugs. A report on some effects of Indian hemp documents the cases of two young European women who fainted after being given hemp for menstrual problems (Bensley, 1866); the author asks whether other doctors have observed similar effects.

As discussed earlier, JN and MM record the successful use of potassium bromide in insanity. Shah (1882: 265), in his note on melancholia, suggests that ‘patients derive great benefit from the acetate of potash and nitric ether treatment’.

Through the mid- to late-nineteenth-century Indian Medical Gazette reports, we thus see a growing interest in biomedical approaches to mental illness and treatment. In Britain and Europe, the work of Hughlings Jackson, Gustav Fritsch and Eduard Hitzig, and David Ferrier led to the development of ‘a structurally oriented neurology’ (Bynum, 1985: 95), and by the twentieth century in Britain and Europe, explanations for trance and hypnotic states were seen to reside in physiology rather than psychology (Williams, 1985: 242). As Meynert was to say in 1890, ‘The more that psychiatry seeks, and finds, its scientific basis in a deep and finely grained understanding of the anatomical structure [of the brain], the more it elevates itself to the status of science that deals with causes’ (Shorter, 1996: 77).

Healy (2000) and Shorter (1996) have shown the extensive use of physical therapies during the nineteenth century: opiates during the first half of the century; henbane alkaloids, hyoscine and hyoscyamine in the mid-nineteenth century; bromides, barbiturates and chloral in the 1860s; and the use of lithium salts for manic depressive disorders between 1800 and 1900. Moreover, this use of ‘organic’ treatments for mental illness suggests a gradual transition, as plant-based medicines, usually sourced from the colonies (and based on awareness of the use in the particular culture), were replaced by products from industrial chemistry. The use of plant-based medicine was now relegated to ‘folk’ (pre-scientific) medicine, though this did not prevent, for example, its rapid use to develop anti-hypertensive and anti-psychotic drugs in the twentieth century based upon reserpine and related alkaloids derived from Rauwolfia (Jain and Murthy, 2009).

Psychological and psycho-social approaches

Psychological and psycho-social approaches to understanding mental illness were prevalent, and we find one of the earliest descriptions of hysteria in the mid-nineteenth century by Pandurang and colleagues (1869). They describe the case as ‘a nervous disorder simulating chorea’ whose aetiology is not entirely organic:

The sudden development of choreaic movements after evident fright, the inability of speech and the extraordinary recovery in the space of three days seem to me rather unusual features in the history of chorea … the patient did not evince any marked deficiency in the general state of nutrition, and bore no evidence whatever of a hyper fibrinated condition of blood … The short duration of the disease, the absence of its connection with some particular dyscrasia, and its reappearance, appear to me related more to a mental peculiarity of the patient, similar to hysteria, than to a true morbid condition, or diseased condition of the corpus striatum (which more generally happens to be the cause) …

Subsequently, Murray (1890) records a case of hystero-epilepsy explicitly stating that the illness is psychological, not entirely organic. He reports the case of a German sailor T. Dahucke, admitted at the Calcutta general hospital in 1885, who showed signs of epileptic seizure and subsequently became mentally deranged. He concludes that the seizure is hysterical in character because of its ‘suspicious regularity at a stated time, morning and evening’ and that the patient ‘premeditated his attack by systematically making his bed and lying down to have a fit’. The surgeon diagnoses the illness as hystero-epilepsy since it has features of both paroxysmal attacks.

Both these reports understand hysteria as a nervous disorder and not as having its origins in the female uterus or genitalia (Altschule, 1976: 296). Pandurang and his colleagues attribute the cause to ‘evident fright’, and Murray to ‘loss of nervous equilibrium’. Murray (1890: 322) says, ‘These nerve storms are a result of nerve exhaustion by debilitating influences of all kinds, whether the enervation be due to prolonged pyrexia, to tropical heat, or other allied causes, operating pathologically on the nerve centres.’ This understanding began with Laycock in A Treatise on the Nervous Diseases of Women (1840) and was taken forward by Briquet in Traité clinique et thérapeutique de l’hystérie (1859). Murray pays direct allegiance to Laycock while remarking on a case of hysterical hemiplegia, ‘I recollect a very singular case that came under my observation a good many years ago when resident physician in the clinical wards of the Edinburgh Royal Infirmary under Professor Laycock’ (Murray, 1890: 323).

Pandurang and his colleagues were drawing on ideas circulating in the nineteenth century but were also making independent observations. Unlike Briquet (Altschule, 1976: 299), they do not see hysteria as a brain disorder (Pandurang et al., 1869). Nor do they, like Breuer or Freud, consider the possibility of the snake symbolizing repressed sexuality (Breuer and Freud, 1955; Freud, 1913: 132). Also, unlike Laycock, Pandurang et al. do not emphasize the gender-specificity of the syndrome, although the patient they happen to be describing is a young woman. Murray (1890) on the other hand remarks, ‘Hysteria is generally rare among the male sex but when it does occur it is of a very severe and pronounced type (hysteria masculine).’

By this time, Charcot was conducting extensive experiments at the Salpêtrière School and he included a chapter on hystero-epilepsy in his Leçons sur les Maladies du Système Nerveux (Charcot, 1872–73). Also, Charcot’s lectures that included case histories of male patients had become well known by 1890 (Charcot, 1887a, 1887b, 1889). The ideas about hysteria advanced by Pandurang and his colleagues, and by Murray, their use of the diagnosis for both sexes, and discussions about its wider implications were recorded well before Freud made his contributions. They reflect an awareness and acceptance of the ‘interior’ of the mind of the patient, both Indian and European.

At the same time, hypnotism was used as an effective therapy in the nineteenth century. In ‘Hypnotic therapeutics in natives of India’, Delany (1899: 445) reports on gunner K.S. whom he cures of partial deafness and blindness that he finds has no organic cause. The second case is of a Pathan border policeman who is addicted to opium. Delany remarks on the particular success of this case because of the multiple translations involved, with Delany knowing only English and the policeman only Pushtu; despite this, an adequate and effective doctor-patient communication had worked. The use of hypnotism needs to be seen as drawing on a long Western tradition but also in the context of medical hypnotism practised in India. James Esdaile, for example, who set up a Mesmeric Hospital in Calcutta in the 1840s, was widely acknowledged during his time (Ernst, 2004; Jain and Sarin, 2000).

‘Native’ psychology

Was the psychological aetiology of mental illness in India or the success of psychological techniques like hypnotism founded on an understanding of a native mind that was ‘primitive’? Such an understanding did exist in the early and mid-nineteenth century. The incidence of mental illness, for example, was seen as increasing with ‘progress’ and ‘civilisation’ (Burrows, 1820; Halliday and Seymour, 1829) or seen as rare in a ‘country where the mental faculties were so less cultivated’ (Wise, 1852). But others disputed the ‘primitiveness’ of the native mind. Winslow Forbes, editor of Psychological Medicine and Mental Pathology, caustically responded to Wise’s opinion as ‘interesting’ but full of ‘error’ and ‘unsubstantiated’. He disagreed with Wise’s opinion that ‘Hindoos [sic] are perhaps in a lower state of mental development than even the rudest savages’ given the literary and architectural achievements in India (Forbes, 1853: 356–7).

However, by the late nineteenth century, the idea of the native mind as ‘primitive’, ‘gullible’ and superstitious became dominant. The Agra asylum report for 1878 pronounces that moral causes were not very significant among the Indian insane because natives are ‘little prone to emotional excitement, while at the same time the requirement necessary to impart contentment to their lives are few and simple’ (Hilson, 1879). Another report suggests that the primitive psychological state of the native was the basis for the predominance of certain disease forms. General paralysis in mental illness was seen as rare among Indians because it was ‘associated with highly civilised states, and most common among men who live in cities and do brain work’; the general Indian masses were instead more prone to syphilis (McLeod, 1899: 373).

Likewise, the ‘simplicity’ of the native mind was seen as the reason for its susceptibility to hypnotism. The Indian mind was seen as ‘saturated with … superstition’, ‘highly imaginative and credulous’, ‘less analytical’ and ‘less enlightened’ than his Western counterpart; the native ‘readily obeys a suggestion, especially under the influence of a Sahib’ (Delany, 1899: 446). Thus, the native’s mind was not only seen as ‘primitive’ but also as acknowledging the mind of the sahib (European, master) as ‘civilized’ and ‘superior’.

Conclusion

The mid- to late-nineteenth-century medical reports show that provision of services for the mentally ill was accompanied by descriptive and analytical efforts to understand insanity. Basic tenets of psychiatry that included classification, descriptive accounts, somatic and psychological therapies were incorporated easily. A caveat that remains is that there are few descriptive accounts of patients’ experiences. Hence, we cannot accurately map the public acceptance of Western medicine. Nevertheless, the vast number of people accessing hospitals and dispensaries perhaps tell the tale. In the Hospital for Peons, Paupers and Soldiers, Bangalore (South India), for instance, 23,406 consultations were documented between 1836 and 1849, and there were 4,336 admissions in 1849 alone, from an overall population of 100,000 (Jain, 2003: 296).

Theories prevalent in the ‘West’ were applied, but since they in turn derived from Galenic/Islamic medicine, there was considerable overlap: urine changes in depression; bazaar medicine; blistering; morphia/cannabis use, etc. By the mid-nineteenth century, as Indian doctors trained in Western medicine emerged, they used ‘Western’ concepts readily, and incorporated prevailing conditions into these theories. Western doctors, too, saw no inherent difference between the Western and native mind. However, by the late nineteenth century, a more biological approach (craniometry, infections), accompanied by imperialist notions of the mind, made the technology and science of ‘western’ medicine demarcate the native mind as ‘less civilized’ and ‘inferior’ to the Western mind.