The role of hydrotherapy in European insanity apartments at the beginning of the twentieth century

The report aims to treat the use of hydrotherapy as a method of treating madness in European psychiatric hospitals of the early 20th century. It takes its cue from a scientific article that appeared in three episodes in 1913 in an Italian medical journal (the "Gazzetta Medica Lombarda"): << The warm lukewarm bath as a sedative >> by dr. Carlo Pontiggia, psychiatrist in the Mombello mental hospital near Milan. The report also mentions the role of the lukewarm bath and hydrotherapy in general in the treatment of mental disorders of the time through the analysis of some treatises by illustrious Italian and foreign psychiatrists.

Article

This is how an important Italian hydrologist expressed himself at the beginning of his book, published in 1888 (G.S. Vinaj, “L’idroterapia nelle neurosi”):

“Hydrotherapy plays a very important role in the treatment of neurosis. This fact is now admitted by the best neuropathologists and is confirmed by the numerous successes obtained in good hydrotherapy establishments”.

In fact, in the second half of the nineteenth century, in parallel with the greater importance attributed by medicine to balneo-thermal treatments and the greater influx of patients to hydroclimatological stations, there was a general interest in the “water cure” also in the neuropsychiatric field. Hydrotherapy was then recommended by official medicine as particularly suitable for “nerve diseases” and hydrologists considered the treatment of neuropaths to be their responsibility. Thus, in volumes such as “Studi sull’idroterapia” by Pietro Chiapponi or “Trattato teorico-pratico di balneoterapia e di idrologia medica” by Plinio Schivardi, hydrotherapy treatments were recommended for many nervous system conditions (neuralgia, paralysis, chorea or tic movements) but also for many mental disorders (hysteria, hypochondria, depression, states of excitement). To highlight the close connection between hydrology and psychiatry at the end of the nineteenth century, it can be recalled that Enrico Morselli (1852-1929), full professor of psychiatry at the universities of Turin and then Genoa, was director, in two successive periods, of two hydrotherapy establishments ¹.

Moreover, in the main European countries, numerous hydrotherapy clinics arose and prospered between the end of the nineteenth century and the beginning of the twentieth century, which in reality mainly hosted psychiatric patients belonging to the middle-upper classes of society. The stay of neuropaths in these private clinics was carried out as an alternative to hospitalization in public psychiatric hospitals, which were certainly more unpleasant for the patients and their social group.

As regards the mechanism of action that the medicine of the time attributed to the hydrotherapy treatment of neuropsychiatric disorders, we can quote what Vinaj wrote in the volume cited at the beginning:

“At this point a question arises spontaneously. How does hydrotherapy work in neuroses? Hydrotherapy, I will say immediately, works by itself, by the modifications it brings to the nervous system, to the blood circulation, to the organic metabolism made more active, and by suggestion.

I have no difficulty in recognizing that one or the other of these factors have a decisive and serious importance.”

For this author, suggestion is an important factor that assists the more strictly physical action of hydrotherapy. In hydro-climatological establishments, patients make a sudden change in life, environment, habits, company; they temporarily move away from the places where the disease originated to move to a territory with a more pleasant and healthier landscape and climate. “All this - continues the author - tends to create in the patient that state of suggestion on which hydro-therapists must honestly make a very great calculation”. Vinay then goes on to describe the physical effects of hydrotherapy, focusing on the thermal and mechanical effect of water on the body of patients. This effect is different depending on the temperature and the method of application of the water. The most exciting action would be that of cold water administered with a stronger jet. He then describes the action of the cold bath and the hot bath on the circulatory system and on the general temperature of the body; he also speaks of the effect of hydrotherapy applications on metabolic exchange and on the functions of the digestive system. He concludes by stating that hydrotherapy, especially that which uses cold water, “acts as a powerful stimulant of the nervous system”.

During the nineteenth century, hydrotherapy-type treatments were used in most mental hospitals and applied to patients hospitalized for various psychopathological conditions. Moreover, already in the Enlightenment era, when mental hospitals had begun to lose, at least in part, their reclusionary dimension to acquire a medical dimension, immersions in water and showers had been practiced on the insane to rebalance the solids and liquids in the sick bodies; sometimes the insane person was suddenly placed in contact with water with the intent of dissipating the madness with a violent emotion. Vincenzo Chiarugi (1759-1820) then in his medical-analytic treatise “Della Pazzia in generale e in specie” (1793) recommended hydrotherapy treatments for various forms of mental illnesses in particular he prescribed baths and showers with water at a temperature lower than room temperature, limiting lukewarm baths to patients with excessive sensitivity. Philippe Pinel (1745-1826) in his “Traitè mèdico-philosophique sur l’alienation mental ou la manie” (1801) had recommended cold or hot baths and especially surprise baths in the treatment of mental alienation. When in the central decades of the nineteenth century the methods of mechanical restraint were progressively abandoned in mental asylums, permanent baths began to be widely used, making the patients remain immersed in water, generally hot, for several hours or days; all the new mental asylums therefore had a special area dedicated to this treatment with several tubs in the same room to allow the staff to assist several patients at the same time.

For example, in 1841 Tommaso Balletti ², a doctor at the Genoese hospital of Pammatone, expressed himself in this way:

“And no one is so little expert in the Hippocratic art that he does not fully know how, at all times, a warm bath was useful in curbing exalted energy or nervous mobility, and tempering vascular vibration. The ancients used this in most cases, and it was no less famous among the moderns; so that not only in the Salpetrière, but in every well-run hospital, this mitigating remedy is a primary part of every treatment, instituted for the relief of long-lasting and serious madness, and is not at all unpleasant to the sick.”

In the mid-nineteenth century, Joseph Guislain (1797-1860) recommended hydrotherapy for melancholy and mania. The Belgian psychiatrist believed that the use of water was simultaneously a hygienic and a curative means; however, at times it could also have a disciplinary function. In melancholics he applied, depending on the case, a hot or lukewarm bath, a cold bath, a shower or a hip bath; in maniacs he applied above all a prolonged hot bath, but in some cases he also used a cold bath and also the application of compresses soaked in icy water to the forehead, temples and nape of the neck. Towards the end of the nineteenth century, Emil Kraepelin (1856-1926) prescribed prolonged hot baths in “circular depressive states”; he then recommended prolonged baths in manic excitement, in the megalomaniac delirium of paralytics and in puerperal psychosis. According to this author, the patient’s immersion in water could last for several hours and could be continued with adequate intervals for several weeks. Kraepelin described the hydrotherapy treatment of patients with agitated delirium as follows:

“The treatment presents great difficulty because the patient can at any moment commit serious acts of violence against himself and others. It is therefore necessary to keep him in bed or in the bath under the most careful surveillance. If the agitation increases to the point of making bath treatment impossible, then we will use wet compresses, applied regularly, which in such cases can render very useful services. The initial resistance of the patients, however, soon wanes. Every two hours we remove the compress from the patient; we repeat it as needed, alternating short pauses, until he has become calm and can be put into the bath. This is usually achieved in a few days.”

In his “Treatise on Mental Illnesses” (1905) Eugenio Tanzi (1856-1934) repeatedly recommended hydrotherapy treatments in the treatment of psychiatric patients admitted to mental hospitals or private clinics. Thus, regarding “amenza” he maintained that hot and prolonged baths are preferable to hypnotics as sedatives and hypnotic inducers. Regarding progressive paralysis he maintained that they are particularly useful during periods of agitation “general baths at 38°C, prolonged for an hour or more with a cold compress on the head or a frontal shower”, then recommending a lukewarm bath even when not in agitation to improve skin hygiene and also “to mildly excite the processes of organic metabolism”. Regarding “melancholy” he stated that “hot baths are also an excellent sedative, and during the convalescence period, cold and short baths, showers, wet sheets as long as they are not too violent”. Finally, regarding “dementia praecox” he states that in this disease “the hot and prolonged baths that give so much relief to epileptics, paralytics and maniacs are often ineffective”.

A study conducted by Dr. Carlo Pontiggia in the Mombello mental hospital in Milan, which appeared in three installments in March 1907 in the “Gazzetta Medica Lombarda”, is dedicated to the prolonged warm bath and its sedative effect ³.

In the first part of the work, the author declares his desire to join the discussion, then underway among psychiatrists interested in mental hospital technique, on the replacement of mechanical restraint of agitated patients with other sedative means, highlighting the therapeutic value of hydrotherapy and in particular of the prolonged warm bath.

After recalling the psychiatrists who in various mental hospitals, first abroad and then in Italy, had already experimented with the usefulness of the prolonged warm bath in various forms of neuropsychiatric pathology, he goes on to illustrate the procedure he followed.

“In keeping with the fruits of the experience that preceded me, I have always used for the warm sedative bath a temperature ranging between a minimum of 35° and a maximum of 36°C. The patient was taken or led to the bathroom taking care to avoid any obstinate violence, and placed in the tub, as soon as — dealing with agitated patients — the first lively and disordered motor reactions against whoever tried to hold her there had ceased, she was covered by a simple sheet that quickly became soaked with water and was enough by itself to keep the patient in the bathroom in a state of greater or lesser tranquility, always carefully monitored by intelligent and well-experienced nurses.”

The author then goes on to describe the department of the Provincial Mental Hospital of Mombello ⁴ where he works: the “Agitated Department” with 136 beds, of which about a hundred occupied by patients permanently hospitalized and the rest reserved for patients passing through from other departments.

Dr. Pontiggia reports that during the calendar year 1906, out of a total of 400 patients hosted in his department, 110 patients had been subjected to a “prolonged warm bath” for a total of 716 hydrotherapy sessions. The hydrotherapy room of the department was usually used for these treatments, of which the author gives the following description.

“In the room, which can be heated in winter, in addition to a shower system, there are four concrete bathtubs, sunk quite deep into the ground so that the patients can easily be held there by the nurses who, kneeling, exercise their dynamic action from top to bottom. Each tub is equipped with a device for the introduction of cold and hot water, and a drain that can be operated with a key by the service staff.”

Dr. Pontiggia adds that, since the tubs in this hydrotherapy room were somewhat limited in number, during the night he occasionally resorted to mobile zinc tubs and during the day he sometimes sent the patients to the hydrotherapy facility that serves the entire female section of the asylum.

The patient was removed from the tub as soon as it was judged that she was no longer agitated and could remain calm for some time. To understand the effectiveness of the sedative bath on the individual patient, her behavior was observed in the first attempts to remove her from the water and then in the first days of this treatment.

Regarding the duration of the immersion in water, the author reports a greater frequency of the two-hour bath, reserved for cases of less agitation; he adds that eight-hour baths, reserved for forms of more obstinate agitation, were also quite frequent. In this last case, the patients were placed in the water in the morning immediately after the medical visit; they were fed while they were in the tub and remained there until the evening when they were taken to their bed where they usually began a peaceful sleep. As for baths lasting more than ten hours, the author states that they were exceptional and did not bring any particular benefits.

Dr. Pontiggia then goes on to report on the results obtained with the lukewarm bath: excellent results in the majority of manic states, better and quicker sedative effect in simple hypomanic excitement, satisfactory results in anxious agitation. He also reports good results in manic-depressive psychosis, paralytic dementia and senile psychosis; he reports fair results in the agitation of secondary dementia and paranoia. The effects on other psychopathological conditions such as epilepsy and hysterical psychosis were less good and inconsistent; the effects on congenital phrenic asthenia were null.

The author then dwells on the possible unwanted effects of hydrotherapeutic applications. He states that he did not observe any particular inconveniences in the patients he subjected to the lukewarm bath. Only in one case did he observe the onset of a “faint” in a patient in very poor nutritional conditions who had to be removed from the tub for this reason.

At this point Dr. Pontiggia states that thanks to the application of the lukewarm bath he was able to very rarely resort to mechanical restraint of agitated patients, also making limited use of chemical sedatives.

The author then focuses on the general physiological actions caused by the prolonged lukewarm bath in the organism, citing what is reported in the most accredited hydrotherapy treatises. The main effects of this method would be: dilation of the superficial vessels, lowering of blood pressure, hindered sweat secretion of the skin with reduced elimination of toxic substances.

In the last part of his work Dr. Pontiggia describes in detail his recent research, carried out in his department on a limited number of patients, on the possible variations in gastric function during the lukewarm bath. As a result of this experimental study the author reports that short baths (3-4 hours) would not significantly modify gastric function, while prolonged baths would cause a state of hypochlorhydria.

Dr. Pontiggia concludes his article with the following words:

The warm sedative bath — from the point of view of mental hospital technique — is an excellent means in the treatment of psychomotor agitation of the insane, so much so as to make exceptional — when it can be used on a large scale — the need to resort to other aids.

At the beginning of the twentieth century, the use of hydrotherapy for mental hospital patients was a widespread practice throughout Europe. At that time, almost all institutions for the mentally ill were equipped with a hydrotherapy service where patients were immersed in special tubs, showered or sprayed, given wet compresses or sponge baths. Furthermore, the hydrotherapy rooms in hospitals also served to ensure the hygiene and cleanliness of the patients, as well as having rehabilitation tasks for specific patients (in the case of neuromuscular or osteoarticular conditions). In Italy, the following mental hospitals can be cited as having an equipped and efficient service for balneotherapy and other hydrotherapy applications: Voghera, Brescia, Ferrara, Reggio Emilia, Florence ⁵, Siena, Lucca, Pesaro and Naples. The purpose of the aforementioned treatments was to sedate and calm the agitated patient; for this purpose, prolonged warm baths such as those described by Dr. Pontiggia in 1907. Already during the previous decades some hydrologists and psychiatrists had however highlighted the possibility of side effects directly linked to this therapeutic method (excessive sweating with dehydration, hypotensive crises with fainting ⁶, skin infections ⁷) and also some contraindications (cachectic states, cerebrovascular and inflammatory conditions ⁸, cardiovascular and pulmonary diseases, chronic ear infections ⁹). Others had then underlined the practical difficulties of this therapy which required continuous and careful surveillance by specially trained personnel ¹⁰ in order to avoid serious accidents (burns from boiling water or syncope from iced water, drowning, suffocation during feeding or from regurgitation of food). Some psychiatrists and hydrologists had criticized balneotherapy for its lack of scientifically proven efficacy ¹¹, instead underlining its restrictive, aggressive and almost punitive aspects (the patient was forced into the tub and kept there for hours against his will, often closed in the tub by a wooden lid or a rigid sheet) ¹².

In the first half of the twentieth century, the use of hydrotherapy within the various procedures of mental hospital technique gradually decreased, to the advantage of the innovative psychiatric treatments discovered in the meantime (malarial therapy, insulin therapy, cardiazole and acetylcholine shock, electroconvulsive therapy, psychosurgery). In the second half of the twentieth century, with the discovery and ever-increasing use of psychotropic drugs, hydrotherapy in mental hospitals practically ceased to exist. Hydrotherapy treatments continued to be used in spa settings, also recommended for psychiatric diagnoses, but limited to minor psychopathological disorders (states of psychic erethism, various neuroses, reactive depressions). For these indications, hydrotherapy still retains its validity for its calming and relaxing effects on the patient with the aim of achieving a state, at least temporary, of both physical and psychological well-being.

In any case, as can be seen from the photograph accompanying the text, the departments and pavilions dedicated to hydrotherapy treatments within psychiatric hospitals continued to function, at least in part (both in Italy and in the rest of Europe), for many decades after the publication of Dr. Pontiggia’s article ¹³. In this regard, we can cite what three illustrious Italian psychiatrists (A. Tamburini ¹⁴, G.C. Ferrari ¹⁵, G. Antonini ¹⁶) still declared at the end of the 1920s in the volume “L’assistenza degli alienati in Italia e nelle varie Nazioni”.

A pavilion that was never missing from the plans of old mental hospitals, but which has disappeared from the most recent ones, is the central pavilion of the bathrooms. In fact, each pavilion must now have a suitable number of tubs and warm shower devices, for the cleaning service of the patients it contains. But this is even more necessary in the pavilions intended for easily excitable patients ¹⁷.

Conflict of interest statement

The author declares no conflict of interest.