Techniques to startle insane patients from senselessness into reason.
“Invasion by wakefulness,” as the eminent social theorist and philosopher Michel Foucault referred to it (Foucault, p. 185), was one of the earliest asylum therapeutics on record. And, it could be convincingly argued, its lingering influence is evident in other early therapeutics such as salutary fear [see Salutary Fear], pious frauds [see Pious Frauds], and even in the much more recent and familiar therapeutic of shock therapy [see Shock Therapy].
Each early nineteenth century asylum physician on record had a preferred strategy for “gathering up the senses” and forcing them to “hie back to their confine,” as John Conolly, medical superintendent of Bethlem Asylum in London, England, once referred to awakenings (Conolly, p. 96). At the Vadstena Asylum, the first of its kind in Sweden, for example, medical director Georg Engström tied up patients in sacks of ants to awaken their senses, and at the private asylum he managed near Berlin, Germany, J.H. Lehmann submerged distracted patients in tubs of writhing eels to get their attention.
While credit certainly has to be given to imagination, the inspiration for awakenings surely must belong to Johann Christian Reil, a German physician who, despite having had little interaction with the insane himself, coined the word “psychiatry” and founded two journals devoted to it, and launched what has come to be known as the Romantic Psychiatry movement in Germany. The term “Romantic” requires clarification, since, in the early nineteenth century, it was meant not so much as a compliment but as a criticism. Romanticism was a reaction against the hegemony of biological theories about the cause of insanity and, to a lesser but still significant extent, to somatic methods in treating it. It entwined psychiatry with philosophy and even poetry to set out what it proposed were the moral causes of insanity and the harmonizing “psychic” therapies aimed at the feelings, desires and ideas that had gone astray. Although the Romantic movement could not hold its own against the biological juggernaut, its historical significance can be found in its introduction of psychological thinking into the emerging discipline of psychiatry.
Reil unabashedly identified with the movement. The title of his widely read text, Rhapsodies on the Use of Psychological Therapies for the Mentally Disturbed, might be considered sufficient evidence, in and of itself, of that identification. But within it, and in homage to the philosophers Immanuel Kant and Friedrich Wilhelm Joseph Schelling, he laid out a complex theory of the mind and of its disturbances. In Reil’s romantic idealism, insanity was a failure in self-consciousness. The self, he argued was fractured by the steady progress of civilization that in equal measures propelled the human race forward and pushed it backwards and “ever nearer to the madhouse” (Reil, p. 12). That fracturing of the self, or soul in his philosophy, resulted in impairments of prudential awareness, attention and self-consciousness. It is the latter that “synthesizes the mental man, with his different qualities, into the unity of a person” (p. 55); thus when self-consciousness was impaired, the world of the person was rendered incoherent.
Reil’s psychological strategies for treating the incoherence of insanity were influenced by experts such as Philippe Pinel in France, Francis Willis in England, and Johann Langermann in Germany. Thus, he advocated good diet, outdoor activities, exercise, sexual intercourse, dancing, music, and education—all progressive treatments of insanity in the early nineteenth century. But some of his therapeutic strategies were distinctly and recognizably his own. Crusting the soles of a patient’s feet with salt that was then licked off by a goat was promoted as a wise therapeutic intervention for restoring self-consciousness, as was submersing a patient in a tub of live eels, and placing an open-bottomed glass dome filled with mice on the patient’s bare skin. All of these “awakened” self-consciousness, drew attention and stimulated awareness, as did the startling cannon shots fired on the asylum grounds, the sudden rat-a-tat of a drumroll and blast of a firecracker disturbing the relative quiescence of the asylum, the unexpected appearance of staff costumed as “furmen” and skeletons, and the discordant sound of Reil’s most innovative awakening therapeutic, the cat-piano.
The cat-piano, or katzenclavier, was described by Reil as such:
[Cats] be arranged in a row with their tails stretched behind them. And a key board fitted out with sharpened nails would be set over them. The struck cats would provide the sound. A fugue played on this instrument—when the ill person is so placed that he cannot miss the expressions of their faces and the play of these animals—must bring Lot’s wife herself from her fixed state into conscious awareness [Reil, p. 205].
Katzenclavier. Johann Christian Reil’s appalling “cat-piano.” The wailing of the cats when the sharpened nails struck their tails was sure to “bring Lot’s wife herself from her fixed state into conscious awareness.” Rumors to the contrary, the cat-piano most likely was never used as an awakening therapeutic (La Natura [1883], v.2.)
Although Reil lamented that the “voice of a jackass [would be] even more heart-breaking” he admitted that the animal suffered from a certain “artistic caprice” (p. 205) and therefore was unsuitable to the task of awakening the insane. In truth, the cat-piano was not Reil’s invention. Its origination was attributed, but not without contention, to Athanasius Kircher in his 1650 text, Musurgia Universalis, and represented in a late sixteenth century woodcut by Theodor deBry. And, in truth once again, Reil’s suggestion that it be used as an awakening therapeutic may never have been more or different than that—a suggestion. Although a few early European and British asylum physicians sometimes mentioned it, there was no indisputable historical evidence that it ever was in use.
The cat-piano, in the end, may be more interesting as an object lesson in how tales of asylum therapeutics circulate and detach from their historical referents, and then take on the mantle of truth. The same could be said of another of Reil’s innovative strategies for awakening patients as they first arrived at the asylum, and that was to attach them to a catapult that would sweep them up into the tower of the asylum and then precipitously drop them into a dark cavern filled with snakes. The Bethlem Asylum superintendent John Conolly was the first to translate this suggestion into English, and he did so with fidelity to Reil’s original assertion that this was something he “wished” were possible, but did not recommend or suggest as an awakening therapeutic. As time went on, “wished” having long since disappeared from the narrative, the now apocryphal account was presented as historical truth.
The euphemism “snake pit” predates Reil’s wistful idea by centuries. The term most likely was derived from the medieval practice of throwing convicts and other undesirables into such pits as punishment for their offenses. The wide circulation of Reil’s fanciful awakening account, however, more strongly linked the euphemism with asylums than with other total institutions.
Beam, A. (2001). Gracefully insane: The rise and fall of America’s premier mental hospital. New York: PublicAffairs.
Conolly, J. (1850). Familiar views of lunacy and lunatic life. London: John W. Parker.
Deutsch, A. (1945). The mentally ill in America: A history of their care and treatment from Colonial times. New York: Columbia University Press.
Foucault, M. (1965). Madness and civilization. New York: Pantheon.
Greenfeld, L. (2013). Mind, modernity, madness: The impact of culture on human experience. Cambridge, MA: Harvard University Press.
Hankins, T.L. (1994). The ocular harpsichord of Louis-Bertrand Castel; or, The instrument that wasn’t. Osiris, 9, 141–156.
Kircher, A. (1650/1970). Musurgia universalis. Rome: Francesco Corbelletti.
Lehmann, J.F. (1837). Remarks on the conduct to be observed towards lunatics by those who are in charge of them. Berlin: Author.
Marx. O.M. (2008). German Romantic psychiatry. In E.R. Wallace and J. Gach (eds.), History of psychiatry and medical psychology: With an epilogue on psychiatry, pp. 313–334. New York: Springer.
Qvarsell, R. (1985). Locked-up or put to bed: Psychiatry and the treatment of the mentally ill in Sweden, 1800–1920. In W.F. Bynum, R. Porter, and M. Shepherd (eds.), The anatomy of madness, Vol. 2, pp. 86–97. London: Tavistock.
Reil, J.C. (1803/2010). Rhapsodieen Uber Die Anwendung Der Psychischen Curmethode Auf Geisteszerruttungen [Rhapsodies on the Use of Psychological Therapies for the Mentally Disturbed]. Whitefish, MT: Kessinger Publishing.
Richards, R.J. (1998). Rhapsodies on a cat piano, or Johann Christian Reil and the foundations of Romantic psychiatry. Critical Inquiry, 24, 700–736.
The strict confinement of insane patients in beds.
This therapeutic was carried out either inside asylum wards, outside in tents or on specially built verandas and patios, or in private clinic rooms. One form or another of this therapeutic was popular in asylums around the world during the mid-nineteenth to the early twentieth century.
Beard, G.M. (1894). A practical treatise on nervous exhaustion (neurasthenia), its symptoms, nature, sequences, treatment. 3rd ed. New York: E.B. Treat.
Boschma, G. (2003). The rise of mental health nursing: A history of psychiatric care in Dutch asylums, 1890–1920. Amsterdam: Amsterdam University Press.
Campbell, B. (2007). The making of “American”: Race and nation in neurasthenic discourse. History of Psychiatry, 18, 157–178.
Clouston, T.S. (1863). Tuberculosis and insanity. Journal of Mental Science, 9, 56–57.
Dickens, C. (1907). The life and adventures of Nicholas Nickelby. London: Chapman and Hall.
Dumas, A. (1848/2013). The lady of the camellias. Trans. S. Schillinger. New York: Penguin Classics.
Easterbrook, C.C. (1907). The sanatorium treatment of active insanity by rest in bed in the open air. British Journal of Psychiatry, 53,723–750.
Engstrom, E.J. (2003). Clinical psychiatry in Imperial Germany. Ithaca, NY: Cornell University Press.
Gijswijt-Hofstra, M., and Porter, R. (eds.). (2001). Cultures of neurasthenia: From Beard to the First World War. Amsterdam: Rodopi.
Gilman, C.P. (1899). The yellow wallpaper. Boston: Small, Maynard.
Haviland, C., and Carlisle, C. (1905). Extension of tent therapy to additional classes of the insane. American Journal of Insanity, 62, 95–115.
Kirkbride, T.S. (1890). On the construction, organization, and general arrangements of hospitals for the insane. Philadelphia: J.B. Lippincott.
Madsen, J. (1966). Some pages from the history of Sankt Hans Hospital. Acta Psychiatrica Scandinavica, 41, 13–56.
Mann, T. (1924). The magic mountain. [Der zauerberg]. Berlin: S. Fischer Verlag.
Mitchell, S.W. (1877). Fat and blood: An essay on the treatment of certain forms of neurasthenia and hysteria. Philadelphia: J.B. Lippincott Company.
Mitchell, S.W. (1888). Doctor and patient. 3rd ed. Philadelphia: J.B. Lippincott Company.
Mitchell, S.W. (1894). Address before the fiftieth annual meeting of the American Medico-Psychological Association. Journal of Nervous and Mental Disease, 21, 413–437.
Neissen, C. (1900). Rest in bed in the treatment of acute forms of insanity, and the modifications which would be necessary in the organization of the insane asylums if this method of treatment were carried out. St. Louis Medical Review, 42, 291–292.
Oppenheim, J. (1991). Shattered nerves. New York: Oxford University Press.
Qvarsell, R. (1985). Locked up or put to bed: Psychiatry and the treatment of the mentally ill in Sweden, 1800–1920. In W.F. Bynum, R. Porter, and M. Shepherd (eds.), The anatomy of madness, Vol. 2, pp. 86–97. London: Tavistock.
Serieux, P. (1899). The treatment of acute psychoses by rest in bed. Medical Press and Circular, 119, 500–502.
Van Deusen, E.H. (1869). Observations on a form of nervous prostration (neurasthenia) culminating in insanity. Lansing, MI: W.S. George.
Wiglesworth, J. (1908). On the treatment of cases of acute insanity by rest in bed in the open air. British Journal of Psychiatry, 54, 105–106.
Wright, A.B., and Haviland, F. (1903–1904). Additional notes upon tent treatment for the insane at the Manhattan State Hospital, East. American Journal of Psychiatry, 60, 53–59.
Strict confinement in bed in order to reduce external stimuli, calm agitation and, most importantly, to convince patients of their own insanity in a setting that optimized physician and staff observations. Bed therapy most likely originated in Germany. In the mid-nineteenth century the psychiatric reformer Wilhelm Griesinger had urged the development of scientific observatories within asylums; over ensuing decades these Wachabteilung, or surveillance wards, as they came to be known, became a feature of many asylums, general hospitals and university-based psychiatric clinics around the country.
Bed therapy was perfectly suited to both surveillance and the new era of scientific psychiatry in Germany. It allowed for the constant scrutinizing of patient behavior as well as the continual monitoring and charting of pulse, blood pressure and temperature. It had other important implications as well. German asylum physicians had been somewhat reluctant to embrace a policy of non-restraint, and had suffered more than a little criticism by their international colleagues for it. Bed therapy allowed them to take Griesenger’s advice and replace “mechanical surveillance with live observation and care,” (Engstrom, p. 64), thus bringing German psychiatry into the mainstream of the international non-restraint movement [see Mechanical Restraints].
Bed therapy and the surveillance it required also served the purpose of keeping order in the bedlamic setting of the asylum, and it was orderliness, methodical regulation, and regimented control that finally erased the distinction between the asylum and the hospital, as well as between mental and physical illness. Although scientific psychiatry implicated the brain and the central nervous system as the seats of insanity, the successful treatment of it required that patients acknowledge they indeed were insane, and bed therapy was a convincing therapeutic for doing just that. Confined to bed and monitored, the patients assumed the sick role, and took the asylum physician’s interpretation and diagnosis of “sick” as their own. These contributions of bed therapy to scientific psychiatry were summarized by Clemens Neissen, assistant physician at the Leubus Asylum in Silesia:
The introduction of treatment in bed in cases of insanity is the last and definite step towards regarding the insane as sick people. Through this the hospital character will become impressed on the insane asylum absolutely; a true and positive care of the sick will follow, and the therapy (especially in the acute psychoses) will be based upon a physiologic conception of the subject [Neissen, p. 291].
Scientific psychiatry required that bed therapy be tightly regimented. The patients first were bathed, then medically examined before being placed in beds; very restless and agitated patients often were consigned to mattresses with three feet high padded sides until calm enough to lie down in beds. As improvement progressed the patients were allowed to sit up and even to take a short stroll outside, but with that exception and one more of a single toilet break, they were not allowed to leave the bed. Any resistance to staying in bed was met with a kind but firm reminder that the patients’ sickness required it; distractions in the form of food, newspapers, or holding hands with a nurse or attendant were recommended to overcome any opposition. The typical patients remained in bed for up to two months; any longer risked creating what was known as the “bed urge,” that is, a refusal to ever leave it.
Bed therapy also required augmented skills for attendants and nurses alike. Not only were they expected to maintain order by keeping patients in their beds, but to prevent bed sores and assist patients with bed pans. German asylum physicians, who had enjoyed a rather high and mighty status that kept them aloof from staff, now found themselves having to educate and supervise their underlings.
Outside of Germany, bed therapy was adopted in Sweden; in Buenos Aires, Argentina by Domingo Cabred at the Lujan Lunatic Asylum; in Denmark by August Wimmer who, upon taking the position of medical superintendent of Sankt Hans Hospital in Copenhagen confined most of the patients to bed; in Russia by Sergei Korsakoff at the Preobrazhenski mental hospital; and in the Netherlands by Jacob vanDeventer at the Meerenberg Asylum when he assumed his position as medical superintendent in the late nineteenth century. Because of vanDeventer’s reported success with bed therapy, other Dutch asylums adopted it as well, but only after architectural changes had been made. Bed therapy required large wards with attached observation rooms, and it is most likely that these architectural demands were behind the unwillingness of American asylum physicians to try it. In the late nineteenth century state asylums were still being built across the country, most of them on the “Kirkbride Plan,” a minutely detailed plan of “moral architecture” which was much more conducive to the activities and independence of moral treatment [see Moral Treatment] than the passivity and dependence of bed therapy.
Strict confinement in a bed placed on an open veranda or in a tent on the grounds of an asylum. The open air treatment was predicated on observations regarding the successful treatment of the contagious bacterial infection of tuberculosis. Although it is likely that tuberculosis, also known as consumption, has a history almost as old as the human race, it was not recognized as a unified disease until the early nineteenth century, and not considered curable until a few decades later when the German physician, Hermann Brehmner, himself a tuberculosis patient, introduced the sanatorium cure that featured good nutrition, rest, and fresh air.
The ravages of tuberculosis were all too familiar to physicians and lay people alike. The English novelist and social critic Charles Dickens described it in this manner:
There is a dread disease which so prepares its victim, as it were, for death; which so refines it of its grosser aspect, and throws around familiar looks, unearthly indications of the coming change; a dread disease, in which the struggle between soul and body is so gradual, quiet, and solemn, and the result so sure, that day by day, and grain by grain, the mortal part wastes and withers away, so that the spirit grows light and sanguine with its lightening load, and, feeling immortality at hand, deems it but a new term of mortal life; a disease in which death and life are so strangely blended, that death takes the glow and hue of life, and life the gaunt and grisly form of death; a disease which medicine never cured, wealth never warded off, or poverty could boast exemption from; which sometimes moves in giant strides, and sometimes at a tardy sluggish pace, but, slow or quick, is ever sure and certain [Dickens, p. 734].
This “dread disease” was represented in popular novels, such as Thomas Mann’s The Magic Mountain, stage plays such as Alexandre Dumas’s The Lady of the Camellias, and operas such as Giacomo Puccini’s La Bohème, but its relationship to insanity was first conjectured in the mid-nineteenth century by Thomas Clouston, superintendent of the Scottish Royal Edinburgh Asylum, also known as Morningside. Based on comparative autopsy data, he found that tuberculosis was more frequently assigned as the cause of the death of asylum patients than of the general population, and that the number of asylum deaths from tuberculosis had increased significantly over just the previous three years. Based on these data, Clouston asked two questions that influenced the practice of open air rest: did tuberculosis cause insanity, and/or do the conditions of asylum life cause insanity? In answer to his first question, Clouston proposed that tuberculosis indeed caused a particular type of insanity which he termed phthisical insanity, characterized by morbid suspicion, withdrawal, irritability, food refusal, and adolescent onset. Open air rest, in so far that it replicated the therapeutically successful sanitaria cures, was established in many asylums to treat the phthisical patient.
Tent therapy at the Manhattan State Hospital in New York, circa 1902. Twenty patients diagnosed as “demented” and “filthy,” that is, unable to tend to their bodily needs, spent the summer in a large tent on the asylum grounds. The experiment was deemed an unqualified success. All of the patients gained weight, participated in exercise, and improved their personal self care (A.B. Wright [1902]. Tent therapy for the demented and uncleanly. American Journal of Insanity, 59, Plate XI).
The contagious nature of tuberculosis answered Clouston’s second question. In crowded, and often unsanitary asylums, the transmission of tuberculosis was a considerable risk for patients and staff alike. Thus open air rest for non-phthisical patients was used as a prophylactic against the disease. At the Ayr District Asylum in Scotland, for example, all newly admitted patients as well as those who had recently relapsed, were confined to beds, separated by wooden screens, on one of the large specially constructed verandas. They remained there from seven in the morning until seven in the evening. as much of the year as possible. In the absence of long-term data on the effects of open air rest, superintendent Charles Easterbrook nonetheless concluded that “it is a more satisfactory method of treating those who are actively insane than either outdoor exercise or indoor rest” (Easterbrook, p. 724). He cited the “rapid subsidence of the active mental and nervous symptoms…[the] rapid amelioration of mania, melancholia, delirium, confusion, stupor, vivid hallucinatory and delusional manifestations, impulsiveness and mental excitement” (p. 737) as evidence of its therapeutic success. Joseph Wiglesworth reported similar success at the asylum in Rainhill, England, where he was superintendent. Although he advised against using open air rest as a panacea, his experience led him to the conclusion that
certain patients get well under this treatment who would not otherwise have recovered, and that the convalescence of many others is appreciably hastened. Even if no more could be said than this, the treatment would more than repay the little extra trouble involved in carrying it out [Wiglesworth, p. 106].
In the United States, open air rest often took the form of what was called tent treatment. At asylums such as the Manhattan State Hospital East, formerly known as Wards Island Asylum in New York City, large tents replete with coal stoves were pitched on the asylum grounds. There both the tubercular insane, the term preferred over “phthisical” by American asylum physicians, and the “dirty” insane, a term used worldwide to label patients who urinated and defecated on themselves, were confined to bed throughout the year. In many American asylums in the early twentieth century, tents were replaced with wooden pavilions, expansive porches or large sun rooms, and the therapeutic value of bed rest gradually took second place to the therapeutic value of fresh air, as patients were increasingly encouraged to actively engage with their surrounding environment.
A strictly enforced regime of six to eight continuous weeks of bed rest, isolation, intellectual and creative inactivity, a diet rich in milk and meat, massage and electrotherapy. The rest cure was devised by the American neurologist Silas Weir Mitchell in the late nineteenth century as a cure for neurasthenia, or nervous collapse.
The term “neurasthenia” was not coined by Mitchell, with whom it was so intimately associated, but by Edwin Holmes Van Deusen, medical superintendent of the Michigan Asylum for the Insane in Kalamazoo, Michigan. Van Deusen had used the term to describe a kind of nervous prostration that had culminated in insanity for some of his patients, most of them hard-working, rurally isolated farmers and, even more likely, farmers’ wives. Lonely, bored, depressed and often overburdened with the demands of child care and housekeeping, the wives were particularly prone to the irritability, insomnia, indigestion and general malaise that were the early warning signs of neurasthenia and that, in Van Deusen’s assessment, developed into insanity if ignored. The treatment of neurasthenia, though, made no special demands on physicians or on the asylums in which they practiced. Gentle exercise, sponge baths, improved nutrition and nerve tonics such as quinine were all indicated and Van Desuen confidently reported that once convalescence commenced there was no tendency to relapse.
Coincidentally, the term “neurasthenia” was being used at the same time by George Miller Beard, a New York neurologist, to describe a chronic functional disease of the nervous system brought on by the hectic pace of urban life, which was made even more so by American “civilization itself,” with its “railways, telegraphs, telephones and periodical press” (Beard, p. 255). Just as Van Deusen had, Beard considered neurasthenia not just treatable but curable. He prescribed exercise, exposure to air and sunlight, a change in diet and, most importantly, electrotherapy that toned up nerves, revitalized nervous energy and repaired nerve tissue.
The fact that Van Deusen attributed the cause of neurasthenia to rural isolation and boredom, and Beard to urban crowding and overstimulation, “aptly illustrated neurasthenia’s capacity to be all things to all medical men” (Oppenheim, p. 93). So to another of those medical men, neurologist Silas Weir Mitchell, it was imagined to be a depletion of nerve force that irritated the brain, the digestive organs and the reproductive system—the latter more so, and with greater debilitating consequences, for women than men. The rest cure was particularly suited to treat women, he argued, if only because the fairer sex better tolerated the ennui of repose and seclusion.
If the rest cure was gendered, it also was classed. Increasingly, physicians in the United States and Europe, where neurasthenia had migrated as a diagnosis, recognized that nervous exhaustion had no economic or social class boundaries, but the rest cure typically was administered to well-heeled women, and occasionally men, to ready them for their highly gendered roles in rapidly modernizing Western society. By enforcing intellectual and creative inactivity, the rest cure assured that neurasthenic women abandoned the pursuits and desires that Mitchell believed undermined their health and reproductive functions. With its combination of high protein diet and bed rest, the rest cure also packed on pounds, sometimes as much as thirty to fifty pounds during a six to eight week course of treatment, thus women patients gained “flesh and color, which means gain in quality and quantity of blood” (Mitchell, 1888, p. 137) and with it, a renewed vigor “to make [them] as a mother more capable, as a wife more helpful” (Mitchell, 1888, p. 150). For men, the rest cure revitalized the nervous system and energized them for their important role as the “brainworkers” who assured the steady progress of commerce and culture.
Public asylums, however, were not filled with these educated, skilled and moneyed kinds of patients. Rather, they were teeming with lower and working class women and men whose insanity did not so much exhaust as disorientate, baffle and delude; they were packed with patients who had little prospect of ever being discharged, let alone being remade into productive citizens. The rest cure ala Mitchell, then, was more likely to be administered in the homes of the neurasthenic patients, or in private asylums, sanitaria or nervine clinics, the latter of which were specially designed for its administration.
Mitchell nonetheless excoriated the physicians of public asylums for not providing at least a semblance of the rest cure, not just for the neurasthenic patients who could be found on their rolls, but for insane patients in general:
Have you people in your asylums trained to use massage? I see plenty of folks in your wards who need this potent blood-stirring tonic. In how many [asylums] is there an electric room and an electrician? … [S]ome of us think hydrotherapeutics of great value. How many [asylums] are provided with the appliances for such treatment? How many of you employ it at all? [Mitchell, 1894 p. 433].
Indeed, some pastiche of the rest cure was patched together in many public asylums towards the end of the nineteenth century; hydrotherapy suites were constructed [see Hydrotherapy], nutritional standards were raised, blood tonics and restoratives were routinely administered, and bed rest sometimes was prescribed. But by the early twentieth century what variously had been called the “fashionable disease” and the “distinguished malady” of neurasthenia had all but disappeared. In many ways it was a victim of its own popularity. The claims that had been made about it “were too vast; the novelty and convenience of the label prompted [physicians] to apply it too sweepingly, so that it covered everything from extreme fatigue to temporary insanity” (Oppenheim, p. 109). Neurasthenia had become everything and, at the same time, nothing. And with its disappearance, the rest cure disappeared as well.
The alteration of respiration and brain metabolism by inducing temporary anoxia.
In the late eighteenth century a well-educated and well-traveled physician by the name of Caleb Hillier Parry set up practice in the fashionable spa town of Bath, England. Many well-to-do people were in the habit of “taking the waters” at the spa, either for relaxation or restoration. One of them was a young woman who suffered from fainting spells that were preceded by throbbing in the head, flushing and hypersensitivity to light and sound. She was referred to Parry when conventional medical treatments had failed. Theorizing that many diseases, most particularly those of a “nervous” origin, as he assumed hers was, were due to a “determination of the blood” due to its excessive flow to and through the brain, he pressed on her carotid artery and immediately terminated the prodromal phase of her fainting spell.
In a presentation to the Medical Society of London, Parry discussed his experiments with slowing the heartbeat through carotid compression and proposed that it should be considered an effective therapeutic for the treatment of nervous disorders, mania, paroxysms of occasional insanity, and even “permanent insanity,” all of which he attributed to the increased impetus of blood that irritated the brain. Parry’s promotion of carotid compression to remediate the symptoms of insanity drew the attention of asylum physicians. Among them was John Gideon Millingen, medical superintendent of the County of Middlesex Pauper Lunatic Asylum, more often known simply as Hanwell, after its location just outside of London. Hanwell was the first purpose-built asylum in England, accommodating nearly 500 patients and had quickly developed a reputation for therapeutic innovation. Millingen used carotid compression to relieve the “excitement” of the brain, although there is no indication he did so frequently or, for that matter, with enthusiasm. He mused that perhaps a yoke of some kind could be constructed and placed around the patient’s neck to free asylum physicians from the somewhat risky intervention of placing their hands on, or around, the necks of their patients. Carotid compression also was advocated by George Mann Burrows, who boasted he was able to calm a violent manic fit with a single finger pressed on the carotid artery. Although Parry had asserted that pressure on both carotid arteries would do the same in a case of violent insensibility and even restore the senses in the bargain, Burrows could not replicate the result with the patients he cared for at his small private asylum near London.
It was not so much carotid compression as a therapeutic that was controversial as it was the theory of insanity that justified its use in the first place. Perhaps it was not the “determination of blood” in the brain that was the cause of insanity, some asylum physicians began arguing in the early twentieth century, but brain metabolism. If that were the case, the purported efficacy of carotid compression could be better explained: the brief anoxia it produced stimulated not only post-compression respirations but brain metabolism as well. Two propositions supported this emerging theory. First, schizophrenia, inarguably the most frustratingly intractable type of insanity, was caused by deficient oxidative processes. Second, the purported success of shock therapies [see Shock Therapy] in ameliorating the symptoms of schizophrenia was due to the alterations they produced in brain metabolism—metrazol, for example, deprived the brain of oxygen; insulin deprived it of sugar. Thus the possibility emerged of treating schizophrenia and other types of debilitating insanity by stimulating respiration and altering brain metabolism with a variety of different chemical agents.
“Cerebral stimulation” was appropriate as a label for these therapeutics; their actions were hypothesized to be directed to the brain. But their influence on the mind was a matter of increasing interest, a consequence, no doubt, of the growing influence of psychoanalysis in the early twentieth century. Psychoanalysis was the brainchild of the Viennese neurologist Sigmund Freud. As a set of techniques for accessing and treating the mind, it was regarded as much more suitable for the treatment of neurosis than psychosis or more particularly, for the outpatients of private practices than the inpatients of asylums. Freud himself had expressed doubt that psychoanalysis would ever be effective as an asylum therapeutic, a doubt not only shared by most asylum physicians but amplified by their concern that it actually might be harmful.
Psychoanalysis was not just a set of techniques, however, it also was a structural and dynamic theory of the mind. It was that facet of it that exercised considerable sway over asylum physicians, so much so that the term “cerebral stimulation” gradually, and without apparent comment, was replaced with “psychic stimulation.” The effects of the administration of these anoxic chemicals, then, were increasingly described in psychoanalytic terms: they were said to activate the unconscious, loosen repressive controls, encourage insight and expression. It was the putative psychic stimulation, in fact, that accounted for the use of anoxic chemicals for several decades after their cerebral stimulation had been discredited. By the mid-twentieth century, however, cerebral or psychic stimulation was no longer in use as an asylum therapeutic.
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The manipulation of the oxygen level of the bloodstream by the alteration of air pressure. Upon his arrival at St. Elizabeths Hospital in Washington, D.C., Walter Freeman was determined to find a cure for schizophrenia. In the mid–1920s the federal asylum, located on a bluff overlooking the confluence of the Potomac and Anacostia rivers, held thousands of patients. Most of those diagnosed with schizophrenia were considered incurable and had been consigned to languish in the back wards. Freeman, whose name would later become synonymous with the controversial surgical procedure of the lobotomy [see Psychosurgery], was an unabashed somatist and as director of the asylum’s laboratory had free reign to examine the bodies and brains of deceased patients. To his consternation he was unable to discover anything that differentiated patients with schizophrenia from patients with other disorders or, for that matter, from persons with no history of insanity whatsoever.
Although stalled in his own research, Freeman was impressed by the methods of what was variously referred to as “cerebral stimulation” or “psychic stimulation” that were being used to treat patients with schizophrenia in various asylums in the United States. At St. Elizabeths he tried to replicate their purported success. He treated schizophrenic patients with carbon dioxide and with sodium amytal, and although he was unimpressed with the results, he remained intrigued by the underlying theory that altering brain metabolism would remediate schizophrenia. Hypothesizing that doing so by non-chemical means may be more efficacious, he sought a way to improve brain metabolism by altering the level of oxygen in the bloodstream. This hypothesis brought him to the Washington navy yard where he subjected himself to sessions in a hyperbaric chamber. He noted that low pressure resulted in headaches and mental dullness; a pressure of forty-five pounds per square inch, or three atmospheres, resulted in hypomania. For patients who had been rendered unresponsive, mute and dazed by catatonic schizophrenia, he reasoned, this hypomanic state would constitute an improvement, not to mention an opportunity for psychotherapeutic intervention.
When administered to patients at St. Elizabeths, however, the manipulation of air pressure failed to live up to expectations. The only observable effect, Freeman wryly noted, was that one catatonic patient who spent time in a hyperbaric chamber was stimulated enough to eat a sandwich instead of being tube-fed. Freeman concluded that air pressure variation was not a viable method of producing cerebral stimulation. Other asylum physicians who experimented with it concurred.
The inhalation of a mix of 30 percent carbon dioxide (the average atmospheric amount is .03 percent) and 70 percent oxygen. The therapeutic caused rapid and deep breathing, heart rate increase, anxiety, panic and eventually unconsciousness. Developed in the late 1920s by Arthur Solomon Loevenhart and colleagues at the University of Wisconsin during their investigation into the metabolic processes of the respiration center in the brainstem, the therapeutic was found in small scale experiments to alleviate the symptoms of catatonic schizophrenia as well as manic-depression and involutional melancholia.
Loevenhart’s experiments with carbon dioxide inhalation came to the attention of László Meduna. The Hungarian born physician, who already had made his name as “the father of shock therapy” for his development of metrazol shock therapy [see Shock Therapy], became intensely interested in the potential of this therapeutic. In his brief autobiography, written for the first issue of the journal Convulsive Therapy, Meduna offered the backstory to this interest. While still in Hungary, he had heard from a German colleague that “some Americans,” presumably Loevenhart and his colleagues, were using “some gas” to resolve the symptoms of catatonic schizophrenia (Meduna, 1985, p. 133). After making inquiries, he heard the Americans were injecting pure oxygen into the subarachnoid space between the cerebellum and the medulla of the brain, known as the cerebellar cistern. Because he could not read English, Meduna was unable to confirm this information against the published report. Nonetheless, he enthusiastically began injecting pure oxygen into the cerebellar cisterns of asylum patients diagnosed with catatonic schizophrenic. “Naturally,” he wrote with neither irony nor regret, ”I did not succeed” (p. 133). It was only later that he learned that the gas being used was carbon dioxide, not oxygen, and that the method of administration was inhalation, not injection.
Armed with these facts, Meduna then attempted to replicate the findings of Loevenhart and colleagues, but with generally poor results. Some of the catatonic schizophrenic patients he treated did seem to benefit from the inhalation of carbon dioxide; they became more responsive, communicative and mobile, just as Loevenhart and his colleagues had found. These effects, however, were short-lived. Every patient Meduna treated slipped back into the catatonic condition within half-an-hour of inhaling the gas. Meduna, for a time, discontinued administering the therapeutic—at least to schizophrenics.
Reasoning that schizophrenia was the result of a biochemical disturbance that was largely unaffected by carbon dioxide inhalation, Meduna considered its use for psychoneurotic asylum patients. This relatively new diagnostic category contained a broad range of anxieties, phobias, compulsions and disturbances of everyday life that were thought to be psychological, rather than neurological, in origin. It was with some of these patients that Meduna boasted success. Giving them the standard mix of 30 percent carbon dioxide and 70 percent oxygen over sixty to one hundred separate sessions, Meduna noted improvement for sixty-eight of his first one hundred patients. The most resistant to improvement were the patients who had been diagnosed with obsessive-compulsive neurosis, but significant successes were noted for patients whose complaints ranged from tension, frustration, anxiety, maladjustment, phobias, nervous tics, homosexuality to stuttering. It was, in fact, in regards to stuttering that the positive results of carbon dioxide inhalation therapy were most remarkable.
Following Meduna’s protocol, D.H. Clark also treated psychoneurotic patients at the Maudsley Hospital in south London. He was particularly struck by the abreactions that Meduna also had noticed, but had not discussed in great detail. Some of the forty-two patients reacted violently to the administration of the carbon dioxide, screaming and fighting with the doctors and nurses; a few engaged in sexualized behaviors, and one had orgasmic spasms. Her case, which reveals as much about the nature of psychoneurosis as it does about the risks of the administration of carbon dioxide inhalation therapy, was discussed in some detail:
Case 4: An unmarried woman of 32 complained of lassitude, dyspepsia, and difficulties in social relationships. She had a disturbed unhappy childhood and lifelong personal difficulties; despite good intelligence and an adequate education she had failed various careers, including nursing; she had several close women friends, but had always showed a marked dislike of men. She had 18 administrations…. She always showed a marked reaction, and on five occasions exhibited body arching and thigh flexing of an unmistakably sexual nature. On recovery she usually wept bitterly, but expressed a desire to carry on with the treatment, claiming that she was better. Two days after her 18th administration, however, she had to be admitted to hospital in a dissociated state which rapidly developed into a state of terror and hallucinations, during which she heard voices accusing her of being a sex maniac and a beast. This state has persisted with brief intermissions for over a year, with only transient improvements over a course of electroconvulsive therapy and later a planned psychotherapeutic approach over two months; she remains a patient in a disturbed ward and … was being considered for leucotomy. In her clearer periods she says she has no doubt that the carbon dioxide treatment made her worse [Clark, p. 724].
The woman was one of nine patients whose condition worsened after the administration of carbon dioxide inhalation therapy. Twenty of the treated patients, however, improved, some of the significantly. And that begged the question: why did the therapeutic work at all? On this point, Meduna had borrowed heavily from the theory of Warren Sturgis McCulloch, a distinguished American physician, neurophysiologist and cybernetician, who had hypothesized that the psychoneuroses were, in essence, a perversion of the reflex circuits. Impulses were diverted from their usual circuit, he argued, into recurrent nervous circuits where they reverberated indefinitely, forming a kind of “repetitive core” that was the diagnostic hallmark of the psychoneuroses. Meduna suggested that this inappropriate circuiting was due to a low threshold, that is, a reduced capacity to conduct nerve impulses, of the component neurons. Carbon dioxide inhalation, he concluded, increased that threshold.
Meduna’s post hoc neurological explanation for the efficacy of carbon dioxide inhalation therapy with psychoneurosis was hardly compatible with the reigning psychological explanation of its cause. As a result, the theory of Joseph Wolpe of the Medical College of Pennsylvania, quickly eclipsed that of Meduna. Wolpe theorized that the maladaptive anxiety that was at the core of all of the various psychoneuroses was the result of learning, that is, it was a conditioned response to the conflict or noxious stimulation that produced it in the first place. Reasoning that the inhalation of carbon dioxide would inhibit free-floating, or pervasive, anxiety by creating intense respiratory excitation and/or by creating later reactive relaxation, he administered the therapeutic to five patients, without significant benefit for four of them. But it worked well for the fifth, a patient who had been diagnosed with “war neurosis,” and who was extremely anxious and had startle responses to loud noises and thunder. Taking one full breath at a time of the carbon dioxide mixture twice a week, the war veteran was cured of his anxiety. So was a scientist Wople had treated for the free-floating anxiety he had suffered for a decade. The scientist described the administration and the effects of the carbon dioxide inhalation therapy in the following manner:
Having emptied my lungs, I put the mask on and inhaled the gas through my mouth as deeply as I could. For a second or two nothing happened. Then I noticed rapid breathing, and for a moment everything became brilliant and detailed. I remember shutting my eyes and holding the cover of the sofa as the gasping for breath became more intense. Then I felt a tingling in my arms and legs and a very odd feeling of being affected all through. When my breathing returned to normal, I felt somewhat more calm and relaxed than usual…[I] discovered that I was already more relaxed than I could ever remember having been before [Wolpe, p. 130].
Wolpe had less success in treating patients with phobias. To desensitize them to the object of their fear, he administered the carbon dioxide mixture and when moderate hyperpnea (deep and rapid breathing) was evident, he asked them to imagine or verbalize a scene from an anxiety hierarchy. This procedure was repeated, using a scene one higher rung up in the hierarchy until the scene ceased to be disturbing. Carbon dioxide inhalation facilitated desensitization; however, it worked well with patients suffering from panic attacks. Theorizing that these patients were reacting to a fearful symptom and that their reaction increased the likelihood they would experience the feared symptom, and on and on in a viciously escalating circle, he administered carbon dioxide inhalation therapy at a time of relative calm until they demonstrated a reduced anxiety in relation to the feared symptom.
While Wolpe recommended the therapeutic, especially for patients with free-floating anxiety, not all asylum physicians had similarly positive results. J.R. Hawkins at the Midland Hospital for Nervous Disease in Birmingham, England, for example, found that patients administered carbon dioxide inhalation therapy fared no better or worse than those administered compressed air under identical conditions. Results like this reinforced for Wolpe and other practitioners of the therapeutic that its effects may be due to nothing more than suggestion, and/or the fear that the sensation of suffocation produced. Indeed, many of the physicians who entered asylum practice in the 1950s through 1970s were more psychologically than somatically orientated and would not use carbon dioxide inhalation therapy without intensive adjunctive psychotherapy, a time-consuming and, on the bottom line, expensive treatment modality for crowded and understaffed asylums.
Carbon dioxide inhalation therapy was used for some time in asylums. Despite the fact that Meduna’s initial use of it was largely ineffective in treating psychosis, and that his neurological theory of what limited success it did have had been discredited, the therapeutic remained so strongly associated with him that the standard mix of 30 percent carbon dioxide and 70 percent oxygen was known as Meduna’s Mixture.
The continuous exposure of patients to an atmosphere containing between 45 and 50 percent oxygen, and between 3 and 4 percent carbon dioxide. The treatment was designed by Leland Hinsie of the New York State Psychiatric Institute and Hospital in the early 1930s. Reflecting that era’s trend to consider schizophrenia as caused by a deficiency in the oxidative processes in the cerebral cortex of the brain, Hinsie and his colleagues placed five catatonic schizophrenic patients in a small portable Barach oxygen chamber where they remained for eighty-seven continuous days. None, however, showed improvement.
Theorizing that the presence of carbon dioxide would make more oxygen available for the cortical brain cells, Hinsie and his colleagues modified their approach. They placed ten catatonic schizophrenic patients in oxygen chambers for ten continuous weeks, however, once a day for six days of the week they were removed from the chamber and placed in an oxygen tent and given inhalations of a mixture of 15 to 20 percent carbon dioxide and 80 percent oxygen via a hood placed over their heads. Before being placed back into the chamber, attempts were made to engage the patients in conversation; when conversations could be sustained, they continued for one to two hours. Two of the patients in this modified procedure improved to the point of remission. The clinical abstract of one of them in particular offers an interesting glimpse into what was understood as the nature of catatonic schizophrenia, as well as into the mediated interaction between patient and therapeutic.
E. Ha, age 23, single…. The onset of his psychiatric disorder was in part at least associated with his effort to develop a love affair with a girl. It was a relatively acute onset, characterized by confusion, anxiety, ideas of reference, insomnia. He subsequently became stuporous, mute, inactive when left alone and negativistic under stimulation…. Treatments were started on April 18, 1931. He protested with great vigor against the administration of carbon dioxide and it was necessary to take such measure as would prevent him from destroying the hood that was placed over his head while carbon dioxide was being given. Treatments were discontinued on June 6, 1931. He began to show improvement during the first week in May, 1931. The improvement continued steadily and he was discharged from the hospital on November 10, 1931, as recovered [Hinsie, Barach, Harris, Brand & McFarland, p. 45].
Seven of the patients in the modified treatment showed partial improvement, and the remaining showed no improvement whatsoever. The clinical abstract of one of those unimproved patients was especially revealing of the complicated family dynamics that just a few decades after brain metabolism theories fell out of vogue, would be considered a possible cause of his catatonic schizophrenia:
E. We., age 19, single. A quiet, seclusive home boy, who was described by his mother as always having been “like a girl.” He was slow, deliberate and disinterested. His only consistent activity was observed in school work. He was bashful, a day-dreamer and never had any companions. What little emotions he exhibited were toward his father. “He was all for his father.” But there were times when he showed antagonisms and these were ordinarily toward his mother. From the age of 4 until 6 (when his father died) he slept with his father. The onset of the psychiatric disorder was insidious; character changes were observed at the age of 14; he became more seclusive at 16 when his father died. He complained of inability to think, insomnia and restlessness. His symptoms became progressively worse; at the age of 19 he began to attitudinize and at times developed periods of excitement during which he assaulted his mother…. From March 15, 1932, until June 10, 1932, he resided continuously in the oxygen chamber. During this time he also received short daily inhalations of carbon dioxide. There were no essential changes during this period, save for the great resistance to carbon dioxide administration. Subsequent to treatment his condition has remained the same—mutism, rigidity, immobility, apathy, unkemptness [p. 47].
Hinsie and his colleagues found the results of the modified continuous oxygen therapy to be promising and decided to carry it out on a larger scale. To that end, they converted a dormitory into an oxygen chamber so that patients could reside in a familiar environment. The dormitory was made leak-tight by heavy coats of paint on the floors and ceiling, and a rubber-gasketed door was put into place. A motor-blower unit delivered the ventilation and the temperature of the room was maintained between 60° and 70° F. Most importantly, the atmosphere of 45 to 50 percent oxygen and 3 to 4 percent carbon dioxide was maintained through carefully calibrated regulators.
Ten patients lived in this dormitory for ten weeks; half of them had no other treatment while the other half had inhalations of carbon dioxide and oxygen six days each week and for ten to fifteen minutes duration each time. For those who had no other treatment than the oxygenated dorm room, no clinical alterations were noted during the period of their confinement. For those who had the adjunctive carbon dioxide inhalation therapy, however, the changes were unexpected and, in Hinsie’s opinion, directly related to the treatment. The changes comprised of:
(1) a distinct and often overwhelming fear of death or injury, followed by vigorous resistance to the inhalation of high concentrations of carbon dioxide. When it appeared that consciousness was about to be lost, the patients protested with great fervor. (2) The strenuous objections were manifested by physical resistance, or by verbal resistance, or by both. Not infrequently the patient beseeched the physician to release him from the impending fearful experience and he promised to speak if the treatment were not given [p. 42].
When the entire procedure had finished, Hinsie and his colleagues further noted, the patients tended to “return to the condition that prevailed before treatment was instituted” (p. 42). Such startling and disappointing results left Hinsie and his colleagues to call into question whether the improvement they had noted in a few of the patients in the earlier version of continuous oxygen therapy had, in the end, anything at all to do with the treatment. On the basis of their findings, Hinsie and his colleagues could not advocate continuous oxygen therapy as a treatment for catatonic schizophrenia.
The replacement of inhaled oxygen with approximately six liters of nitrogen per minute through a tight fitting face mask. Developed by Frederick Alexander and Harold Himwich at the Albany Medical College in New York as a safer and more manageable alternative to metrazol and insulin shock treatments [see Shock Therapy], nitrogen inhalation therapy produced short periods of cerebral anoxia with transient facial twitching, clonic contractions of the muscles and unconsciousness. Lasting only five to six minutes, the treatment was immediately terminated by the administration of oxygen. Nitrogen inhalation therapy typically was administered three times per week and because it did not produce confusion, stiffness or soreness, patients required little post-treatment nursing or supervisory care.
In 1938 Alexander and Himwich administered more than 300 nitrogen inhalation therapy treatments to twelve schizophrenic patients at the Albany Hospital without serious complications. Four of the patients went into “full remission, although one had a “mild relapse”; one “greatly improved”; one “definitely improved” and showed “better adjustment”; three “improved,” one with “better adjustment” and one not; two “somewhat improved” and one of them “left of own accord”; and one remained “unimproved” (Alexander & Himwich, p. 646). Although these evaluative terms were not defined, Alexander and Himwich concluded that the ease of administration of nitrogen inhalation therapy and its low risks to patients constituted convincing evidence for its further use.
But how did it work? Basile Lipetz, who had been involved in the pioneering use of the therapeutic at the Albany Hospital, demonstrated that nitrogen inhalation therapy not only deprived the brain of oxygen, a critical metabolic factor, but carried the resulting cerebral anoxia further by reducing the saturation of hemoglobin to a mere 15 percent, one-third the saturation rate produced by metrazol shock treatment [see Shock Therapy]. It was this severe, albeit short-termed, cerebral anoxia, he argued, that was responsible for the effectiveness of the treatment.
Lipetz brought a somewhat more critical evaluative eye to the outcomes of nitrogen inhalation therapy for the seventeen schizophrenic patients he had treated. He defined the outcome for each with a very brief clinical vignette that provided a glimpse into how improvement was envisioned, if not measured. For the five patients who went into remission, for example, he described changes in behavior and mood that were indicative of cure, such as “more cheerful, less seclusive,” the number of treatments after which the changes were noted, the length of remission, and the current mental status of the discharged patient. Similar details were noted for the five patients who showed no improvement. For the remaining seven patients, however, the differences between the evaluations of “greatly improved,” “improved,” and “slightly improved” were perplexing. The “great improvement” of one patient, for example, was based on her developing doubts about her delusions; the “slight improvement” of another was rather redundantly based on “some improvement noted” (Lipetz, p. 499).
The imprecision in evaluative language both problematized the replication of the findings of these early reports on the effectiveness of nitrogen inhalation therapy, as well as dampened the enthusiasm for its widespread use. At Brooklyn State Hospital, for example, Leonard Sillman and Christopher Terrence found that when they used more rigorous evaluative definitions their nitrogen inhalation therapy patients had an improvement rate equal to the 20 percent spontaneous remission rate of schizophrenia. They saw no reason to recommend it.
The administration via a well-fitting rubber mask of nitrous oxide, colloquially known as “laughing gas.” The colorless, odorless gas was hypothesized to increase the oxygen-carrying capacity of the blood vessels.
At the Warren Sate Hospital in Pennsylvania, E.J. Fogel and his colleagues administered nitrous oxide to twelve patients experiencing an acute episode of schizophrenia, as well as to twelve patients whose schizophrenia had been chronic for longer than two continuous years. All of the patients reported having experienced pleasant dreams during the five minute treatment sessions, and looked forward to continued treatments over several subsequent days. Only the acute patients, however, experienced any amelioration of their symptoms, and those changes were transitory. Fogel, nonetheless, argued that because nitrous oxide inhalation therapy was both easy to administer and well-tolerated by patients, it might be considered in some cases a viable alternative to insulin shock therapy [see Shock Therapy], or at least as a preparation for it.
Frederick Alexander and Harold Himwich at the Albany Medical College in New York disagreed. They found that the brief amelioration of symptoms post-nitrous oxide inhalation for the twenty schizophrenic patients they treated was often followed by an increase in cognitive confusion. In addition, reports of nausea and findings of cardiac arrhythmias for some of the patients argued against its use as an asylum therapeutic.
The injection of small doses of sodium cyanide, a highly toxic asphyxiant, to alter respiration and thus brain metabolism. The therapeutic was first experimentally used by Arthur Solomon Loevenhart who was conducting research at the University of Wisconsin on metabolic processes in the respiratory center located in the medulla oblongata, the lowermost part of the brainstem. In experiments on dogs, he attempted to stimulate the respiratory center with lactic acid, atropine sulphate, caffeine and strychnine sulphate, but discovered that sodium cyanide was particularly effective to the task while not simultaneously raising blood pressure. Further experiments showed that the continuous, as opposed to intermittent, administration of the drug produced continuing stimulation of the respiratory center.
In this dawning era of biological psychiatry, one emerging area of inquiry was on metabolic theories of insanity. Because respiration was considered a key element in both brain blood flow and metabolism, the respiration patterns of asylum patients was of some interest. It was noted that neurotic patients tended to have shallow respirations, irregular inhalations and exhalations, and sighing, while psychotic patients variously had low, irregular or rapid respirations. Thus the brain flow and metabolism were compromised in both groups.
The prospect of producing continuous respiratory center stimulation of almost any intensity and duration through the administration of sodium cyanide to these patients enticed Loevenhart to focus further research on asylum patients diagnosed with catatonic schizophrenia. Their inert, often silent and even motionless state, allowed for the easy observation and measurement of their breathing; it also obviated the concern about obtaining informed consent. He administered sodium cyanide to ten asylum patients and produced results that fully supported the earlier animal experiments. Each patient showed marked and almost immediate improvement. The most dramatic recovery was noted in a twenty-one-year-old patient. Institutionalized for a year, he had never spoken a word, but after receiving a continuous drip of sodium cyanide over sixty-four minutes, he “conversed, answered questions and attempted to explain his prolonged silence” (Loevenhart, Lorenz, Martin & Malone, p. 128). To Loevenhart and his colleagues, the sodium cyanide had done more than stimulate the respiration center—it had stimulated the cerebrum of the brain in its entirety, and most especially its “psychic centers” (p. 129).
At the advent of World War I, Loevenhart’s laboratories at the University of Wisconsin were seconded to the Chemical Warfare Service of the United States Army. It was his experience working with a team of chemists, pharmacologists and others on organic arsenic compounds that convinced Loevenhart that a collaborative effort towards therapeutics, whether psychiatric or medical, would most benefit patients. Upon his return to civilian life, he put that ideal into practice and turned his team’s attention once again to the treatment of psychosis. He administered sodium cyanide to patients in a catatonic depression, and found that it animated them, making conversation and insight possible, but that the salutary effects could not be maintained for more than a half-an-hour.
Loevenhart died in 1929, but the Chemical Warfare Service had a continuing interest in sodium cyanide. At the start of World War II, it contacted the Hungarian physician László Meduna who already had achieved considerable notoriety for his development of metrazol shock treatment [see Shock Therapy] and asked him to experiment with its use. Meduna injected forty schizophrenic patients at the Illinois Neuropsychiatric Institute with sodium cyanide, took electroencephalographic readings during the resulting convulsions and compared them to those taken during convulsions produced by metrazol and electroconvulsive shock treatment. He found that metrazol and electroconvulsive shocks increased the activity of the cortex of the brain, while sodium cyanide reduced it to “almost complete inactivity and silence” (Meduna, p. 132), even while it stimulated the deep motor structures of the brain. In the end, however, the sodium cyanide induced convulsions were of no lasting benefits to the patients.
Sodium cyanide treatment was cautiously used in some asylums until the mid-twentieth century.
The treatment of insanity through the use of color.
In the late nineteenth century G.L. Ponza, superintendent of the insane asylum in Alessandria, Italy, speculated that solar rays might have a therapeutic effect on the insane. Influenced by observations being made in Europe and the United States that sunlight filtered through colored glass had an invigorating effect on plant and animal life and, perhaps, on human health and well-being as well, he consulted Father Pietro Angelo Secchi, director of the Roman College Astronomical Observatory, and an expert on astronomical spectroscopy. He encouraged Ponza to experiment in treating insane patients by replacing clear window panes with violet colored panes—violet being, in his opinion, the color of insanity—and painting the walls of the room the same color. A furious maniac placed in that room, he hypothesized, would be calmed and soothed by the color. Ponza reported an excellent outcome with a single patient who, after passing the day in the violet room, asked to be sent home because he believed himself cured. Buoyed by the result, Ponza immediately began experimenting with other colors: red to stimulate the melancholic, blue to calm the manic, and all with good results which he explained as follows:
The violet rays are of all others, those that possess the most intense electro-chemical power; the red light is also very rich in calorific rays; blue light, on the contrary, is quite devoid of them as well as of chemical and electric ones. Its beneficent influence is hard to explain; as it is the absolute negation of all excitement, it succeeds admirably in calming the furious excitement of maniacs [“Colored Light,” p. 451].
What quite quickly became known as the “color cure” prompted a variety of experiments in asylums around the world, but with decidedly mixed results. Henri Taguet, painted the walls and floor of a south-facing room blue in the Asylum of Ville-Evrard in a suburb of Paris, France, and fitted it with a blue window. The first patient placed in the room was in the early stages of general paresis (neurosyphilis) and was in the throes of maniacal excitement so severe that he had to be restrained on the bed. He remained in the blue room three hours, his eyes closed the entire time, leading Taguet to hypothesize that the blue light seemed to fatigue him. The following day, however, it had no effect, nor did it on the second patient who was in the throes of acute mania, nor with a hysterical patient whose only response to several hours in the blue room was the exclamation, “How very strange that blue room is!” (Aldridge, p. 117). Although Taguet found some reason to agree with Ponza that blue light produced a slight fatigue, he was forced to conclude that it did not have the therapeutic effect that Ponza had observed.
The findings of Ludwig Schager at the Vienna Asylum in Austria were more encouraging. He, too, observed the effects of several hours in a blue room on sixty patients over a three year period and found, as Ponza had, that the color had a calming, albeit not a curing, effect. His experiments with a red room to stir melancholic patients out of their torpor also had reassuring consequences. Experiments with other colors soon followed in asylums around the world. The violent patient was housed in a violet or yellow room; since either color was believed to dampen the spirits of a sane person to the point of depression, its inhibiting effect on someone violent was fully anticipated. The irritated and restless patient was housed in a brown room or made to wear brown clothing. The choice of that color may have been influenced by the idiom “in a brown study,” a phrase that can be traced back to the sixteenth century and that referred to a kind of daydreamy tranquility.
Asylum physicians argued about the effect of the absence of color, i.e., black, on the insane patient, but none seemed willing to experiment until George Zeller was appointed superintendent of the Peoria Asylum in Illinois in at the start of the twentieth century. Zeller was an ardent devotee of the color cure. Influenced not only by reports on its use from asylums physicians in France, Russia, Spain and all the way from Uruguay where a blue glass roof was constructed over the first asylum ever built there, Zeller also was inspired by the “blue glass craze” that briefly took hold in the United States. A retired Civil War general, Augustus J. Pleasonton had published a book in 1876, on blue paper and in blue ink, titled The Influence of the Blue Ray of the Sunlight and of the Blue Color of the Sky, in which he argued on the basis of his experiments that sunlight filtered through blue panes of glass increased the growth and vigor of plants, the weight and health of animals, and most certainly would have health benefits for humans as well. As a result of the “blue glass craze” his findings set off, many farmers began growing crops under blue lights, people started replacing the clear glass of their spectacles with blue-tinted glass, and asylum physicians, who may or may not have even heard of Ponza’s findings in Italy, began painting some of their rooms blue.
On his arrival at the Peoria Asylum, Zeller had seven cottages on the grounds painted blue and immediately observed its restful effect on the patients. Having heard that female workers at a film developing business where they had to work under red light were so giddy as to be non-productive, he painted one cottage red and placed melancholy female patients there. Two years later, he was pleased to report that there was a “growing cheerfulness” among them (Lisman & Parr, p. 75). Zeller then experimented with black. He placed a very violent, manic female patient in a black room, completely devoid of light, where she remained for three days, checked every half hour by a nurse, and with a physician nearby the entire time. The patient slept a great deal, and upon awakening on the third day, appeared so calm and docile that she was returned, without further violent incidents, to her regular ward. From that point on, the black room was used to quiet female patients diagnosed with hysterical insanity.
Zeller then traveled to Denmark to visit the laboratories of the late Niels Finsen, a physician and Nobel Prize Laureate who had experimented with the “light cure” of skin diseases, small pox, tuberculosis and lupus. Impressed with the results of what Finsen had called “phototherapy,” he returned to the Peoria Asylum and had red incandescent bulbs installed in an operating room to reduce inflammatory conditions, blue panes of glass in the solarium to enhance the healing of tubercular patients, and painted the walls yellow in the epileptic ward to reduce the likelihood of seizures. About these experiments with the color cure, Zeller wrote:
I have been exceedingly reticent in claiming beneficial results. The whole subject of phototherapy is yet in its infancy and even the literature is meager. I do not wish to add to it unpreparedly, but I do wish to say that something has benefited these patients beyond the power of the pen to describe. They have been brought here in many instance in the wildest of maniacal excitement and with no other treatment than exposure to violet or amber ray of the leucodescent lamp have speedily recovered and always and invariably without narcotics, without imprisonment and without mechanical restraint. Not only the acute but the chronic patients have improved beyond measure and our institution partakes of the nature of a village with its two thousand inmates contented and happy and engaged in a variety of labor extensive as to bring our per capita cost of maintenance far below the allowance. Some influence has calmed these excited minds and perhaps the same influence has cheered up the depressed and changed despondency into contentedness [Lisman & Parr, p. 76].
Anecdotal evidence of the curative power of color also came from the Wards Island Asylum in New York City where physicians used the standard blue to calm, red to stimulate, black to soothe, and added a bright white room for the patient who was “practically well” and almost ready to be released. A newspaper report explained how the asylum’s various colors cured by relating the case of a recently admitted melancholic woman who was being led down the hall:
First come the black rooms; these she passed without evincing any difference in her state of observation. The violet, green, and blue rooms had the same effect; before each door she paused, but did not raise her eyes. Then came the brilliant orange room. For a moment she raised her eyes, then lowered them again. Three of these rooms she passed, and was then brought abruptly in front of the room with the red walls. She raised her head instantly, looked into the room, and then about her. The vibrations produced by this color had evidently been felt by her, while the others had no effect [“Use Colors,” p. 25].
Whether it was by “vibrations,” or “electro-chemical power,” the color cure was used extensively in the early twentieth century in asylums around the world, even as experiments and controlled observations called into question the promising reports of some asylum physicians. “I am satisfied that colored light has no greater power in the cure of insanity,” wrote one asylum physician who had experimented with its use, “than colored water has in the treatment and cure of the diseased stomach of the inebriate” (Reed, p. 554). All skepticism aside, the color cure was built into asylums, from specifically colored rooms, to tinted panes of glass, to the hallways so universally painted the same calming color that the hue has come to be known as “institutional green.”
At the Salpêtrière Asylum in Paris, France, however, color was used in a particularly creative way. It was there that physician Albert Pitres cured a patient of hysteria by having her put on red-tinted spectacles every time she felt the aura of an imminent hysterical attack. In one month, she was completely cured. Although Pitres and his colleagues were investigating what they referred to as the “ocular stigmata” of hysteria, including color-blindness, tubular vision, and such a predominance of the red color field that a physician once declared that “it may be affirmed that red is the hysterical color” (Thompson, p. 88), he only occasionally prescribed the use of the red-tinted spectacles to prevent a hysterical attack, all the while warning that certain colors also could set one off.
Yet red also was considered the “schizophrenic color” by D. Ewen Cameron, then a newly appointed physician at the Brandon Hospital for Mental Diseases. Located on the prairie of Manitoba, Canada, “the Hill,” as the asylum was known to locals, had ambitions to be at the forefront of North American psychiatry, an ambition shared by Cameron who would go on to become president of the both the Canadian and the American Psychiatric Associations, as well as the World Psychiatric Association. Like other asylums around the world, however, the Hill’s back wards were filled with schizophrenic patients who seemed to stifle both institutional and personal ambitions. Because none of them had been responsive to the shock treatments that were all the vogue in the early twentieth century [see Shock Therapy], Cameron tried red light treatment. He had read how red light stimulated the growth of plants and animals, and had a salutary effect on the fertility of humans. Drawing on received medical wisdom of the era that schizophrenia was often accompanied by endocrine disorders, especially those involving the sex glands, he improvised a red-light cage, fitted with fifteen 200-watt lamps, filtered by an inch of running water and a layer of sodium salt of sulfuric acid infused into cellophane, in order to transmit the light at the appropriate wave length.
The Hill’s schizophrenic patients were then made to lie naked below the filters for as long as eight continuous hours each day, and over as long as eight continuous months, bathing in what Cameron hypothesized would be the restorative red light. Of the fourteen patients thus treated, Cameron reported that five were discharged, one showed marked improvement, four showed slight improvement and four demonstrated no change. Although not confident that schizophrenic symptoms in some of the patients had been remediated by red light working on the endocrine system as hypothesized, he nonetheless recommended its use as a therapeutic agent. Cameron, a bit of a therapeutic gadfly, became bored with the red-light cage and dismantled it, soon after recommending it to his colleagues.
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Cameron, D.E. (1936). Red light therapy in schizophrenia. British Journal of Physical Medicine, 10, 11.
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“Colored light a cure for insanity” (1876). United States Medical Investigator, 12, 451.
Lisman, G.L., and Parr, A. (2005). Bittersweet memories: A history of the Peoria State Hospital. Victoria, BC, Canada: Trafford.
Pitres, A. (1887). Des anesthésies hystériques. Bourdeaux, France: G. Gounouilhou.
Reed, J.A. (1876). Annual report of the Western Pennsylvania Hospital, 1876. Journal of Insanity, 33, 554.
“South American Insane Hospital” (1884). Boston Medical and Surgical Journal, 110, 295–296.
Thompson, J.H. (1893). Hysterical disturbances of special senses Medical Review, 28, 87–89.
“Treatment of hysterical convulsions” (1891). Pittsburgh Medical Review, 5, 137–138.
“Use colors to cure insane” (1902, October 26). New York Times, p. 25.
The production of irritation, tumescence, burns, lacerations or vesication of the skin in order to favorably influence the brain.
One of the oldest asylum therapeutics, counterirritation was informed by the humoural doctrine of the ancient medical philosophers. The doctrine held that four humours, or “vital spirits,” were produced by the digestive process and then circulated to the heart and brain by the heat generated by that process, thus determining and maintaining both physical and mental health. Blood, not to be confused with veinous blood, was the primary of the four humours. Warm and moist, it was thought to be produced in the liver, and to determine a sanguine, that is social and expressive, temperament. Black bile, a cold and dry humour that actually was blue in color, was thought to be stored in the spleen and to determine a melancholic temperament. Phlegm could be found in any part of the body. A cold, moist and colorless humour, it resulted in the meek but trustworthy characteristics of the phlegmatic temperament The fourth humour, yellow bile or choler, was thought to be produced in the gallbladder and to determine a choleric temperament, characterized by confidence and competitiveness.
In traditional humouralism, black bile and yellow bile were most often indicted in cases of insanity. The former, when it accumulated in the spleen, contaminated the other humours and circulated peccant spirits to the brain, causing the lethargy, self-loathing and ineffable sadness that were the hallmark symptoms of melancholia. In contrast, the excessive secretion of the latter irritated the brain into frenzy and mania. Treating the melancholic and the manic, then, required counterirritation, that is, the drawing of the noxious humours away from the brain and out of the body. Such treatments were done either by derivation, that is, the application of a counterirritant close to the irritated brain, such as on the shaved skull or the nape of the neck, or by revulsion, an application distant from the irritated brain, such as on legs. Because it was believed that insanity was incompatible with another somatic ailment, if only because the body did not have the requisite power to sustain both simultaneously, the irritation, tumescence, burning or vesication caused by counterirritation would in the words of David Uwins, physician to the Peckham House Asylum in Surrey, England, “set up disorder in one part, for the purpose of knocking it down in another” (Uwins, p. 64). Balance, and mental health, in other words, would then be restored.
Although traditional humouralism had yielded slowly over time to new theories, and a new lexicon—nerves, fibers, brain congestion or inflammation, morbid action—asylum physicians remained loyal to both its logic and its therapeutics. Thus, the various techniques of counterirritation were used well into the nineteenth century, not just to treat melancholia and mania, but the growing list of their types and subtypes with which asylum patients were being diagnosed.
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Burrows, G.M. (1828). Commentaries on the causes, forms, symptoms, and treatment, moral and medical, of insanity. London: Thomas and George Underwood.
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Valentin, L. (1815). Mémoire et observations concernant les bons effets du cautère actuel [Memoir and observations concerning the good effects of the actual cautery cautery]. Nancy, France: C.-J. Hissette.
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Werber, G. (1910). Junod’s blood derivations. Journal of Advanced Therapeutics, 28, 241–247.
The burning or searing of the skin by an instrument such as a red hot poker or iron. The adjective “actual” was used to distinguish this therapeutic from the moxa, which sometimes also was referred to as a cautery. While the mere sight of a red hot poker often was enough to render the most obstreperous patient submissive [see Salutary Fear], the actual cautery also was used to create a suppurating burn, usually on the nape of the neck or the top of the head of the insane patient, and therefore was considered a counterirritant by early asylum physicians.
Perhaps the most extensive, and certainly enthusiastic, use of the actual cautery was by the early nineteenth century French physician Louis Valentin, who had published an award winning treatise on the therapeutic. Although Valentin was not an asylum physician—he was in fact a former military physician in the West Indies and specialist in diseases of the eye—he had in fact encountered a number of cases of delirium and/or mania that were the results of the malignant fevers that were epidemic in St. Domingo where he had been stationed. In those cases, he had found that the application of the actual cautery to the top of the head or the nape of neck quelled the symptoms and eventually restored reason. One of his most dramatic cures took place when he was stationed in the United States. The case was that of young girl who had been struck with mania a few years before, and would no longer speak. He applied the actual cautery and she immediately improved. Although he was unable to follow her progress, he was confident that the therapeutic had achieved its curative purpose. Upon establishing a private practice in Nancy, France, he continued the use of the actual cautery in similar cases, usually of mania, and reportedly with similar success.
A receptacle for burning coal to heat cautery instruments. Asylum physicians debated whether it was the pain from the burn produced by the cautery or the fear of the pain that was more therapeutic (courtesy of the Wellcome Library, London).
Valentin downplayed, even ignored, the terror the actual cautery created in even the most insensible patient, but asylum physicians who studied his treatise did not. Jean-Étienne Dominique Esquirol, médecin ordinaire at the Salpêtrière Asylum in Paris, France, for example, suggested that its therapeutic efficacy was due more to its “frightful moral influence” than for the actual festering burns it produced (Esquirol, p. 411). Nonetheless, he occasionally used it, and sometimes with success. He detailed one such case:
V.V.P., twenty-six years of age, and of a lymphatic temperament, becomes a maniac during the month of April, 1823. She is bled and bathed at home, but without success. She is admitted at the Salpêtrière on the 26th day of May following, in a state of mania, attended with a degree of agitation and fury, which nothing composes. In the month of October, I apply the actual cautery to the neck. The preparations for this operation disturb her much. Scarcely had the red hot iron been applied to her neck, when, to her cries and agitation, succeeds a moment of silence. She then sheds a torrent of tears, and afterwards makes regular progress towards recovery, which is perfected at the expiration of two weeks. She still remained for some time in the division of convalescents, and returned to her family, November 19th, of the same year [p. 411].
The actual cautery was used in some French and German asylums in the early to mid-nineteenth century. John Gideon Millingen, superintendent of the Hanwell Asylum outside of London, England, also recommended its use for monomaniacal patients who had delusions of demon possession. “The pain it excites,” he wrote, “draws their attention from their melancholy apprehensions…. This sudden excitement has been known to cure patients who fancied that they heard various menacing voices denouncing perdition and celestial wrath” (Millingen, p. 60). Delimiting its use to such a specific, and probably quite rare, type of insanity made the actual cautery a seldom used therapeutic in British asylums.
The raising of pustules, usually on the neck, shoulders, inside of the forearms or on the shaved head, by the vigorous frictional application of antimonial oils such as tartar emetic or croton oil, also known as oleum tiglii. Erupting within hours after the application, the pustules produced a burning sensation and a purulent discharge of pus before scabbing.
As with all counterirritants, the production of artificial eruptions was based on the humoural doctrine to which most early asylum physicians were devotees. As the doctrine began to wane in influence, so did the practice of producing artificial eruptions until it was revived in the early nineteenth century by the British physician Edward Jenner, who had pioneered the smallpox vaccine. In a widely cited monograph, Jenner wrote that “diseases of the skin are diversions in the animal economy for transferring diseased actions from parts vital to parts not immediately vital” (Jenner, p. 59). The artificial creation of a skin “disease” via artificial eruptions, he hypothesized, would transfer the disease of the brain of the insane patient to the skin. Although neither an asylum physician nor a specialist in insanity, Jenner nonetheless treated several cases of mania with artificial eruptions, and reported success in doing so. One of those cases was a young woman on whose shaved head he rubbed tartar emetic, producing oozing eruptions. Immediately her symptoms abated, only to return a short time later; the procedure was repeated, and once again she improved. Upon her second relapse, however, her parents, to whom her care had been entrusted, neglected to repeat the procedure, and the young woman regressed into what Jenner considered to be incurable insanity.
Jenner’s treatise renewed asylum physicians’ interest in artificial eruptions, as well as in other counterirritants. After administering the therapeutic to nearly every patient at the Julius-Spital in Würzberg, Germany, quite regardless of diagnosis, Aton Müller expressed unbounded confidence in artificial eruptions. Müller had used a tartarized ointment developed by Johann Heinrich Ferdinand von Autenrieth, professor of medicine at the University of Tübingen in Germany. Autenrieth Ointment (unguentum antimonii tartarizati), as it was referred to, was promoted as superior to other substances, and Joseph Guislain, physician at the asylums in Ghent, Belgium, was eager to use it. His first trial was with four patients with different types of insanity, and the results were encouraging: one patient was cured, the worst symptoms of another two were ameliorated, and the reason of the remaining patient was restored although, inexplicably, she was rendered paralytic in her lower extremities.
Cautiously optimistic, Guislain then conducted a second trial on thirty additional patients, with decidedly disappointing results. No patient was cured, no symptoms were ameliorated for any appreciable length of time, and many patients suffered with deep ulcerations to the tops of the head and inflammation of the conjunctiva of their eyes. More worrisome to Guislain was that some patients who could not comprehend the reason for the therapeutic in the first place, came to see him as having “nothing but the malignity of a demon—the unrelenting author of their misery” (“M. Guislain,” p. 109). Guislain was forced to conclude that whatever favorable changes might be the result of using antimonial friction to raise oozing pustules on the heads and bodies of insane patients did not in the end justify its use.
Despite this cautionary note, the use of this counterirritation therapeutic continued. And it did so with so much enthusiasm that more than a half-century after Jenner’s publication George Henry Savage, physician superintendent of Bethlem (better known as Bedlam) Hospital in London, England, wondered aloud if fellow asylum physicians were, like he was, just “reverting to the old lines” by using counterirritants. After all, he reminded his colleagues, oozing pustules “did not look ornamental” (“Medico-Psychological,” p. 600). To this musing, his colleague Daniel Hack Tuke replied that it would be a “great pity” to refrain from using counterirritants since so many cases of chronic insanity had improved with their use (p. 600). Tartar emetic, in fact, remained in use as a counterirritant in British asylums until the mid-twentieth century.
The creation of a localized collection of fluid on the upper layers of the skin, or under the surface of the skin. The blister usually was raised on the head, neck or extremities with an application of mustard powder or a vesicant of cantharadin in the form of powdered Spanish fly.
For early asylum physicians blistering was one of the so-called “heroic treatments” that, along with purging, vomiting and bleeding [see Depletive Therapy] was used routinely, even ceremonially, on patients quite regardless of their diagnosis or the duration or circumstances of their insanity. At Bethlem (better known as Bedlam) Hospital in London, England, for example, patients were blistered every spring in keeping with the humoural doctrine of seasonal repletion. It was that ritual, in fact, that drew criticism from William Battie of nearby St. Luke’s Hospital, whose mid-eighteenth century treatise was one of the first monographs on the subject of insanity. Battie, a devotee of the Enlightenment movement, possessed what was in that era an unusual optimism that insanity could be cured, but only if the differences between what he called “original” and “consequential” insanity were understood, and only if treatment was individualized. “Although madness is taken for one species or disorder,” he wrote, “nevertheless, when thoroughly examined, it discovers as much variety with respect to its causes and circumstances as any distemper whatever: Madness, therefore, like most other morbid cases, rejects all general methods” (Battie, p. 94).
While Battie dismissed as unenlightened the routine and ritualized practice of blistering all patients, he did somewhat reluctantly conclude that it might be necessary and efficacious, but only if used “with great caution” and not at all with the patient who was in a “fit of fury” (p. 94). Interestingly, it was John Monro, physician to Bethlem Hospital who, without apparent irony, defended the ritual use of the heroic treatments in the asylum with which his family was so long associated, while at the same time dismissing blistering as neither a necessary nor efficacious treatment. “I never saw the least good effect of ‘blisters’ in madness,” he wrote in his rejoinder, “unless it was at the beginning, while there was some degree of fever, or when they have been applied to particular symptoms accompanying this complaint” (Monro, p. 47).
Blistering thus became a topic of discussion, pursued with “earnestness and ingenuity” (Pargeter, p. 75) among and between asylum physicians in Great Britain and the United States. John Haslam, apothecary to Bethlem Hospital after Monro’s death, found that blisters were of little use when raised on the preferred site of the shaved head, but were more effective if raised on the inside of the legs. This suggestion at first stymied Benjamin Rush who blistered many of his patients on the head at the Pennsylvania Hospital in the United States and who was resistant to relinquishing the therapeutic. Rush, however, came to realize the principle behind the change in the preferred site of administration and found in it a rationale for the continued use of the therapeutic:
In the first stage of tonic, or violent, madness, the disease is entrenched, as it were, in the brain.—It must be loosened, or weakened, by depleting remedies, before it can dislodged or translated to another part of the body. When this has been effected, blisters easily attract it to the lower limbs, and thus often convey it at once out the body…. The blisters do the same service when applied to the wrists, and still more when applied at the same time, or alternately, to both extremities.—After the complete reduction of the pulse, they may be applied with advantage to the neck and head [Rush, p. 193].
As the humoural doctrine gave way to different theories of the causes and treat-ments of insanity, blistering all but disappeared from asylums. By the mid-nineteenth century it was virtually unheard of to blister a patient on any part of the body and asylum physicians were taking some pride in having relegated that therapeutic to the unenlightened past. It was a different matter in Colonial asylums, however, where blistering continued for decades longer. At the Dullunda Asylum near Calcutta, India, for example, physicians blistered patients both as a counterirritation treatment and as a punishment, as the case notes on a woman suffering from mania illustrated:
On admission she was very violent + excited, would not wear clothes, tore everything to pieces + struck + bit every body approaching her. It was necessary to put her under restraint, a Blister was applied to the nape of her neck + sharp purgatives administered. Gradually the violence of the symptoms began to subside…. Discharged cured, October 21, 1862 [Mills, p. 420].
A poultice or plaster composed of irritating or sometimes emollient substances applied to the shaved head. It was the practice of early asylum physicians to shave the heads of most of their patients in order to cool what they assumed to be the hot and inflamed brain. The cataplasm added an additional therapeutic benefit in that when placed on the shaved head, it was thought to stimulate the circulation of blood through the brain.
Asylum physicians had their favorite substances for cataplasms. Joseph Guislain, physician to the asylums in Ghent, Belgium, favored a tincture of cantharides, or Spanish fly for the manic patient, but found the blisters it raised too stimulating for the melancholic. To treat that type of patient he experimented with Hoffman’s Balsam of Life, a stimulating tincture of amber, lavender, cloves, nutmeg and cinnamon, but was disappointed in its effect. German asylum physicians tended to favor Autenrieth Ointment (unguentum antimonii tartarizati), but their enthusiasm for it was not shared by many others.
The fact that asylum physicians were not in consensus as to what type of substance served as the most efficacious counterirritant in a cataplasm opened the way for a considerable amount of entrepreneurship, not to overlook quackery. In regards to the latter, the case of Thomas Fallowes and his “incomparable Oleum Cephalicum,” deserves mention. A private madhouse owner, Fallowes had awarded himself a medical degree before concocting his nostrum, a cure for maniacal frenzy and, he hastened to add by way of promoting the £4 a quart mix of animal, vegetable and mineral substances, any kind of insanity at all. Oleum Cephalicum, he went on to say, not only has a pleasant smell, but as a cataplasm raised small pustules on the head and stimulated the brain to release black vapors. After all, he wrote, the seat of insanity is the brain,
which is disturbed by black vapors which clog the finer vessels thro’ which the animal spirits ought freely to pass, and the whole mass of blood, being disordered, either overloads the small veins of the brain, or by too quick a motion, causes a hurry and confusion of the mind, from which ensues a giddiness and at length a fury. The abundance of bile, which is rarely found to have any tolerable secretion in such patients, both begets and carries on the disorder [Tuke, p. 93].
Cupping glasses and a brass scarificator. Dry cupping drew blood to the surface of the skin; the additional step of cutting the tumefied skin with a scarificator was known as wet cupping. In either case, cupping was considered an art: the placement of the cup, the duration of its application, the depth of the incision, the handling of the various cupping tools all required the skill of an asylum physician—not of a barber or self-trained empiric (courtesy of the Wellcome Library, London).
The fact that Fallowes was dismissed as a quack by his contemporaries must be reconciled with the fact that his incomparable Oleum Cephalicum was used for cataplasms by British asylum physicians well into the nineteenth century and even, on occasion, into the twentieth.
The application of a cupping instrument such as a glass, usually to the head or neck, in order to draw blood to the brain, or to the extremities to relieve the “congestion” of the brain that was thought to be a cause of insanity. The cups used in dry cupping usually were small glass orbs with thick rims that either contained a wick of burning lint or were heated on a flame before being applied for approximately ten minutes; as they cooled they drew blood to the surface of the swollen skin, bursting the capillaries. Other dry cupping instruments included animal horns, plant gourds and vulcanized rubber cups. By the nineteenth century there were numerous technological improvements on the cup heating apparatuses, from grease and alcohol lamps that afforded better heat regulation, to a cupping torch. The latter had a piece of hollow metal tubing cut at an angle on one end, through which a wick protruded. The wick was dipped in alcohol, lit and inserted into the cup to heat it; via the bulb or ring on the other end of the cupping torch, the wick was then pulled back into the tube, extinguishing the flame.
Although dry cupping was particularly recommended as an alternative to bleeding for debilitated and emaciated patients, it was a matter of debate as to how it worked. Some asylum physicians argued that it affected only the surface blood vessels, thus relieving the affected brain by inducing a distracting secondary inflammation; others posited that it affected the nervous system and through it, the secretory organs of the body. Regardless of its therapeutic function, there was startling evidence that dry cupping often was indiscriminately used. When British physician Daniel Hack Tuke visited the asylum in Toronto, Canada in the mid-nineteenth century, he found it one of the “most painful and distressing places” he had ever visited. The aggressive therapeutic regime of dry cupping had left the seventy patients with disfiguring scars on their foreheads and necks.
After conducting an autopsy on a patient who had died hours after dry cupping, the British physician George Mann Burrows, proprietor of a private madhouse in Chelsea, found that all of the blood vessels of the pericranium, cerebral membranes and the brain, itself, were richly distended with blood, thus providing evidence that dry cupping indeed had pulled blood to the surface of the head. An autopsy on a second patient who had died days after dry cupping, however, did not confirm these findings, leading Burrows to conclude that the effects of dry cupping were short-lived. To maximize those effects, he recommended that after the dry cupping the patient’s head be vigorously rubbed and the feet plunged in a pediluvium in order to encourage the circulation of blood throughout the body.
The irritation of the skin by the hand, rough towel, horsehair glove or a brush in order to “excite the sensibility of the skin, and render perspiration more active” (Galt, p. 169). Asylum physicians often explained the use of dry friction by citing Hippocrates who had written that a physician should be skilled in many things especially in the nature of friction. Typically used after dry-cupping, douches and therapeutic baths [see Hydrotherapy], dry friction was considered a serviceable remedy for all types of insanity, but was particularly recommended for suicidal monomania, melancholia and hypochondriasis.
The cutting away of the gums to expose and to hasten the emergence of new teeth. Until the twentieth century the infant mortality rate was disturbingly high. Because most deaths occurred between the ages of six months and two years, physicians theorized that teething was a common cause, thus justifying the practice of blistering, bleeding and leeching the gums, and applying cautery on the backs of the heads of infants and toddlers to hasten the emergence of their teeth. Ambroise Paré, a sixteenth century French barber-surgeon, sought a more humane alternative: he lanced or incised the gums of young children, and this procedure remained in vogue for hundreds of years.
While children that young rarely found their ways into asylums, adolescents and young adults certainly did. Often in poor physical health and inadequately nourished, these patients had an array of dental problems, among them impacted or partially erupted molars or wisdom teeth that caused persistent pain and often were prone to infections. These reactions in turn, it was argued, could excite the brain and exacerbate the symptoms of insanity or even cause insanity in the first place.
While at the Salpêtrière Asylum in Paris, France, Jean-Étienne Esquirol, observed the case of a delirious young woman who had a bloated face, salivated excessively, and complained of pain in her head and jaw. Left untreated, her delirium abated when two new teeth pierced her gums, only to return sometime later and last for several more months until two more new teeth emerged. The usually confident Esquirol was left to wonder if he should have lanced her gums to hurry the process. He speculated that the prevailing medical wisdom that teething in a young child can cause irritation of the brain very well also might be applicable to his patient, who was “rapidly approaching the period of maturity” (Esquirol, p. 197). Yet, he did not incise her gums. In his own defense, he explained that he had refrained from doing so because his young patient had been so agitated and was under the delusion that he was trying to kill her, an explanation dismissed out of hand as nothing more than evidence of “childish weakness” (p. 198) in the translator’s footnote in his widely read text.
It is not evident how much gum lancing actually occurred in asylums, but that there was a robust body of medical and dental literature that posited a relationship between the molars and insanity is indisputable. After summarizing that literature, Joseph R. Buchanan concluded that the location of the molars, or wisdom teeth,
enabled them to exert a greater power over the cerebral circulation and excitability—a depressing and deranging influence—which may be manifested in a thousand different ways, especially in melancholy gloom, disqualifying for study and the enjoyment of life, unfitting for business, and producing mental confusion and hallucinations, ill-temper, restlessness, and unpleasant dream, and in extreme cases mania and even paralysis [Buchanan, p. 198].
What lancing of the gums over the molars that did occur as a therapeutic was replaced by surgical extraction [see Exodontia] by the turn into the twentieth century as the theory of focal sepsis took hold and asylums in the United States and Europe added dentists and dental surgeons to their staffs.
The injection of pustular fluid or dried smallpox scabs into the skin of the uninfected patient to produce a mild case of the disease that typically lasted one week. Preparations for the inoculation most often involved bleeding, purging and vomiting [see Depletive Therapy] to “lower” the humours. The inoculation produced a primary lesion and satellite pustules around the site of administration, and an extensive and itchy rash. The inoculation of smallpox had been a practice for centuries in India, China, many countries in Africa, and in Turkey from where it was brought to Great Britain in the early eighteenth century by Lady Wortley Montagu, wife of the British ambassador to Constantinople, and was first used there as a prophylactic against a serious acquired case of smallpox.
It is not clear how the inoculation of smallpox came into asylum therapeutics nor, for that matter, how widely it was used. In his text, Joseph Mason Cox, proprietor of the private Fishponds Asylum near Bristol, England, presented a rationale for its use as a counterirritant, but did not describe any cases he, or any of his colleagues, had actually treated:
[E]very means employed for the removal of mental diseases, whether moral or medical, when successful, relieves by introducing some important change into the general system; but certain it is, that if any considerable commotion, any violent, new, action can be excited in maniacal complaints, by whatever means, the mental derangement is often considerably relieved if not permanently removed; thus smallpox has dissipated the most obstinate melancholia, and where affections of the intellect have resisted common remedies I should place considerable hopes on inoculation, had the party not previously had smallpox, taking care by proper medicines and management to increase the symptoms that usually attend this disease to such a degree that the whole system should be considerably affected without endangering life [Cox, p. 177].
The rubbing on the skin, or the injection into the skin, of the pus from the scabies pustules. Scabies, a skin disease that produces intense itching, especially in the evening, and a pimple-like rash, is caused by the Sarcoptes scabiei, or human itch mite that burrows into the upper layer of the skin where it lays its eggs. Although the intense itching could lead to severe skin infections as the patient vigorously kept scratching, the itch was considered an effective, even curative, counterirritant, as Joseph Mason Cox, proprietor of the private Fishponds Asylum near Bristol, England, explained:
Itch has been known to bring about the same happy effect, the cure of insanity … by abstracting attention from the wanderings of the deluded imagination, exciting new ideas by the means of strong impressions made on both mind and body, by the irritation excited on the surface [Cox, pp. 177–178].
In the early nineteenth century when inoculation of the itch was used as a therapeutic in many European asylums, the mechanism of its transmission was a matter of some disagreement. Some asylum physicians thought that the itch was a contagious disease, spread from one person to another by direct or indirect contact. Others thought it was an infectious disease spread by the pus of the pustules. Each theory was imprecise, and had a contradictory relationship with the other, but the lack of certainty regarding the mode of transmission sometimes left asylum physicians frustrated in trying to produce this counterirritant.
That frustration was exemplified by the case Mr. deX., described in detail by Jean-Étienne Dominique Esquirol. Mr. deX., a general and inspector had “given himself up to excessive masturbation” (Esquirol, p. 187), a fact that he could not reconcile with his otherwise principled conduct. He became increasingly irritable and on occasion even threatening and in the early nineteenth century was committed to the Salpêtrière Asylum in Paris, France, where Esquirol was médecin ordinaire. The treatment regime focused on preventing masturbation by the use of the itch as a counterirritant.
Hoping that I could again communicate to him the itch, I should cure him, I employed tepid baths, and friction morning and evening. He takes tonics internally and sleeps in the shirts of those affected with this disorder for fifteen nights. Professor Aibert provides me with the virus of psora. I make about the articulation of the limbs, more than eighty punctures, with no better success. I cause the patient to sleep anew in infected shirts, with no better success [p. 187].
Although Esquirol had used both the contagion and the infection approach, he much later attributed his failure to produce the itch in the patient by reference to the latter. In the years subsequent to this case, medical researchers had discovered that the pus of the scabies pustules did not contain the itch mite, and therefore was not a medium for the infection. Interestingly, it was the crowded conditions of so many asylums that was a better medium for the transmission of the itch. The superintendent of the Danvik Asylum near Stockholm, Sweden once reflected without irony that he had no need to inoculate the itch until the early nineteenth century when patients were moved from crowded dormitories into small two-person cells, thus reducing significantly the spread of scabies.
The infliction of a lesion, wound or ulcer in order to produce a discharge of pus. An issue often was produced by the application of a cautery or with a caustic of some kind, and the wound frequently was kept open in order to maximize the duration of the discharge. As a result, the risk of infection was considerable, and both the sight and smell of the suppurating wound often was reported as distressing to the patient and physician alike. Once the wound was allowed to scab over, it was theorized that the body’s effort to “throw off” the scab withdrew blood from general circulation, thus exerting a salutary influence on the brain. There was never strong support for the efficacy of the issue as a stand-alone therapeutic, however. It was used in asylums into the nineteenth century, but most often in conjunction with other therapeutics.
A metal boot, secured to the leg by a silk or rubber cap. The air was withdrawn from the boot via a flexible tube attached to a stop-cock pump; an attached manometer measured the resulting pressure. Although it remains contestable as to whether he actually invented the boot, it was so aggressively advocated in the mid-nineteenth century by French physician Victor-Théodore Junod that it bore his name.
Reflecting on the received wisdom of that era, Junod posited that insanity was caused by imbalanced blood circulation, therefore blood had to be drawn from and into other parts of the body, a process he referred to as “hemospasia.” To remedy the imbalance, he advocated the boot as an alternative to the more traditional therapeutics of bloodletting and dry cupping. Its mechanism was ingenious: once attached to the leg, the air in the boot was gradually exhausted via the pump; the resulting vacuum withdrew as much as seven pints of blood from other parts of the body into the boot-encased leg even while it stimulated the absorption of serum in other parts of the body. The vacuum was maintained for as long as several hours and/or until the patient fainted, a reaction Junod interpreted as a sure sign that the remedy had been applied “to effect.” Once released from the boot, the blood in the incredibly swollen leg gradually returned into circulation and into healthful balance.
Junod’s theory of hemospasia appealed to competing schools of thought about the cause and treatment of insanity. Some asylum physicians, even as late as the mid-nineteenth century, were still wedded to the ancient theory of the bodily humours and cited blood as the cause of insanity and its removal as the cure. Others found the cellular theory more explanatory. They posited that the origin of insanity was in the tissues and that the flushing of toxins from them would be its cure. And then there were those more interested in the nervous system as the origin of insanity, and its restoration and revitalization as its cure. Junod’s theory of hemospasia resonated with all, and his boot worked in each therapeutic modality: it withdrew and redistributed blood, drained the tissues, and deprived the brain of enough blood to reduce its power to supply nerve impulses to the rest of the body through the spinal cord.
In his 1875 text, Traite theorique et pratique de l’hemospasie [Theory and practice of hemospasia], Junod presented 293 cases in which the boot brought about either cure or remedy for patients suffering from mania, hysteria, epilepsy, apoplexy, cerebral congestion, and a variety of nervous and neuralgic afflictions. Because he also advocated the boot for the relief of medical disorders, such as laryngitis, asthma, hernias, bone dislocations, dysmenorrhea, rheumatism, gout and even cholera, the boot was widely used outside of asylums by private physicians and quacks alike. So popular had the boot become, in fact, that it was advertised in medical journals, specialty magazines and newspapers, and sold for as much as $25, a considerable sum in the mid-nineteenth century.
Junod’s boot was used in asylums in France, England, Norway, the Netherlands and, to much lesser and briefer extent, in other European countries as well as in the United States. Junod’s Arm, manufactured for application to the patient’s arm, was less often used in asylums. And there is no evidence for the use of the Junod’s Depurator, a casket-like metal case that enclosed the entire body of the patient, leaving only the head exposed, in asylums for the treatment of insane patients.
The inducement of the shedding of tears, or of crying. Tears were of some interest to ancient Greek physicians who believed they were “humours from the brain” and when given to excess, as so often observed in the melancholic patient, had to be purged by weeping (Lutz, p. 73).
The inducement of tears as an asylum therapeutic, however, might very well have been more for its cathartic than counterirritational effect. At the Pennsylvania Hospital in Philadelphia, the prominent physician Benjamin Rush treated grief-stricken patients not only with generous and repeated doses of opium, but by “obtruding upon the mind a sorrow of a less grade than that by which it is depressed” (Rush, p. 318) in order to produce relief through a discharge of tears.
Although he induced lacrimation only infrequently and without a great deal of confidence in its effect, Jean-Étienne Esquirol, observed a case at the Salpêtrière Asylum in Paris, France, in which crying cured insanity. Although he neither theorized as to the reasons why, nor particularly recommended lacrimation as a therapeutic, he nonetheless described the case in detail, if only to illustrate what he asserted was the puerile and proud nature of nervous disorders in women:
A lady, thirty-four years of age, of a lymphatic temperament and nervous constitution, and of a mild and timid disposition, has always enjoyed good health, although the menstrual flux is not regular. For some months she takes care of a lady whom she tenderly loves. She labors day and night, and watches for fifteen nights in succession. Whilst greatly and constantly troubled, through fear of seeing her friend perish, she learns that her lover has fought a duel, and been wounded. After concealing her despair for some hours, she becomes delirious, and reveals her secret. They bleed her, and prescribe foot-baths and diluent drinks. After fifteen days, the violence and agitation are subdued. The patient is conscious that during her delirium, she has revealed the secrets of her heart. From this period, she believes herself despised by every one, detested by her husband, and destined to some punishment. She desires to die. Five days are spent in vain solicitations to induce her to take some aliment, and for eight days, she takes but a few swallows of broth. She is committed to my care. The countenance of the patient is pale, the lips brownish, eyes dull, the physiognomy expressive of pain, and the movements slow. At times, she heaves a profound sigh, her breath is fetid, and she suffers from constipation. On the day after her admission, I place with the patient, beside the women who serve her, a young lady of an agreeable exterior, mild and engaging, who converses at first, with an air of indifference, then with an accent of benevolence and friendship, and at length, commits to her certain confidential matters, and invites our patient to unfold her feelings. After twenty-four hours of gentle and adroit perseverance, the patient takes the hand of her new friend, sheds a torrent of tears, and then reveals all the secrets of her heart; pointing out the cause of her delirium, the motive that induced her to resolve to eat no more, in fine, the fears that harass her. She decides also, to take some nourishment. On the day following, there is a new struggle against her notions, resolutions and fears; a new crisis, a new effusion of tears, and progress towards convalescence. After three weeks the cure is completed, on my assuring the patient that nothing that she had said was believed, but had been attributed to her delirium [Esquirol, pp. 194–195].
Although the cathartic effect of a “good cry” is still recognized, the purposeful inducement of it to relieve the irritation of the brain has long since ceased to be an asylum therapeutic.
The application of a small cylinder or cone of burning artemisia herbs to various points on the body. Used for centuries in traditional medicine, the moxa came to the attention of Dutch East India Company physicians posted in China and Japan in the mid-seventeenth century. In the traditional medicine of those countries, the balance of yin and yang was seen as crucial to physical and mental health, and for the therapeutic heat it provided the moxa most often was used as an adjunct to acupuncture. In that case, a moxa cone of rolled artemisia leaves was placed on the acupuncture point, ignited, and allowed to burn down close to the surface of the skin before being extinguished.
It is doubtful whether European physicians understood or appreciated the healing theory on which the use of the moxa was based, despite its resemblance to the humoural theory to which they were wedded. Most, therefore, used it as a counterirritant in the belief that it could draw humours from various parts of the body to a specific site, thus reducing any underlying inflammation which they presumed was the cause of insanity. British and European physicians experimented with different leaves and substances when artemisia herbs were difficult to source; these ranged from stalks of wild sunflowers to small cylinders of carded cotton wrapped in linen. They also invented specialized tools for applying the moxa. The portemoxa, for example, was an ebony-handled small metal ring to which three ebony ball feet were attached; the moxa could be inserted through the ring and ignited, while the ball feet kept it from direct contact with the patient’s skin.
The moxa was used in general medical practice in Europe and to a lesser extent in the United States well into the nineteenth century for a variety of physical ailments, including gout, bladder inflammation, rheumatism, epilepsy and even paralysis. Its migration into asylum medicine is uncharted, however. It does appear that in France, where the use of the moxa in general medicine was being vigorously promoted, some provincial asylum physicians were experimenting with its use. It was met with less positive reactions in metropolitan asylums, however. Jean-Étienne Dominique Esquirol, médecin ordinaire at the Salpêtrière Asylum in Paris, France, for example, tried it without benefit in a case of dementia, and remained unconvinced of its efficacy in treating any type of insanity. The spread of the use of the moxa beyond France is evidenced by the widely read text by J. Schroeder Van Der Kolk, professor and physician to the Utrecht, Netherlands insane asylum. A somatist who believed that bodily disease was the cause of insanity and that to cure it the underlying disease first had to be treated, Van Der Kolk prescribed an astonishing array of materia medica, including the moxa on the crown of the head, for each and every case of insanity. The moxa, however, also held an appeal to psychists such as Karl Wilhelm Ideler. Positing that moral failure was the cause of insanity and moral discipline and re-education its cure, he used the moxa at the Berlin Charité Hospital in Germany less for its alleged ability to reduce inflammation than for its definite ability to frighten patients into moral submission [see Salutary Fear].
American asylum physicians made little use of the moxa. In his influential text, Medical Inquiries and Observations Upon the Diseases of the Mind, Benjamin Rush listed the moxa as one of several methods for the “excitement of pain” (p. 104) which he, rather like Ideler, believed was necessary for the moral discipline of the patient. He neither elaborated nor presented any cases in which it was used.
Discussion on the moxa may have been somewhat occluded in the nineteenth century asylum literature by a confusion of terms. At times moxa, which when correctly applied did not burn the skin, may have been referred to as “cautery.” The term “actual cautery” was used to indicate the definite burning of the skin by a red hot poker or some other device.
Only infrequently used in the treatment of the insane, the mustard pack was a cloth that had been wrapped around two handfuls of crude mustard, dipped into hot water, and then squeezed. It always was placed on the abdomen of the patient, and sometimes also on the legs, then covered with a dry towel that was secured behind the back, and further by a rubber, or mackintosh, sheet.
Samuel Newington, medical superintendent of the Ticehurst House Private Asylum in East Sussex, England, may have been the first to recommend its use as a counterirritant treatment for insanity after having experienced it himself at a spa. He wrote:
I was induced to try the effects of being wrapped in clothes steeped in mustard-and-water, and applied to the whole legs and to the lower part of the abdomen.… I began to experience the most soothing effects, and gradually passed into a dreamy semi-conscious state, which lasted the half-hour I was under treatment. On getting up, I felt very lively and joyous, the liveliness lasted the whole day…. It occurred to me at once that this kind of application might be very serviceable in certain cases of insanity [Newington, p. 72].
Newington had experimented with the mustard pack on himself before trying it on a patient, eventually determining that two handfuls of crude mustard was the most efficacious formula. The first patient he administered it to was suffering from acute mania, and was restless, sleepless and refusing food. Before the application of the mustard pack his pulse was 180; after two hours it dropped to 60 as he drifted into what Newington described as a “semi-conscious state” (p. 73). After this single treatment, the patient took food regularly, and after a short time was released from the asylum as “perfectly recovered” (p. 73).
Theorizing that the mustard pack abstracted blood from the head, causing a state of anemia in the brain, and that it increased the circulation of blood through the capillaries, Newington increased the duration of its application from two to six or seven hours to maximize its therapeutic effect of lessening the “congestion” of the internal organs, thus bringing about calmness and sleep. At the start of the twentieth century, however, the Lunacy Commission limited the use of the mustard pack to two hours; finding that untenable, Newington ceased using the mustard pack altogether. Until this regulation, the mustard pack had been used quite frequently in British asylums.
The secretion of mucus as a result of the administration of any one of a number of errhines, medicated snuffs and sternutatories to the mucous membranes of the nose, causing often violent paroxysms of sneezing. Nasal discharge was favored as an adjunctive treatment by early nineteenth century asylum physicians who reasoned that the discharge was composed of “mucid lymph secreted by the glandular pituitary membrane, which lines the cavity of the nostrils and the sinuses of the brain” (Pargeter, p. 93). The relief that many insane patients reportedly felt after repeated sneezing was taken as evidence that brain congestion not only had been relieved, but that the nervous system had been healthily stimulated.
The so-called vegetative errhines, such as mustard, horseradish, white hellebore, capsicum, ginger, catharide and euphorbium, were often used to stimulate nasal discharge. So was tobacco. But some asylum physicians, such as Benjamin Rush at the Pennsylvania Hospital, found tobacco ineffective, largely due to the “insensibility of the nose to the stimulus of common snuff, from its habitual use by that class of patient” (Rush, p. 222). He preferred sulphate of mercury or muriate of ammonia, mixed with a little flour.
The insertion of a string of peas into a four to five inch incision on the top of the head and along the sagittal suture. The string of peas kept the incision, or issue, open and suppurating, thus acting as a counterirritant to what was assumed to be the inflammation in the brain of the insane patient. Although James Cowles Prichard, an English physician and Commissioner of Lunacy is cited as the originator of peas therapy, its use as a counterirritant in cases of insanity predated by more than a century his early nineteenth century article published in the London Medical Gazette. A naval surgeon by the name of Hugh Ryder described his cure of a “naval lunatic” in 1685 by the application of a caustic to the crown of his head, the cutting out of the scab that had formed, and the insertion of a string of peas into the incision. The “naval lunatic,” who had been bled, blistered and cupped to no avail, was immediately cured upon removal of the string of peas a month later.
There is little evidence in the nineteenth century asylum literature that peas therapy was used very often in the treatment of insanity, with the exception of an 1869 description of its use by J. Schroeder Van Der Kolk. The professor and physician to the Utrecht, Netherlands insane asylum advocated peas therapy for the treatment of visual hallucinations which, he theorized, were caused by a congestion of the optic nerves that could be alleviated by the counterirritation effect of a string of peas.
The plunging of the feet into either cold or hot water that contained an irritating substance, such as salt, ammonia, mustard powder or muriatic (hydrochloric) acid. Used during the early nineteenth century, the pediluvium was based on the premise that the irritating shock of the treatment would divert blood from the head of a manic patient, and into the extremities.
In his visit to the Stephansfeld Hospital for the Insane, near Strasbourg, France, the American physician Pliny Earle was particularly impressed not only with how often the pediluvium was used, but by the technology of its administration. He described a large room with a fixed bench along the wall, in front of which were a dozen small metallic tubs. These were fixed to the floor, and all were supplied with water from two pipes that connected them.
The inducement of an excessive flow of saliva. Physicians had long noted that salivation increased at the onset of attacks of mania, causing furious spitting, and decreased at the onset of attacks of delusions and hallucinations, often referred to as dementia. They also observed that the suppression of excessive salivation seemed to worsen symptoms, while the stimulation of salivation appeared to ameliorate or even terminate symptoms completely. In the interest of achieving the latter, physicians experimented with a wide variety of herbs and botanicals, such as ginger and bloodroot, to spur copious salivation in their patients. But it was mercury, first used by the British physician Thomas Willis, one of the preeminent figures in seventeenth century medicine, that made its way into asylum use.
Theorizing that mercury “stimulates every part of the body, renders the vessels pervious to their natural juices, [and] coveys morbid action out of the body by the mouth” Benjamin Rush, physician to the Pennsylvania Hospital in Philadelphia, used it to ”restore the mind to its native seat in the brain” (Rush, p. 103), for one of his patients, a young woman who had recently given birth:
I once advised [salivation] in a case of [insanity] from parturition, in which the patient conceived an aversion from the infant that had been the cause of her suffering. On the day that she felt the mercury in her mouth, she asked for her infant, and pressed it to her bosom. From that time on she rapidly recovered [Rush, p. 197].
Although Rush found no use for inducing salivation as a treatment for what he referred to as “general madness” (p. 197), he did so in conjunction with other counterirritation treatments in cases of mania and dementia. Patients, however, often resisted the administration of mercury. To overcome their refusal or, perhaps, to deceive them, Rush recommended that several grains of mercury chloride, also known as calomel, be sprinkled on generously buttered slices of bread which usually overcame the reluctance of even the most stubborn of patients.
British physician George Mann Burrows also cited mercury for producing the salivation needed for cure, arguing that it equalized circulation, restored the balance between the vascular and the nervous systems, and relieved the inflammation of the brain. Unlike Rush, however, Burrows had been a somewhat reluctant convert to its use. He had never prescribed it at his private asylum in Chelsea until he witnessed the sudden recovery of an insane patient after the ingestion of a mercury-laced tonic on a cold and drafty night. He described the case of Miss C., a corpulent forty-year-old respectable businesswoman who developed delusions and fears after a friend was injured in a household accident. Gloomy and suspicious, she began planning her own death:
Early in June she was so low-spirited and morose, that her friends were alarmed, and consulted her medical attendant, Mr. Hunter, Senior, of Mincing Lane. That gentleman prescribed a most judicious plan to be pursued; but she was refractory, and rejected his advice; and her friends, unfortunately, did not enforce it. A few days after, she contrived to squeeze herself through a small stair-window, apparently of dimensions inadequate to admit her passing, and from which there was a perpendicular descent of about thirty feet to the pavement of a court behind her dwelling. Luckily, and unknown to Miss C, some empty beer barrels had been piled up immediately under this window, and upon these she fell. By the interposition of these barrels, the height was reduced; and by the effect of gravitation, she happily came on her seat. By this means, the suicide she meditated was prevented.
She was taken up, apparently not much injured, and walked into her house. Mr. Hunter came to her assistance. On examination, one of her legs was found to be considerably bruised. She complained of no other part. She was copiously bled, purged, and received such medical attention as her case required, and was very prudently placed under the supervision of a nurse accustomed to insane persons. Fever followed, without any abatement of her mental disorder … a week after I first visited her. The countenance presented an extreme cast of despair and melancholy…. The propensity to suicide was still very active; for although, from bodily inability, she could not move from her bed, yet, by various and unequivocal little plots, she plainly indicated that was still her intention. All the features of the case at this stage were, indeed, very unpropitious.… My first object was to prescribe such means as might arrest the progress of the mortification. Sloughing to a great extent, and an immense discharge, took place, without any abatement of the mental affection. The patient’s health varied much, and at length appeared to give way.…
She had been for some weeks taking a tonic … calomel [mercury chloride] and squills [an herbal diuretic] were combined with it. She now mended every day and was very tractable; but all her pristine mental aberrations prevailed. After persevering in this plan a fortnight, she caught cold by falling asleep with the window open; the consequence was, salivation, but not excessive. It was suffered to take its course. Concurrent with this ptyalism was an instant amelioration of her mental symptoms. She grew more cheerful, and every aberration by degrees vanished. Three weeks from the appearance of the salivation she was so well that I took my leave [Burrows, pp. 645–646].
After that experience, Burrows experimented with mercury-induced salivation with his asylum patients, but with disappointing results. He urged his colleagues to exercise caution in its use. “The rage for prescribing this mineral, as a panacea in almost all diseases, has already tempted many to try it, and pretty indiscriminately,” he wrote. “However, we may infer that the success of it has been equivocal” (p. 648). That observation notwithstanding, Burrows stated his intention to stimulate salivation with mercury when other means of cure had failed, but only as part of a general regime of counterirritation administration.
Despite Burrow’s restraint, salivation remained part of the therapeutic regime in asylums throughout Great Britain, the United States and Europe well into the nineteenth century, and mercury remained the substance of choice for producing it. When used only as part of that regime, cases of mercurial poisoning were only rarely reported in the asylum literature. It should be noted, however that until the twentieth century, mercury was the primary treatment for syphilis, once known as “general paralysis of the insane.” Cases of mercurial poisoning of syphilitic asylum patients, with its attendant damage to the nervous system, were much more frequently reported in the literature.
A horsehair, silk or canvas thread, string of gauze, or a wire passed with a knife or needle through subcutaneous tissue usually at the nape of the neck or between the shoulders, and left there until it festered. The discharge of pus was believed at various times to either release the “evil humours” or relieve the underlying brain inflammation that caused insanity.
The case files of British physician William Perfect, proprietor of a private asylum in West Malling, exemplified the fact that few asylum physicians used the seton alone or, for that matter, even recommended it as a standalone treatment. In every case he detailed, the seton was used in conjunction with a variety of other medical, moral and social treatments that were part of the armamentarium of early asylum therapeutics. Case 62 illustrated that point. The patient in question was an otherwise physically healthy young boy who suffered from mania. His personal history offered no clues as to what the proximate or distal causes of his insanity might have been. Apothecaries and general physicians treated him at home for months with blisters, baths and purges, but to no avail. Coming under the care of Perfect, the child was restrained in a straitjacket when necessary, vomited repeatedly, bled often, sedated with a camphor concoction, and fed a “cooling diet” of apples, cherries and jellies. All objects that might stimulate or distract him were removed from his view, and he was encouraged to engage in mild exercise. A seton was applied to his spine and when it began to copiously discharge, the headaches and sleeplessness finally abated, and after a time, and with a host of other therapeutic interventions, he became more rational. “It is truly singular,” Perfect wrote, “that since his recovery his temper and disposition have regenerated, and without the least vestige of the reserve and dullness which had always before been the prominent traits of his character” (Perfect, p. 281).
Perfect did not credit the seton with the boy’s cure, but certainly stressed its importance to the therapeutic regime. Indeed, the seton was used by asylum physicians throughout Great Britain, Europe and the United States well into the nineteenth century. It was used extensively by Ernst Horn at the Berlin Charité; Pliny Earle, resident physician of the Friends’ Asylum in Pennsylvania, also expressed great confidence in it as a remedy, stating that the “greater the irritation or inflammation excited by it, the greater the benefit produced” (Galt, p. 415).
Interestingly, there was a patient who would have agreed with that assessment. Walter Abraham Haigh was admitted to Bethlem Hospital in London in the late nineteenth century, diagnosed with delusional insanity. The twenty-seven-year-old Oxford University graduate was quite the favored patient at the asylum that was better known as “Bedlam.” His intelligence and social class standing distinguished him from the other patients, and his active interest in his own recovery inspired confidence that he indeed would recover. But how? While editing a book manuscript written by George Savage, the asylum’s superintendent, Haigh became convinced that a seton inserted in his neck would ease his delusions and hallucinations. He convinced Savage to administer it. He recovered completely and was discharged as cured. Haigh went on to become a priest and although he continued to suffer from delusions, he was never recommitted.
The use of the seton certainly outlived criticisms of it. Joseph Guislain, medical superintendent of the asylums in Ghent, Belgium, for example, found that with the exception of case studies offered by Perfect, as well as by John Ferriar, physician to the insane asylum in Manchester, England, and George Mann Burrows, proprietor and physician of a private asylum in the Chelsea area of London, England, who boasted he had cured a deranged and violent woman with a well-placed seton on the back of her shaved head, few of his colleagues gave much credit to the singular or even cumulative therapeutic effect of the seton.
The inducement of the excretion of perspiration through the pores of the skin. It long had been noted that paroxysms of mania caused profuse sweating, but it also had been observed that melancholia suppressed perspiration, thus accounting for the dry skin and brittle hair and nails of patients so afflicted. To induce healthy sweating, asylum physicians relied on a range of therapeutics, from evaporating lotions to stimulate the excretory activity of the skin, mildly acidulated drinks, warm and tepid baths [see Hydrotherapy], camphor, to concoctions such as Dover’s Powder, a mix of ipecac and opium, all in an effort to sweat out the peccant humours that were considered the cause of insanity.
One of the nostrums given to produce sweating was Venetian Treacle or Venice Treacle, also known as theriac and mithridatium, a concoction of herbs and spices, seeds and gums, plants, and animal parts including the flesh of vipers, the original recipe of which could be traced to the second century C.E. In today’s parlance “treacle” is molasses, but its use here was a corruption of the Latin theriaca, or antidote. During the height of its popularity in the seventeenth and early eighteenth centuries, Venetian Treacle was touted as an antidote for accidental poisoning, and as a cure for everything from common colds to the plague. And it was used with some success, but always as an adjunctive diaphoretic therapy, to treat insanity. The eminent British physician, Thomas Sydenham, was one of the strongest advocates of the distasteful elixir. He recommended its administration to cure melancholia, mania and hysteria, the latter of which occurred so frequently, in his assessment, that he diagnosed it in one out of every six of his female patients. Although it was imported to North America in the eighteenth century, there is little evidence that the use of Venetian Treacle was widespread in asylums there or in Europe, perhaps because of the increasing regulation of its production and sale.
William Hallaran, the superintendent of the County and City of Cork Lunatic Asylum in Ireland had a more innovative approach to induce sweating. He had invented a circulating swing [see Rotation, Oscillation and Vibration], a box that was twirled as many as 100 turns a minute by means of a windlass. He found that extended sessions in the swing tended to produce therapeutic sweating, as did the dread being placed in it.
Sweating was not just considered a cure in and of itself, but a symptom of a cure. The therapeutic success of some of the hydrotherapy techniques such as the cold wet pack and the Turkish bath [see Hydrotherapy], and of all of the fever induction therapeutics [see Fever Therapy], was gauged by how much the treated patients perspired; the greater the perspiration, it was thought, the greater the reduction of the brain inflammation that caused insanity.