The use of drugs to keep patients deeply asleep for several continuous hours, days or as long as weeks.
The curative value of sleep was known by the ancients and prescribed by doctors for physical ailments and mental distress for centuries. With the advent of asylums, however, restorative sleep was increasingly problematic. Overcrowded conditions, large wards filled with patients in various states of torment and misery not only left patients tired, but mentally and physically exhausted. It is little wonder, then, that asylum physicians in the nineteenth and early twentieth centuries, often devoted whole chapters in their texts to the importance of sleep. John Mortimer Granville drove home that point:
Sleep, when the intellectual faculties are deranged or the mind is diseased, may be justly regarded as one of the most important functions to be performed by the organism…. Inability to sleep is distressing, and not unfrequently a premonitory symptom of mental disease. Slumber is anticipated as the harbinger of improvement [Granville, p. 160].
To assure the restorative and prophylactic benefits of sleep, asylum physicians relied on such drugs as opium. The “Plant of Joy” had been in use in folk medicine for millennia, and asylum physicians found its sedative effects “most effectual and salutary” (Woodward, p. 1). But opium also had deleterious side effects, most notably nausea and constipation, the latter of which often required a reliance on the anachronistic depletive treatment of purging with salts, cremor tartars, senna, calomel or jalap in order to relieve the distress [see Depletive Therapy]. Morphine was used as well. Administered orally when first introduced and then later subcutaneously via the newly invented hypodermic needle, it was ideal for general sedation, so ideal, in fact, that by the mid-nineteenth century morphine was the most widely used drug in asylums. Its praises were sung by one of the most prominent asylum superintendents of his generation, Samuel Woodward, of the Worcester Asylum in Massachusetts:
The manner in which morphine has been used in this and other hospitals in this country, continuing until the symptoms have subsided, then omitting it and seeing them return, then again and again removed by the renewal of this medicine, affords unequivocal evidence of its power to subdue maniacal excitements, relieve the delusions of the insane, and restore the brain and nervous system to a sound and healthy state [Woodward, p. 62].
Hydrotherapy also was relied upon for its sedative effects [see Hydrotherapy]. Cold wet packs, continuous hot or warm baths, and drip sheets often calmed the most furiously insane patients and lulled them into a few hours of refreshing sleep. Even the swings, hammocks and cradles that spun, shook and swayed patients were considered soporific [see Rotation, Oscillation and Vibration]. Bouts of vertigo and nausea aside, patients were reported to eventually feel the “soothing, lulling effects” that were “succeeded by the most refreshing slumbers” (Cox, 139–140).
Therapeutics may have left minds vacant, but it was asylum order and routine that filled bodies enough for sleep. Large evening meals, sometimes accompanied by beer or wine [see Diet], exercise, and constructive activities carried out in the fresh air, if possible, were considered valuable aids to recuperative sleep.
It was in the early twentieth century that the inducement of not just restorative sleep, but deep and prolonged sleep, was made possible by the introduction of barbiturates into asylum therapeutics. Giuseppe Epifanio, a physician at the University Psychiatric Clinic in Turin, Italy, was the first to administer doses of the phenobarbital Luminal over a four day period to a young woman who had been institutionalized for manic-depressive psychosis. She fell into a deep sleep for two weeks. Upon awakening, her symptoms had been ameliorated enough that she was discharged several weeks later and remained in remission for more than two years. Published in an Italian medical journal and at the start of World War I, Epifanio’s report had little international impact.
But just a few years later, Jakob Klaesi’s reports did. Klaesi, a physician at Burghölzli, Zurich University’s psychiatric clinic, published accounts of his successful treatment of profoundly disturbed patients with deep sleep therapy. The reports were widely read and discussed, and to this day, he is credited with the introduction of deep sleep into asylums where it remained a trendy therapeutic, especially in Europe and Great Britain, for several decades.
If Klaesi was most intimately associated with the debut of deep sleep therapy, Ewen Cameron was with its finis. The deep sleep experiments he conducted at McGill University’s Allan Memorial Institute in Montreal, Canada and funded, in part, by the U.S. Central Intelligence Agency, brought opprobrium to the therapeutic. Anxious to disassociate themselves from the brewing scandal, asylum physicians turned away from deep sleep therapy and to newer and less controversial therapeutic interventions. When Cameron died in the mid–1960s deep sleep therapy, for all intents and purposes, did as well.
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The administration of sodium bromide to induce sleep for a continuous period of several days. In the late nineteenth century, a Scottish physician by the name of Neil Macleod who practiced in Shanghai, China, ordered a twelve ounce bottle of twelve drams of sodium bromide and directed a patient he had been treating for neuralgia to ingest a half-ounce of the mixture every four hours. The patient, a twenty-five-year-old woman, had become addicted to the morphine that had been used to treat the neuralgia, and attempts to withdraw her from it had been unsuccessful. On the first day of taking the sodium bromide the patient was drowsy; on the second day she had fallen into such a deep sleep that she could not be roused. It was evident to Macleod that she had “accidentally” exceeded the prescribed dosage and the overdose was keeping her in a deep sleep for four continuous days. During that time, she could not sit or stand, muttered answers to questions, and urinated and defecated in her bed. As she slowly awoke she became restless and confused, and mumbled incoherently. Over the next two weeks a daily improvement of her thought and speech processes was noted, and her physical strength gradually returned. Upon release from the hospital, she was astonished, as Macleod surely was as well, that she no longer had any craving for morphine.
As word of Macleod’s apparent success in treating addiction spread, patients as desperate for a cure as they were to avoid the extreme discomfort of withdrawal symptoms, found their way to him. All were relieved of their various addictions to morphine and/or cocaine, with the exception of one, who died a week into the treatment from double pneumonia. That death Macleod attributed to a pneumonia epidemic in a region the patient had recently visited.
Although “bromide sleep,” as Macleod christened his therapeutic, held promise for the treatment of drug addiction, it was his experiment in administering it to a woman in the throes of acute mania, without the complication of addiction, that brought the therapeutic, however briefly, into asylums. The patient, a woman, had to be brought from the interior of Japan to Shanghai, where she was to be treated for her mania. The prospect of the trip was so daunting that serious concerns were raised as to whether she would have to be restrained for its duration. Macleod suggested bromide sleep to ease her transport, and “in the hope also of benefit to the nervous condition” (p. 135). The woman not only arrived without incident, but was free of her manic symptoms upon waking from the bromide sleep.
While asylums had their share of addicted patients, Macleod’s conclusion that a bromide sleep could cure, as opposed to temporarily relieve, acute mania was appealing. His reports had been republished in North American psychiatric and medical publications, most notably Merck Archives that stated that because “higher cerebral functions” were affected by bromide sleep, it was not only an effective cure for acute mania, but may “prove a powerful and effective means of dealing with all maladies of the nervous system” (“Bromide Sleep,” p. 111). By attributing its efficacy to its ability to act on the nervous system, the tidy entry in the Merck Archives established the bona fides of bromide sleep as a somatic therapeutic. Since it was nervous maladies of all kinds that were filling asylums at the start of the twentieth century, stoking a fear that insanity was epidemic and a concomitant anxiety among asylum physicians that they were almost helpless to intervene, they were intrigued by the remedy and eager to try it.
Their experiments, however, were decidedly mixed in their outcomes. Archibald Church, a professor at the Chicago Medical College, used it with great success on a morphine addict who, upon awakening not only lost his desire for the drug, but had a renewed feeling of “strength [and] buoyancy” (Church, p. 293). His second patient, however, died during the course of the treatment, most likely from the cumulative effects of the bromide. Church’s conclusion that bromide sleep was effective, albeit more risky than Macleod had acknowledged, put somewhat of a damper on its use as an asylum therapeutic. Some asylum physicians continued the treatment, much more for morphine addiction and alcoholism than for mania or the spectrum of nervous disorders, and did so with some reported success, but most considered the risk of overdose too high.
The administration of drugs to keep insane patients asleep for an extended period of time. In the early twentieth century Jakob Klaesi, a physician at the Burghölzli, Zurich University’s psychiatric clinic, hypothesized that the hallucinations and delusions that were the hallmark symptoms of schizophrenia, were expression of an overactive nervous system. If so, then deep sleep for a prolonged period would reduce that activity, and thus diminish those symptoms upon waking, leaving the patient more amenable to adjunctive therapies, especially psychotherapy. On that point, Klaesi stated:
Now that physician is needed again. The physician and the staff members now have the opportunity to present themselves as useful and necessary and gain through the treatment the patient’s gratitude and confidence. The patient is forced to use meaningful words and gestures, and to consider and to adjust to the environment. If the patient establishes contact with the environment and becomes interested and concerned, then after the end of physical depression and succoring, he will not again sink into autistic habits, but become open to experiences [Windholz & Witherspoon, p. 84].
To produce that deep sleep, Klaesi first administered morphine and scopolamine, followed by the intravenous administration over a ten day period of somnifen, a compound of two barbiturates which had been developed in Switzerland a decade before and was being used in some asylums to sedate loud and boisterous patients. His first subject was a woman, successful in business until a psychotic episode brought her into the asylum where she lay naked in a padded cell that had not been used in twenty years. She was put into a deep, barbiturate-induced sleep on three separate occasions, and upon awakening from the last was free of hallucinations and delusions, and soon well enough to return home. Interestingly, although her husband was delighted in her improvement, she had confided to Klaesi before being discharged that her marriage was troubled and unhappy. Klaesi concluded that this insight was a result of deep sleep therapy, supporting his hypothesis that it would prepare patients for the work of psychotherapy.
Encouraged by the result, Klaesi went on to administer deep sleep therapy to twenty-six asylum patients, most of them women, who had been diagnosed with schizophrenia. All were kept in a state of deep sleep for ten days, with a daily dosage reduction so they could be roused to eat and use the toilet. Upon awakening, and with some adjunctive intervention, eight of the patients improved well enough to either be discharged or transferred to another, less closely supervised ward. Three patients, however, died. Klaesi attributed those deaths to pre-existing medical conditions, but the fact remained that as deep sleep therapy gained popularity as an asylum therapeutic, the mortality rate hovered between 3 and 5 percent. Other complications were noted as well: barbital rash, cardiovascular collapse, bronchopneumonia, acute renal insufficiency with anuria, respiratory depression, dehydration, fever, toxic confusional states, occasional brief delirious episodes, and withdrawal type convulsions at the termination of treatment.
Schizophrenia had already proved itself to be an frustratingly intractable disorder, so the prospect of reducing, even eliminating, its most deleterious symptoms was appealing. But what was equally, maybe even more so, appealing was that deep sleep seemed to prepare patients for intensive psychotherapy, and if it could do that, it also could be used to treat patients with other types of insanity. Not quite a panacea, deep sleep therapy nonetheless was an immensely popular asylum therapeutic, especially in Great Britain and Europe, well into the twentieth century.
It had three noticeable drawbacks, however. First, the risks associated with somnifen kept revealing themselves as considerable, thus the search for new and safer barbiturates, such as somnifaine, continued for decades. Second, deep sleep was labor intensive to administer and monitor. It required not only repeated injections of the barbiturate agent but, given its risks, close monitoring throughout the several day period of deep sleep. Not only did nurses and attendants have to rouse the patients to eat and use the toilet, but they also had to sit at their bedsides for the entire duration of the treatments to record verbatim every word the patients mumbled, as well as to describe in written detail the emergence of the patients from the sleep. Each of these was thought to reveal something about the cause of the insanity each patient was experiencing and therefore would inform the adjunctive psychotherapy that would follow.
Third, the outcomes of deep sleep therapy were mixed. Some asylum physicians reported even higher recovery rates than did Klaesi, others significantly lower, and some found no appreciable changes in their patients at all. While generally optimistic about the potential of deep sleep therapy to aid in recovery two British asylum physicians, Harold Palmer and Alfred Paine, cautioned against its panacean use. They recommended that carefully designed and controlled large scale clinical studies using various types of barbiturates, different modes of administration (injection, intravenous and oral) and doses, differently diagnosed patients, and with both short- and long-term scopes be conducted. These were not done, however. By the time that cautionary note appeared in the psychiatric literature, deep sleep therapy already was being replaced by insulin and metrazol shock therapies, and later electroconvulsive shock therapy [see Shock Therapy]. Although a modified version—one that kept patients in that state for a few short days to quiet their agitation—was used well into the 1970s, deep sleep therapy already had been relegated to occasional use in asylums a decade before that.
Another use for deep-sleep therapy was found during World War II. Battle-fatigued soldiers sometimes were administered barbiturates to put them into a deep sleep for several days. When the dose was reduced to bring about a state of dreamy wakefulness, the soldiers not only ate and used the toilet, but were questioned by psychiatrists about their emotional reactions to battle. What they revealed was then used as the grist of intensive psychotherapy sessions conducted over the next several days. Military physicians claimed that 75 percent of all soldiers undergoing the treatment returned to the front lines within ten days.
Despite the claim that deep sleep therapy was “the first asylum therapy that offered any hope” (Shorter, p. 205), it might be better remembered for the scandals in which it was implicated. The Ward 5 sleep room, referred to as the “Zombie Room” by its patients, at London’s Royal Waterloo Hospital, for example, was the subject of considerable controversy. Overseen by William Sargant, a standard bearer for the somatic therapeutics and an expert on brainwashing, Ward 5 was reserved for intractable women diagnosed with anything from postpartum depression to anorexia. Sargant injected them with large doses of barbiturates to put them into a deep sleep and subjected them to daily electroconvulsive shocks while they slept. One of those patients, a twenty-two-year-old diagnosed with obsessional neurosis, described deep sleep therapy in Ward 5:
It was like being buried alive. I was lying there in the dark, hour after hour, and couldn’t move. I wasn’t aware of my body, just my head in this darkness. You could hear people moving around and other people breathing and moaning … I can remember the sound of the ECT [electroconvulsive shock treatment] machine being wheeled down the corridor and it being switched on and off in other rooms…. It was so frightening. First of all, they injected you and you had an awful feeling of falling backwards into yourself. After ECT, you didn’t know who you were…. We were like zombies. I couldn’t walk. I had to be lifted. Afterwards, they put you back to sleep again. The worst time was when I started not to be asleep. I was awake, but couldn’t move or speak. It was torture, lying there for hours in the darkness [Davies, para. 3, 15, 16, 18, 19].
It was not Sargant’s goal to ready his deep sleep patients for psychotherapy, which he despised, but to “re-pattern” them—wipe their brains clean of the memories that had caused their disorders. Sargant destroyed all records after he left the hospital in 1973, giving more grist to the rumor mill that Ward 5 had been an experiment in brain-washing that was funded and supported by British Intelligence and/or the U.S. Central Intelligence Agency.
While Sargant was interested in re-patterning, Ewen Cameron of McGill University’s Allan Memorial Institute in Montreal, Canada was focused on de-patterning, that is, breaking up pre-existing memories, thoughts and patterns of behavior, and adding new ones. To that end, he isolated patients in specially built boxes in a converted horse stable on the hospital grounds, with goggles on their eyes and cardboard tubes on their arms to prevent them from touching themselves. After sensory deprivation was complete, he induced deep sleep that lasted fifteen to thirty days, with as many as three electroconvulsive shock administrations daily. Hypothesizing that patients in deep sleep were particularly suggestible, he played a continuous loop of tape over the many days the patients were asleep, with the goal of replacing their own memories with the propagandist messages on the tape. This process of “psychic driving,” as he referred to it [see Psychic Driving], was of great interest to the Central Intelligence Agency which, it later was revealed, had generously funded these de-patterning experiments on unwitting patients.
Deep sleep also was implicated in the Chelmsford Private Hospital scandal in Sydney, Australia where over fifteen years Harry Bailey put more than 1,000 patients into barbiturate-induced deep sleeps for two to three weeks, and gave them daily electro-convulsive shocks. Because the barbiturate dosage he administered was so high, the patients could not be roused, thus they had to be fed through nasogastric tubes and were left to urinate and defecate in their own beds. Although Bailey claimed an 85 percent success rate in the treatment of a range of disorders, from schizophrenia, depression, drug addiction, alcoholism, to anorexia, twenty-five of his patients died as a result of deep sleep therapy, and several hundred were left psychologically and/or physically disabled. Although there were a number of coronial inquiries into Bailey’s administration of deep sleep therapy, it was not until three years after his suicide that the Chelmsford Royal Commission began an inquiry into his practice. In 1990, it filed a twelve-volume report, replete with the sordid details of Bailey’s flamboyant personal as well as professional life. As a result of the report, deep sleep therapy was banned in Australia.
The intravenous, intramuscular, oral or rectal administration of an approximately 5 percent solution of sodium amytal, also known as amobarbital sodium and even more familiarly as “truth serum,” to bring about deep sleep. The onset of sleep occurred within several minutes, and the deep sleep lasted for two to eight continuous hours, at which time patients would be awakened with painful stimuli. During their subsequent lucid intervals the patients participated in “amytal interviews” that probed their painful, repressed and delusional thoughts and desires.
The therapeutic was first used in the early twentieth century by William Jefferson Bleckwenn, a neurologist and psychiatrist who had a keen interest in Freudian psychoanalysis. In his position at the Wisconsin Psychiatric Institute in Madison, he was particularly concerned about patients diagnosed with catatonic schizophrenia. Considered incurable, many of them were unable to speak, move, feed themselves or attend to their bodily needs. Bleckwenn hypothesized that sodium amytal would relax the mind enough that upon awakening the catatonic patients not only would be able engage in daily activities but, more importantly, in insightful “amytal interviews” with asylum physicians. Such therapeutic discussions later were referred to as “narcoanalysis” or “narcosynthesis.”
While Bleckwenn certainly was interested in restoring mobility and activity to catatonic patients, it was the therapeutic potential contained within the lucid interval that was more intriguing. All of the first fifty patients he treated with sodium amytal sleep experienced that interval, but none showed its narcoanalytic potential better than a twenty-year-old college student whose case Bleckwenn discussed at some length:
J.L., aged 20, a university student, had catatonic excitement, which had had a sudden onset with confusion and mutism and refusal of food; after three weeks he went into a state of marked excitement with active hallucinations and bizarre gesticulation and grimacing. He set fire to his bed and yelled “fire.” He was given 0.6 Gm amobarbitol sodium. Just before he went to sleep he said that he realized he was having a terrible time and hoped to recover to enter school in February. When he awakened, he behaved in a normal way, and discussed current topics, his illness, school, and his future plans. The lucid interval lasted for almost two hours. After a short sleep, he returned to an excited state. At the time of writing, he had made similar responses after further treatment, was less hyperactive [Fink & Taylor, p. 139].
Bleckwenn published three papers on his quite startling results, but it was a grainy black-and-white film he produced and distributed in 1930 that drew the attention of asylum physicians around the world to sodium amytal sleep. Titled Catatonic Cases After Intravenous Sodium Amytal Injection the silent film showed the before and after results of sodium amytal sleep: mute, posturing and unresponsive patients could be seen talking, eating and walking soon after they were awakened.
In a short time sodium amytal was being used in asylums across the country, as well as in Great Britain and Europe, and for types of insanity other than catatonic schizophrenia. It was observed to create lucid intervals for patients suffering from depression as well as from mania. The psychoneuroses also proved themselves vulnerable to the relaxing and disinhibiting effects of sodium amytal sleep, thus its use as a treatment for “combat neurosis” was widespread during World War II.
Its prevalent use as an asylum therapeutic, however, could not gloss over concerns about both the administration and efficacy of sodium amytal sleep. First, there was the problem of determining the proper dosage to induce sleep, and then the problem of assessing just how many times and over what period the therapeutic should be administered for maximum effect. Although adverse physical effects of the treatment were uncommon, it did have a mortality rate of approximately 1 percent. And then there was the concern that the lucid intervals, those windows of opportunities for catharsis and abreaction, closed all too quickly, shutting off possibilities not just for cure or remission, but for lasting improvement.
Those concerns aside, sodium amytal sleep ushered in a new era of psychopharmacology as a vast array of sedatives and hypnotics were introduced into asylums, some for producing deep sleep, but most others for calming patients and rendering them more amenable to therapeutic intervention. It might be interesting to note that sodium amytal administered at a dosage that produced hypnotic drowsiness, rather than sleep, was often used to facilitate therapeutic interviewing. Sometimes, however, using a truth serum to get to the “truth” of the problem was a daunting task. This amytal interview of a twenty-nine-year-old patient who had acute onset catatonia that had left him mute illustrated that point:
Dr. A: You have been with us for quite a long time, and in all those days you haven’t told us much. Do you think you could do it today?…
Dr. B: We know you can talk. Suppose you tell us your name. What is your name? Huh?…
Dr. A: Who are you? Now tell us, who are you?…Can you keep awake, huh?
Dr. B: Supposing you tell use your name…. What is your name?
Dr. A: Could you be good enough and tell us who you are?
Dr. B: What is your name. Come on, tell us…
Dr. A: Do you hear us?…Give us a sign whether you hear or not, huh?
Dr. B. Open your eyes…. Who are you? Tell us who you are [Lyons, p. 272].
These two asylum physicians continued this line of questioning for some time before asking the unresponsive patient to write his name on a pad of paper. The patient did, and then also wrote his age when requested to do so. When asked what branch of the military he had recently served in, the patient wrote “Army” and then, speaking for the first time, said that word aloud. Then, using single words or simple phrases, he began to reply to their questions.
When the asylum physicians began to inquire about the reason for his mutism, suggesting to him that he may be hearing voices that commanded him to be silent or that he had a deep secret he was too ashamed to tell, the patient retreated once again into silence. And there he remained for many frustrating minutes. Changing tactics, the asylum physicians began inquiring about his family, and the patient, now in simple declarative sentences, replied to their questions, stating the names and occupations of his parents and siblings, and the place of his birth. Apparently encouraged by his responsiveness, the asylum physicians again turned to the reasons for his mutism:
Dr. B: When you came in you weren’t talking to us. Did you stop talking a long time before you came to the hospital?
Patient: I never did talk too much.
Dr. B: No, but you talked some.
Patient: Yep, a little…
Dr. B: Do you have any idea why you stopped talking, or did you just decide to quit?…You haven’t answered my question. Why did you stop talking?…What do you say?
Patient: I couldn’t say yes and I shouldn’t say unh-uh.
Dr. B: You mean you don’t know why you stopped talking?
Patient: No [Lyons, p. 274].
Confused by his response, the asylum physicians again suggested some reasons for his mutism, and the patient again retreated into silence. This prompted the third asylum physician to ask:
Dr. C: Can you say why you can’t talk, whether it is too complicated, you don’t know, or because it is so personal you just don’t want to talk about it?
Patient: One should talk when you are spoken to.
Dr. C: Yeah—but well, that is when you are with people who aren’t your friends, but you have got to feel friendly towards people…. Here we are…. You are free to say anything you want to. You will find us pretty understanding people to talk to. Did this come as a decision on your part not to—I mean, we know that there is nothing wrong with your mouth or your vocal cords, it is possible for you to talk. Now, is this a decision on your part not to talk? Are you familiar with the old saying “You can lead a horse to…” What is the rest of that?
Patient: …horse to water but you can’t make him drink.
Dr. C: What do you think of that? Huh? Think there is any truth in it? Huh?
Patient: Yeah [Lyons, p 276].
The amytal interview was terminated at the point; minutes later the patient fell into a deep sleep. The asylum physicians, whose frustration was evident throughout the interview, nonetheless concluded that it revealed something about catatonic schizophrenia that was empirically investigable:
[T]he schizophrenic steps out of his own history and undertakes to refrain from any commitment to responsible action with others; that he then presents himself, not as a living person with significance to himself and to others, but in the “third person” sense of a set of statistics; and finally, that the catatonic stupor is a state of vigilance in which his declaration of lack of commitment is guarded and preserved. Stated as hypotheses, this proposal as well as all of the other issues raised, would appear to be amenable to rigorous experimental investigation [Lyons, p. 277].
When William Jefferson Bleckwenn returned to the United States after his distinguished service as an officer in the Pacific Theater during World War II his attention, just like that of most other asylum physicians, turned to the therapeutic potential of the new and dramatic shock therapies [see Shock Therapy] that had been introduced into asylums. Although used on occasion and well into the twentieth century, sodium amytal sleep therapy was not able to stand up against the potential of remissions and cures promised by the shock therapies.
Therapeutic strategies to reduce the vascular congestion, often referred to as “inflammation,” of the brain that was thought to cause insanity.
As is true with so many early asylum therapeutics, depletive therapy can be traced to antiquity. Its golden age as an asylum therapeutic, however, was between the late eighteenth and mid-nineteenth centuries, and was so intimately associated with a single physician—the inestimable Benjamin Rush of the Pennsylvania Hospital—that the term “Rush’s system” soon achieved synonymity.
Rush had matriculated at the University of Edinburgh medical school and had been profoundly influenced by its most admired professor, William Cullen. A central figure in the Scottish Enlightenment, Cullen believed that the progress of medicine necessitated the development of a new nosology of disease, thus he classified all nervous diseases as “neuroses,” a term he coined, and then further subdivided the neuroses into additional orders and species. One of those orders was “Vesaniae,” or insanity proper, and Cullen attributed its cause to imbalanced states of “excitement” and “collapse” in the judgment faculty of the brain. The restoration of reason, then, required the use of coercive therapeutics that inspired fear and awe so intense as to diminish excitement and overwhelm collapse. Bleeding, purging, vomiting, sweating—all depletive therapies—were the recommended therapies, and it was these that Cullen’s student, Benjamin Rush, relied upon in his practice at the Pennsylvania Hospital.
Departing somewhat from his mentor who had posited that too much or too little nervous energy was the cause of disease, Rush set out a unitary theory that postulated that all disease, insanity included, was due to the morbid excitement in the brain caused by convulsive actions in the blood vessels. Thus all disease, insanity included once again, urgently required depletive therapy to restore balance. And it was depletive therapy that Rush practiced with relish when, in addition to his general medical duties, he was placed in charge of the thirty to forty insane patients at the Pennsylvania Hospital in 1787. So intimidating in their administration, so dramatic in their effects and so feared by patients, depletive therapy became known as “heroic therapy,” and largely because of Rush’s considerable influence was used in the new private and public asylums that were being built during that era across the United States.
Rush, who was also an abolitionist, environmentalist, prison reformer, treasurer of the United States Mint, and signatory to the Declaration of Independence, eventually was castigated for his reliance on depletive therapy as a treatment of physical disease, indeed his own death from fever in 1813 most likely was hastened by his insistence that he be bled repeatedly. But depletive therapy continued for a few decades longer in the treatment of insanity, its use hidden behind the high walls of asylums. Its disappearance from asylum medicine most likely was due to a combination of reasons. New theories of the cause of insanity challenged Rush’s unitary theory of disease, and new pressures on asylum physicians to bring the treatment of insanity out of the unenlightened past and in parity with enlightened medicine certainly were significant factors. Interestingly, so was the War of 1812. The conflict between the United States and Great Britain churned an animosity against the “Mother Country,” and towards its medical schools. Many American medical students who aspired to be asylum physicians turned to France for their education. Although there were exceptions, of course, for the most part French asylum physicians were considerably more restrained in their use of depletive therapy in the treatment of the insane, combining it with other remedies such as hydrotherapy [see Hydrotherapy], or eschewing it altogether in favor of more vis medicatrix naturae approach that emphasized the healing power of commonsense remedies, rest, diet and fresh air. Those, in turn, were both harbingers and constituents of what became known as moral therapy [see Moral Treatment].
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The withdrawal of blood from a vein.
“Breathing the vein” to treat insanity was one of the oldest therapeutic interventions on record. Bleeding was intimately associated with the humoural doctrine of the ancient medical philosophers Hippocrates and Galen who posited that the body held a mix of four humours, or “vital spirits,” that were produced by the digestive process and then circulated to the heart and the brain by the heat generated by that process. According to the doctrine, each person had a specific, although not unique, humoural constitution that had to be kept in balance to assure both physical and mental health.
Blood was one of those humours. Warm and moist, it was thought to be produced by the liver and was further associated with the spring season, during which time it was at risk for unhealthily accumulating in the body. Blood determined a sanguine temperament and when plentiful and in balance with the other humours of black bile, yellow bile or choler, and phlegm, was the reason for the sociability, pleasure-seeking, optimism and warm-heartedness that were characteristic of that temperament. When in excess, whether due to the season or to changes in the climate, diet, or life circumstances to which it, just as every other humour, was cosmologically connected, it caused the emotional and behavioral excesses of mania. The relief of this excess of blood in the brain, variously referred to as “inflammation,” “plethora” or “congestion” called for the therapeutic intervention of bleeding.
As the mad-doctoring trade professionalized, asylum physicians took great interest in determining the physiological basis of insanity. Theories that focused on the pressure, flow and constitution of the blood extended the therapeutic intervention of bleeding to patients with types of insanity other than mania. Thus bleeding became de rigueur in asylums around the world throughout the nineteenth century and, in fact, was the preferred treatment for virtually all types of insanity. At the Bethlem Asylum in London, England, for example, bleeding not only had been part of the therapeutic regime since its establishment centuries before, but was a highly ritualized component of the asylum’s culture. Patients at “Bedlam,” as the asylum was better known, were bled at a particular time and on a particular day every spring. Asylum physicians moved from one patient to another, opening a vein in the arm or the foot with a sharp-pointed, double-edged blade known as a lancet. When the desired amount of blood had been removed, as measured by the line on the interior of the pewter bleeding bowl placed under the incised limb, the patient was returned to the cell.
So ritualized had this procedure become at Bethlem that it not only persisted decades after the humoural doctrine had fallen out of favor, but in the face of increasingly stinging professional criticism and even public ridicule. By the mid-eighteenth century the zeitgeist was changing. Insanity was being seen as more nuanced than just mania or melancholia, its cause envisioned as more complex than just congestion of the brain, and its treatment as more in need of management than bloodletting. At the vanguard of this change was William Battie whose Treatise on Madness, published in 1758, was the first English monograph on insanity. The entrepreneurial Battie who spearheaded the establishment of St. Luke’s Asylum for Lunatics and who had a lucrative practice in the management of private madhouses in London, attacked the ritualized practice of bleeding at Bethlem, an asylum on whose Board of Governors he had once served:
Madness, rejects all general methods, e.g. bleeding…. For bleeding, tho’ apparently serviceable and necessary in inflammation of the brain, in rarefaction of the fluids, or a plethoric habit of body, is however no more the adequate and constant cure of Madness, than it is of fever. Nor is the lancet, when applied to the feeble and convulsed Lunatic, less destructive than a sword [Battie, p. 94].
The broadside, aimed squarely at Bethlem, was met by another, this one authored by John Monro, visiting physician at Bethlem and Battie’s rival for esteem as the country’s most authoritative mad-doctor, as asylum physicians then were known. Sarcastic in tone, Monro’s rebuttal dismantled every one of Battie’s assertions about the nature and treatment of insanity, including bleeding. He defended bleeding not only for its therapeutic efficacy but for the exercise of good medical judgment that prescribed its use in the first place. Although the two archrivals found common ground on more than a few points, their debate etched out the leading edge of a changing approach to the treatment of asylum patients that eventually would resign bleeding to an embarrassing footnote in the history of asylum therapeutics.
It was not just at Bethlem that bleeding was a standardized therapeutic. In France, patients in the two overcrowded insane wards at the Hôtel-Dieu were bled after the eleven o’clock meal, twice yearly, in the spring and autumn before being plunged into the river for their semi-annual bath, a standing order of physician Édouard Françoise Marie Bosquillion. So intimately was bleeding associated with this hospital, the oldest in Paris, that it often was flippantly referred to as “traitement de l’Hôtel-Dieu.” In Germany, Johann Christian August Heinroth, also prescribed bleeding, despite the fact that he considered insanity to be a moral, rather than a humoural, imbalance. The influential professor of physical medicine at the University of Leipzig and founder of the “psychic school’ of psychiatry, rhapsodically declared that the hot blood of the insane patient should be made to gush from the veins, “as if rejoicing over its escape from the prison in which it was raging” (Kraepelin, p. 37). And in United States, there was no more staunch proponent of bleeding than Benjamin Rush, attending physician to the Pennsylvania Hospital in Philadelphia. The “Father of Psychiatry,” as he posthumously came to be known, found bleeding beneficial, even curative, in its ability to relieve the plethoric condition of the brain, not to mention its ability to frighten and deceive patients [see Pious Frauds]. The case of a young man under his care who had become insane after killing a friend in a duel illustrated that latter point:
In the year 1803, I visited a young man in our Hospital who became deranged from remorse of conscience…. His only cry was for a pistol, that he might put an end to his life. I told him, the firing of the pistol would disturb the patients in the neighboring cells, and that the wound made by it would probably cover his cell with blood, but that I could take away his life in a more easy and delicate way by bleeding him to death, from a vein in the arm, and retaining his blood in a large bowl. I then requested Dr. Hartshorn, the resident physician and apothecary to the hospital, to tie up his arm, and bleed him to death. The Doctor instantly feigned compliance with this request. After losing nearly twenty ounces of blood, he fainted, became calm, and slept soundly the ensuing night. The next day I visited him, he was still unhappy; not from despair and a hatred of life, but from the dread of death; for he now complained only, that several persons in the hospital had conspired to kill him. By the continuance of depleting remedies, this error was soon removed, and he was soon afterwards discharged from the hospital [Rush, pp. 127–128].
Technology kept pace with the therapeutic imperative to bleed asylum patients. The lancet, never a particularly cumbersome device but always feared for the pain it produced, underwent many improvements. The scarificator had multiple steel blades and a depth adjustor; the blades of the spring lancet, tightly fitted into a brass box, were controlled by a lever and cut to a uniform depth; the thumb lancet, protected by a cover or leaves that folded back when the blade was gripped between the thumb and index finger, was small, portable and allowed a certain degree of accuracy in the cutting. These, and other, bloodletting instruments often had bone, horn, tortoise shell, ivory or mother-of-pearl handles or covers, and were carried by asylum physicians and apothecaries in elaborately designed cases.
There were objections to the bleeding of asylum patients that was so lavishly indiscriminate by the early nineteenth century that the French reformer Philippe Pinel was given to muse aloud as to “whether the patient or his physician has the best claim to the appellation of madman” (Pinel, p. 251). Although he did not call for an end to bleeding, he recommended it only for when the exuberantly loquacious patient’s complexion was flushed, pulse quickened and eyes protuberant, all diagnostic signs of an incipient paroxysm of mania. The American asylum physician Pliny Earle, however, did call for its end. The nearly half century that separated the two reformers had witnessed a sea-change of opinion about how to treat the insane, and the growing hegemony of the moral treatment approach [see Moral Treatment] relegated those asylum physicians who still practiced bleeding to the backwaters of asylum medicine.
“To bleed, or not bleed” was the question that opened Earle’s meticulous investigation into the therapeutic (Earle, p. 9). And the answer given by the most prominent asylum physicians to the interrogative was “not bleed”—or at least, not generally and indiscriminately. Their responses indicated not just a change in therapeutic practice in mid-nineteenth century America, but a change in theory about the cause and nature of insanity. Departing from Benjamin Rush’s canonical assertion that all insanity, mania in particular, was caused by an imbalance in the vascular system that inflamed the brain, the surveyed asylum physicians were more inclined to indict the nervous system, lesions on the brain, metabolic disturbances, and even moral affectations such as over-ambition, hyper-religiosity or over-indulgence as the culprits. While many recommended “local” or “topical” bleeding via leeches or wet cupping, they eschewed general bleeding for other therapeutic interventions such as moral treatment, hydrotherapy [see Hydrotherapy], a change in diet [see Diet], or simply rest and quiet. And one respondent after another cited cases in which bleeding exacerbated the insanity, rather than relieved it.
Earle’s treatise tolled the demise of bleeding as an asylum therapeutic in the United States and, in many ways, the humoural doctrine that originally had influenced it. By that time bleeding almost had entirely disappeared from British and European asylums as well.
The replacement of withdrawn blood with blood from a donor into a vein or artery. One of the first attempts to transfuse blood from an animal to a human was performed on an insane man in the mid-seventeenth century. The anatomist Richard Lower had approached Bethlem Asylum in London, England, for a “lunatic” to be his experimental subject, less out of the belief that a blood transfusion would cure insanity than out of desperation to find a willing volunteer. The superintendent of “Bedlam,” as that asylum already was known, refused his request. But a former Cambridge University divinity student who had become a “little frantic” from a brain that was “sometimes a little too warm” (Schaffer, p. 100), offered his services in exchange for one guinea. In the presence of more than forty distinguished physicians, academics and Members of Parliament, Arthur Coga was transfused with eight or nine ounces of lamb’s blood.
The carotid artery of the lamb was lanced and a thin silver pipe with a quill to regulate the flow was inserted; the blood flowed into a silver porringer bowl. Coga, who was inebriated, offered his arm so that Lower could “breathe the vein” and remove several ounces of blood. A silver pipe was inserted into the wound and the lamb’s blood slowly dribbled into Coga’s vein. “Well and merry” during the procedure, Coga drank more wine after its completion and enjoyed a smoke (Schaffer, p. 100).
Lower had hoped that given the docile nature of the species, the lamb’s blood would quiet the tempestuous disposition of Coga’s insanity. And, for a time, that seemed to be true. A week after the transfusion Coga addressed the Royal Society of Medicine and proclaimed that he felt considerably better. Asked why he thought that lamb’s blood, in particular, had had a salutary effect, he replied in Latin, “Sanguis ovis symbolicam quandam facultatem habet cum sanguine Christi; quia Christus est agnus Dei,” saying, in effect that lamb’s blood had symbolic power in that it was like the blood of Christ who is the lamb of God.
Whatever improvement Coga experienced as a result of the initial blood transfusion and the second one performed a month later, was short-lived, however. When the eminent diarist Samuel Pepys was introduced to him at a local tavern, he observed that though Coga spoke “very reasonably and well,” he still was “cracked a little in his head” (Braybrooke, p. 463). Coga indeed appeared quite affected by the transfusions. A letter received by the Royal Society of Medicine and signed by “Agnus Coga,” who may have been his wife or mother or, for that matter, Coga himself since the name can be translated from the Latin as “Coga the Sheep,” described the “forfeit of his nerves” and the “loss of his own wool” and begged for another transfusion to transform him “without as well as within” (Moore, p. 137). The Royal Society of Medicine refused his request, noting the “wildness of his mind” (Shaffer, p. 100). The discouraging outcome of the Coga experiment, coupled with the deaths of several transfusion patients in France and Italy, led the Royal Society of Medicine, as well as the French Parliament and the Catholic Church to issue prohibitions against blood transfusions. These remained in place for nearly 150 years.
Curiosity, however, persisted. It is important to note that Coga was not chosen as a subject of this transfusion experiment because he was insane, nor was the transfusion conducted to cure his insanity; rather, he was a convenient subject to test a technical procedure. Yet Coga might be seen as the embodiment of an ancient humoural question: if blood carried mental, spiritual and physical evidence of the kind of person in whose circulatory system it flowed, then was the blood of the insane different in some way from that of the sane? In the mid-nineteenth century that that specific question was investigated.
W. Lauder Lindsay, assistant physician of the Crichton Royal Institution in Dumfries in the south of Scotland, pricked the fingers of 236 insane patients and 36 staff members to examine their blood under a microscope. Pricking the fingers of the patients was no easy task and Lindsay’s description of the process was a reminder of how both experimental and therapeutic interventions could be complicated by both the mental states of the patients and the total institutional context of the asylum:
As a general rule, the insane are extremely bad subjects for such experiments.… They are extremely sensitive, restless and suspicious of operative interference, even of a slight nature. Many obstinately refused to allow their fingers to be pricked. Some did so from a firm conviction that a deep-laid conspiracy against their lives or welfare lurked under the cloak of an apparently simple experiment; others simply objected to becoming tools of experiment or amusement; some declined on the plea that in their greatly debilitated condition they could ill afford to spare even a single drop of blood; others lacked courage to submit to the operation; some demanded full explanation of the motives which led to my making a singular request of allowing their finger to be pricked by a needle; in others this formed the keynote of their delusions, delirium or vituperation.… [S]ome presented their fingers under the impression that, from the single drop of blood, the state of their constitution, the chances of cure, and the period of their removal, could infallibly be predicted [Lindsay, p. 82].
After comparing the structures of the red and white corpuscles as well as the proportion of serum, fibrin and globules in the sampled blood, Lindsay found no differences either between the blood of the insane patients and that of the staff, or between insane patients with different diagnoses. He concluded that insanity was an ordinary physical disease or, perhaps, a mental reaction to a physical disease, thus emphasizing the intimate relationship between the mind and the body.
More sophisticated laboratory methods for examining blood were made available to asylum physicians during the late nineteenth century. S Rutherford Macphail, Medical Superintendent of the Garlands Asylum in Carlisle in the north of England, for example, discovered differences in the amount of hemoglobin in the blood before, during and after episodes of insanity. This “corpuscular richness” theory was the subject of a number of subsequent published clinical observations that found that corpuscular richness was notable in asylum patients diagnosed with mania, and notably absent in those diagnosed with melancholia; that it was not distinctly different in women diagnosed with puerperal insanity as compared to other women; that it waned during an episodic attack of maniacal excitement; and that it was lower in male than in female patients who had been diagnosed with epilepsy. Clinical observations also concluded that improvement in the quality of the blood was associated with improvement in the mental condition, thus blood tonics such as iron, cod liver oil, quinine and strychnine were highly recommended. Blood transfusions, though, were not. Asylum physicians generally agreed that replacing blood lost through injury or disease was one thing, but replacing it to try to cure insanity was quite another.
That attitude was revisited in the mid-twentieth century. Experiments were conducted by a number of American physicians, most notably Arnold Pfeffer and Michael Pescor, in replacing the blood of schizophrenic patients with that of “normal” donors in order to correct the faulty metabolism of brain cells, which they hypothesized was the cause of schizophrenia. The results were not impressive. The faulty metabolism hypothesis, however, was appealing in its logic, so a decade later Robert Galbraith Heath, chair of the Department of Psychiatry and Neurology at Tulane University in New Orleans, Louisiana, and his colleagues isolated an abnormal blood protein in patients diagnosed with schizophrenia. When injected into monkeys, the protein which they called “taraxein,” from the Greek taraxis, or confused mind, produced unusual behavior. When injected into humans, prisoners at the state penitentiary, who had never been diagnosed with schizophrenia, it produced what Heath reported was a temporary psychotic disorder that mimicked schizophrenia. He replicated this finding with sixteen other human volunteer subjects, each of whom became symptomatic—disorganized thought, depersonalization, shortened attention span, apprehension, impaired concentration—within two to ten minutes after the injection, with symptom intensity peaking at fifteen to forty minutes, and subsiding after two hours.
The Heath study immediately brought new therapeutic strategies into discussion: perhaps schizophrenia could be cured by exchange transfusions, or by hemodialysis. The press cited one asylum physician after another who was buoyed by the hope of finally curing one of the most intractable types of insanity. As is true with so many therapeutic proposals, however, the enthusiasm outpaced the sober progress of testing and evaluation. When Heath’s study was replicated with better controls, the results could not be replicated.
The drawing of twenty to forty ounces of blood in a single instance. The treatment was enthusiastically advocated by Benjamin Rush, attending physician to the Pennsylvania Hospital in Philadelphia, the first colonial medical institution to treat insanity. Rush distinguished himself as the embodiment of Enlightenment ideals; he was a scientist, teacher, writer, abolitionist, signatory to the Declaration of Independence, and during his tenure at the hospital from 1783 to 1813, a psychiatric innovator. Confronted by a handful of “furious, fierce and dangerous” patients held in cells in the hospital’s basement (Tomes, p. 4), Rush experimented with a variety of aggressive therapeutic interventions that came to be known as “heroic treatments,” not so much for their laudable outcomes as for their daring administrations. Among those heroic treatments was copious bleeding.
Rush had matriculated at the University of Edinburgh Medical School, studying under the esteemed physician William Cullen. “Old Spasm,” as Cullen was affectionately known, had set out the medical canon of that era. All disease, insanity no exception, he posited, was caused by an alteration in the excitement of the nervous system. That alteration either depressed the nervous system or, as in the case of mania, excited it, thereby producing vascular spasms that interfered with proper blood circulation. Depletive or antiphlogistic therapeutic strategies, in that case, were required to restore the balance, thus Cullen recommended bloodletting for mania. Departing from that canon, Rush posited that an alteration in the excitement of the nervous system produced “morbid excitement” of the circulation (Rush, p. 25); thus all illness, both mental and physical, stemmed from the overactivity of the vascular system. Rush, as a consequence, bled all of his patients, but copious bleeding, he argued, was the only real remedy for the “arterial disease, of great morbid excitement or inflammation in the brain” (p. 183) that was mania.
He set out the rules for copious bleeding via the jugular, occipital, or frontal vein, or the temporal artery in his text, Medical Inquiries and Observations upon the Diseases of the Mind, the first psychiatric text published in the United States:
Bleeding should be copious on the first attack of the disease. From 20 to 40 ounces of blood may be taken at once, unless fainting be induced before the quantity be drawn. It will do most service if the patient be bled in a standing posture. The effects of this early and copious bleeding are wonderful in calming mad people. It often prevents the necessity of using any other remedy, and sometimes it cures in a few hours [Rush, p. 185].
With neither caveat nor criticism, Rush offered case after case in which what had appeared to be hopeless states of mania were not just relieved, but cured, by copious bleeding. And the bleeding indeed was copious. A Mr. T.H. lost 200 ounces of blood in several sessions during a two month period; Mr. D.T., who had been bled forty-seven times over nine consecutive months, lost a total of 470 ounces. Rush declared each cured.
The influence of Rush was considerable, especially in the United States where asylums were being frantically constructed and quickly filled beyond capacity. The fidelity to Rush’s approach, however, would prove to be fickle, but certainly while the “Father of American Psychiatry” was alive, and then for a decade or so after his death, copious bleeding was the standing order of the day in American asylums. Yet by the mid-nineteenth century, when Pliney Earle published his comprehensive survey of asylum physicians on the therapeutic of bleeding, it was clear that Rush had steadily accumulated more detractors than supporters. Many asylum physicians simply found copious bleeding less heroic than cravenly aggressive and, in the bargain, much too risky to administer to manic patients whose resistance often was considerable. Others rejected Rush’s underlying theory that insanity of all types originated in the vascular system. The strongest skepticism, however, was reserved for Rush’s claims of the curative power of copious bleeding. Asylum physicians had increasingly observed that the therapeutic left patients weak, depleted, exhausted and, even more disturbingly, sometimes more floridly insane. Earle cited the case records of attending physician James Macdonald of the patients who had undergone copious bleeding at the Bloomingdale Asylum in New York City, or at other asylums before being transferred there, to illustrate these points:
M.K. with Dementia: a striking example of the indiscriminate and excessive employment of the lancet in mental diseases. In this case, which was one of low, brooding melancholy, the most active bloodletting was employed, and repeated, day after day, until his physical energies were so far prostrated as to incapacitate the brain from performing functions common to brutes, and the heart almost circulating the blood.… [W]as discharged “by request,” the expression used by that institution for unimproved.
[A] woman was admitted who had been bled to the amount of eighty or ninety ounces, which had only the effect of weakening her mind without in the least allaying the violence of the paroxysms or lessening morbid strength. She remained six months and was discharged “much improved,” but …was readmitted and became a permanent resident of the institution…
A/C/F/ was admitted. He had been bled from twelve to sixteen ounces, every third or fourth day, for the space of six months. After being subjected to treatment for two years, he was discharged “by request.” Two months afterwards, he was brought back and remained until his decease from typhoid fever.…
J.W.J. was admitted. He had bled at different times to the amount of three or four quarts. He was discharged “cured,” five weeks after his reception, but was readmitted after an absence of seven months. He was now incurable.…
Admitted H.J. who had been treated by copious bleeding and other depletion. Discharged one month afterwards, “demented.”
J.U.…had been repeatedly bled and exceedingly reduced. Remained six months and discharged “demented.”
C.R. had lost sixty-four ounces of blood in a few days before her admission. After a residence of two years, she was transferred…“demented” [Earle, pp. 19–20].
A letter to the editors of the Boston Medical and Surgical Journal also emphatically made all of these points. Citing cases of mania successfully treated with diet and tinctures of opium, the author implored his colleagues to question the received wisdom of the “justly celebrated Dr. Rush” that mania was the result of an inflammation and that copious bleeding was its only cure:
Cases of [mania] are almost daily coming under my observation, and the result of the treatment [by diet and drug] has taught me an important practical lesson in insanity—not to mistake excessive nervous action for inflammation, nor be led to consider the great muscular power of the maniac any proof of the strength and vigor which requires active depletion [Author, p. 21, italics in original].
Some of the most eminent and respected asylum physicians around the world, who otherwise contentiously argued about therapeutics, were in agreement. Philippe Pinel, then a physician at the Salpêtrière Asylum in Paris, France, declared that “bleeding, practiced as it is without rules or bounds, is found to exasperate the complaint, and to cause periodical and curable mania to degenerate into dementia or idiotism” (Pinel, p. 252). A former advocate of copious bleeding, George Mann Burrows became its adversary. The distinguished British expert on insanity had slowly come to the realization that rates of recovery were much higher for patients who had not been copiously bled, a realization that led him to the conclusion that the therapeutic was based on an incorrect theory about the origin of mania and that, as carried out, was little more than “a practice fraught generally with mischief” (Burrows, p. 583).
The therapeutic use of copious bleeding in asylums certainly outlived its use in general medicine and, interestingly, it even outlived the concomitant blows to Rush’s reputation as a physician. In 1793, more than 4,000 people died as the result of a yellow fever epidemic that struck the city of Philadelphia. Most of the patients Rush treated for the acute viral hemorrhagic disease were among those fatalities. With fidelity to his theory that all disease was vascular in origin, he had treated these patients with copious bleeding and, as a consequence, found himself being ridiculed by detractors and pilloried by the press. The English-born pamphleteer and crusading journalist William Cobbett launched a campaign against Rush, defaming him as a “potent quack” whose reliance on copious bleeding was little more than a bloody purge that killed one patient after another. Rush, his reputation sullied, sued for libel and won. Cobbett, however, fled to England and left the $8,000 judgment against him unpaid. Perhaps the ironic distance between Rush’s good intentions and the bad outcomes of copious bleeding for both asylum and medical patients was captured in a letter Thomas Jefferson wrote about his good friend: “In his theory of bleeding…. I was never opposed to my friend … whom I greatly loved; but who had done much harm, in the sincerest persuasion that he was preserving life and happiness to all around him” (Miller & Miller, p. 39).
The application of medicinal leeches, i.e., Hirudo medicinalis, to the skin for the localized depletion of blood. Leech therapy for the treatment of insanity dates back millennia, and was even promoted by the tenth century Persian physician, Avicenna, as a prophylactic—a regular leeching, he proposed, kept ardent lovers out of the throes of madness. During the seventeenth and eighteenth centuries, barber-surgeons sometimes eschewed the scalpels, lancets and fleams of their trade in favor of less intimidating leeches, as did military surgeons whose need for them bolstered a vigorous international trade in these segmented worms that attach with strong suckers, secrete the anticoagulant hirudin, and suck out ten times their body weight in blood before they release themselves from the skin.
Eighteenth century asylum physicians, influenced as they were by humoural doctrine, were of a mind that it was an excess, or plethora, of blood that was irritating and inflaming the brain that caused insanity, and just as the barber-surgeons and military surgeons had done, they often relied on leeches for general bloodletting. In London, England, at Bethlem Hospital, better known as Bedlam, leeches were applied in the spring to every patient, regardless of diagnosis or prognosis, since it was that season that corresponded with the vital spirit of blood, according to humoural doctrine. So ritualized had that treatment become, in fact, that it outlived the influence of the doctrine, leaving physician Thomas Monro to weakly defend leeching in front of a skeptical Select Committee that was investigating conditions at the asylum in the early nineteenth century:
Patients are ordered to be bled about the latter part of May, according to the weather…. That has been the practice invariably for years, long before my time; it was handed down to me by my father, and I do not know any better practice [House of Commons, p. 110].
During that time most British asylum physicians had the same devotion to the time-honored treatment of leeching as had Monro, if no longer to the humoural doctrine that gave rise to it in the first place. Taking a more iatro-mechanical view, they reasoned that leeches were best suited for localized, rather than generalized, bloodletting, so their careful application to plethoric bodily sites—the forehead, behind the ears and in the nostrils for relief of melancholic congestion of the brain; the vulva and inner thighs to stimulate menses, alleviate puerperal mania, or inhibit nymphomania; the hemorrhoidal vein in the anus, thought to have an intimate sympathy with the brain, to quiet mania—became the treatment of choice.
By mid-nineteenth century, however, whatever passion there had been among British asylum physicians for bloodletting—generalized or localized—and by any means, had waned considerably in the face of high regard for moral treatment [see Moral Treatment]. This was evident in the response to John Conolly’s recommended treatment for melancholia. Physician to the Middlesex County Lunatic Asylum at Hanwell, just outside of London, Conolly was particularly interested in melancholy, as evidenced by his highly regarded study of Shakespeare’s Hamlet, and for its treatment he advised that leeches applied to the forehead and behind the ears would alleviate symptoms and, on occasion, cure it altogether. Only a few of his colleagues agreed. When fifty-two of them were questioned as to their treatment preferences, only thirteen were still using leech therapy for melancholia, and none for mania.
Leech therapy, in fact, always was used cautiously in cases of mania due to what often was the vigorous resistance of patients. Pundits, however, had much to say about the “leech mania” that swept across France and soon penetrated the bastilles of insane asylums. In the late eighteenth century, François-Joseph-Victor Broussais, an army physician who had once studied with Philippe Pinel at the Salpêtrière Hospital in France, advanced a new system of what became known as “physiological medicine” that attributed all illness, including insanity, to an irritation of the gastrointestinal tract that passed “sympathetically” to other organs, including the brain. The only cure, he posited, was bloodletting, but because that often weakened patients, he advocated a localized application of leeches. So popular had leeching become for illnesses ranging from colds to cancer, itches to insanity, that more than a billion leeches had to be imported into France to meet the demands that local leech farming could not. For creatures so low on the evolutionary scale, leeches became very fashionable in French culture. These fresh water invertebrate parasites, prized for their sensitivity to atmospheric conditions, also were used as barometers, and inspired the paisley-like design of brooches and of clothing, the latter of which popularly were known as “robes à la Broussais.”
The influence of Broussais, who had earned both the posthumous sobriquet of “the most sanguinary physician in history,” and the less flattering contemporary nickname of the “le vampire de la médicine,” on the treatment of insanity in France also was considerable. The great reformer Philippe Pinel continued to use leech therapy for chronic insanity long after a new era in the humane treatment of the insane was announced by the striking of the chains of insane patients at the Salpêtrière Asylum in Paris. Another notable French asylum reformer, Jean-Étienne Esquirol, also used leeching as part of a complicated treatment regime that included tepid baths, exercise and purgings in his practice at the Charenton Asylum. His successor, Louis-Florentin Calmeil continued leech treatment well past the mid-nineteenth century, touting it as a treatment, although not a cure, of a peculiar form of insanity he labeled “monomania with paralysis.” The delusions of wealth and grandeur that were its hallmarks, he posited, inevitably would deteriorate into chronic dementia or even bring about death unless stability was gained through the repeated applications of leeches to the anus.
One type of many mechanical leeches that were invented in the early nineteenth century when the medical demands for Hirudo medicinalis was so great that it nearly led the species to extinction. Squeamish patients favored the mechanical version, as live leeches tended to drop off the skin and reattach in unexpected places (courtesy of the Wellcome Library, London).
Leech mania also had spread to the asylums of Germany. At the small Halle-Nietleben Asylum near Leipzig, for example, physician Heinrich Damerow routinely prescribed leeches to the anus for all patients, quiet regardless of diagnosis or prognosis. That practice was so widespread that a British physician dismissed it as a peculiarly German interest in revulsion as a therapeutic; whether peculiar or not, Germany capped the exportation of leeches to the United States in the early nineteenth century for fear it would exhaust its own supply.
American asylum physician were faced with a dual dilemma in the early nineteenth century: the Hirudo decora leeches native to the country had less capacity for bloodletting than the Hirudo medicinalis of Europe, and thus were not up to the formidable task of treating “American insanity,” which was imagined to be more belligerent, obstinate and autonomous—rather like the county, itself—than its European counterpart. Perhaps because of the high cost of procuring leeches, American asylum physicians used them more sparingly than did their international colleagues.
One famous American case involving leech treatment deserves mention. In 1833, Jane C. Rider, a nineteen-year-old servant of a prominent Springfield, Massachusetts, family, began experiencing episodes of sleepwalking, rising from her bed at night and wandering about, and even engaging in a parody of her housekeeping activities while asleep. Her concerned employers took her to a physician who, although believing her somnambulism was due to a paroxysm in the brain, nonetheless was quite taken by her ability to read letters with her eyes closed, recite poetry long forgotten, and mimic people while in a somnambulistic trance. His public discussions about her case brought a constant stream of fascinated lay-people and physicians to his office where, for their edification, he would subject Rider to a variety of tests that exhibited her unique abilities. Eventually unable to manage the curiosity-seekers, the physician had the “Springfield Somnabulist,” as she had come to be known, admitted to the Worcester State Lunatic Asylum and placed under the care of one of the country’s preeminent asylum physicians, Samuel Woodward. Already interested in phrenology, the trendy “science” of inferring character traits from the shape of the skull, Woodward concluded that Rider’s persistent headaches on the left side of her head were the result of the overexcitation of the corresponding faculty of the brain, thus causing both her somnambulism and her unusual abilities. He then subjected Rider to a vigorous regime of diet, laudanum, emetics, purgatives, baths and, finally, leeches. Awaking from a somnambulistic trance to find leeches clinging to the left side of her head, Rider was “not a little surprised at her new head ornaments” (Belden, p. 91). She improved significantly although not completely, however, and was released soon after.
Leeches were stored in what often were elaborately decorated porcelain, glass or ceramic jars, and transported from the pharmacy to the asylum in pewter or silver leech carriers, all of which have considerable value as antiques in today’s market. Also valuable is the so-called “mechanical leech.” Invented in the early-nineteenth century, this spring loaded device simulated leech bites by the tightening and turning of springs that lacerated the skin, and the pulling back of a pump to extract blood via suction. There were several models of it and one of the first, if not the first, was designed by Jean-Baptiste Sarlandière, a French physician. Although ingeniously designed, and much preferred by squeamish patients, the use of what Sarlandière named the bdellomètre required considerable manual dexterity on the part of the physician and thus quite quickly fell out of what was its already rather limited use as an asylum therapeutic.
By the mid-nineteenth century leech therapy, which had been used in asylums around the world, had all but disappeared from use as humoural and inflammation theories of insanity fell out of vogue.
The evacuation of the bowels produced by the administration of an aperient, enema or clyster, or smoke. The humoural doctrine had proposed that there was a link between the abdominal region, particularly the stomach and the intestines, where the humours were replenished during digestion and expelled when depleted, and some types of insanity. Thus the purging of the bowels long was thought to efficaciously expel the excessive, stale, noxious and peccant humours that could inflame the brain. Purging as a therapeutic, in fact, long outlived the humoural doctrine that first rationalized it. As more mechanistic theories of insanity achieved hegemony, asylum physicians well into the twentieth century still “cleared [the] heads, improved [the] tempers, and aborted or cut short a mental crisis,” by regulating the bowels of their insane patients (Lomax, p. 99).
Asylum physicians had a veritable cornucopia of aperient herbs, flowers, roots, salts, oils and berries at their disposal to purge insane patients. Jalap, rhubarb, aloe, senna, valerian root, bryony, gamboge, Rochelle and Glauber’s salts, castor oil, cream of tartar, croton oil, calomel and colocythn, among other aperients, were used alone or in combination, steeped in hot water or mixed with honey or treacle and sometimes flavored with sassafras chips or juniper berries, mixed with butter and spread on bread, or dissolved in beer, and given orally to patients as many as three or four times each day to stimulate evacuation.
The English madhouse owner Thomas Bakewell, whose flamboyant personality and widely read text on insanity still could not completely elide the fact that he had no formal medical training, was indifferent as to which purgative was best. “Most families have a predilection for some particular purge, and this may be indulged,” he wrote, “for I don’t perceive it to be of any great consequence” (Bakewell, p. 64). Not everyone agreed. Jean-Étienne Dominique Esquirol, médecin ordinaire at the Salpêtrière Asylum in Paris, France, for example, stated emphatically that “the choice of purgatives is not a matter of indifference” (Esquirol, p. 86). In so declaring, Esquirol defended the steady progress of professionalizing the care of the insane—no self-taught empiric such as Bakewell, after all, was likely to appreciate that some purgatives were best suited for their special action on the hepatic system, others for their effect on the hemorrhoidal vessels, and that in all cases in which they irritated the skin, their administration had to be alternated with tepid baths. Nor was a self-taught empiric likely to know that purgatives were contraindicated for certain types of insanity: hypochondriacal insanity, for example, only worsened because of their irritating effect on the abdominal viscera where it was thought to originate; and epileptic insanity, as another example, was not at all ameliorated by the administration of purgatives. And quite contrary to Bakewell’s assertion that “there is very little danger of [purgatives] being too strong, for those laboring under this disease will not at all be injured by what would be extremely hurtful to persons of sane mind” (Bakewell, p. 64), Esquirol reminded that potent purgatives can exhaust and weaken patients, rendering the administration of supplemental therapeutics, such as bleeding, particularly risky.
A collection of brass, ivory, ebony and pewter enema syringes. The practice of purging, or evacuating the bowels, far outlived the humoural doctrine on which it was based (courtesy of the Wellcome Library, London).
Esquirol eschewed only the routine use of drastic purgatives in the treatment of insanity. He, like most asylum physicians, often found it necessary to prescribe carefully concocted and calibrated purgatives to relieve the constipation that afflicted so many insane patients as a result of poor diet, sedentary conditions, the costive effects of therapeutic remedies such as opium, and even “the voluntary retention of feces so common in lunatics” (Burrows, p. 636). Because some patients resisted the therapeutic, often strenuously, asylum physicians were forced to be innovative. The eminent British expert on insanity, George Mann Burrows, recommended the use of suppositories such as a piece of soap or a twist of tobacco, the tickling of the anal sphincter with a feather, and galvanism which, when applied twice daily for one-half hour, produced a “rumbling noise in the bowel” (Burrows, p. 636) that announced evacuation. In reference to some of the emerging therapeutics of the early nineteenth century, Burrows also suggested that a stream of cold water propelled at the anus [see Hydrotherapy], or a session or two in a vibratory chair [see Rotation, Oscillation and Vibration] would work well to overcome the torpidity of the bowels.
Perhaps one of the most innovative of the purging techniques was the tobacco smoke enema. The narcotic and purgative medicinal effects of tobacco, whether smoked, chewed, inhaled, smoldered in the form of “burn cigars,” swallowed as an infusion or rubbed in as a salve, had long been touted as a cure for diseases such as headaches, abdominal cramps, coughs and colds, rheumatism, toothache, and even typhoid fever and cholera. But the insufflation of tobacco smoke into the rectum of insane patients as a method of purging had an interesting history. North American indigenous groups had been using the tobacco smoke enema for as long as centuries to resuscitate those who had nearly drowned. The practice was adopted, and adapted, by European humane societies during the eighteenth century. A victim of near-drowning in London’s Thames River, for example, would have been revived by the “pipe smoker medic” affiliated with the Royal Humane Society, who would blow tobacco smoke into an enema tube inserted into the victim’s anus. The smoke was thought to both warm the body and stimulate the respiration, thus reviving the victim. This use of tobacco smoke also was found useful by a few asylum physicians who subjected patients to near-drowning via the bath of surprise [see Salutary Fear]. It may be interesting to note that the phrase “to blow smoke up one’s ass” originated with this method of resuscitation, and to this day refers to getting a reaction or a rise out of someone.
Because tobacco smoke stimulated the intestinal tract as well as the respiratory system, it also acted as a purgative and for asylum physicians looking to add to their therapeutic armamentarium, the insufflation of tobacco smoke was ideal and new technological devices on the market made administration quite effortless. These “fumigators,” as they were called in the United States, had metal boxes to hold the lit tobacco; a tube attached to one side of the box was inserted into the patient’s rectum, and a second tube on the opposite side of the box was attached to a pair of bellows. The tobacco smoke enema was used and recommended by a few prominent asylum physicians in Great Britain, Europe and North America, but did not have widespread use.
If the use of tobacco smoke enema as a purgative was short-lived, purging was not. As a family physician who had been seconded to work during World War I in the Prestwich Asylum in northern England, Montagu Lomax was appalled at the routine use of therapeutics which he saw as inhumane. And high on his list was the administration of croton oil as a purgative. Extracted from the seeds of Croton tiglium trees, the viscid oil raised blisters when applied to the skin [see Counterirritation], and caused severe diarrhea when taken internally. While Lomax agreed that the occasional administration of purgatives to relieve constipation was necessary, it was the routine and sometimes castigatory use of croton oil that he found most offensive:
Nearly all insane persons, whether in asylums or not, are habitually constipated. And nothing tends more to clear their heads, improve their tempers, and abort or cut short a mental crisis, than the proper regulation of their bowels. This is commonplace in the treatment of all mental patients. Nevertheless, the aperients employed should be properly chosen, medically supervised, and their effects carefully noted. They should never be given indiscriminately … and the use of stock bottles and routine treatment by the Ward Charges is to be deprecated…. When I first took office I found the use of croton oil almost universal…. [T]he drug is used much too frequently and indiscriminately, and, worse still, often as a punishment. It is in that latter light that all patients regard it…. It is probably responsible for more harm [e.g. dysentery, colitis] than all the other drugs used in asylums put together…. I once took a two minim capsule myself, for I was anxious to judge of the effects of a drug in such constant use. The experience was extremely unpleasant…. The bowels, after a strong cotton purge, may be opened ten or even twenty times. Often there is severe griping as well, and the patient may be violently sick. The pulse rate is markedly lowered, feeble cases may become blue and cyanotic, and may even faint [Lomax, p. 99].
Lomax’s expose on asylum therapeutics, published in 1922, was unsettling to professionals, politicians and the public alike. A Departmental Committee was put together to examine the charges made in it and summoned Lomax to give testimony. He declined. Certain that the Committee was intent on glossing over the most serious of his allegations, Lomax took his case once again to the public whose concern about the treatment of the insane had taken on fresh urgency as asylums brimmed with shell-shocked and mind-shattered ex-soldiers. He reprinted, in book form, a series of articles that appeared in a magazine about the experiences of the pseudonymous Rachel Grant-Smith who had been held in five different British asylums. In unembellished prose, Grant-Smith described the appalling treatment she both had experienced and witnessed over the twelve years of her institutionalization. Although her complaints about maltreatment were dismissed at the time of her confinement as “delusions of persecution” by asylum officials, and the magazine articles published after her release prompted no official enquiry, the book figured significantly in what came to be known as the “Lomax Affair”—a series of investigations, enquiries, cover-ups, whitewashes and inter-professional squabbles that circuitously led to the passage of the 1930 Mental Treatment Act.
The ejaculation of sperm, either through masturbation or coitus. Historically, masturbation had been condemned by the Church as a sin, but it was with the 1715 publication of a pamphlet with the long-winded titled of Onania, or the heinous sin of self-pollution, and all of its frightful consequences in both sexes considered, with spiritual and physical advice to those who have already injured themselves by this abominable practice, that the “trinity of ideas that would come to dominate the nineteenth century—sin, vice, and self-destruction” first emerged (Stengers & Van Neck, p. 38). That trinity was reified by Samuel Auguste Daniel Tissot, an influential Swiss physician and Vatican advisor who labeled all non-procreative sexual activity as onanism and cited the ominous physical debilitations that resulted: decay of bodily strength and agility, aching in the head and joints, disorders of the intestines, and weakening of procreative power.
The earliest link between masturbation and insanity was forged by the “Father of American Psychiatry,” Benjamin Rush in the early nineteenth century. Citing several cases he had treated, he conjectured that masturbatory insanity was more common than most asylum physicians realized, and that they should consider themselves well advised to be vigilant about the “train of physical and moral evils which this solitary vice fixes upon the body and mind” (Rush, p. 31). So warned, asylum physicians kept a keen eye out for signs of masturbatory insanity—and found them. After all, asylum patients often were seen masturbating, so the link between onanism and insanity was easily imagined. So easily, in fact, that in the early nineteenth century the renowned French asylum physician Jean-Étienne Dominique Esquirol declared that masturbation “is signalized in all countries, as one of the frequent causes of insanity” (Esquirol, p. 51).
While Esquirol’s statement may have been hyperbolic, the fact remained that the notion of masturbatory insanity held sway throughout Western society for much of the nineteenth century and that the asylum therapeutics for treating it—wiring, circumcision, castration [see Genital Surgery]—were in widespread use. Therefore it is a bit ironic that spermatic evacuation by means of masturbation was ever recommended in that century for the treatment of insanity. That irony was compounded by the fact that it was Esquirol, himself who, however cautiously, recommended it. Esquirol cited several cases that had come to his attention in which insanity was cured by spermatic evacuation. One of those was of a twenty-four-year-old soldier who had contracted gonorrhea which, upon the advice of his comrades, he treated by drinking a tumbler of brandy in which the powder of three cartridges had been steeped. The gonorrhea disappeared, but in its place a raging insanity appeared. The soldier was wildly hallucinatory; he saw a skeleton rise from the floor of his asylum chamber, and an eagle emerge from his straw bed, ready to devour him. To protect himself, he made a circle of straw and mattress ticking on the floor, laid in the middle, and moved his head rapidly from left to right, all the time huffing and blowing to keep the skeleton and the eagle at bay. After six months in this state of fury, he began masturbating, and calmed considerably. Although both the gonorrhea and the insanity reoccurred more than once over the next several years, the calming effect of spermatic evacuation was not lost on Esquirol. Somewhat reluctant to prescribe it, he nonetheless considered the possibility that by doing so he would remove the moral condemnation from the act and that that alone would have a more salutary outcome than the act itself. “It is not easy to establish the degree of influence,” he wrote, “which, in this act, belongs, respectively, to the physical and moral impression” (Esquirol, p. 197).
For Esquirol the “moral impression” of spermatic evacuation during sexual intercourse was less complicated, but he was still reticent in recommending it as a therapeutic for men or for women. Without judgment, he cited cases relayed to him by other asylum physicians of two insane patients who had engaged in the “wildest venereal transports” (Esquirol, p. 195) that cured the female and killed the male; an insane female who was cured when her long suppressed menses started again after being gang-raped; of young girls cured of hysterical melancholy by marriage. He regarded these cures as exceptions and countered that his experience showed that sexual intercourse and, for that matter, rape, marriage and/or pregnancy, risked aggravating rather than curing insanity.
A generation earlier there were asylum physicians who lauded the salutary effects of spermatic evacuation during sexual intercourse. Vincenzo Chiarugi, for example, found it to be perfectly compatible with the humanitarian reforms he was instituting at the Ospedale di Bonifazio in Florence, Italy. He had recommended it for both male and female melancholics, and actually encouraged asylum physicians to act as brokers by finding new love interests for their patients and then easing them into relationships, so as to not set off episodes of mania. Johann Christian Reil would have agreed. The physician who, although feted as the “Father of German Psychiatry” actually had little experience in treating the insane, nonetheless had strong opinions as to how they should be treated. And although the list of his prescriptions reads more like acts of medieval torture than not—hunger, thirst, red hot iron, submersion in water—he also recommended sexual intercourse, with prostitutes if necessary, to “reduce the accumulated lascivious energy that might contribute to mental disturbance” (Richards, p. 271).
That history aside, British and American asylum physicians, the latter of whom were particularly influenced by Esquirol, heeded his caution and did not recommend spermatic evacuation through sexual intercourse as an asylum therapeutic. American asylum physicians, in fact, argued whether there should be social intercourse between male and female insane patients within the walls of an asylum and, even more urgently, whether both sexes should be housed in the same asylum in the first place. John Minson Galt, the superintendent of Eastern State Hospital in Williamsburg, Virginia, the first asylum in the United States exclusively devoted to the care of the insane, offered an eloquent, if occasionally obtuse, argument in favor of separate asylums for the sexes. Reminding his colleagues of the “evils of this admixture” of the sexes (Galt, p. 493), and appealing to God’s “unity of design” that makes it possible for birds to fly and camels to thrive in arid conditions, he argued that “it is but an extension of this idea, when we adopt the plan of providing different establishments for the two sexes, for in each case simplicity and unity are the objects sought” (Galt, p. 494).
The inducement of the violent ejection of the contents of the stomach through the mouth. Based on the ancient humoural doctrine that insanity was both caused and worsened by an accumulation of bodily toxins, vomiting long was considered a particularly effective evacuant. It “stimulated the nerves in the abdominal region and heightened the activity of various organs; rid the stomach and upper enteron of mucus, bile, undigested foods, poisons, acids and other harmful substances; and finally, calmed or excited certain nerve centers antagonistically by inducing nausea” (Kraepelin, pp. 58–59).
A wide variety of emetic agents was used by asylum physicians to induce therapeutic vomiting. An infusion of wine with crocus metallorum, the yellowish or reddish oxides of some metals was favored for some time, as was black hellebore, a species of the evergreen flowering plants in the Ranunculacea family. “That drastic vegetable,” as it came to be known, was entwined with myth, legend and superstition. In legend it was called the “Christmas Rose” because it was said to have bloomed in the snow from the tears of a young girl who had no gift to give the Christ Child in Bethlehem. Lauded by Hippocrates and Pliny for both its emetic and purgative qualities, touted in myth as having cured the insanity of the daughters of Proteus, feared for its propensity to slow and then stop the heart rate, asylum physicians administered black hellebore with both reverence and care, but not always to good effect. Philippe Pinel, physician to the Asylum de Bicêtre in Paris, France, explained why: asylum physicians were ignorant of the fact that the hellebore of legend was not black, but white and belonged to a different plant family. By the early nineteenth century the use of black hellebore as an emetic had all but ceased, and it was Pinel who eulogized its passing: “Whether we consider its empirical administration or the unfounded theories and superstitious fancies which in some instances sanctioned its employment, the disuse into which this remedy is fallen, ought to cause little regret” (Pinel, p. 254). Unwilling to give up the therapeutic with the emetic, asylum physicians then turned to ipecac syrup, powdered ipecac and especially tartrate of antimony, or tarter emetic as it was often referred to, all of which were easily administered and more efficacious in effect.
Pinel had not condemned vomiting as a therapeutic, although he, just as a number of other prominent asylum physicians of the day, had spoken out against its indiscriminate use. And for good reason. Vomiting quite recently had been the therapeutic of choice in a number of asylums and it had had its own very vocal proponents. Among them was John Monro, a member of the Monro dynasty that had been exercising its medical authority at Bethlem Hospital in London, England, since the early eighteenth century. In response to a broadside against the antiquated therapeutics of Bethlem published by William Battie, a self-proclaimed “progressive mad-doctor” at nearby St. Luke’s Asylum, Monro had launched a caustic defense of the depletive therapeutics as a general method for treating insanity. On the merits of vomiting, his response to Battie dripped with sarcasm although, ironically, it actually supported his archrival’s assertion that this treatment was particularly prone to misuse:
The evacuation by vomiting is infinitely preferable to any other [depletive], if repeated experience is to be depended on; and I should be very sorry to find any one frightened from use of such an efficacious remedy by it’s being called a shocking operation, the consequence of a morbid convulsion. I never saw or heard of the bad effect of vomits; nor can I suppose any mischief to happen, but from their being injudiciously administered; or when they are given too strong…. Why should we endeavor to give the world a shocking opinion of a remedy, that is not only safe, but greatly useful both in this and many other distempers? [Monro, pp. 50–51, italics in original].
The Monro versus Battie debate could be dismissed as nothing more that the head-butting of two physicians with sufficient ego to claim authority in all things related to insanity, but its context would argue against that dismissal. Battie’s slogan “management does much more than medicine” (p. 68) anticipated the development of what came to be known as moral treatment [see Moral Treatment] which in its ideal, or perhaps idealized practice, eschewed such violent therapeutics as vomiting. But only in its idealized practice. In the daily task of caring for the insane, management perforce had to at least occasionally rely on medicine—even the violent medicine of vomiting.
Thus when the York Retreat was established in northern England in the late eighteenth century by Quaker coffee and tea merchant William Tuke, its mission of providing humane treatment of the insane was not considered compromised by the occasional therapeutic administration of vomiting. The depletive was used only when the “general health strongly indicated its necessity,” and always with concomitant awareness that the “probable good would not be equal to the certain injury” (Tuke, p. 112). As moral treatment’s hegemony spread, other practitioners and proponents of it also occasionally relied on what arguably was the most violent of the depletives. The forty year career of Thomas Story Kirkbride as superintendent of the Pennsylvania Hospital for the Insane in Philadelphia was co-extensive with the vogue of moral treatment in the United States. An Orthodox Quaker, Kirkbride set out a detailed plan for both the moral treatment of the insane and the moral architecture of the asylums that contained them. Yet as a physician, he was not at all opposed to using the materia medica of his profession, including vomiting, although more perhaps for its placebo than its medical effect. The induction of vomiting, he argued, demonstrated to insane patients that the asylum physician had mastery over their bodies as well as their minds, and that demonstration not only buoyed patients’ trust in the physician but, in the process, also facilitated their recoveries. A similar philosophy underpinned the continued use of therapeutic vomiting by Vincenzo Chiarugi who introduced moral treatment to the care of insane patients at the Ospedale di Bonifazio in Florence, Italy, and by his French counterpart Philippe Pinel who, as previously noted, had spoken out against its excessive use but had incorporated it into the moral treatment regime at the Asylum de Bicêtre in Paris.
Certainly the advent of moral treatment had a great deal to do with the decline in therapeutic vomiting, as did the weakening to the point of irrelevance of both the humoural and brain inflammation doctrines that had originally justified it.
The induction of superficial or capillary bleeding. The process of wet cupping was not only detailed in procedure but highly choreographed in execution. First, a spot free of bone and dense fat was chosen on the body of the patient and fomented with hot water. Then, a wick was dipped in alcohol, lit and swirled for mere seconds around the inside of a cupping glass [see Counterirritation]. The cup was placed on the chosen spot where it was to remain for only one minute, during which time the scarificator was warmed between the hands of the asylum physician. Upon removal of the cup, the tumefied skin was cut with the scarificator blades, the wick was applied once again to the cup, and the cup was placed over the incisions to collect the blood. Because each cup held approximately four ounces of blood, the juggling of multiple cups often was necessary.
“Cupping is an art,” proclaimed Samuel Bayfield, a professional cupper at Guy’s Hospital in London, who ran a three month course on the art in the early nineteenth century for interested students. For three guineas qualified physicians under Bayfield’s stern tutelage developed the dexterity to handle glass, lamp, wick and scarificator, and the deftness to apply, reapply and remove the cups. But cupping also was a science. It was a therapeutic that was intimately linked to the theory of humouralism, and therefore made eminent sense for the treatment of insanity. It relied upon careful calibrations. Not only did the spot on the body for wet cupping have to be carefully chosen, but the blades of the scarificator had to be adjusted for the spot: one-quarter of an inch for incising the limbs, one-sixth of an inch for the scalp, one-seventh of an inch for behind the ears, and one-eighth of an inch for the temple. The amount of blood to be collected for the maximum therapeutic effect not only had to be determined before the procedure, but assessed in relationship to the physical health of the patient.
The treatment of insanity by the alteration of the nature, quantity and quality of the food consumed by patients.
With changing beliefs about the nature of insanity, and about the relationship between the body, brain and mind, diet has assumed various degrees of importance to the therapeutic regimes of asylums. In the early era of asylums, and certainly before the institutionalization of the insane became de régle, the prevailing view of insanity was that those who suffered from it not only were deprived of reason, but of the sentience of others. What they were fed, or for that matter if they were fed at all, was of little interest. John Conolly, the medical superintendent of the Middlesex County Asylum, better known as Hanwell, reflected with disgust on his early nineteenth century predecessors’ treatment of their insane patients:
No mercy, no pity, no decent regard for affliction, for age, or for sex, existed. Old and young, men and women, the frantic and the melancholy, were treated worse, and more neglected, then the beasts of the field. The asylum resembled the dens of a squalid menagerie: the straw was raked out, and the food was thrown in through the bars; and exhibitions of madness were witnessed which are longer to be found, because they were not the simple product of malady, but of malady aggravated by mismanagement [Conolly, 1856, p. 33].
Conolly, who had led the charge in abolishing the chains, fetters and straps of his predecessors [see Mechanical Restraints], took on the proper feeding of insane patients with equal fervor. Physical discomfort, he argued, impaired mental recovery, and a “scanty, ill-cooked, unwholesome diet creates a chronic uneasiness and dissatisfaction, impairs the health, and increases the mortality of an asylum” (Conolly, 1846, p. 161). To that end, he argued that diet should be regulated, at least somewhat, by the class of the patient: wealthy patients were to eat simpler and plainer food than they were accustomed to, while pauper patients were to be fed more robust and nutritious food than was their common fare. Because Hanwell Asylum was purpose-built in 1831 to care for the pauper insane, Conolly took special care with dietary arrangements. In addition to fifteen pints of fluid, the weekly quantity of solid food for female patients was slightly less than the 247.5 ounces designated for male patients. The typical menu, costing a thrifty eight-pence/day/patient, was as follows:
Breakfast: cocoa or milk porridge, and bread.
Dinner: steamed meat, yeast dumplings and vegetables on Tuesdays, Wednesdays and Fridays; baked meat on Sundays; soup and bread on Mondays; Irish stew and bread on Thursdays; and meat and potato pie on Saturdays. Each dinner meal was accompanied by a half pint of beer.
Tea: one pint of tea with bread and butter for female patients only.
Supper: cheese, bread and a half pint of beer for male patients only.
Perhaps it was inevitable that such a fare would come under criticism by those who thought it was wasted on the pauper insane who were unlikely to ever leave the asylum. The satirical magazine Punch certainly took a jab at it. In an article titled “The Hanwell Cookery Book,” the magazine asked readers to imagine the menu that patients working in the kitchen would come up with if left to their own devices. That menu included “Apoplectic Jelly” made with 400 kangaroo eggs and steel-filings; “Methuselah Fritters” and Oltenitza Pudding”; and the perennial favorite “Croquettes a la Conolly,” comprised of charred marrow bone, spring onions, oyster shells and dry glue. If left to mold, the magazine hinted, the croquettes tasted particularly good when dipped in hot treacle.
The jab aside, asylum physicians were embedded in nineteenth century society where rapid industrialization was metaphorizing the human body as a machine whose efficiency was assured by proper diet. And a properly functioning body meant a properly functioning mind—a view shared by the various regulatory bodies that oversaw public insane asylums. As a result, in their annual reports asylum physicians took great pains to discuss in detail the diets of their patients and to link them, if only inferentially, to therapeutic progress. In colonized countries such accountability was particularly problematic. Asylum physicians not only had to list the diet, but explain the nature, nutritional value, accessibility, and even the cultural and religious traditions surrounding its unfamiliar ingredients. Such was the case in Bengal, India where British physicians superintended five asylums in the late nineteenth century. Such dietary items as moong and chana dal, ghee, betel-nut, ginger and turmeric required description, as did the dietary needs of the asylums’ various “Hindoo, Mahomedan, and Christian” patients (Brown, p. 5). Yet, the readers of the annual report were assured that as a result of attention to diet all patients “improve considerably in physical condition, and, with this, in most cases, there is corresponding mental improvement” (p. 64).
While a nutritious diet, in and of itself, was thought to be therapeutic, so were the social graces required for its communal consumption. In the early era of asylums, food was delivered to, sometimes even thrown into, the cells or stalls of patients. Dishes, crockery and utensils were deemed dangerous, so food had to be substantial enough to be eaten by hand. By the mid-nineteenth century, as a reflection of the growing hegemony of moral treatment [see Moral Treatment], communal dining was instituted in most asylums. That may seem to be nothing particularly noteworthy but, in fact, the change to communal dining was one marker of moral treatment’s rejection of the age-old representation of the insane as bestial, and its acceptance of their humanity. Thus, it represented a significant reform in both procedure and philosophy. It was not instituted, however, without control and caution, as evidenced by Jean-Étienne Dominique Esquirol’s description of instituting communal dining at the Salpêtrière Asylum in Paris, France:
I chose eighty patients, and I divided them into groups of ten. In each group. I took a leader whose job it was to get the tablemates together, bring them to the table, and make sure that they all took off their hats and washed their hands when they came in. The leader was to preside over the table and make sure that at the end of the meal everyone put his spoon, fork and knife back on his plate; for I am not afraid to give them knives, on condition of course that they never take them away, and I take precautions so I will know right away who is not respecting this duty. From the very first day, everything proceeded in an orderly fashion, and from that point on letting the [patients] eat in the dining hall has been a great favor to them, a favor that works to the benefit of their cure [Leuret, pp. 170–171].
As therapeutic as good diets were, the cost of food was a hefty line item in any asylum’s annual budget. In the United States, where asylums often were constructed in rural areas, many state asylums were self-sustaining, or at least, very nearly so. Traverse City State Hospital in northern Michigan, for example, purchased its first cows and a bull in the late nineteenth century and over subsequent years developed a sizeable dairy herd that included a world champion milk cow named Traverse Colantha Walker. On the asylum’s grounds, the cow’s gravestone commemorates the 200,114.9 gallons of milk she produced over her lifetime. The asylum also had a piggery, and an extensive system of greenhouses in which a wide assortment of vegetables were grown.
Yet, and especially in urban asylums, the temptation to scrimp sometimes was considerable. In virtually every official inquiry into the treatment of asylum patients, the quantity and quality of food was an item on the agenda. Such was the case in the investigation of the New Jersey State Asylum for the Insane in Morris Plains in the late nineteenth century. There, a legislative committee heard testimony that rotting meat, old eggs, beans filled with worms, musty tea, and bitter bread were being served to the patients. A slab of “atrocious [and] rank” butter, taken from the asylum larder, was presented in evidence, generating an “animated discussion” among repulsed committee members as to whether it was “lard, oleomargarine [or] a conglomeration of axle grease, lard and cottonseed oil” (“Bad Butter and Bread,” p. 8). Its composition undetermined, sheets of paper then were placed over the slab until it was finally taken away—that way, no committee member had to look at it, or smell it. The inquiry led to the firing of the asylum’s warden.
Throughout history, periods of collective trauma often resulted in food shortages and diet crises in asylums around the world. During the two World Wars, for example, food was severely rationed, resulting in the deteriorated mental and physical health of insane patients, as well as in high mortality rates. French asylums during World War II provide an interesting illustration. By 1940, the German-occupied country was verging on famine. Starving asylum patients at times were reduced to eating eggshells and grass; severe weight reduction often resulted in edema, diarrhea, chronic fatigue and, for some, coma and death. Between 1940 and the end of the war in 1945, in fact, more than 40,000 French asylum patients starved to death; if that number were to be reduced to a mortality rate, it would be more than three times higher than that of the five years both preceding and following the war.
Even in more contemporary times, the impact of civil unrests, political upheavals, economic crises, and government corruption on food security, and the consequent impact of food insecurity on the mental and physical health of asylum patients is profound. At the Accra Psychiatric Hospital, for example, asylum officials warned in 2006 that the looming food crisis in Ghana, coupled with the government’s indifference towards the insane, would surely mean that patients would starve to death. That same fear was expressed in Greece in 2012. The economic crisis there left the State Infirmary of Leros without the requisite funds to feed its 350 insane patients. As late as 2013, patients in the Zanzibar Psychiatric Hospital in Tanzania were assured of a light breakfast and a light dinner, courtesy of private donors, to keep them from starving to death. The asylum no longer had funds to purchase food.
A crisis such as this was not predicted by the asylum physicians of previous eras. By the early nineteenth century virtually all agreed that a nutritious diet was therapeutic, in and of itself. But it was the distinguished German physician, Johann Gaspar Spurzheim, who warned at the time that all patients should not be nourished “out of the same kettle” (Spurzheim, p. 184). Rather, he argued, diet should be adjusted not only to the type of insanity patients suffered, but to the therapeutic strategies that were being used to treat them. This admonition, voiced by other asylum physicians as well, prompted creative attempts throughout the nineteenth century to match diet to disorder. None of these attempts proved particularly successful and most were no longer in use by the turn into the twentieth century.
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A diet composed of a large quantity of fatty foods. The gospel of fatness was preached by Thomas S. Clouston, superintendent of the Royal Edinburgh Asylum, also known as Morningside, in the late nineteenth century. It was his observation that the personal and social stresses that caused melancholia also caused poor general health, such as sleeplessness, sluggish bowels, low pulse and, most particularly, thinness. A significant gain in weight, he reasoned, would restore general health and cure melancholia. Insisting that the melancholic patient “cannot fatten too soon or too fast,” he provided a steady diet of ham, eggs, cheese, fish, fowl, game, claret, burgundy, ale, porter, custard and as many as sixteen tumblers of milk every day (Clouston, 1883, p. 113). In addition, any particular food the patient especially liked was provided in as great a quantity as could be digested.
Clouston claimed great success with the gospel of fatness, although the diet was only part of a tightly regimented therapeutic regime. The case of J.R., a young melancholic, illustrated that point:
She was ordered, and made to take, iron and aloes, with fresh air and fattening diet. She got worse at first, and hallucinations of hearing developed. She distinctly heard voices telling her she was the worst person alive. She would have refused food had she been allowed to do so. In about two months she began to improve in body and mind, especially in bodily looks and weight. For three months longer she remained depressed, and then menstruated after a series of hot baths and mustard to her feet. She brightened up from the first day of menstruation as if a cloud had been lifted off her mind, and she kept well ever after [Clouston, 1883, pp. 475–476].
Interestingly, given the fact that most of the patients in the Royal Edinburgh Asylum were paupers, many felt they benefited more from the long walks, the dances and lectures, the productive work and the sports activities that Clouston insisted upon than they did from the diet. In fact, many loathed both the quantity and the quality of the diet, as these excerpts from patients’ letters indicated:
Miss E.D.: I feel I cannot stand this place a minute longer and soon I lose the brains I had and not be able to interest myself in others and everything that goes on in the world…. I feel I shall go on degenerating in this environment into an animal that only lives to eat—as we do here!—and has not thought beyond. For really that is all the “treatment” consists of.
Miss D.: I am suffering the most awful agonies inwardly by being forced to swallow unlimited quantities of every kind of food and liquids every few hours.
Robert C.: I have been required to take such quantities as I could never comfortably take all my life. I assure you my life here has been one of exceptional horror, forced to eat large quantities of coarse food which I could not digest.
George R., 26, clerk: The food here is of the very coarsest. Porridge or coffee for breakfast with dry bread, at 11 o’clock dry bread and cheese, beer or milk… Dinner at 2 o’clock broth and mutton … then tea at 6, one cup and almost dry bread [Beveridge, pp. 431, 440].
Despite Clouston’s proclamation that asylum physicians should “preach and practice the gospel of fatness in season and out of season to melancholics” (Clouston, 1911, p. 115), it was neither scientifically nor economically appealing to most of them. With the noted exception of several asylums in Australia that had used it in the early 1900s, only a few scattered and short-lived experiments with its use, all with less positive results than Clouston touted, were conducted in asylums around the world.
The addition of milk, eggs and wine to supplement the standard asylum diet of tea, bread, soup, beef and potatoes. The hospital diet generally was reserved for patients whose physical health had been significantly compromised by their insanity. Such was the case at the Connaught District Lunatic Asylum in Ballinasloe, Ireland, one of the earliest of the twenty-two district asylums built in that country during the nineteenth century. There, women patients were most likely poor, often malnourished and physically exhausted from childbearing and childrearing. The health of those diagnosed with puerperal insanity was of considerable concern, and the hospital diet was found to accelerate their recovery.
A diet predicated on the greatest possible abstinence from food. Over the course of several days or weeks patients’ food intake was diminished by degrees until they were consuming only enough to sustain their lives. As their symptoms of insanity abated, their food intake was gradually increased. It was typical in the nineteenth century for patients undergoing the hunger cure in German asylums to also be isolated in dimly lit, closed rooms with only a light circulation of air in order to reduce any stimuli that might act adversely on them.
The hunger cure represented a depletive or antiphlogistic approach [see Depletive Therapy] to the treatment of aggressive and agitated types of insanity in particular. The received wisdom of this approach was that when food was withheld, the diseased and toxic humours were thrown off first, thus purifying the blood as it circulated through the body and the brain. One of the more enthusiastic devotees of this theory, and of the hunger cure as a therapeutic, was Christoph Wilhelm Hufeland the director of the medical college at the University of Berlin who also was affiliated with the Berlin Charité Hospital. He claimed to be able to cure two-thirds of all cases of insanity by irritating the abdominal nervous system which, he argued, was strongly influential on the brain. While that irritation could be produced by the administration of cream of tartar, hellebore or calomel, it was just as effectively produced, he argued, by hunger.
His colleague, Anton Müller, agreed and cited two cases of insanity cured by the hunger cure. One was of a patient who had become disorientated after a series of epileptic attacks. He had languished in an asylum for three years, his disorientation unremediated, before he was administered the hunger cure. Over several weeks his food intake was reduced to a twice daily offering of two ounces of lean meat and two ounces of bread. Within days his disorientation disappeared and he remained in remission until he returned to his normal diet. Müller somewhat reluctantly acknowledged that the remarkable cure could have been attributed to the daily administration of a sarsaparilla concoction, powdered belladonna leaves and a few grains of powdered rhubarb or, for that matter, to those substances in conjunction with the hunger cure, but the second case he cited had none of those complications. That was the case of an adolescent peasant boy whose insanity had resisted all conventional treatments. As a last resort, his food intake was reduced to a twice daily offering of two ounces of lean meat and two ounces of bread. He was discharged as cured six weeks later and suffered no remission when he resumed his normal diet.
While the hunger cure was not practiced just in German asylums, many asylum physicians outside of Germany were interested in at. At the Pennsylvania Hospital in the United States, Benjamin Rush was inclined to accept its underlying rationale, although he continued to administer a slightly more generous version of the hunger cure referred to as the “low diet.” Yet, in regards to the hunger cure, he wrote: “I am disposed to think favorably of it. [It] is calculated to work in two ways….by lessening the quantity of blood by the abstraction of the ailment and by exciting the disease of hunger in the stomach to such a degree as to enable it to predominate over the disease of the brain” (Rush, p. 191).
Other early nineteenth century asylum physicians disagreed. Philippe Pinel, for one, recalled the scarcity of food during the French Revolution that reduced the diet at the Asylum de Bicêtre in Paris to one pound of bread per day per patient, leaving them wandering around the asylum in a “delirium of hunger” (Pinel, p. 32). When food supplies stabilized after the Revolution in 1792, the diet was increased to two pounds of bread per patient per day, along with one or two servings of soup. Not only did the mortality rate decrease sharply, but the overall physical and mental health of the patients increased dramatically. The experience left him with the impression that hunger fueled insanity more than it ever cured it.
Although Pliny Earle, the resident physician of the Friends Asylum for the Insane near Philadelphia, Pennsylvania, made no definitive statement on the hunger cure, it would be reasonable to assume he would have agreed with Pinel. In the first edition of his book that detailed his visits to a number of European asylums, if he mentioned food at all it was to describe its method of delivery to the patients rather than its quantity or quality. But in the second edition, to which he appended descriptions of asylums in other parts of the word penned by other physicians, the deprivation of food, whether by fate or fiat, was not glossed over. Earle appended a report from the Irish physician Richard Madden of his visit to the Cairo Lunatic Asylum in Egypt in the early nineteenth century. There he found filthy patients chained in cells who cried out for food as he passed by. He learned that they had not eaten for more than a day because the only source of food was the charitable offerings of people in the community. When two local women then came into the asylum with two cakes and a large watermelon that was broken into pieces and thrown at the patients, Madden was appalled by what he witnessed. “They devoured what they got like hungry tigers, some of them thrusting their tongues through the bars, others screaming for more,” he wrote. “I have never seen nature subdued to such lowness” (Earle, p. 79).
The withdrawal of food, not for the purpose of achieving a hunger cure but for disciplining or punishing patients, was often tempting to asylum physicians. The eminent German physician Johann Christian Heinroth dismissed any concern and encouraged his colleagues to do what he himself regularly did, and that was “punish disobedience and bad manners displayed by the mentally disturbed by depriving them of food” (Heinroth, p. 297). This method of discipline certainly outlasted the hunger diet as a therapeutic. By the turn into the twentieth century, most asylums physicians agreed that a wholesome, if not generous, diet was an important adjunct to other therapeutics. And, especially in North America, where cattle and chickens often were being raised on asylum farms, and vegetables and sometimes grain were growing in surrounding fields, the diet of patients improved considerably and the deprivation of food, whether for punishment or treatment, increasingly was considered anti-therapeutic.
It may be interesting to note that the hunger cure is still practiced in some Eastern European asylums. Renamed “controlled fasting,” and sometimes also referred to as “total food abstinence” or “controlled starvation,” it is most often used to rest the brain and nervous system and detoxify the blood of treatment-resistant schizophrenic patients. The controlled fast, which involved twenty-five to thirty continuous days of consuming only water, was preceded by a several month long preparatory protocol that involved weekly fasting for thirty-six hours, and followed by the gradual introduction of food during a month long recovery period. Yuri Serge Nikolayev, who was in charge of the fasting unit at the Moscow Institute of Psychiatry, treated more than 6,000 such patients by controlled fasting and reported that 70 percent achieved such significant improvement that they were restored to full functioning.
One of those patients was a twenty-seven-year-old Polish student. Withdrawn, isolated, restless, he had been unable to concentrate on his studies and had traveled to Moscow to admit himself into the Institute, despite having resisted on previous occasions the suggestion that he seek psychiatric care.
On admission he was described as being well oriented exhibiting circumstantial speech and feelings of unreality. He complained of weakness, poverty of ideation, poor memory and quick exhaustion…. His facial expression was rigid, speech was monstrous, and he found great difficulty in communicating. He felt hopeless and saw no future for himself. He was treated with insulin coma and his condition remained essentially unchanged [Cott, 1971, pp. 8–9].
After a twenty-eight day fast he was put into a recovery program, and his spirits gradually rose, his appetite returned, “his head felt clear, thinking was clear and concentration was markedly improved.… [C]olors became brighter, thinking became easier” and his feeling of emptiness was filled with the hope that he would have a bright future (Cott, 1971, p. 9).
Nikolayev’s claims attracted the attention of Alan Cott, a former psychoanalyst who had an increasing interest in the trendy emerging field of orthomolecular psychiatry [see Orthomolecular Therapy]. After observing Nikolayev’s treatment protocol, Cott selected thirty-five schizophrenic patients at the Gracie Square Hospital, a private and short-term psychiatric hospital in New York City, as subjects of his own experiment with controlled fasting. All of the subjects had been diagnosed more than five years before, and none had demonstrated any significant improvement under conventional treatments. Just as his mentor had done, Cott withheld all food from them, allowed them to drink as much water as they desired, and required that they adhere to a daily regime of outdoor walks, breathing exercises, hydrotherapy procedures [see Hydrotherapy], cleansing enemas and general massage. At the completion of the controlled fast, the patients remained in the hospital for a month, during which time food in the form of milk, fruit and vegetables was gradually introduced into their diet.
Cott noted significant improvement in schizophrenic symptoms for 70 percent of the patients, as long as they remained on a post-treatment low fat diet and took prophylactic fasts three to five days each month. That improvement was maintained for six years for those patients who followed the post-treatment protocol.
Controlled fasting had a short shelf life as a therapeutic. Despite having been heralded as an epochal breakthrough in the treatment of schizophrenia, the same encouraging results of the studies conducted by Nikolayev and Cott were not repeated in controlled clinical trials. The therapeutic certainly stimulated interest in the role that diet and even specific types of foods might play in both the etiology and treatment of schizophrenia, an interest that persists to the present day. And it also piqued some interest in its efficacy in treating psychoneurotic patients. In Japan, a regime of controlled fasting resulted in the significant improvement of 87 percent of the forty-nine psychoneurotic patients to whom it was administered.
The creation of a state of drunkenness by the administration of large quantities of alcohol. While beer often accompanied meals in nineteenth century asylums and occasional glasses of wine were given to induce sleep, excessive imbibing by patients not only was forbidden but, for some patients, was suspected as the cause of their insanity in the first place. Thus the recommendation of Joseph Mason Cox, physician and proprietor of the private Fishponds Asylum near Bristol, England, that intoxication be used as a therapeutic, was vehemently dismissed by other asylum physicians.
Cox’s argument for intoxication was based on his observation that when certain types of melancholy, particularly religious in nature, progressed as they inevitably did into paroxysms of furious mania, recovery usually quite quickly followed. Therefore, he reasoned, if paroxysms of mania could be induced by continuous intoxication, then recovery could be accelerated.
Despite the fact that early nineteenth century asylum physicians were experimenting with all types of stimuli for producing therapeutic states of excitement to counteract insanity [see Rotation, Oscillation and Vibration], Cox’s use of continual intoxication was widely ridiculed. Among the critics was the estimable John Haslam, apothecary to Bethlem Hospital in London, who dismissed Cox’s recommendation to “await the feast of Reason from the orgies of Bacchus” (Haslam, p. 307) as unworthy of detailed comment.
Unworthy of comment it may have been, but intoxication as a therapeutic maintained enough appeal that as late as the early twentieth century it was used to treat catatonic schizophrenia. Two asylum physicians, N.V. Kantorovich and S.K. Constantinovich intravenously administered a watery solution of brandy to fifteen catatonic patients at the First and Second Psychiatric Hospitals of Leningrad, Russia. Their blood alcohol concentration levels were raised to 0.2 percent, a level generally associated with slight euphoria, mild relaxation and some lightheadedness. Their results revealed that four patients showed no change in symptoms; four showed some improvement, becoming more talkative and sociable; and the remaining seven not only showed improvement but maintained it—but only as long as they were under the influence of alcohol. Continual intoxication was not strongly recommended as a therapeutic by the asylum physicians, but was used sporadically in some Eastern European asylums well into the mid-twentieth century.
A diet consisting mainly of liquids such as milk, tea and broth, with rice, gruel, or vegetables. Not to be confused with the hunger or famine cure, the low diet provided small quantities of food for antiphlogistic purposes, and under the theory that it worked as well as bloodletting in removing the excess blood that inflamed the brain causing mania and violence.
At the Pennsylvania Hospital, Benjamin Rush administered the low diet which consisted wholly of water and vegetables “of the least nutritious nature” (Rush, p. 191). He hastily noted, though, that this diet would succeed in reducing mania only if the patients had been accustomed before the onset of their insanity to a diet rich in meat and bread; for those who were not, it was unlikely to be effective. In Rush’s opinion, the low diet rarely was sufficient in and of itself to deplete the cerebral vessels, thus he used it in conjunction with purging and copious bleeding [see Depletive Therapy].
Such allegiance to the phlogistic theory of insanity also was expressed in the therapeutics of William Rees at the Toronto Temporary Asylum in Canada. As late as the mid-nineteenth century, and much to the chagrin of his colleagues, Rees was still bleeding his patients, applying blisters and setons, and subjecting them to a low diet, all in an effort to reduce and tranquilize vascular and nervous action. Against criticism, Rees boasted a cure rate of 60 percent. Rees was, in many ways, a “transitional figure in [asylum] therapeutics” (Moran, p. 82), caught in the cross-stream of the historical humoural treatments of bleeding, purging and vomiting that assaulted the body, and the more modern suasions of moral treatment that engaged the mind [see Moral Treatment]. As the latter gained prominence, even hegemony, the low diet by itself or in combination with other therapeutics was increasingly disparaged.
In his description of the York Retreat in northern England, inarguably the loco laudato of moral treatment, Samuel Tuke described a daily menu rich in milk, bread, cheese, meat, fruit and beer and acknowledged that it would be dismissed as “more liberal than judicious” by those asylum physicians who still relied upon reducing therapeutics including the low diet (Tuke, p. 124). His own experience, however, showed that not only did the low diet fail to relieve the symptoms of insanity, but that it often exacerbated them. Feeling no inclination to alter the Retreat’s menu, he cited in detail a case in which a substantial diet cured a “dangerous lunatic” after a low diet had failed to do so:
Case 74 affords very striking evidence in favour of a liberal, nourishing diet, even when great irritation or violence exists. The patient was described as a furious, dangerous lunatic; and the reducing system had been fully tried upon him, with an aggravation of his complaint. The opposite mode was then pursued; and his appetite, from being long famished, was almost voracious for many days. It gradually lessened, till it arrived at the common standard. He took no medicine; and under the treatment he met with, his irritation of mind gradually subsided, and his recovery was very rapid and complete [Tuke, p. 125].
As phlogistic theories of insanity lost their hold by the early twentieth century, the low diet was abandoned as a therapeutic, whether stand alone or adjunctive. Diet, of course, remained a topic of considerable discussion, but that conversation between asylum physicians increasingly focused on achieving the proper restorative balance of protein, fats and carbohydrates. On the necessity of finding that balance, Arthur Van Gellhorn, medical superintendent of the Provincial Lunatic Asylum at Ueckermünde, Germany, was fond of reciting the old aphorism, “As a man eats, so he thinks,” a proverb appropriate for this new interest in how the functions of the brain might be influenced by the nourishment of the body.
The substitution for, or the supplementation of, a standard asylum diet with milk consumed every few hours. Although a staple of diet today, the very idea of milk as a dietary food source, and a nutritious one at that, hid scientific, technological, legal, commercial and even moral considerations under milk’s “blanket of innocent whiteness” (Atkins, p. 217). By the early nineteenth century, however, milk had become an accepted and relatively inexpensive food source in industrialized countries of the world and often was used to supplement the standard diet of insane asylum patients. Many asylums, in fact, maintained their own herds of cows and had milking barns on the grounds.
Successes in treating chronic physical diseases such as colitis, asthma and heart problems with the substitution version of the milk diet were reported in the mid-nineteenth century by the Estonian physician Philipp Karell, physician to the Emperor of Russia, and were widely reported around the world. Similar successes in treating nervousness and neurasthenia during the rest cure [see Bed Therapy] with the supplementation version of the milk diet were reported by the American neurologist, S. Weir Mitchell.
That said, the milk cure was not particularly portable as far as public insane asylums were concerned. It was experimented with and with disappointing results in a few asylums in Europe where, aside from Karell, it had no particularly enthusiastic proponents, In the United States, the milk cure often was used by homeopathic physicians in their outpatient practices and clinics, so when the first state homeopathic asylum was established in Middletown, New York, in the late nineteenth century, the milk cure achieved some institutional legitimacy as a therapeutic.
That homeopathic asylum proved itself loyal to its informal motto of “Meat, milk and rest.” Its 875 patients had consumed nearly 75,000 gallons of milk the previous year, as a supplement to the regular asylum diet, and in service of the milk cure which, at this asylum, was a curious hybrid of Karrel’s substitution and Mitchell’s supplementation version. According to the annual report:
We have come also to use more frequently than formerly a warm liquid diet. We give our patients all the milk they will drink, and use only a moderate amount of solid food. In some instances we mix raw egg with the milk; and in others we give a mixture of milk, Mellin’s food [a milk modifier comprised of wheaten flour, malt and potash], and bovinine [condensed beef juice]—one pint of the former to a tablespoon of each of the latter [Managers of the Middletown State Homeopathic Hospital, p. 111].
As in all asylums, food food-refusing patients posed a difficult problem. Loathe to use the aggressive feeding techniques employed by many other asylums [see Forced Feeding], the physicians at Middletown came upon a unique remedy. Having read of the successful treatment of two food-refusing patients by a German asylum physician who had injected them with salt water in order to produce a burning sensation that distracted them from their delusions, the Middletown physicians mixed one teaspoon of salt with one pint of milk to produce “salted milk” that they then administered to food-refusing patients via feeding tubes. Seven of the twelve patients to whom the salted milk cure was administered began eating by the end of the day; the remaining patients were given multiple applications of salted milk and all began eating after a few days, although each reverted to food-refusal, if only on occasion, after that.
A diet that used little or no maize and that was rich in niacin, or vitamin B3. In some parts of the world, the diets of the poor were heavily reliant upon maize. This was especially true in India, Egypt, Romania, Italy and in the Southern United States. As a result, a large number acquired pellagra, a disease characterized by dermatitis and diarrhea, as well as by delirium that often brought them into asylum care. Because its cause was at first unknown, pellagra was thought to be a communicable disease and those who were diagnosed with it often were shunned in their communities as well as isolated in asylums once they were admitted.
A series of empirical and observational studies in different parts of the world, however, eventually convinced asylum physicians that pellagra was the result of a dietary overreliance on maize and that it could be cured by a more wholesome diet. One of those studies was reported in the mid-nineteenth century by the controversial Italian physician Cesare Lombroso who posited that toxins produced by fungi that grew on maize exposed to moisture were the cause of pellagra. While this theory explained the cause of pellagra, what remained unanswered was why pellagra outbreaks also occurred in asylums among patients who had been admitted for other types of insanity. That had been the case at the Mount Vernon Hospital for the Colored Insane in Mount Vernon, Alabama. There, eighty-eight Black patients came down with pellagra in the early twentieth century, and more than half of them eventually died from it. Because the staff who attended them were not affected, any lingering suspicion that pellagra was an infectiously communicable disease could be dismissed. Since it was diet that differentiated the stricken patients from the staff, with the patients being fed a monotonous corn-based diet and the staff having a choice of more nutritious foods, it was theorized that corn lacked a basic nutrient for the maintenance of good health. That nutrient, niacin or vitamin B3, was isolated several years later. With public education programs, crop diversification initiatives and the fortification of processed food such as flour with niacin, pellagra was eradicated by the mid-twentieth century, thus assuring no new asylum admissions for pellagra-induced dementia. For those patients already institutionalized, the administration of niacin, then known as nicotinic acid, often reversed their delirium and restored their physical health enough to ensure their discharge.