A method of treatment in which the body temperature is raised to, and sustained at, an elevated level.
The therapeutic value of fever was noted by ancient physicians. Hippocrates, in fact, once mused that had he the power to produce fever, he could cure all disease. As late as the nineteenth century, physicians occasionally commented on the remediating effects that typhoid fever had on the patients in their overcrowded and unsanitary asylums that were prone to epidemics.
The value of inducing fever to treat insanity, rather than waiting for an outbreak or epidemic to occur, had an interesting evolution. It very well may have begun with the germ theory of disease that emerged in the late nineteenth century with the discoveries that some infectious diseases, such as malaria and typhoid that the ancient physicians would have been familiar with, were caused by microorganisms. Germ theory, as this hypothesis came to be known, replaced earlier miasma and contagion theories of disease; the former had posited that a poisonous vapor in the air carried disease, the latter that direct contact between infected people was responsible for its spread.
The scientific research of the French chemist and microbiologist, Louis Pasteur, validated the propositions of germ theory. Early in his career he had discovered that it was yeast, a living organism, that turned beet root into alcohol, but that another microbe, Mycoderma aceti, was responsible for souring the alcohol into vinegar. His patented process for destroying that microbe through boiling and then cooling the liquid came to be known as “pasteurization.” While the discovery delighted Napoleon III who had supported his research in the hope of both saving the French wine industry and ensuring France’s scientific superiority, it was the pasteurization of a much more mundane liquid—milk—that had the most potent effect on health in developing countries as well as in industrialized countries where urban growth had lengthened the supply chain between food source and consumers.
When pasteurization was patented in the mid-nineteenth century, a significant number of all admissions to asylums in industrialized countries were for what was variously termed general paresis, general paralysis of the insane, or dementia paralytica. This progressively degenerative type of insanity was first described decades before it even had a name, by John Haslam, apothecary at the Bethlem Hospital in London, England:
Paralytic affections are a much more frequent cause of insanity than has been commonly supposed. In those affected from this cause, we are, on enquiry, enabled to trace a sudden affection, or fit, to have preceded the disease. These patients usually bear marks of such affection, independent of their insanity; the speech is impeded, and the mouth drawn aside; an arm, or leg, is more or less deprived of its capacity of being moved by the will; and in by far the greatest number of these cases the memory is particularly affected. Very few of these cases have received any benefit in the hospital; and from the enquiries I have been able to make at the private houses, where they have been afterwards confined, it has appeared, that they have either died suddenly from apoplexy, or have had repeated fits, from the effect of which they have sunk into a stupid state, and have gradually dwindled away [Haslam, p. 120].
Haslam, who did not have a formal degree in medicine, was certainly aware of the outbreaks of syphilis that had plagued Europe since the fifteenth century. The Great Pox, as it was known, had killed thousands and its venereal origin in sex and sin already had been established. Yet Haslam posited no etiologic connection between the general paresis he was seeing in Bethlem and the syphilis that was epidemic in his own country. In fact, he specifically denied it. Venereal pus, he insisted, did not infect the brain.
Antoine Laurent Jessé Bayle disagreed. The physician who practiced at the Charenton Asylum in France challenged this prevailing view that there was no organic cause of what later would be termed general paresis. On the basis of postmortem research, he proposed that the paralysis observed in these patients was but one symptom of a complex disorder that included dementia, as well as other mental symptoms. Most importantly, this disorder was caused by a chronic inflammation of the arachnoid lining of the brain. He described the progression of the disorder in detail. First, the developing inflammation caused serous fluid to press on the brain, and resulted in a mild paralysis of speech, monomania and grandiose ideas. Second, the increasing pressure on the brain produced spastic paralysis, agitation and generalized mania. Third, the now chronic inflammation, coupled with ever increasing pressure on the brain, resulted in severe paralysis, loss of sphincter control and complete dementia.
Bayle, in essence, had offered the first description of an organic brain disease; his research was to have a profound influence on asylum medicine. But it was not until 1875, several decades after the publication of his research, that Alfred-Jean Fournier, physician at the Hŏpital St. Louis, a renowned hospital for diseases of the skin, would find that syphilis was the cause of this complex disorder. Fournier, who later would be appointed professor of dermatology and syphilology at the University of Paris, was once described by Oliver Wendell Holmes as the “Voltaire of pelvic literature” (Waugh, p. 232). Indeed, his catalogue of publications on the topic was impressive, as was his concern about the public, social, economic, and moral implications of the disease, a concern that definitely was shared by asylum physicians who nonetheless still remained skeptical that syphilis was the cause of general paresis. That skepticism prompted Fournier to muse, “Several times I had the experience of having to diagnose syphilitic madness in the presence of very competent and justly famous psychiatrists; and almost inevitably my opinion was received as a hypothesis that was possible, rational, perhaps tolerable, but singularly adventurous and tainted with heresy” (Quétel, p. 163).
The heretical nature of his hypothesis diminished when the spirochete bacterium Treponema pallidum that caused syphilis was isolated and identified by Fritz Shaudinn and Erich Hoffman in research conducted in the women’s ward of the dermatology department of the Berlin Charité Hospital in 1905. The development of diagnostic tests, most particularly the Wassermann, quickly followed. To asylum physicians working on the cusp of the twentieth century, it was now apparent that general paresis, a debilitating type of neurosyphilis, was not a functional disorder after all. Its cause was neither the “competition, reckless and feverish pursuit of wealth and social position, overstudy, overwork, unhygienic modes of life, the massing of people in large cities, the indulgence in tea, coffee, tobacco, stimulants,” nor even in the “sexual excesses” of rapidly modernizing societies (Kellogg, p. 657). Rather, its cause was organic—a motile spirochete that was spread by sexual contact. By the turn into the twentieth century more than 20 percent of all asylum admissions were for all types of neurosyphilis, yet physicians were just as helpless to treat it as they were before they had identified its cause.
In 1910, after 605 successive failures, the German bacteriologist Paul Ehrlich discovered “compound 606,” the “magic bullet” (magische Kugel) that selectively targeted the Treponema pallidum spirochete. Salvarsan, as he referred to, was an arsphenamine, an arsenic compound that produced pain upon injection, but that offered a significant improvement over the mercury preparations used in so many asylums that too often left patients sweating and salivating, their tongues lacerated, teeth loosened by softened gum tissues, stomachs and bowels irritated, and bones so weakened that their noses collapsed and their jaws crumbled. But salvarsan was not without its toxic side effects, and certainly not without its detractors who accused Erlich of criminal negligence for aggressively marketing the drug for personal profit and for forcing prostitutes to undergo the treatment at Frankfurt Hospital. He eventually was exonerated of the charge and went on to develop neosalvarsan that was to be the treatment of choice well into the mid-twentieth century when penicillin replaced it. Yet at prescribed doses neither of these arsenical compounds crossed the blood-brain barrier, so they could do little to cure paretic neurosyphilis, although they were effective in preventing it in those asylum patients for whom early stage syphilis had been diagnosed.
Neurosyphilis continued to drain asylum resources; patients with it required intensive nursing and constant supervision. And, since the majority of those patients were middle-aged men, their commitment to asylums for care taxed their families and reduced the work force. In the face of the repercussions of this incurable type of insanity, a new and different therapeutic was needed. The Austrian physician Julius Wagner-Jauregg provided it. In the late nineteenth century he proposed that it would be possible to successfully treat paretic neurosyphilis by the induction of fever.
Wagner-Jauregg, who had only reluctantly settled on the specialty of psychiatry, developed an interest in the expanding organic approach to insanity that germ theory had generated. He had observed, while doing his obligatory residency at an asylum, that the psychosis of a female patient who had come down with erysipelas, a bacterial skin disease accompanied by high fever, remediated somewhat when the fever subsided. His interest piqued, he speculated that paretic neurosyphilis, also a bacterial disease, could be similarly and successfully treated by the induction of fever, as could other types of insanity for which bacterial causes had not been discovered. To that end, he began by injecting patients at the Clinic for Psychiatry and Nervous Diseases with the streptococcus bacterium that causes the erysipelas, or St. Anthony’s Fire, that had produced the skin lesions and fever of the patient he had observed during his internship. When he received the Nobel Prize for Physiology or Medicine decades later for the fever therapy of neurosyphilis, he was to reflect upon this early trial with erysipelas as “an unfortunate experiment” that he “hardly had the authority then to carry on with” (Eghigian, p. 262).
The same reflection would have held true for his experimentation with tuberculin, a recently developed vaccine meant to be effective in cases of tuberculosis. Wagner-Jauregg injected several neurosyphilitic asylum patients with the vaccine in an effort to induce a tuberculin fever. The results were promising, despite a significant proportion of relapses, yet he was forced to abandon the treatment in the wake of alarming reports that tuberculin’s toxic effects could lead to death.
In 1917, after years of experimentation, Wagner-Jauregg revived an earlier hypothesis that malaria-induced fevers would be effective in treating neurosyphilis, and they did prove to be just that. Malarial fever therapy spread quickly across the world, arresting the progression of syphilis in about 70 percent of all cases. Wagner-Jauregg’s cure not only earned him the 1927 Nobel Prize for Physiology or Medicine, but “broke the therapeutic nihilism that had dominated psychiatry in previous generations” (Shorter, p. 194). After all, if the progressive dementia of the paretic type of neurosyphilis could be halted by fever, then certainly other types of insanity could be as well. For the next several decades, enterprising asylum physicians induced fevers in their patients with an array of febrile agents and raised artificial fevers with ingeniously designed machines and gadgets, all in an effort to arrest their insanity.
In the end, there was little success in treating anything other than paretic neurosyphilis with fever therapy. While many reports of its efficacy flattered to deceive, fever therapy nonetheless was considered an effective treatment available until the mid-twentieth century.
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The replacement of approximately twenty-five cubic centimeters of cerebrospinal fluid with an equal amount of inactivated horse serum introduced into the subarachnoid space via a lumbar puncture, in order to produce fever, headache and inflammation of the meninges surrounding the brain.
In the early twentieth century, Constantin von Monakow, director of the Brain Anatomy Institute in Zurich, Switzerland, theorized that the permeability of the choroid plexi, that is, the ventricular structures in the brain that produce cerebrospinal fluid, was compromised in patients with schizophrenia, perhaps due to a food-chemico deprivation. A resetting of the permeability by means of meningeal irritation, he reasoned, would significantly improve or even cure schizophrenia. While Monakow’s contributions to the study of the brain were both far-reaching and interdisciplinary, his interest in schizophrenia was deeply personal: two of his siblings had suffered from it. In interactions with his discussion club, the “Monakow Kränzli,” that included such illustrious members as Eugen Bleuler, Carl Gustav Jung and Max Cloetta, he endeavored to solve the riddle of schizophrenia which he considered one of the great mysteries of the brain. His paper, coauthored with a Japanese colleague and outlining his theory of choroid plexi permeability, prompted research interest in Great Britain, Germany and Japan.
In the United States, experiments with aseptic meningitis to actually treat schizophrenia originated with a somewhat unlikely source. Robert Carroll was director of the Highland Hospital in Asheville, North Carolina, a rather “tony” sanitarium that specialized in the treatment of nervous disorders and addictions. While the treatment regime focused on exercise, healthy diet and occupational therapy, Carroll’s earlier experience as an assistant to Henry Cotton at the Trenton State Hospital in New Jersey, continued to influence him. Cotton was surgically removing the teeth [see Exodontia], tonsils, gallbladders and/or colons of his patients in efforts to cure the focal infections he believed caused schizophrenia [see Surgery]. Although he eventually would fall miserably from grace, in the early twentieth century Cotton enjoyed both professional and public adulation, although less for his therapeutic results than his grandiose claims that schizophrenia had somatic origins and its cure was in easy reach.
Carroll took a different approach to infection, positing it not as the cause of schizophrenia, but the cure. Citing a number of observations that patients with schizophrenia sometimes had lucid moments after injections of such infectious agents as typhoid fever and malaria raised their white blood cell counts, he sought to initiate a similar regenerative response that specifically would target the choroid plexi. He replaced approximately twenty-five cubic centimeters of the cerebrospinal fluid of each of five patients he had diagnosed as schizophrenic with an equal amount of inactivated horse serum in order to produce fever and brain inflammation that would not only stimulate their immune systems to attack the meningitis, but restore the permeability of the choroid plexi. “Temporary or permanent improvement” was noted for all five.
Interestingly, Carroll never wrote a case study of one of his most famous patients, Zelda Fitzgerald, for whom the horse serum injection produced a moment or two of encouraging lucidity after three days of recurring high fevers, vomiting and debilitating headaches. Diagnosed as schizophrenic, the writer, artist, dancer and wife of novelist F. Scott Fitzgerald, had been admitted into the Highland Hospital in 1936, reluctantly discharged four years later, relapsed and was readmitted several times over.
Although skeptical of the underlying theory of choroid plexi permeability, physicians at the Philadelphia Hospital for Mental Disease attempted to “submerge prejudice against it and arrive at impartial conclusions” (Carroll, Barr, Barry & Matke, p. 675) by injecting horse serum into forty-nine schizophrenic patients. The results were generally consistent with Carroll’s initial findings: six of the patients went into remission, although one relapsed; twenty-eight showed continuing or marked improvement, although six relapsed after several weeks; fourteen showed either temporary improvement or none at all, and one died of a pre-existing condition. Since the evaluative terms “remission” and “improvement” remain operationally undefined, just as they did in Carroll’s report, a sample of the case studies offers a glimpse into how the efficacy of this therapeutic was “impartially” assessed:
Case 11—P.M., age 18, single, white male… with a provisional diagnosis of dementia praecox (catatonic)…On admission was superficially depressed, negativistic and mute. Cleared up and was paroled, but soon relapsed and had to be returned. Later notes state he was much overweight (gained 50 pounds in two months). Talked fairly coherently and was without judgment or insight…. Following second treatment, said “I must have been crazy or I wouldn’t be here.” Claims he does not remember events happening just before his commitment. Following his final treatment it was noted that he had lost a great deal of weight but was untidy and rather silly. At present … is much brighter, relevant, cleanly and works willingly. Final result: improved physical condition, possibly due to adjustment of endocrine system. Not much improvement mentally though he seems brighter and happier. Is to be paroled soon.
Case 26—C.N., female (colored), age 37… A case of hebephrenic dementia praecox. Symptoms, silly, foolish, untidy, evasive, hallucinated and at times excited and violent. Given five treatments, has had no attacks of excitement since last treatment (two months ago). Is quiet, tidy and works on ward, still foolish and reacts to hallucinations. Final result, better institutional adjustment.
Case 38—R.K., white male, age 29… A case of paranoid dementia praecox of several months’ duration. Symptoms: Restive, negative, seclusive, at times assaultive in reaction to tormenting hallucinations. Given five treatments. Is much brighter, talks and laughs quite normally, cheerful and helps willingly with hard work. Had formerly been regarded as a dangerous patient. His parents regard him as cured. Final result, remission.
Case 40—F.H., white male, age 22…A case of catatonic dementia praecox of several weeks’ (?) duration. Symptoms: Mute, restive, and negative. Filthy in habits and very destructive. A “runaway.” Given five treatments without a particle of improvement; in fact, grew worse. Final result, nil.
Case 42—H.Y., white male, age 34…A case of paranoid dementia praecox of several year’s duration…. Symptoms: seclusive, paranoid, hallucinated and very fearful. Given four treatments. For a time appeared much better; talked coherently about his former ideas and hallucinations, laughing about them, but suddenly relapsed and became violent and homicidal in his actions. Final result, nil [Carroll, Barr, Berry, & Matzke, pp. 691, 694–695, 697].
The considerable variation in therapeutic outcome suggested to some asylum physicians that the duration of both the patients’ schizophrenia and the asylum physicians’ observations post-treatment should be taken into consideration. When physicians at the Osawatomie State Hospital in Kansas induced aseptic meningitis in twenty-three chronic schizophrenic patients who had been institutionalized an average of six years and had never responded adequately to any therapeutic intervention, the promising results it had immediately produced for just six of them had all but disappeared months down the road. Only two of those six patients continued to maintain “increased interests, personal, occupational and recreational, loss or great diminution of hallucinations and delusions…[and] very satisfactory institutional or social adjustment” that the treating physicians defined as “good results” (Kubitschek & Carmichael, p. 104). One of those two patients was a thirty-nine-year-old male who had been institutionalized for a decade:
Case No. 43—H.G., a white male, 39, admitted to hospital July 24, 1915, with outstanding symptoms of muscular rigidity, attitudinizing, alternate stupor and excitement, mute but hallucinated. Diagnosis of dementia praecox, catatonic made and confirmed by course in hospital. Patient grew careless of appearance, seclusive, restive and negativistic, took no interest or participation in occupation or recreation and was in poor physical state when treatment was started. A series of four injections was followed by slow but progressive improvement, both mental and physical, interest in his surroundings, in occupation and recreation was gradually reestablished; he became neat, cooperative and friendly; improvement continued during the following year, patient has returned home and is making a very good social readjustment. Result in this case is considered most satisfactory [Kubitschek & Carmichael, p. 134].
Persistently good results, such as was documented in H.G.’s case, however, may have had nothing to do with the horse serum or the aseptic meningitis it caused. Rather, the asylum physicians argued, the pain of repeated lumbar punctures and the fear of death evidenced by virtually all of the treated chronic patients, “made a strong appeal to the individual’s instinct of self-preservation, produced a re-synthesis, to some degree, of the dissociated personality which resulted in re-establishment of contact with reality” (p. 120).
By the time Carroll’s most famous patient, Zelda Fitzgerald, had died along with eight other patients in a fire at Highland Hospital in 1948, the aseptic meningitis treatment for schizophrenia had been relegated to the margins of asylum therapeutics. Long-term follow-up studies had revealed that the initial positive effects—whether from the introduction of horse serum or the fear of death—were short-lived at best, even for those asylum patients whose schizophrenia was of quite recent onset.
The prevention of the radiation of body heat by wrapping patients in blankets and adding heat from an external source. This method raised body temperature to 104° F. within two hours. For neurosyphilitic patients, five continuous hours of fever, one time per week for ten weeks was the standard protocol. Although low-tech, blanket therapy still required that patients be carefully selected; it was contraindicated for the aged as well as those who had cardiac disease or hypertension.
The blanket method was devised to treat early stage syphilis by Norman Epstein and Maurice Cohen, both affiliated with the Mount Zion Hospital in San Francisco, California. Its results, however, were disappointing. The blanket method was unable to completely eradicate the syphilitic infections of the patients to whom it was administered. It was more successful, however, in the treatment of neurosyphilis, with results largely consistent with other methods of artificial fever induction.
The artificial induction of fever by high frequency electrical currents administered by electrodes which were strapped to the bodies of neurosyphilitic patients who were then insulated in rubber sheets and wrapped in heavy wool blankets. Diathermy was devised in the early twentieth century by Clarence Neymann, a faculty member of the Northwestern University Medical School and an affiliate of several asylums in Chicago, Illinois. In early experiments with diathermy, Neymann and his colleagues followed the protocol of malaria fever therapy, still the treatment of choice for neurosyphilis. On a biweekly basis, and for three months, they induced temperatures above 103.5° F. for five continuous hours. Within a short time, however, they found the protocol too conservative. They increased the number of fevers to as many as forty-nine over a three month period, their duration to as long as nine continuous hours, and their temperature to as high as 107.6° F.
The evidence for what Neymann claimed was the therapeutic success of diathermy was inconsistent. He variously reported the remission rate for treated neurosyphilitic patients as 24 and 65 percent, and provided little explanation for this significant difference. Nor did he sufficiently clarify why he reversed his opinion that fever therapies of any kind would be ineffective with “dilapidated and deteriorated patients” (Neymann & Osborne, p. 9), and began to use diathermy with “aged patients having arteriosclerosis, diabetes and advanced organic heart disease” (Neymann & Koenig, p. 1860). One other inconsistency was particularly disturbing. Neymann claimed that the “complications of diathermy treatment are absolutely nil,” (Neymann & Koenig, p. 1860), yet patients often were burned, sometimes quite severely, by the diathermy electrodes. In an effort to reduce the risk of burns, a more coercive approach to diathermy was instituted. Confused or resistant patients were sedated, and their arms and legs restrained before the artificial fever was induced.
These inconsistencies and contradictions did not go unnoticed by other asylum physicians who were keen on trying therapeutics for the treatment of their neurosyphilitic patients that were more expedient, less risky and less expensive than malaria fever therapy. One of the most vociferous of them was Walter Freeman of St. Elizabeths Hospital, the federal asylum in Washington, D.C. Freeman, who would soon step into a controversy of his own making by promoting and performing lobotomies on both private practice and asylum patients [see Psychosurgery], acknowledged the drawbacks of malaria fever therapy but stated emphatically that the use of diathermy at St. Elizabeths “met with almost complete failure” (Freeman, Fong, & Rosenberg, p. 1750). In contrast to Neymann’s various claims, only 20 percent of the neurosyphilitic patients Freeman and his colleagues had treated showed any improvement; 52 percent remained unimproved and, most alarmingly, 28 percent had died. Far from being an “innocuous treatment” (p. 1753), diathermy had disturbing results: patients sometimes were burned by the electrodes, and they invariably complained about discomfort while undergoing the treatment which more often than not left them listless, confused and dispirited—just as Freeman’s lobotomy patients later, and with the same acrimony, would be described.
Freeman’s criticisms were dismissed as a “clouded judgment” due to a “desire to defend the superiority of malaria [fever therapy]” by Samuel Epstein and his colleagues (Epstein, Solomon, & Kopp, p. 1527). Yet they were even more critical of Neymann’s claims of therapeutic success with diathermy, characterizing them not only as another instance of “clouded judgment,” but as the product of a naïve enthusiasm that was “likely to add to wishful thinking” (p. 1527). The Boston Psychopathic Hospital physicians presented their own findings on diathermy: only 27 percent of the treated neurosyphilitic patients went into remission while twice as many went into remission with malaria fever therapy. This remission rate stood in stark contrast to the claims of Neymann, and also the reports from asylums where diathermy was being met with some success. That difference between published empirical and unpublished observational findings was at the core of an exchange between Walter Bruetsch at Central State Hospital in Indianapolis, Indiana, and Neymann. Breutsch had castigated Neymann for claiming the therapeutic efficacy of diathermy in the face of such inconsistent empirical results, to which Neymann responded:
If Dr. [Bruetsch] would have taken the trouble to scrutinize the tabulation of the results obtained in the treatment of dementia paralytica with [diathermy], he would know that these results originate from investigators all over the world, from England, Mexico, France, Italy, Belgium and even from Australia. Now everybody, all over the world, cannot be wrong, Good clinical results are, therefore, obtainable by the use of fever, produced by physical agents [Neymann, 1936, p. 531].
These acrimonious exchanges occurred several years after Neymann had developed diathermy as a treatment for neurosyphilis, and should be read as a defense of artificial fevers in general, rather than of diathermy in particular. Neymann, in fact, had all but abandoned diathermy as a therapeutic, but his enthusiasm for artificial fevers remained unabated, as did his lack of same for malaria fever therapy:
Indeed, many physicians, and especially neuropathologists, still cling to the belief that we are dealing with something mysterious when a patient is infected with a febrile disease, or when injections of fever-producing substances are given. Many fail to recognize that fever alone is the important common factor of all such therapeutic measures. I have heard of the mythical, unproved, and much extolled action of the plasmodium of malaria in the treatment of general paresis until I have come to believe we are dealing with a fetish or taboo in the minds of its most ardent advocates [Neymann, 1938, p. 96].
Neymann may have found some vindication in the fact that the use of diathermy alone or in combination with other therapeutics, continued in asylums around the world until penicillin, the most effective cure for all stages of syphilis, was mass marketed in the mid–1940s.
The generic name of any one of a number of differently designed cabinets that raised body temperature to approximately 105° F. through the radiant heating devices of radiators or light bulbs. The cabinet, either box or coffin-shaped, enclosed the body and left the head of the patient free. In some designs, a small fan attached to the top of the cabinet cooled the patient’s face during the treatment.
In the early years of the use of the fever cabinet, patients often experienced nausea, vomiting, cramps and precipitous drops in blood pressure due to the loss of salt during profuse sweating. These uncomfortable reactions were later ameliorated by the ingestion of salty water during the treatment. It was standard protocol to confine neurosyphilitic patients in a fever cabinet for as long as seven continuous hours and over several consecutive days.
A generic name of any one of a number of different apparatuses that circulated hot air around the patient. In the mid-nineteenth century, the preferred hot air bath method of treatment involved a fireproof wooden box, the interior of which was heated by an alcohol lamp or a gas burner and through a chimney attached to an opening at the bottom. This method was improved by manufacturer Frank Betz who developed a metal cylindrical box, lined with asbestos, into which hot air was forced and circulated. The fully clothed patient was inserted into the cylinder via a sliding frame. Usually the patient remained in the hot air bath no longer than an hour; once removed, the patient was rubbed dry, put into a change of clothes and made to rest.
The Betz Hot Air Bath, as this device was known, was extraordinarily popular in the United States where it was manufactured. In 1897 it sold for $3.50 to private practice physicians, and the price included a secret “formula” that was guaranteed to cure syphilis. The device also was used in asylums for the treatment of neurosyphilis, but generally was found ineffective in arresting this last stage of the disease. It was, however, used as an adjunct to other neurosyphilis therapeutics well into the twentieth century.
The hot air bath, usually as an adjunctive treatment, was used to treat functional, as opposed to organic, types of insanity as well. The Berlin Charité reported some success with its use in the treatment of acute schizophrenia, as did the McLean Hospital in Massachusetts. In Ireland and England, the hot air bath primarily was used to ease the coexisting physical complaints, such as arthritis and rheumatism, of insane asylum patients.
The elevation of body temperature by the action of hot water or steam in a closed chamber. Hot bath therapy was one of the oldest treatments of syphilis on record and was even rhapsodized in a sonnet by William Shakespeare as a “seething bath, which yet men prove/Against strange maladies a sovereign cure.” So therapeutic were hot baths assumed to be that for centuries physicians sent their syphilitic patients to health resorts to “take the waters” as a cure.
The question remained, however, if hot bath therapy would have the same salutary effects on neurosyphilis, particularly of the paretic type where dementia was progressive and hopeless. In experimental conditions, Jay Shamberg and Anna Rule of the Research Institute for Cutaneous Disease in Philadelphia, Pennsylvania, determined that hot baths could raise body temperature to as high as 106° F., a temperature that attenuated the Treponema pallidum bacterium in recently inoculated animals.
Hot bath therapy was administered to eleven paretic neurosyphilis patients by Henry Mehrtens and Pearl Pouppirt of Stanford University Medical School in California. The temperatures of the patients were raised to 104 to 107° F. and maintained in that range for thirty continuous minutes on five consecutive days. The outcome roughly paralleled that of malaria fever therapy: two of the patients improved sufficiently enough to resume daily activities including employment; four more improved, and the remaining five were unimproved. Yet, as was the case with all of the various fever therapies, the assessment was conducted on a short-term basis, leaving unaddressed the question as to whether the positive outcomes were maintained over time.
By the early twentieth century, many asylums around the world already had built what often were palatial hydrotherapy suites and buildings [see Hydrotherapy], and had specially trained staff to administer and monitor the various treatments. Thus the use of the hot bath for the treatment of neurosyphilis, despite caveats as to its effectiveness, continued well into mid-century.
A method of artificial fever induction developed by Harry C. Solomon at the Boston Psychopathic Hospital in Massachusetts, in which the body temperature of neurosyphilitic patients was lowered to 90° F. and then rapidly raised to 105° F. via confinement in a fever cabinet. While it had been well established by the early mid-twentieth century when this therapeutic was devised that the Treponema pallidum spirochete was killed by high temperatures, Solomon and his colleagues conjectured that it also may not be able to withstand low temperatures. A relatively wide swing of temperatures, then, might be particularly effective in “sterilizing the human brain of the spirochetal invaders” (Solomon, Kopp, & Rose, p. 96).
The administration of hypohyperthermia was as follows:
The patient is prepared by a cleansing enema on the evening before and by the omission of breakfast. He is placed in a fever cabinet with the cover open, and the constantly recording rectal thermometer is inserted. After a period of ten or fifteen minutes for stabilization of temperature, the anesthetic is injected slowly to produce satisfactory anesthesia. Approximately one hundred pounds of finely-cracked or shaved ice are placed about the patient from axillae to below the knees, excluding the back. One arm is kept exposed for blood pressure readings and subsequent venipuncture. More pentothal is injected from time to time in decreasing doses to maintain the anesthesia. When the temperature falls to the desired level, the ice is removed, the body is dried, warm blankets applied, and the cabinet cover is lowered and the heat turned on. After the patient’s temperature begins to rise, the inductotherm is turned on and cabinet temperature maintained at 102 to 105° F. until the patient’s rectal temperature reaches the desired level above normal. The cabinet is then opened, and the body temperature is allowed to return to normal [Solomon, Kopp, & Rose, p. 98].
The patients were described as content with the treatment, although Solomon and his colleagues hastened to note that the amnesia caused by the administration of the anesthetic during the course of the treatment most certainly had contributed to their satisfaction. At the end of several experimental trials, Solomon and his colleagues were more optimistic about hypohyperthermia’s potential than its outcome. The therapeutic was never widely used in asylums.
A device that used electromagnetic induction via a current run through a large, elliptical copper strip located beneath the patient. The prone patient was sandwiched between a flat shelf and cover, and was insulated from direct contact with the inductor. The heat in the cabinet raised the patient’s body temperature to 105.8° F. in approximately two hours and was kept at that level for several more hours by the hot and highly saturated air that circulated through the cabinet. The standard protocol was thirty hours of fever over eight to twelve separate treatments.
Invented in the 1930s by Charles Franklin Kettering, vice president of General Motors, in conjunction with the Fever Research Project at the Miami Valley Hospital in Dayton, Ohio, as an improvement on the radiotherm. The hypertherm had heavily insulated walls and two chambers. The larger chamber had a semi-circular portion cut out so that the patient’s head and neck was exposed; the smaller chamber at the foot of the cabinet housed an air-conditioning mechanism. The hypertherm was heated by a 1550 watt resistance unit controlled by a thermostat, and humidity was secured by a pan of water heated by a 2000 watt electrical immersion heater and controlled by a humidostat. The heated and humidified air was then circulated through a blower. The therapeutic goal of the hypertherm was to raise body temperature to between 106° and 107° F., and to maintain that temperature for several consecutive hours. The typical regime for neurosyphilis was to repeat this treatment every few days.
With the assistance of the Frigidaire Division of General Motors, a supply of hypertherms was manufactured and furnished on loan to more than fifty asylums in North America and Europe. The supply, however, did not meet the demand. More than 300 asylums around the world had requested hypertherms, specifically for the treatment of neurosyphilis.
One of the more enthusiastic proponents of the hypertherm was Abram E. Bennett who had founded the Department of Fever Therapy Research at the University of Nebraska College of Medicine. At the Hastings State Hospital, with which Bennett also was associated, neurosyphilitic patients routinely were treated with a combination of hypertherm and chemotherapy (bismuth and arsphenamine), and the results were noteworthy. In one published study, Bennett and his colleagues reported that of the seventy-nine neurosyphilitic patients treated, more than half of whom were in advanced stages of the disease, 19 percent had experienced full remission and 33 percent showed improvement; the remainder showed no improvement and several patients died.
Inoculation via intravenous injection with tertian malaria, a rarely fatal type of malaria caused by the protozoan Plasmodium vivax. After an incubation period of about a week, the patients experienced chills and nausea, followed by raging fevers of more than 106° F. that lasted several hours. Over the next several days, fevers alternated with chills until the patients were administered quinine sulfate to terminate the malarial infection, but not before a few milliliters of their blood were extracted to be used to infect another group of neurosyphilitic patients.
Malarial fever therapy was developed by the Austrian physician Julius Wagner-Jauregg at the Clinic for Psychiatry and Nervous Diseases. He had experimented with the production of fever in neurosyphilitic patients by inoculating them with a variety of vaccines, including typhoid fever, tuberculin, recurrent fever and erysipelas, none of which had a notably successful therapeutic outcome. Wagner-Jauregg had long suspected that malaria may be not only a more effective febrile agent, but one that produced a fever that could quite easily be arrested by quinine. He came across the opportunity to test that hypothesis during World War I when a soldier was brought from the Italian front to the clinic for treatment. Although hospitalized for shell-shock, the soldier also had a raging tertian malaria fever; left untreated with quinine, his blood was drawn and injected into a neurosyphilitic patient who was near death. “T.M.,” as the 37-year-old patient has been noted in the literature, had his first paroxysm of fever a few weeks after the injection; after the sixth febrile attack his syphilitic convulsions stopped, and after the ninth, quinine was administered. Over the next few months, “T.M.” steadily improved. An actor before he was hospitalized, he was now able to entertain clinic patients and staff with musical numbers and dramatic recitations.
By the time “T.M.” was discharged, Wagner-Jauregg had injected an additional eight neurosyphilitic patients with malaria and had published his encouraging results. His “fever cure,” a slightly misleading moniker given the fact that it actually did not cure neurosyphilis, although without question it added reasonably healthy years to patients who most certainly would have died from it, was enthusiastically received by asylum physicians around the world. In just a few short years published case studies showed that more than half of all treated patients either went into full remission or showed at least some improvement, and the popular press already had proclaimed the procedure a “therapeutic noble deed” (Brown, p. 380). Wagner-Jauregg, against whom charges of maltreating soldier-patients with painful electrical treatments had been dismissed after the War [see Electrotherapy], was awarded the Nobel Prize for Physiology or Medicine in 1927 for the malarial fever cure.
Quite aside from its therapeutic effectiveness, malarial fever therapy had another, more subtle, effect as its use spread throughout Europe, Great Britain and North America: it transformed the asylum physician-patient relationship. That relationship had probably reflected the larger social attitude that syphilis was the consequence of, indeed even the punishment for, moral failure. Prior to malarial fever therapy, asylum physicians had little to offer their patients except a good dose of moral condemnation; after, they began engaging their patients in a therapeutic dialogue, listening to them and soliciting their ideas and their cooperation for courses of treatment. It is possible that “shared belief and the altered relationship brought about by changes in perception created malaria fever’s apparent biological success” (Braslow, p. 93).
Its effectiveness in treating neurosyphilis well established, malaria fever therapy then was tried on asylum patients who had been diagnosed with another type of frustratingly intractable insanity—schizophrenia. The results were dissatisfying. W.L. Templeton treated twenty such cases at the City of London Mental Hospital near Dartford, England. He noted that immediately post-treatment most of the patients demonstrated a “brightening of intellectual interest, a desire to converse, to read the newspapers and books” (Templeton, p. 94). Yet in the absence of supportive psychotherapy and occupational therapy at the under-financed asylum, such noted improvement could not be sustained. “At the end of two months there were few who had not materially lapsed,” he observed, “and it seems only a matter of time before all or most will have resumed their former mental state” (p. 95).
Leland Hinsie also found no reason to recommend malaria fever treatment for patients diagnosed with schizophrenia. He had treated thirteen New York State Psychiatric Institute patients, all of them female, with abysmally bad results: two died during the treatment, ten remained unimproved, and one worsened. There were, he acknowledged, some improvements immediately post-treatment. One patient, for example, who had “laughed boisterously nearly all the time,” ceased doing so; another who had never inquired about situations at home, asked about her family (Hinsie, p. 213). These, he hastened to add, were “fleeting and on the whole superficial” (p. 213); in the end, they were more likely attributable to nursing care during treatment, rather than to the treatment, itself.
At the Utica State Hospital in New York, George Warner treated thirty-six schizophrenic patients and found that “the results obtained have not been sufficiently encouraging to warrant a continuation of this mode of treatment” (Warner, p. 494). While his published report may be read as just another litany of ephemeral improvements, it is more revealing when read as an account of the suffering of the treated patients, the challenges they posed to asylum staff, and the havoc they must have created in their families of origin. “M.M.,” for example, aged 24, had been in the asylum for thirty months:
At the time of treatment he had been unsociable, restless, discontented and had frequently attempted to escape from the ward. He was also irritable, impulsive, and committed frequent unprovoked attacks upon other patients. He was untidy in personal habits and destructive to his clothing, requiring much supervision and resisting attention. Was also very greedy and messy at the table. He could not be induced to apply himself in any way but wandered aimlessly about the ward, usually muttering, grimacing and laughing in a silly manner and making grotesque and purposeless motions, and at times becoming for a brief period excited and noisy, screaming and banging his head against the wall, probably hallucinating. He was inaccessible and appeared very stupid, simply grinning or making some inarticulate sound in response to simple questions or directions…. He was inoculated with malaria … and allowed to have 8 paroxysms with 62 hours of fever above 102 degrees…. During treatment he continued restless and noisy, particularly at night, but he was cleanly in his personal habits, and immediately following treatment a change in his attitude and conduct was observed. Although still unsociable, he had become relatively quiet, composed and compliant…. He was able to understand directions given and when interviewed appeared more intelligent.… The improvement lasted two months…. He has slumped to his previous low regression and has since shown no amelioration of symptoms [Warner pp. 501–502].
While the weight of evidence accumulated that malaria fever was ineffective in treating schizophrenia and other psychoses, “the malarial treatment of the paretics was a standard procedure in nearly all of the institutions for the insane” (Dennie, p. 18). But it was not without its own complications. It was tricky to dispense, requiring the careful matching of blood type between donor and recipient, and the laboratory confirmation that it was tertian malaria, and not some other strain, that was being administered. The question of how many paroxysms of fever should occur before quinine was administered, and at what temperature, or perhaps temperatures in the plural, the series should reach for each treated patient was never satisfactorily resolved. Relapses were noted in some cases, fatalities in others. And there were ethical concerns, most notably raised by William Alanson White, superintendent of St. Elizabeths Hospital, the government asylum in Washington, D.C. White had not particularly shared the optimism of his colleagues regarding malaria fever therapy, but had felt an obligation to do something about neurosyphilis which was, to all extent and purposes, a death sentence. To that end, he ordered a supply of a dozen mosquitoes contaminated with tertian malaria. Only one survived the transit from Puerto Rico. That single mosquito was placed in a small wire mesh cage that was then attached to the arm of a neurosyphilitic patient. After being infected by the bite, the blood of that patient was drawn and used to treat an additional group of neurosyphilitic patients, and so on. While the treatment was largely effective the risks were high, in White’s opinion, that a misdiagnosis would mean that a patient without syphilis would be infected with malaria. The risk exceeded the benefit in his calculation, and he refused to authorize the continued use of syphilitic donors.
Few other asylum physicians, however, came to the same calculation; neither did the American Psychiatric Association which generally endorsed the therapeutic innovations that were sweeping across the country in the early twentieth century. In Denmark, however, the ethical questions raised by malaria fever therapy brought about the first regulations regarding patient consent to treatment in that country’s history. Malaria fever therapy had been introduced in Danish asylums in the early twentieth century after an asylum physician witnessed the administration of the therapeutic during a study tour in Austria and convinced Axel Bisgaard, the director of the Sankt Hans Hospital in Copenhagen, to use it. Accompanied by an asylum physician and a nurse, Bisgaard took two neurosyphilitic patients to Wagner-Jauregg’s clinic in Vienna where they were inoculated with malaria. The blood of these patients then was passed on to other patients. Of the twenty-one infected, ten improved enough to be discharged and the remainder, although still institutionalized, had improved significantly. Bisgaard, however, was reticent to declare a therapeutic victory over neurosyphilis. “Time,” he declared, “must decide here and as elsewhere, how long these improvements will last” (Kragh, p. 447).
Time, in fact, was not on the side of cure. Although one of the patients who had been infected in Vienna was discharged and remained in remission for years, the other was recommitted a year later and died during a convulsive seizure. Yet the administration of malaria fever therapy spread quickly through Danish asylums, where the mortality rates were carefully calculated. Noting those rates, the Directorate of the State Mental Hospitals issued a an informed consent directive in 1924, the first regulation of its kind in Denmark. The directive required that all asylum patients who were being considered for malaria fever therapy had to give their consent to the treatment; if unable to do so, such consent had to be obtained from a spouse, parent or other relative.
A second complication of malaria fever therapy was that it was expensive to administer. Treated patients required close medical supervision and vigilant nursing care, a staffing expense that taxed underfunded and overcrowded asylums. Vials of infected blood had to be stored in optimum conditions and were for some asylums, quite difficult to obtain. There was, in a fact, an interesting trade in malaria infected blood. Thermoses of it had to be shipped between asylums. In those asylums in which infected mosquitoes, rather than the blood of syphilitic patient donors were used to infect, special rooms had to be constructed to assure the safety of other patients as well as the staff. That was necessary at Sankt Hans Hospital, for example, where the windows of the purpose-built treatment room had to be covered with a fine mesh net that the mosquitoes could not pass through, and an extra entrance door had to be put in place to make it possible to look for mosquitoes before entering the room.
It was not effectiveness, ethics or expenses that brought an end to malaria fever therapy, however. Its therapeutic hegemony was first challenged by the introduction of machines and gadgets that produced artificial fevers to the same effect, and then quashed by the introduction of penicillin, which quickly proved itself many times more effective for the treatment of neurosyphilis.
An alternative to diathermy, radiothermy eliminated the need for electrodes. The neurosyphilitic patient was suspended on interlaced cotton tapes stretched across a wooden frame; an eight inch high celotex cover was placed over the body, allowing the head to protrude from the cabinet. At each end of the cabinet there was an aluminum condenser plate covered with hard rubber. Between them a short-wave radio field was concentrated via a vacuum tube oscillator. The heat produced circulated around the recumbent patient, raising the body temperature to 103.5° F. Ordinarily, the patient was not kept in the radiothermy cabinet after the desired temperature was achieved; rather, the body temperature was maintained by wrapping the patient tightly in heavy wool blankets and surrounding him or her with hot water bottles. This treatment typically was repeated bi-weekly for ten to twenty weeks.
Just as the diathermy it was designed to replace, radiothermy carried risks of burns by arcs produced by the radio waves that tended to concentrate in the perspiration on the patient’s skin. Radiothermy also raised the risks of dehydration and collapse, and was considered too risky to use with patients whose neurosyphilis was in an advanced stage.
At the New York Psychiatric Institute and Hospital, Leland Hinsie and Joseph Blalock used a radiotherm apparatus provided by the General Electric Company to treat sixty-eight neurosyphilitic male and female patients. The clinical remission rate was 18 percent, a rate comparable to a comparison group of patients who had been treated with malaria fever therapy, but much lower than expected for each group. Hinsie and Blalock attributed that finding to the fact that females were included in both the radiothermy and the comparative group of malaria fever patients. They took pains to point out that in the “thousands of reports in the literature on results with malarial treatment there is an outstanding silence on the results among women,” except for the passing observation that they have a “relatively lower remission rate” (Hinsie & Blalock, p. 205).
Gender aside, Hinsie and Blalock also were concerned about the fact that six of the sixty-eight patients treated with radiothermy died, two of them during the treatment, itself, and the rest months after the treatment. While they considered it safe to say that in the latter case the radiothermy was not the proximate cause of death, it certainly was for the other two. One died as a result of having “lost the temperature regulating mechanism within the body” (p. 206), and the other from convulsive seizures.
Hinsie and Blalock concluded that radiothermy, despite its risks, was a less hazardous febrifacient agent than malaria fever therapy.
The injection of Spirochaeta morsus-muris (later renamed Spirillum minor) to produce paroxysms of fever with temperatures of 104° to 105° F, along with swelling of the lymph glands, eruptions of the skin, thirst, nausea and vomiting, and anxiety sometimes accompanied by hallucinations. The spirochete is found in the saliva of infected rats and produced the same reaction—commonly known in the West as rat-bite fever and in the East as sodoku—in injected asylum patients as it did in those outside of asylums who had been bitten or scratched by infected rats. The course of rat-bite fever was quite easily arrested by salvarsan (arsphenamine).
The treatment of choice for neurosyphilitic asylum patients in the early twentieth century was malarial fever therapy, but it was not without its drawbacks. Looking for an alternative, Harry C. Solomon of the Boston Psychopathic Hospital began injecting neurosyphilitic patients with Spirochaeta morsus-muris to produce rat-bite fever. The hospital had been established just a decade or so before to treat acute cases of insanity and to serve as a teaching hospital for Harvard University Medical School. Experimental therapeutics would be its métier for decades to come. As its chief of therapeutic research, Solomon was able to address his own interest in neurosyphilis through a variety of what he referred to as “non-specific” interventions with either “greater power of permeation into the nervous tissue,” or more capability of “inducing greater immunity on the part of the patient” (Solomon, p. 1728). Among those interventions was rat-bite fever.
It may be interesting to note that the strain of spirochetes used by Solomon was obtained from a baby hospitalized at the time with rat-bite fever; the strain was then passed through two mice, two rabbits and four guinea pigs. From the hearts of these lab animals, blood was extracted and injected into the thighs of eight neurosyphilitic patients, one of whom died of the disease before the treatment could be concluded. After a couple of days, the temperatures of the remaining seven patients rose and remained at elevated levels for a few hours to a few days before subsiding, only to rise again. This cycle continued for two weeks until it was terminated by salvarsan. Although detailed in their description of the treatment, Solomon and his colleagues were conjectural in their appraisal of its outcome, stating that it was “too early to attempt to evaluate the therapeutic results” (Solomon, Berk, Theiler, & Clay, p. 404), but that the observation of improvements in some of the patients was “at least suggestive of the therapeutic value of the method” (p. 404).
Despite this cautious appraisal, other asylum physicians were ready to use rat-bite fever as a therapeutic. Alex Hershfield and his colleagues set out a regime for its use in three Illinois asylums. They injected a total of seventy-two neurosyphilitic patients with the rat-bite fever spirochete. All patients were then confined to bed, their temperatures recorded every four hours. The inoculation period varied from eight to fifteen days, and started with an inflammation at the site of the injection and was followed by swelling of the lymph glands, and fever that ranged from 102° to 105° F., lasting four or five days. The fever reoccurred over the next several weeks. Some complications were noted: more than half of the patients suffered from severe neuralgia post-treatment; two developed delirium and had convulsions, and another two suffered from disorders of the heart and shortness of breath. All of the complications were satisfactorily resolved with one or two administrations of arsphenamine. In addition, ten patients died during the treatment, although Hershfield and his colleagues stated that only two of those deaths could be attributed to the treatment.
Hershfield and his colleagues observed patients for a year post rat-bite treatment and concluded that 50 percent of them “were more or less physically improved,” 20 percent showed “from slight to marked mental improvement,” 20 percent did not show any difference mentally,” and 10 percent showed initial mental improvement and “then became worse” (Hershfield et al., p. 773). The outcome of “physical improvement” was not defined, except for a brief statement that many patients had gained weight; “mental improvement” remained undefined as well. Curiously, the description of the treatment ended with neither the authors’ endorsement nor their dismissal of rat-bite fever as a therapeutic for the treatment of neurosyphilis. The press, nonetheless, reported the findings with some enthusiasm. Time magazine, for example, lauded it as a valuable alternative to malaria fever treatment; the Chicago Defender, somewhat ironically given the headline “Medical Science Finds Cure for Paretic Insane,” merely repeated Hershfield’s conclusion that some of the treated patients showed some mental improvement.
The induction of fever by injections of the human louse spirochete, Borrelia recurrentis (previously named Spirochaeta duttoni). Relapsing fever therapy dates to the late nineteenth century when Alexander Samoilovich Rosenblum (sometimes spelled “Rosenblium”) infected thirty-two patients at the Odessa Psychopathic Hospital in Russia with relapsing fever, typhoid, or malaria. The patients had been diagnosed with either schizophrenia or manic-depression and none had neurosyphilis. He claimed to have cured sixteen of the patients, all of whom had been treated with malaria; the effects of both relapsing fever and typhoid were negligible. Published in an obscure medical journal, his findings were largely ignored although Julius Wagner-Jauregg, who would later be lauded as the founder of fever therapy, cited them in his early papers on malaria fever therapy.
The use of relapsing fever for the treatment of neurosyphilis was tried with some success by German physicians Felix Plaut and G. Steiner at the German Research Institute for Psychiatry in Munich, decades after Rosenblum had published his study. Hypothesizing that because there was a close relationship between the relapsing fever and the syphilis spirochete, the former would produce antibodies that affected the latter, they injected neurosyphilitic patients with a domestic relapsing fever virus. The course of the resulting recurrent fever was easily arrested by salvarsan. Although the results were encouraging, they did not meet expectations. Plaut and Steiner then injected an African strain of the virus into six patients with paretic neurosyphilis and two with schizophrenia. The paroxysms of fever lasted several days and were accompanied by chills, profuse sweating, headaches and nausea. Unexpectedly, the fever of this African strain could not be arrested by salvarsan, so it was left to run its course for each patient. Once again, the results were encouraging, but only just that: one of the neurosyphilitic patients went into remission, two improved, and the remainder showed no improvement. Both of the schizophrenic patients remained unimproved by the treatment.
Plaut and Steiner remained uncertain as to whether the results obtained were caused by the recurring fever treatment, or coincident with it. As a result, they did not enthusiastically endorse it. In the wake of what often were overinflated success stories about the effects of malaria fever therapy on paretic neurosyphilis, relapsing fever therapy was never widely used.
The intense stare used by an asylum physician to subjugate, and later to diagnose, an insane patient.
Fixing may have been influenced by the spellbinding command to “gaze into my eyes” delivered by mesmerists, professional and quack alike, who were plying their trade across Europe in the late eighteenth century. It most certainly was influenced, however, by the power dynamics of the asylums that were being built during that same period. It was there that physicians were ardently establishing, and jealously protecting, a kind of god-like supremacy over their hapless patients.
A clash between god-like supremacy and royal supremacy was famously played out in Francis Willis’s treatment of George III, King of Great Britain and of Ireland, and fixing was a contentious issue in it. Willis, a clergyman as well as a physician, hence the sobriquet “the Duplicate Doctor,” owned a private madhouse in the Lincolnshire countryside where, it was said of him, he controlled his patients with his gaze. Of that inimitable skill, one of his contemporaries wrote:
Of the celebrated Willis it has been said, that the utmost sweetness and affability is the usual expression of his countenance. But, when looks a maniac in the face for the first time, he appears instantly to change character. His features present a new aspect, such as commands the respect and attention, even of lunatics. His looks appear to penetrate into their hearts, and to read their thoughts as soon as they are formed. Thus does he obtain an authority over his patients, which afterwards cooperating with other means, contribute to restore them to themselves and their friends [Pinel, 1806, pp. 49–50].
Authority over the insane King, however, already had proved difficult to establish. Other treating physicians had used everything from a straitjacket [see Mechanical Restraints], to purging and vomiting [see Depletive Therapy] to blistering [see Counterirritation] in the treatment of the mad King, but it was through fixing him with the eye that Willis finally established supremacy over him and secured his submission.
So piercing was Willis’s gaze, in fact, that the estimable Edmund Burke, House of Commons Opposition leader, shied away from it during a 1789 meeting with him to discuss his treatment of the King. A particular point of that discussion had been to ascertain why Willis had allowed the imperiously defiant King to have a razor. Burke had demanded to know,
“If the Royal patient had become outrageous at the moment, what power the Doctor possessed of instantaneously terrifying him into obedience?”
“Place the candles between us, Mr. Burke,” replied the Doctor, in an equally authoritative tone—“and I’ll give you an answer. There, Sir! by the EYE! I should have looked at him thus, Sir—thus!”
Burke instantaneously averted his head, and, making no reply, evidently acknowledged this basiliskan authority [Macalpine & Hunter, p. 272].
The desire, and the need, to exercise a “basiliskan authority” over asylum patients who were more riffraff than royalty, led many physicians to emulate Willis and use fixing both as an expression of their authority and an exertion of power not only over their corporeal patients, but over their corporeal patients’ incorporeal hallucinations, delusions, and fantasies. To that end, fixing was a necessary requisite for producing the salutary fear that controlled, manipulated and sometimes humiliated and ridiculed patients into what physicians believed would be rational thought and behavior [see Salutary Fear].
Willis’s influence even reached over the ocean and the just as wide political divides between the “Mother country” and a former colony. From the Philadelphia Hospital in Pennsylvania, Benjamin Rush had kept up a lively correspondence with Willis, trading ideas about the most efficacious strategies for treating asylum patients. He was obviously impressed by Willis’s use of fixing, since it appealed to that odd combination of supremacy and suggestion that characterized the treatment regime put into place by the “Father of American Psychiatry.” On fixing, Rush wrote:
[T]he first object of a physician, when he enters the cell or chamber of the deranged patient, should be, to catch his EYE, and look him out of countenance. The dread of the eye was clearly imposed upon every beast of the field. The tiger, the mad bull, and the enraged dog, all fly from it; now a man deprived of his reason partakes so much of the nature of those animals, that he is for the most part easily terrified, or composed, by the eye of a man who possess his reason. [A stern or ferocious look] may sometimes be necessary; but a much greater effect is produced, by looking the patient out of countenance with a mild and steady eye, and varying its aspect from the highest degree of sternness, down to the mildest degree of benignity; for there are keys in the eye, if I may be allowed the expression, which should be suited to the state of the patient’s mind, with the same exactness that musical tones should be suited to the depression of spirits in hypochondriasis [Rush pp. 173–174].
Rush went on to suggest that what the physician sees when fixing on the patient should determine his comportment with the patient. Fixing, therefore, was transformed from a coercive strategy to a diagnostic assessment and a therapeutic tool:
VOICE: In governing mad people it should be harsh, gentle, plaintive, according to circumstances…
COUNTENANCE: It should assist his eye and voice in governing his deranged patients. It should be accommodated to the state of the patient’s mind and conduct. A grave countenance in a physician has often checked the frothy levity of a deranged patient in an instant, and a placid one has suddenly chased away his gloom. A stern countenance in like manner has often put a stop to garrulity, and a cheerful one as extorted smiles even from the face of melancholy itself…
CONDUCT: It should be uniformly dignified…. He should never descend to levity in conversing with them. He should hear with silence their rude or witty answers to his questions, and upon no account ever laugh at them or with them…
ACTS OF KINDNESS: [A]ll his directions for discontinuing painful or disagreeable remedies, and all his pleasant prescriptions, should be delivered in the presence of his patients; while such as are of an unpleasant nature, should be delivered only to their keepers. Small presents of fruit or sweetcake will have a happy effect in attaching maniacal patients to their physicians for it is a fact, that in proportion to the intensity of misery, the subjects of it feel most sensibly the smallest diminution of it [Rush, pp. 175–178].
It has been argued that as the result of the Enlightenment, and Rush indeed was the embodiment of the American Enlightenment, sight was valued as the most rational of the senses. The visual arts of that era gave testimony to that. In paintings, sketches and drawings asylum physicians were always depicted as having a steady and evaluative gaze that was meant to represent the epitome of rationality, and that stood in stark contrast to the distracted, wild or plaintive gazes of the depicted insane patients. Thus, the role of sight, if not fixing in the manner that Willis and Rush had so successfully used it, became central to the asylum physician-patient interaction.
A Carl Josef print of an asylum physician with eyes so bulging as to “fix” a patient with an intense stare. This “awful imposition of the eye” was condemned by John Haslam, apothecary to Bethlem Hospital in London, but valued by most of his early nineteenth century contemporaries (courtesy of the Wellcome Library, London).
John Haslam, apothecary to Bethlem, better known as “Bedlam,” Hospital in London agreed that an informed gaze was necessary for the evaluation of patients, but was critical of the blunt use of fixing. In his well-regarded text, Observations on Madness and Melancholy, he suggested that the “fascinating power” of fixing “ought now be lamented among the artes deperditae” (p. 277). Could the attention of the insane be fixed, and could they be reduced to obedience by nothing more than the eye, Haslam asked? The fact, he replied to his own interrogatory, was “notoriously otherwise” (p. 275). And he seriously questioned both the claims and the integrity of those asylum physicians who thought differently:
It has, on some occasions, occurred to me to meet with gentlemen who have imagined themselves eminently gifted with this awful imposition of the eye, but the result has never been satisfactory; for, although I have entertained the fullest confidence of any relation, which such gentlemen might afterwards communicate concerning the success of the experiment, I have never been able to persuade them to practice this rare talent tetè a tetè with a furious lunatic [Haslam, p. 278].
Yet Haslam acknowledged that gaining some ascendancy over insane patients was necessary for their management. Self-deprecatingly, he admitted that had no “rare qualities” that other asylum physicians were boasting—“no thunder in my voice, nor lightening in my eye” (p. 295)—therefore it was necessary for him to have recourse to other expedients:
A mildness of manner and expression, an attention to their narrative, and seeming acquiescence in its truth, succeed much better [than staring them out of countenance]. By such conduct they acquire confidence in the practitioner; and if he will have patience, and not too frequently interrupt them, they will soon satisfy his mind as the derangement of their intellects [Haslam, p. 296].
Haslam’s comments presaged a different understanding and use of fixing. As coercive mechanical restraints increasingly were being replaced in the early nineteenth century with the persuasive techniques of moral treatment [see Mechanical Restraints; Moral Treatment], fixing symbolized a new relationship between physician and patient—one that involved the physician’s comportment as well as his authority.
Fixing might very well have been reduced to a footnote in the historiography of asylum therapeutics were it not for the critique of medical power by the twentieth century French philosopher Michel Foucault who was no fan of moral treatment. The “gaze” or “observing gaze,” as he variously referred to it, led patients to believe that physicians could penetrate artifice and deceit, ignorance and naïveté, to see through to the truth, he argued. That vested asylum physicians with an unchallengeable wisdom that assured both their authority and their status in a modernizing and secularizing society that was finding it increasingly necessary to confine the diseased, disordered and the discontents in purpose-built institutions.
In Foucault’s argument, the gaze served to benefit nineteenth century asylum physicians. It did nothing of the kind, however, for asylum patients. The gaze stripped them of their individuality and their agency, reduced them to their diagnoses, and granted asylum physicians supremacy over their minds.
Foucault, M. (1989). The birth of the clinic: An archaeology of medical perception. Trans. A.M. Sheridan. London: Routledge.
Gillman, S.L. (1995). Health and illness: Images of difference. London: Reaktion Books.
Haslam, J. (1809). Observations on madness and melancholy. London: J. Callow.
Hunter, R., and Macalpine, I. (1963). Three hundred years of psychiatry, 1535–1860. London: Oxford University Press.
Macalpine, I., and Hunter, R. (1991). George III and the mad-business. London: Pimlico.
Pinel, P. (1806). A treatise on insanity. Trans. D.D. Davis. Sheffield, UK: W. Todd.
Rush, B. (1830). Medical inquiries and observations upon the diseases of the mind. 4th ed. Philadelphia: John Grigg.
A method of putting food into the body of patients who were incapable of feeding themselves, or who refused to do so.
In a statement that captured the seventeenth century take on insanity, William Salmon declared that “those taken with this disease seem to be mad as wild beasts, nor do they differ much from them…[They have] a prodigious Herculean strength … endure the greatest hunger, cold, and stripes without any sensible harm” (Salmon, 56). Although he concocted physics, cast horoscopes, practiced alchemy and defended his quite dubious medical credentials, Salmon’s characterization of the insane as insensible, in every sense of that term, was shared by his contemporaries who bona fides were not in question. Among them was Thomas Willis. Physician, founding member of the Royal Society, and Sedleian Professor of Natural Philosophy at Oxford University, Willis affirmed that “madmen, what ever they bear or suffer, are not hurt; but they bear cold, heat, watching, fasting, strokes, and wounds, without any sensible hurt” (Willis, p. 205).
This image of the insane as “wild beasts” persisted well into the eighteenth century, and certainly influenced what was passing at that time for asylum therapeutics. Whippings and beatings [see Salutary Fear], seclusion in cold and dark cells [see Isolation], mockery and harassment by physicians, attendants and gawking visitors alike were endured by insane patients who were imagined to have neither the sense nor the sentience to be very much inconvenienced by any of it. In the confines of asylums, this confrontation between “man and beast” made food irrelevant [see Diet], and what patients ate, or for that matter, if they ate at all, was a matter of little concern.
Revolutions—political, social, industrial, intellectual—encouraged a new, more humanitarian, view of insanity and an imperative to treat, rather than control, it. Food now was considered not only essential for fueling the bodily machine, but for healing the ravages of the mind. When patients refused to eat the food offered to them, then, asylum physicians were faced with a new and disturbing dilemma. Loathe to carry on the coercive practices of their predecessors, they nonetheless were faced with the prospect of having to force feed their food-refusing patients.
The influential reformer Philippe Pinel, so intimately associated with the moral treatment movement [see Moral Treatment], found nothing contradictory between his humanitarian approach and the forceful methods sometimes needed to feed patients. While at the Salpêtrière Asylum in Paris, France, he both used and recommended the use of feeding bottles and the nasal feeding tubes used with success by his former pupil Jean-Étienne Dominique Esquirol to nourish food-refusing patients until they gained the requisite strength and insight to eat on their own. On his advice, feeding tubes were so regularly used in French asylums that there was little discussion among and between asylum physicians about the method or, for that matter, the ethics of their use.
An article published in a widely read medical journal in 1845, however, initiated a lively debate about the practice among French asylum physicians who soon were joined by their German and British contemporaries. The instigator of this debate was François Leuret, chief physician at the Bicêtre Asylum in Paris. Leuret had departed from the prevailing ideas of that era by insisting that the origin of insanity was, in fact, unknown, therefore it was necessary to supplement the suasions of moral treatment directed at the mind with rough handling directed at the body. In the article, though, Leuret focused his discussion on the technical problems with the use of the standard nasal feeding tube on food-refusing patients. In its place, he recommended a more flexible tube of his own design. The article prompted other French asylum physicians to discuss their own preferred methods of forced feeding, thus revealing for the first time not only the wide range of technical devices actually in use behind asylum walls, but the sheer extent of food-refusal among insane patients.
German asylum physicians followed the technical debate with some interest. The preferred method of forced feeding there was the manual forcing open of the mouth, a low-tech method, certainly, but a low-risk one as well. Nasal and gastric tubes were rejected for the most part, and rectal feeding was promoted in their place, an alternative that British asylum physicians, who had entered the debate when Leuret’s article was re-published in the Lancet, rejected emphatically in favor of the stomach pump. In response to both the German and British reactions, Jules Baillarger, a long-time physician at the Salpêtrière in Paris, promoted a technological innovation: electricity. Well-placed charges to the neck, he argued, both opened the mouth and forced swallowing. His recommendation made strange bedfellows not only of British and German asylum physicians, but his French colleagues as well who declared the method dangerous and unnecessary.
The international debate continued for some time, focusing more on the best technology for forced-feeding rather than the underlying, and in many ways more unsettling questions, about how to calculate the degree of force needed against the degree of resistance demonstrated; how to determine when acceptable force crossed the threshold into unacceptable violence; and whether patients had some inherent right to refuse food, and if their insanity diminished that right. Typologies of food-refusing patients, also known as sitophobic patients, also were constructed. The clinical nuances of food-refusal were discussed, albeit briefly during the mid-nineteenth century. Physical illness certainly could cause it, asylum physicians agreed, as could anorexia nervosa and bulimia, delusions about poisoning and filth, shame, defiance and obstinacy, and suicidal intention. Whether the dynamics of each of these required a different technological approach, however, was not often a matter of discussion among asylum physicians whose attention turned once again to the improvement of the technology of forced-feeding and stayed on that topic into the early twentieth century.
That technological debate had not just to do with the type of device to administer the food, but where the food should be delivered. Whether food was to be placed in the mouth alone, or into the esophagus via the mouth, or through the nose with or without entering the esophagus, or into the stomach, or via the rectum, not only determined the type of device that was used, but the nutriment that was administered. Beef-tea and brandy were considered best for feeding by mouth; eggs, milk and pearl barley for feeding by nose; butter, port wine and beef tea for feeding by rectum. Some devices worked best if the patients were physically or mechanically restrained; others if they were sedated, perhaps by a whiff or two of chloroform.
When the technological debate over forced-feeding finally waned, however, the ethical issues waxed. From the imprisoned British suffragettes who were violently force-fed in reaction to their hunger strikes, to the Irish Republican prisoners at the start of the twentieth century and the Guantanamo Bay prisoners at the century’s end, to the terminally ill, the elderly, the intellectually handicapped, and the insane, forced-feeding has become a complex human rights issue. In regards to the latter, it is entwined with mental health legislation and with considerations of “best interests,” “medical justification,” and “informed consent.”
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Dickens, C. (1852). A curious dance round a curious tree. Household Words, 11, 362–370.
Digby, A. (1985). Madness, morality and medicine: A study of the York Retreat, 1796–1914. Cambridge: Cambridge University Press.
Doyle, D. (2005). Per rectum: A history of enemata. Royal College of Physicians Edinburgh, 35, 367–370.
Friedenwald, J., and Rühräh, J. (1906). Diet in health and disease. Philadelphia: W.B. Saunders.
Gostin, L.O. (2000). Human rights of persons with mental disabilities: The European Convention on Human Rights. International Journal of Law and Psychiatry, 23, 125–129.
Haslam, J. (1809). Observations of madness and melancholy. 2nd ed. London: G. Hayden.
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“The Kalamazoo Asylum: In a general way its affairs are found all right” (1878, April 15). Daily Gazette, p. 1.
Leuret, F. (1845). Note sur une nouvelle sonde destinée à l’alimentation des aliénés. Gazette Médicale de Paris, 1, 540–541.
Mickle, W.J. (1884). Rectal feeding and medication. New York Medical Abstract, 4, 152–156.
Moxey, D.A. (1869). On the administration of food and medicine by the nose when they cannot be given by the mouth. Lancet, 93, 394–395, 425–426.
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“On the feeding of the insane” (1850). Journal of Psychological Medicine, 3, 219–221.
Pritchard, T. (1855). To the editor of the Asylum Journal. Asylum Journal of Mental Science, 1, 189–190.
Reeve, J.F. (1851). An apparatus for administering nourishment to insane persons who refuse food. Lancet, 2, 90–91.
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Sammet, K. (2006). Avoiding violence by technologies? Rectal feeding in German psychiatry, c. 1860–1885. History of Psychiatry, 17, 269–277.
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Williams, E.A. (2008). Gags, funnels and tubes: Forced feeding of the insane of suffragettes. Endeavor, 32, 134–140.
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Intended to supersede the use of the stomach pump for the forced feeding of the food-refusing patient, the feeding apparatus was comprised of a narrow tube that was inserted into the nose, rather than the mouth, passed into the pharynx, and then into the stomach via the action of the constrictor muscles. The insertion required little force, and except for a slight choking sensation it was not particularly uncomfortable to the asylum patient. The nutriment liquid was then dispensed via a syringe through the several inches of tube that remained outside the nose.
Thomas Prichard, physician at Abbington Abbey, a private lunatic asylum in Northampton, England, stated that he had kept food-refusing patients alive for several weeks with the feeding apparatus. He cited the case of a patient who had refused all nourishment for some time, having made a vow to starve himself to death. In a weakened state, he was forced-fed with the feeding apparatus and after several administrations he was able to sit up in bed, and soon developed a hearty appetite.
The feeding apparatus was invented by John Balmanno, visiting physician to the Glasgow Royal Asylum. It used throughout Scotland and in some asylums in England during the mid- to late nineteenth century.
A metal-encased pump that ejected nourishing liquids through an attached tube that was snaked down the patient’s throat and into the stomach. The irrigateur worked rather like a cafetiere in which hot water is poured into a receptacle and then forced, by pressure, through the coffee beans.
In the mid-nineteenth century the irrigateur, which had been patented in France by its inventor, Maurice Eguisier, an obstetrician, was used with some enthusiasm in European and in provincial British asylums. Phillip Stiff, resident physician at the County Asylum in Nottingham, England, reported on his success in improving the physical health of a fifty-year-old patient who was under the delusion that he had been sold to the devil. He had refused all food. His breath became fetid, his tongued furred, and his bones were evident under his skin. At times, Stiff recounted, “he appeared to be sinking” (Stiff, p. 225). The patient was forcibly fed with the irrigateur twice daily for three weeks. Although he gained weight and looked healthy as a result of the forced-feeding, his state of mind remained unimproved.
The eminent British asylum physician Harrington Tuke was unimpressed with the device, stating that he did not much admire the “clock-work plan of squirting sustenance into the stomach” (Tuke, p. 216), adding almost parenthetically that he did not care for its bulky appearance either. He rather reluctantly conceded that it might be of more use in provincial asylums where physicians and attendants were in short supply, than in the more modern and better staffed city asylums where the skills of physicians were put to better use than do nothing more than attaching a tube and priming a pump.
It may be interesting to note that the alternative placement of the tube of the irrigateur also made the device handy for performing enemas and vaginal douches.
A metal spoon with a long point bent at a right angle that was inserted into the pried open mouth of the patient; a funnel at its other end dripped liquid nutriment into the mouth. The feeding spoon was used in asylums around the world throughout the nineteenth century. Some asylum physicians were opposed to it; the often protracted struggle to insert the spoon exhausted both the patient and the physician. Other asylum physicians, however, reported satisfaction with its use. Among them was S.W.D. Williams of the Northampton General Lunatic Asylum in England, who set out a detailed and choreographed plan for the successful use of this very low-tech device for forced-feeding:
With the aid of three attendants the patient is placed on his back on a mattress on the floor, and covered by bedclothes, being, as sine qua non, in his night dress, as far as the armpits, the arm being free. The head rests on a well-filled bolster, an attendant kneels on each side of the bedclothes covering the patient, and thus easily but effectually secures his body. One hand is placed on the patient’s wrist, and the other presses of his shoulder. By these means he is perfectly restrained in the least irksome way to both patient and attendant, and, which is of primary importance, but few if any bruises need be inflicted…. The operator kneels at the patient’s head, and, if the patient is very restive, may steady his head with his knees, but that is seldom necessary. A third attendant takes his place at the operator’s left elbow…. The next operation is to get the spoon into the patient’s mouth: this, if the patient be a woman, is generally easily done by getting her to talk, and slipping it in when the mouth is opened to speak; this device failing, however, persistent but moderate pressure with the spoon against the teeth, aided, if necessary, by inserting a finger between the upper and lower gums behind the last molar, will soon effect our object. Of course, in putting a finger into the mouth, one must look out for being bitten; but if the spoon is firmly pressed against the teeth so as to slide between them immediately the masseters are relaxed, such an accident cannot readily occur. [The spoon] should be placed far enough into the mouth to command the tongue…. It should then be restrained by the thumb and index finger of the left hand, the palm and remaining fingers firmly grasping the chin and preventing any to-and-fro or lateral motion of the head. The third attendant now passes his right hand under the operator’s engaged arm and firmly closes the nostrils…. The operator can now with his right hand pour the food into the patient’s mouth [Williams, pp. 374–375].
A variation of this method was the simultaneous use of two feeding spoons. For this administration the patient could sit or lie down, the mouth was pried open and kept open with one of the feeding spoons, and liquid was poured from the second spoon into the first. The asylum physician or attendant then gently touched the back of the pharynx with the first spoon while the nose was being pinched, thus forcing the patient to swallow the liquid.
The feeding spoon, in its single and double use, was used in asylums around the world throughout the nineteenth century, including the York Retreat, an asylum in northern England that not only was dedicated to non-restraint, but that could claim credit for having initiated the moral treatment movement [see Moral Treatment]. In a letter dated 1829, superintendent George Jepson described the necessarily forceful use of the spoon to feed a food-refusing patient:
The way we have found effectual is to fasten the patient in a chair a little leaning backward with a person to hold the head and another the hands. If the patient refuses to open her mouth it becomes necessary to force it open by inserting the handle … of a key between the teeth in the mouth and then turning it by hold of the web so as to force the mouth open to make room for the introduction of the spoon. Then with another spoon nearly fill that between the teeth and push it forward till the point passes the ridge of the tongue, then lean the patient backwards till the liquid is passed down the throat and if she should refuse to swallow, by closing the nostrils a short time and gently stroking the throat she may be inclined to do so. A teacup of milk and the yolk of an egg beat up [in] it and a little sugar and, if she be very reduced, a little brandy may be added [Digby, p. 132].
One of the most persistent problems with forced-feeding by mouth was that patients sometimes spat out the food or liquid. Henry Sutherland, physician to a number of private asylums in England and a well-regarded lecturer on insanity at the Westminster Hospital, had no hesitance in recommending that force be used to preclude this disgusting response. He suggested that an attendant wrap an arm around the resistant patient’s neck and then use his hand to clamp the mouth closed until the food is swallowed. That force, coupled with well-timed “threats and shaming” by the asylum physician (Sutherland, p. 100), usually secured the cooperation of even the most recalcitrant patient.
A straight or curved piece of wood with a hole in it that was inserted into the mouth that had been opened by a screw or by some other means. The gag had a hole through which a tube was threaded so that liquids could be slowly decanted down the esophagus via a funnel at the other end of the tube.
The gag posed several problems in administration: patient resistance made it difficult to insert, even if the mouth was being kept open by a screw; the hole could be covered by the tongue; the threading of the tube through the open hole required considerable skill and because it bent against the posterior wall of the pharynx before entering the esophagus, it often caused severe retching and contraction of the pharynx.
The insertion of two needles connected to a voltaic pile, an early form of an electrical battery, into the digastric muscles. The resulting shock opened the mouth widely so that the patient could be fed. Although there is some dispute as to its originator, Angelo Filipi of Milan, Italy claimed he was the first to use it in the mid-nineteenth century to feed a particularly intractable case of food-refusal. Upon the second and third administration the patient, who had come to believe that he was dealing with a supernatural, rather than electrical, force, capitulated and agreed to feed himself. He was quite quickly cured and discharged from the asylum.
Although the galvanic method forced open the mouth so food could be placed in it, it could not ensure that the patient would swallow the food. Addressing that issue, Jules Baillarger, physician at the Salpêtrière Asylum in Paris, France, applied electrical plates to each side of the neck of a food-refusing patient to force him to swallow. The patient, a twenty-seven-year-old who had continued to lose weight while being fed via a nasal tube, the preferred practice at that time in French asylums, improved significantly over six weeks of such treatment.
Despite criticisms that the use of electricity was dangerous and unnecessary, the galvanic method was used with some success in Italy, France as well as in Austria in the mid-nineteenth century.
A large iron key that pressed down on the tongue on the food-refusing patient while keeping the jaws apart; once inserted via a long wooden handle, the nose of the patient was pinched to keep the mouth open so that fortifying liquids could be slowly poured through a hole in the center of the key. The key was invented by John Haslam, apothecary at Bethlem Hospital, better known as Bedlam, in London, England, in 1798 after having come across a “number of interesting females who, after having suffered a temporary disarrangement of mind, and undergone the brutal operation of spouting, in private receptacles for the insane, have been restored to their friends without a front tooth in either jaw” (Haslam, p. 317, italics in original).
Although intended to be a humane alternative to the spouting boat, the use of the key required some initial deception. The patient was blindfolded, “which never fails to alarm him, and urges him to enquire what the persons around him are about,” according to Haslam (p. 320). The administration of a pinch of snuff or pepper, or the use of a feather to tickle the nose, caused the patient to sneeze, which opened the mouth sufficiently for the insertion of the key.
One of many devices, screws and gags that were used to force-feed patients. Haslam, apothecary to London’s Bethlem Hospital, intended the key to be a kinder and gentler alternative to other devices that broke teeth, but realized soon that patients were none too keen on his invention. Thus it was often necessary for them to be blindfolded, then a little pinch of snuff or a tickle on the nose with a feather forced them to open their mouths just enough for the key to be inserted (P.S. Knight [1827]. Observations of the causes, symptoms and treatment of derangement of the mind. London: Longman, Rees, Orme, Brown and Green).
Haslam boasted that the key had never deprived a patient of a tooth, yet its administration required a considerable degree of force, as he described:
The manner in which this compulsory operation is performed, consists in placing the head of the patient between the knees of the person who is to use the instrument: a second assistant secures the hands, (if the straight-waistcoat be not employed) and a third keeps down the legs. The nose of the patient is held by the person who uses the instrument [Haslam, p. 319].
Replaced by nasal tubes in the early nineteenth century, Haslam’s key became a symbol of what the author Charles Dickens referred to as the “unconscious cruelty” in the treatment of asylum patients in previous generations. Its abandonment as a technology of forced-feeding was, to him, a marker of the “substitution of humanity for brutality, kindness for maltreatment, peace for raging fury; in the acquisition of love instead of hatred; and in the knowledge that, from such treatment, improvement, and hope of final restoration will come, if such hope be possible” (Dickens, p. 370).
The use of the hands to open the mouth of the food-refusing patient. Although this undoubtedly was the fallback technique used by frustrated asylum physicians around the world, it was the preferred technique of German asylum physicians in the nineteenth century. Karl Hergt, physician at the Illenau Asylum near the Black Forest in Baden, Germany, described how manual force was to be used:
The patient is laid down in the horizontal position … pelvis, shoulders, hands and head are to be held by a sufficient number of attendants. The physician standing by the side of the patient presses the lower jaw with the hand which is positioned under it against the upper jaw meanwhile fixing the middle finger of the same hand between the opened lips at the line where both rows of teeth meet. The forefinger of the other hand, crooked like a hook, is introduced into the free corner of the mouth into the outer mouth cavity and with the help of the … thumb, by pulling, … a pocket is made in which … liquid is gradually poured [Sammet, p. 262].
Hergt, who practiced in an asylum at the vanguard of moral treatment, not only found such a technique necessary, but actually advantageous. Unlike many of the devices, such as the gag and the key, it did not break teeth, and unlike the various nasal and gastric tubes, it posed no danger of perforation or laceration.
It was not the use of manual force that was of concern to one of the leading German asylum physicians of that era, but the reliance on it that was disturbing. Heinrich Philipp August Damerow argued that its quite easy use undermined the dogma of individualization, that is, the calibration of therapeutic intervention to the special needs of the individual patient. Damerow, who loathed the positioning of any technology, including the hands, between the patient and the asylum physician, encouraged his colleagues to be innovative, even spontaneous, in their treatment of the sitophobic patient. Although inspiring, his idealism stood at odds with the daily management of large and complex asylums and had little impact on the use of manual force as a method of forced-feeding food-refusing patients.
A face mask composed of an elliptic piece of wood or a metal plate with an aperture over the area of the mouth. When opened, a shutter over the aperture allowed food to be introduced in the mouth; when closed, the shutter prevented the patient from spitting or otherwise ejecting the food. The mouth-opener was used well into the nineteenth century in asylums in France and Germany.
An oiled flexible tube that was passed through one nostril and as far as the cavity of the pharynx so that it did not enter the esophagus. A nutriment liquid then was poured into the tube, via a funnel, and the patient’s nose and mouth were pinched shut. This method of forced-feeding was attributed to French asylum physician Alexandre Brierre deBoismont who presented it as a “vigorous, striking, and energetic measure” to overcome what he assessed was the obdurate stubbornness and sly deceptiveness of the sitophobic patient (Tuke, 1858, p. 210).
While the nasal tube assured that the patient’s teeth would not be broken as they so often were with the feeding spoon and the spouting boat, it had its own drawbacks. The tube often was difficult to insert due to the accumulation of mucus within the nose, and when inserted at times became plugged with mucus, requiring that it be withdrawn, cleaned and reinserted, sometimes repeatedly and almost always to the great distress of the patient. In addition, it pitted the asylum physician against the resistant patient, thus reducing the former’s moral authority. Another complication that initially had not been anticipated by asylum physicians is that some patients were able to contract the muscles at the back of the pharynx, thus forcing the tube into the larynx, causing choking. Others were able to twist the tongue backwards behind the tube, force it forward between the teeth, and bite it in two.
French asylum physicians, such as Jules Baillarger and Guillaume Ferrus, the latter affiliated with the Bicêtre Hospital in Paris, improved the design of the nasal tube by adding stylets of iron and whalebone, to carry the tube into the nose. A significant design improvement was the articulated stylet, or articulated catheter. Invented by Emile Blanche of the Salpêtrière Asylum in Paris, France, it was composed of thirty-one rings controlled by a watch-spring; the stylet moved the gum elastic tube quite freely when flexed, but made it rigid when extended. In its flexed state the tube was inserted in the nostril and on to the pharynx, and then was straightened by a pull on the watch-spring of the stylet so as to avoid the larynx. When it reached the esophagus, liquid nutriment was introduced through the tube. The stem connected to the stylet’s watch-spring then was released making the tube flexible, thus allowing for its easy withdrawal. Although recognized for its ingenuity, the articulated stylet was not often used by asylum physicians who found it unnecessarily technologically complex. In his survey of forced feeding techniques, the eminent British asylum physician Harrington Tuke revealed that Blanche himself rarely ever used his own invention, preferring instead the simple gum-elastic feeding tube that it was designed to improve. In fact, none of the improvements did much to expedite the insertion of the nasal tube and, in the end, were deemed largely unnecessary.
The insertion of a nasal tube that delivers nutriments directly to the stomach. In use today, it allows for the continuous feeding of food-refusing patients through the use of a gravity-based system in which the bag containing the liquid is situated above the patient’s head. The end of the tube, which is plastic, is lubricated and an anesthetic spray often is applied before insertion through the nose. Its position in the stomach can be affirmed, if necessary with a chest/abdomen X-ray.
The insertion of a funnel or syringe, or the emptying of a spoon or feeding cup of nutriment liquid into the nostril of the recumbent patient. D. Anderson Moxey, medical officer at the Hants County Lunatic Asylum in Hampshire, England, in the mid-nineteenth century, was one of the first physicians to call attention to this method of forced-feeding. The patient’s arms and legs were restrained by three to five attendants, and a funnel was placed in one of the nostrils. Liquids, such as milk, beef tea, broth, coffee, wine or spirits diluted with water, or semi-solid foods such as soup, or eggs mixed with milk, were then poured from a sauceboat into the small Wedgewood funnel and into the nostril of the patient.
Moxey had experimented with the method, administering diluted brandy and eggs mixed with milk to himself without adverse results. Neither painful not irritating, the experience nonetheless was “sufficiently unpleasant” to cause him to appreciate “why many patients, after a very short trial, prefer to take their food in the usual way.” (Moxey, 1869, p. 425).
The wholly unanticipated lack of resistance of patients during that “very short trial,” however, was explained by Moxey as a consequence of three factors. First, he argued, even the insane “have a tolerably shrewd appreciation of the power of numbers” (p. 426), so when confronted by several attendants “a feeling of alarm often prompts them to give in, even before they are laid down on the couch” (p. 426). Second, restraint by the attendants degraded and produced a feeling of utter powerlessness that was “not agreeable to the natural vanity of anyone, sane or insane” (p. 426), thus bringing about unconditional surrender. Third, the administration of nutriments via the funnel was sufficiently disagreeable, as Moxey himself testified, to “bring most patients to terms, particularly when the luxury of a stout resistance is so completely precluded” (p. 426).
Nose feeding was used during the late nineteenth century, despite the concern of many asylum physicians about the degree of restraint it required for its administration. In most asylums it eventually was replaced by the nasal tube.
The low tech method of pinching the nose to force the mouth open to receive food. It was commonly used in asylums prior to the mid-nineteenth century.
A glass-covered funnel with a spout shaped like a goose’s bill. The spout was forced between the teeth of the patient, a spring lever was then compressed to release liquid down the throat. The glass cover on the funnel allowed the asylum physician to measure each release of liquid. Paley’s Feeder was not recommended for the resistant patient, since it was likely to break teeth or injure the tongue.
The delivery of nutriments in concentrated form by injection or insertion into the rectum of the food-refusing patient. Although Egyptian papyri dating back to 1500 b.c.e. list more than 700 different medications that could be administered through the rectum, it may have been the Mongols who were the first to administer nutrients via an animal bladder filled with nourishing fluid and attached to one end of a cow’s horn.
Although the origin of rectal feeding as an asylum therapeutic is unclear, the role of Bernhard Oebeke and Franz Richarz, both of whom were affiliated with a private asylum near Bonn, Germany, is notable. In the mid-nineteenth century they initiated a lively debate among their peers about sitophobic patients, their humane treatment, and the ethical responsibilities of attending physicians that went on, unresolved, for several decades. The debate was hardly parochial: asylum physicians around the world were expressing discomfort with the standard technologies, such as the stomach tube and the screw, that required such force to administer that they terrified and injured patients. Some were declaring forced-feeding unethical; others were insisting that the reliance on technology in any form to deal with food refusal breached the very physician-patient relationship that was necessary for recuperation and cure in the long-term. All also were agreeing that forced feeding, at times, was absolutely necessary. Oebeke and Richarz proposed rectal feeding as a compromise: it was non-violent in its administration and, as a result, did not disrupt the therapeutic alliance, and it saved lives. But it also posed a significant problem: its occasional use in asylums in the past led to the conclusion that it was a “poor and insufficient substitute for natural feeding” (Neumann, p. 207).
Oebeke and Richarz, armed with more recent physiological findings that the rectum absorbs more nutrients than previously thought, then set out to increase the nutritional value of the nutriment to be rectally injected. They conferred with chemist Hans Heinrich Landolt who recommended cold Liebig’s meat extract, a viscous black spread comprised of reduced meat stock and salt that, he asserted, had all the nutritional value of lean meat. Oebeke and Richarz rectally administered this meat extract peptone to ten of their food-refusing asylum patients. Although they reported encouraging results, the death of a patient who had refused repeated injections was a stark reminder of the obduracy of the problem of sitophobia.
The reluctance of asylum physicians to adopt this technology of forced feeding could be accounted for, in part, by the ream of research that was being conducted on Leibig’s meat extract. Nearly 500 tons of it was being produced yearly in a manufacturing plant in Uruguay in anticipation of its proposed use to supplement the diets of the under-nourished and feed the famished people around the world. The research quite consistently found that it was absorbable by the rectum, but that it had little nutritive value and could not, by itself, sustain life.
Oebeke resisted this conclusion of the scientific community and argued that in the case of the food-refusing asylum patient, the rectal injection of Liebig’s meat extract could act as a “prophylactic measure before the voluntary taking of food,” thus buying time for the patient to develop the requisite insight that food acceptance was necessary to continue living (Oebeke, p. 469). Despite this objection, the weight of scientific findings decreased the enthusiasm of even Oebeke and Richarz for its use in the rectal feeding of the food-refusing patient. Physicians at other asylums experimented with other nutritive substances, such as Mickel’s formula of milk, hot water, bicarbonate soda, and Benger’s liquor pancreaticus; or Dujardin-Beaument’s formula of milk, egg yolk, bicarbonate and laudanum; or Riga’s formula of milk, eggs, salt and red wine. The outcomes, however, were not encouraging. Without a nutritive substance that could be well absorbed and that could sustain life for some time, rectal feeding as a forced-feeding technology all but disappeared by the start of the twentieth century from those asylums that had ever used it.
As an interesting aside, the popularity of Liebig’s meat extract did not suffer from the scientific findings. The extract was further refined into a granular powder and remarketed as the Oxo bouillon cube. This handy trick to assure “flavorsome home cooking” can be purchased in any supermarket today.
Two plates of iron that when inserted in the mouth were slowly separated by means of a screw, thus forcing the mouth open. Fortifying liquids then were poured either directly down the throat, or through a tube that was inserted into the esophagus. The screw was used in many asylums around the world well into the twentieth century and was notorious for breaking teeth, lacerating the tongue, and even fracturing the jaw of the food-refusing patient.
Daniel Hack Tuke refined the screw in the late nineteenth century to expedite the threading of a tube into the esophagus. Using iron prongs, as opposed to iron plates, his fish tail screw, as he referred to it, was easier to insert between the teeth and left more space in the opened mouth for the insertion of a tube.
A teapot-shaped vessel constructed of soft metal with a long tin pouring spout that was forced between the teeth. Its use in the early nineteenth century required such force that it inevitably broke the teeth of the resisting patient. This “most destructive and devilish instrument,” as Bethlem Hospital apothecary John Haslam once called it (Haslam, p. 316) was marginally easier to use if the patient had no teeth to clench, thus many asylum physicians as a matter of expediency pulled the teeth of their patients.
The infamous spouting boat that was used to force feed food-refusing asylum patients. This one was constructed of pewter and when forced into the mouth, the long spout often broke teeth and lacerated the tongue and cheeks (courtesy of the Wellcome Library, London).
In the mid-nineteenth century John Foster Reed, resident medical officer at Kensington House, a private asylum in London, redesigned the notorious spouting boat which was so feared by asylum patients and physicians alike. He constructed a teapot-shaped vessel with a pewter mouthpiece to fit around the chin, and strong flattened mouth tube, perforated at the sides, slightly curved, and with a blunt, wedge-shaped apex. He described how it was to be used:
First, fill the vessel with the required liquid…. The patient is then to be placed on a bed, in the recumbent position; the head, supported on a pillow, must be firmly held by the assistants, as well as the trunk and extremities…. The instrument is then to be taken in the right hand, and while the spout is applied to the lips, a small quantity of the contained fluid may be allowed to flow over them; at the same time the nostrils should be compressed with the thumb and forefinger of the left hand. By this means it will be found the patient is soon compelled to open his mouth, and gasp for breath, when the spout of the instrument should be quickly insinuated between the teeth. The vessel can be maintained in its situation, with the pewter mouthpiece applied firmly to the face. The flow of the liquid can be regulated at pleasure by the application of the thumb to the valve at the top of the handle [Reeve, pp. 90–91].
A narrow twenty-eight inch long tube, inserted through the mouth and into the stomach, into which a nutriment liquid could be passed via a funnel, syringe, or valve and piston driven pump. The tube often had a rounded wooden end with openings on each side so that if it rested against the walls of the stomach liquid could still flow through it.
The use of the stomach pump required considerable expertise, and could not be left to staff or attendants. The asylum physician began the procedure by dipping the end of the stomach tube in warm liquid, then passing it through the mouth of the patient to the back of the pharynx, over the epiglottis, down the esophagus and into the stomach. Once in place, the nutriment liquid was administered, and the tube was withdrawn. Although a few patients were sedated with chloroform before the procedure, most were not, and the effect of the procedure on them was considerable. Daniel Hack Tuke warned his colleagues of this:
The patient should be kept lying down when the feeding is over, as the operation generally causes no little shock to the nervous and circulatory systems. This is partly due to the struggle which almost always ensues, and to the anxiety which is frequently produced in the patient’s mind by the process, and also partly due to some obscure nervous connection between the stomach and the heart through the medium of the pneumogastric and sympathetic nerves [Tuke, 1892, p. 500].
The term “stomach pump” is somewhat misleading today, since it refers to the process of pulling out the contents of the stomach through a long tube, rather than putting in liquid nutriments. As an indication of a method of forced-feeding, however, the term “stomach pump” was used throughout the nineteenth and into the early twentieth centuries.
A block of wood, five to six inches in length, approximately one inch thick at one end and tapering down to a lesser thickness on the other end, that was inserted into the mouth of the patient to keep it open so that nutriments could be poured down the throat. The insertion of the wedge invariably broke teeth and lacerated the tongue and palate.
Lydia Smith, a patient at the Michigan Asylum for the Insane in Kalamazoo, Michigan, in the mid-nineteenth century, described in her asylum memoir her experience with the wedge:
I soon felt the weight of the attendant on me, with one knee pressing directly on my stomach, and one hand, like the grip of a tiger, on my head. The wedge was then forced into one side of my mouth, crowding out a tooth in the progress—a tooth which had been filled not long before—causing the most excruciating pain. I cannot tell why, unless it was convulsions, caused by the great pressure on my stomach, but my teeth were set, my lips seemed glued together, and I could not have opened my mouth, even had I known what they wanted me to do. Crash! Crash! went another of my teeth, and another, until five were either knocked out or broken off. I laid in a pool of blood that night [Smith, p. 4].
In state hearings about the treatment of patients at the Michigan Asylum for the Insane, Smith, who had escaped from the asylum and was subsequently declared sane by a court of law, testified as to the use of the wedge. In the face of contradictory testimony by asylum physicians and staff, and by the submission into evidence of her case file in which the wedge was not noted, her testimony was treated with skepticism by hearing officers, and mocked as “merest moonshine” by the press. She was not accused of perjury, however, because, as the press noted, “It is a curious fact connected with the restoration of the person to sanity that some of the delusions which possess the mind while unsound are still believed in implicitly” (“Kalamazoo Asylum,” 1879, p. 1).
The use of the wedge for the forced feeding of the food-refusing patient continued into the early twentieth century in many asylums. It was gradually replaced with the stomach pump and the nasal tube.
Surgical procedures performed on the otherwise healthy sex organs of male and female asylum patients.
There may be no asylum therapeutic that was so inextricably entwined with the ideologies of the era than genital surgery. To separate the strands of the skein would be challenge enough; to retangle them to make sense of the surgical obsession with the sex organs of asylum patients in the late nineteenth and early twentieth centuries would be no less a challenge.
Any attempt, though, had best begin with a discussion of gender ideology or, perhaps better stated, “ideologies” in the plural. While it would be a facile overstatement to maintain that social attitudes and ideas about the appropriate roles, rights and responsibilities of men have been historically and culturally invariant, it would not be to insist that in Western culture, at least, men always have enjoyed a position of power and privilege. Women, in contrast, have not. More often defined by their biology and the destiny that was imagined to follow it—wife, mother, helpmate, caretaker, empathizer, moral standard bearer, epitome of fragile innocence—they have been in a state of relative dependency. So deeply was this ideology engrained, repeated and represented, that it passed as “natural,” as truth with a capital “T.” Thus women’s challenges, whether incidental or determined, to male hegemony in that era were often pathologized. New diagnostic categories—ovariomania, nymphomania, masturbatory insanity, neurasthenia, uterine epilepsy—were added to the quintessential women’s insanity of hysteria, bringing more women into asylums and under the clinical gaze of male asylum physicians. And because all of these disorders were thought to be the reflexive consequences of their sex organs, genital surgery was considered a logical therapeutic intervention.
Men, too, were subjected to genital surgeries, although the therapeutic rationale for performing them was never as convincing as it was in the case of women. The social control rationale, however, was overt. In an era of rapidly changing morals and mores, sexual psychopath statutes were hastily passed, criminalizing a long list of male-perpetrated sexual offenses, from rape and child molestation, exhibitionism and voyeurism, to consensual same-sex acts. Convictions resulted not in prison sentences, but in asylum commitments. Discharge from the asylum, then, was contingent on the reduction of the threat the sexual psychopath posed to society, and because that threat was considered to be the result of what were imagined to be uncontrollable sexual urges and desires, genital surgeries once again were logical therapeutic interventions.
Fears about the sexual psychopath arose from another ideology of that era, and that was eugenics. Eugenics, literally translated as “good in birth” or “well born,” was both a scientific ideology and a vigorous social movement to better society. It was predicated on the notion that the undesirable traits of those deemed unfit were inheritable and passed on to the next generation. Just as was the case with the diagnostic categories of hysteria and sexual psychopath, “unfit” was a pliable category that could be used to label criminals, alcoholics and drug abusers, chronic paupers and ne’er-do-wells, the feeble-minded and the insane—in other words, those who were filling asylums. The solution to the problem they posed was obviously surgical: involuntary sterilization.
Class ideology entwined around eugenics ideology. Those most likely to be seen as unfit and committed to asylums were the urban and rural poor who lacked the resources and opportunities to change their station and life, and the social capital to resist their labeling and commitment. Racial ideology also was influential. In the United States, foreign-born asylum patients were far more likely to be involuntarily sterilized than native born patients; black and Latino patients far more than whites. Mixed-race asylum patients in Sweden, Denmark, Finland and Norway, all of which had vigorous eugenics initiatives, also underwent the “surgical solution” at higher rates than native-born patients. That racial ideology was made brutally obvious during World War II. In Nazi Germany more than 450,000 unfit people, many of them asylum patients, were involuntarily sterilized in the name of preserving the “Master Race.”
Ideologies do change. Even those as deeply entrenched as gender, class and race ideologies yield to one degree or another, and in one way or another, to politicized resistance, organized social movements, new knowledge, and the changing conditions of society. Its ideological underpinnings challenged by changing gender roles, new theories about the causes of insanity, resistance to the surgical solution by some asylum physicians and their patients, and social adaptation to emerging moral and social orders, genital surgeries all but disappeared as an asylum therapeutic in the mid-twentieth century.
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The surgical removal of the testicles. The first castrations of asylum patients were carried out in the late nineteenth century at the Burghőlzli, the psychiatric hospital of the University of Zurich in Switzerland. Founded as a modern clinic for the humane treatment of insanity, the Burghőlzli had achieved international recognition for its unique combination of moral treatment [see Moral Treatment] and somatic therapeutics. The physician Emil Oberholzer, who later would emigrate to New York City and establish a private psychoanalytic practice, described the first three cases of surgical castration at the Burghőlzli:
Case 1. A man, who on account of uncontrollable sexual longings and perversions, eagerly desired operation, submitted to castration, which resulted not only in enabling him to refrain from perverse practices (especially homosexuality) but from other breaches of the law of which he had previously been guilty. Shortly after castration, however, an inexplicable, though transient anxiety state, with vague ideas of reference, developed in the patient.
Case 2. An alcoholic delinquent, with very strong sexual abnormalities, was castrated at his own request, but the operation was ineffectual in diminishing his sexual phantasies. He was permitted to leave the hospital on the ground that he was no longer a social menace, but his psychosexual desires continued unabated. Failure to have erections in response to psychosexual stimulation and also his impotency were a great and constant source of irritation to him.
Case 3. A worthless, criminal imbecile permitted the operation for testicular neuralgia. Notwithstanding his comparatively advanced age of 34 at the time of the castration, physical changes soon occurred so that at the age of 41, he had the appearance of a youth of 20, with a feminine distribution of adipose deposits, which persisted in spite of a generalized emaciation, and with a general diminution of the hairy growth. The operation in no way affected his mental state, for although physically impotent, his psychic cravings were not lessened. He indulged in copulation with his mistress, but, curiously enough, is said not to have regretted the operation. Some years after the operation he developed hemorrhages from the urethra every six weeks, with general physical and mental disturbances such as women experience at the menstrual periods [Obendorf, pp. 110–111].
The case studies made no compelling argument that castration was therapeutically efficacious. Its continued use could only be legitimated by linking the best interest of the embodied patient with the best interest of the body politic. The passage of sexual psychopath laws in many countries during the early twentieth century formalized that link. By treating the individual’s best interest as synonymous with society’s best interest, castration could be used for the dual purpose of treatment and protection. Under those laws if an individual were convicted of molestation, rape, sodomy, corrupting the morals of a child or indecent exposure, as examples, and was also diagnosed as a sexual psychopath, he was civilly committed to an asylum, rather than criminally sentenced to a prison. Castration then could be used therapeutically to ease the symptoms of sexual psychopathy and/or to protect society from further offenses upon his discharge.
In Denmark, for example, an asylum patient so committed could be castrated if the Medico-Legal Council had convinced the Minister of Justice that the therapeutic would resolve the mental suffering and social opprobrium caused by his sexual psychopathy, and also reduce his risk for re-offending after his release. The Netherlands had enacted a similar legal procedure in the late 1930s; over the subsequent three decades, 400 asylum patients who had been diagnosed with sexual psychopathy had been castrated. The majority of them were homosexual child molesters. In twenty U.S. states sexual psychopathy was broadly enough defined that homosexuals could be committed to asylums for sex acts with consenting adults. In seven of those states they could be castrated in order to suppress their “unnatural desires” and, somewhat ironically if only because it anticipated the failure of castration as therapeutic, to protect society from them.
By the mid-twentieth century much of the panic over sex and its threats to innocence and morality had dissipated, as panics inevitably do, and the legal, psychiatric and social implications of the sexual psychopath laws were more heatedly debated. In the United States, Michigan was the first state to repeal its psychopath law and to abolish the legal category of “criminal sexual psychopath.” Most states followed suit.
The repeals had essentially disarticulated psychopathy and sexual threat. By doing so, sexual offenders were criminally sentenced to prison. No longer therapeutically necessary, castration now was legitimated largely in terms of the protection of society. That was evident when the state of Florida passed the Chemical Castration Statute in 1997. It mandated that anyone convicted of sexual battery undergo chemical, as opposed to surgical, castration by means of weekly injections of Depo–Provera (medroxyprogesterone acetate, or MPA). The drug reduces the production of testosterone in the testes and adrenal glands, thus reducing the sex drive. No therapeutic counseling was mandated in conjunction with castration. Eight additional states passed similar chemical castration statutes, all predicated on the best interest of society, although few chemical castrations actually have been carried out. International interest in chemical castration has waxed and waned, but in quite recent years forcible chemical castration laws have been passed in Poland, Moldova, and Estonia, and proposed in Macedonia and India.
The surgical excision of the clitoris.
In late nineteenth century there were four types of clitoral surgery: removal of smegma from the glans of the foreskin and the labia minor; separation of adhesions to the hood of clitoris; circumcision, in which the hood of the clitoris was excised; and clitoridectomy. In deference to the fact that clitoral stimulation was considered essential to women’s healthy sexual desire and drive, physicians turned to the clitoridectomy only as a surgery of last resort.
The “last resort” was turned to most often in cases of chronic masturbation, considered in that era to be both a cause and a consequence of insanity. The medical logic was as such: female sex organs sympathetically influenced the brain, and their periodic irritation by menstruation, pregnancy and menopause, coupled with chronic masturbation, increased the risk for insanity; insanity, in turn, reduced social appropriateness and self-control, thus increasing masturbation and exacerbating the insanity. In this endlessly recursive logic, women indeed were both the “product[s] and prisoner[s] of [their] reproductive systems” (Smith-Rosenberg & Rosenberg, p. 334).
As a specialty gynecology had achieved considerable status by the mid-nineteenth century, and in Great Britain there was no more esteemed practitioner than Isaac Baker Brown who was senior surgeon at the London Home for Surgical Diseases of Women, which he had founded. Baker Brown had been frustrated by patients whose gynecological problems were complicated by that quintessential women’s insanity—hysteria—and had found in the reflex irritability dogma an avenue for resolving that frustration. Hysterical women, he concluded, must be chronic masturbators and that unspeakable vice must be damaging and depleting the central nervous system. It did so, he hypothesized, in stages: first chronic masturbation caused the restless, excited, ailing and complaining symptoms of hysteria, then it irritated the spinal nerves causing hysterical epilepsy, then cataleptic fits and then epileptic fits which collectively led to idiocy, then mania, and then death. The surgical extirpation of the cause of the irritation, then, not only seemed a logical conclusion but a medical imperative. “The treatment must be the same,” he insisted, “whether we wish to cure functional disturbance, arrest organic disease, or, finally, if we have only a chance of averting death itself” (Baker Brown, pp. 8–9).
Thus Baker Brown performed a clitoridectomy on his first patient, a twenty-six-year-old dressmaker who was a patient at his proprietary hospital and had all of the symptoms of hysteria, obviously caused by the “peripheral irritation of the pudic nerve” (Baker Brown, p. 33), a medically polite term for masturbation. He anesthetized her, seized her clitoris with a forceps, ran the thin edge of a red hot iron around its base until it was loosened, and then cut it away. He then severed the adjacent nymphae with a sawing motion of the hot iron which he then used to saw the surfaces of the labia. After the surgery, he waited for her to regain her health after two days of heavy post-operative hemorrhaging. She recovered completely and remained in cheerfully grateful contact with him after her discharge.
Baker Brown discussed her case as well as those other patients on whom he had performed the surgery in his 1866 book, On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy and Hysteria in Females. The slim red volume created quite a sensation. In the parlance of the day, it traversed social taboos with its discussion of female sexual anatomy and sexual desires, and suggested a certain patriarchal zealousness in controlling both. Many of his colleagues were outraged, not so much at the genital surgery as Baker Brown’s relentless pursuit of public attention for performing it. After a series of vitriolic exchanges with and between contributors to several prestigious medical journals, Baker Brown was ignominiously expelled from the Obstetrical Society. He died some time later, impecunious and defamed, but not before his book had come to the attention of asylum physicians in the United States.
The fact was that clitoridectomies already were being performed in the United States, mostly on the patients of gynecologists in private practice. A few years before Baker Brown’s book was published, for example, a report was published in a local medical paper about the successful clitoridectomies performed on two girls who were “addicted to the habit of masturbation,” as a prophylactic against insanity (“Excision of the Clitoris as a Cure for Masturbation” p. 164). One was cured of the habit, the other not.
Baker Brown’s thesis that clitoridectomy could not only prevent insanity, but remedy it, was intriguing to some asylum physicians, although most were reticent, if not completely resistant, to leaving their carefully cultivated art of treating the insane to scalpel-wielding gynecological surgeons. The waning of the reflex irritability theory of insanity certainly rendered the decision to use clitoridectomy sparingly as an asylum therapeutic easier to make. There was little discussion of its use in the asylum literature, although quite recent archival research of patient records show that clitoridectomies were occasionally performed as late as the mid-twentieth century.
The surgical removal of the ovaries. One of the first published reports of the castration of female asylum patients was authored by Emil Oberholzer, physician at the University of Zurich’s psychiatric hospital, the Burghőlzli. There, four patients were surgically castrated in the late nineteenth century. All were released after the surgery but the therapeutic outcome for each failed to meet even low expectations: one improved temporarily before mania recurred; one had a recurrence of psychosis and had to be readmitted to the asylum, although she was later discharged; another experienced no change in her mental symptoms; and the remaining woman died of post-surgical peritonitis.
Oberholzer’s may have been one of the first published observations on female castration, but some of his predecessors already had experimented with the surgical removal of the healthy ovaries of women. One of those physicians was a Rome, Georgia, surgeon by the name of Robert Battey who in 1872 performed his first “normal” ovariotomy on a thirty-year-old woman. Death, she had averred to him, would have been a relief from the epileptiform convulsions that accompanied her occasional menstrual periods, the gastric and rectal bleeding that left her depleted and exhausted. Battey surgically removed both of her ovaries, which from all appearances were normal. Although she developed post-surgical peritonitis, she recovered fully.
Battey’s discussion of his first case, published in a regional medical journal, set out the single criterion for the surgery: “any grave disease which is either dangerous to life or destructive to health and happiness, which is incurable by other and less radical means” (Longo, p. 249). Only a few years later, and having performed the procedure on many more patients, Battey added “in cases of insanity or epilepsy caused by uterine or ovarian disease; and in cases of protracted physical and mental suffering associated with monthly nervous and vascular perturbations” (Longo, p. 249) to his growing list of surgical indicators. These additional criteria expanded the pool of potential patients from the nervous and anxious women who often requested their private physicians to “Batteyize,” them, as the surgical procedure was colloquially known, to the insane women who were confined in asylums.
It was the underlying rationale for Battey’s operation that erased any distinctions between private and public patients. The surgery was based on the rather simple, and even by the late nineteenth century rather antiquated, theory of reflex irritation, that is, that every organ of the body affected every other organ, including the brain. The periodic irritation of the ovaries by menstruation, pregnancy and menopause, it was argued, was transmitted to the brain via the sympathetic nerves, thus accounting for the disproportionate number of women confined in asylums.
The sociological rejoinder to this conclusion eluded Battey and his nineteenth century colleagues, and that was that the diagnostic criteria for what was considered at the time types of insanity unique to females, including menstrual, pregnancy, puerperal, lactation and climacteric insanity, as well as nymphomania, neurasthenia and hysteria, were broadly and vaguely defined. In addition, new and accommodating gender-specific diagnoses were being proposed with something tantamount to wild abandon, thus widening further the diagnostic net. One of those new diagnoses was ovariomania, sometimes also called uteromania or “Old Maid’s Insanity.” David Skae and Thomas Clouston, both physicians to the Royal Edinburgh Asylum for the Insane, also known as Morningside, took credit for the new diagnosis. One of their colleagues provided a case description of a thirty-five-year-old ovariomanic woman who had been admitted on two separate occasions to the asylum. On the first, she was depressed and complained that spirits were “tearing her entrails, to which they gained admission by the vagina” (Wright, p. 247). This state of excitement abated, however, and she was released several months later. Upon second admission she insisted that her neighbors were accusing her of having given birth to a child, whom she had murdered. She also complained that the spirits were torturing her again, this time by thrusting sharp objects into her womb. She died of exhaustion and malnourishment before an oophorectomy could be performed.
It was not just new diagnostic language that brought more women into asylums in the late nineteenth century and decades beyond, but the considerable influence of eugenics ideology. Quite regardless of the diagnosis, insanity was thought to be largely inherited and thus inheritable. And while that assumption, along with Battey’s expanded indicators for the oophorectomy should have eased the entry of the surgical procedure into asylums, that was not always the case. Many asylum physicians resisted the challenge to their status as experts on insanity, and were loath to vest gynecological surgeons with authority over their patients. Some asylums did add gynecological surgeons to their staff, others such as the Norristown State Hospital for the Insane in Pennsylvania, hired them as visiting physicians. Norristown, however, provided an interesting example of the turf wars and professional jealousies that tolled the demise of the oophorectomy as a therapeutic procedure. Visiting gynecological surgeon Joseph Price had performed four oophorectomies on patients there and had fifty more on his waiting list when the Committee on Lunacy of the Pennsylvania State Board of Charities visited in 1893. They were far from impressed with the procedure nor the fervor with which it was being pursued. Their report, published in part in an editorial in the Journal of the American Medical Association, was unusually acerbic:
The zeal of the gynecologist is being carried to an unusual extent when it proposes to use a State Hospital for the Insane as an experimental station, where lunatic women are be to subjected to doubtful operations for supposed cures. If it is to be permitted in some forty or fifty cases, as proposed, it might be well to practice the experiment on the entire female lunatic population, so that the gynecologist may have the large opportunity he doubtless craves to see just what would happen. At the expense of some lives, the continued and aggravated insanity of most of his subjects, with a few supposed cures and improvements, he could read his conclusions learnedly to his gynecological brethren, with the resultant added forward movement up his ladder of fame [“Removal of the Ovaries,” p. 136].
The editorial agreed with the Committee’s findings, if not with the sarcasm with which they were offered. It appropriately pointed out that oophorectomies had not been shown to ameliorate insanity, quite regardless of diagnosis, and that they had a disturbingly high mortality rate of 20 percent. It also questioned the reflex irritation theory that had legitimated the procedure in the first place, conceding at the same time that if the theory were viable “the brain and spinal cord have doubtless become permanently altered, or impelled to disordered action,” so removal of the irritating organs would offer no relief (“Removal of the Ovaries,” p. 135). In addition, the editorial appealed to the personal rights of asylum patients and the legal ramifications of violating them. Arguing that because of their insanity patients could not give consent to the surgery which, it hastened to add, extirpated otherwise healthy organs, it came down adamantly against the surgery.
There are no reliable data on how many asylums patients underwent oophorectomies. There is information, however, that the surgical procedure was practiced in Great Britain, where it was called “Tait’s surgery” after the “Father of Gynecology,” Lawson Tait, and in many European countries, as well as in the United States. Few of these surgeries specifically for the treatment of insanity were reported in the literature after the turn into the twentieth century.
A surgical procedure for female sterilization that involves the cutting of the fallopian tubes. The sterilization of asylum patients during the late nineteenth and early twentieth centuries was justified on two fronts: as an intervention in the mother and wife role, and as the prevention of future reproduction.
While many more asylum patients were sterilized for the latter eugenical justification, the former deserves mention. In an era where the causes of women’s insanity were still largely attributed to essential difference in biology, sex and sexuality, there was recognition that the stresses and strains of women’s lives, especially in regards to their roles as mothers and wives, at times caused and more often exacerbated their mental instability. Asylum physicians for the most part were heeding the plea of Clara Barrus, assistant physician to the Middletown State Hospital in New York and, in the late nineteenth century one of the few women asylum physicians in the United States, to see women patients as something different and more than just their biology:
The causes of insanity in women may be, nay, they probably are, as varied, and many of them identical with, the causes of insanity in men; for we have always to remember that both before and after one is a wife and mother, one is a human being, and the elements that enter into the causation of mental aberration in women will develop along the line of the experiences and inheritances that come to her as a human being, with the addition of those which to her as human being of the female sex [Barrus, p. 477, italics in original].
Those “additions” included the demands of the still strictly prescribed roles of mother and wife. So when twenty-six-year-old Alma H., diagnosed with schizophrenia, told physicians at the Dorothea Dix Hospital in Raleigh, North Carolina, that she was overwhelmed by her household duties, frightened that she would become pregnant for the fourth time, and feared that she would kill her young children when their crying exhausted her, she was sterilized. And when Nelly S., a twenty-three-year-old who had tried to poison her seven children who ranged in age from four months to eight years, was committed to the same asylum, she was sterilized as well.
Like Alma H. and Nelly S., many young women confined to asylums could anticipate being discharged to return to their children and husbands. Their symptoms often ameliorated with little more than rest, and although not recovered, and certainly not cured, they would have been considered well enough to return to their roles as mothers and wives. Asylum physicians reasoned that if some of the stress, distress and fear that attended either one or both of those roles could be relieved by the assurance of no additional pregnancies and childcare burdens, sterilization served a therapeutic end. In addition, it was a relatively low-cost and low-risk procedure that, according to the received medical wisdom of the era, had no deleterious effects on the nervous system or brain.
Determining if these “additions,” as Barrus referred to them, indeed factored in as cause or consequence of any woman asylum patient’s insanity was more daunting than the surgery, itself. Most asylum physicians were men and in possession of cultural capital—education, style of speech, intellect, clothing and authoritative comportment—that women patients especially in state or public asylums did not have. So discussions about these “additions,” and coming to agreements that sterilization was a viable therapeutic option, were sometimes awkward, as this transcribed interview revealed:
Doctor: How are you?
Patient: I don’t feel very good.
Doctor: You have been tired out a long time?
Patient: Yes.
Doctor: How many children have you at home?
Patient: Five at home and one died and I am six months pregnant…
Doctor: How many babies do you want, about a dozen?
Patient: Oh lord, I got enough [Braslow, p. 66].
Regardless of whether that Stockton State Hospital physician in that case was engaging in good natured jesting or a stern reminding of the patient’s “proper” role as mother and wife, he decided that the patient should be sterilized after giving birth to her sixth child. She became one of the 9,000 female asylum patients who underwent tubal ligations between 1900 and 1940 in the United States.
The number, though, is misleading. Some asylums also confined women who were not insane, but “unfit to breed” because of feeblemindedness, low intelligence and/or moral deviance. Hastily passed laws in most states in the United States and in many other countries mandated their involuntary sterilization. The purpose here was clearly and unabashedly eugenic: the best interest of society trumped the therapeutic best interests of the patients.
The surgical cutting and sealing of part of each vas deferens, typically as a means of male sterilization. An editorial published in the prestigious Journal of the American Medical Association in 1915 drew attention to research conducted in Italy by Carlo Todde who had compared the testicles of 200 asylum patients with thirty subjects who had no history of insanity. Todde found that the testicles of the asylum patients were smaller than those of the comparison patients. The differences, however, were particularly noted for those twenty-five patients of the group who had been diagnosed with dementia praecox. Their testicles not only were smaller in size and weight, but had “altered structure and function” including an “alteration in the filial cells … a degeneration of the cells which have to do with the production of spermatozoa, or an atrophy of the seminiferous tubules” (“Sex Organ Changes in Insanity” p. 254). This observation was confirmed by a number of asylum physicians and researchers, most notable among them Frederic Mott, then the director of the laboratory of the Claybury Asylum, a London county council asylum. Mott, who would go on to become president of the Royal Medico-Psychological Association, described the testicles of patients with dementia praecox as looking like those of elderly men, suggesting to him that dementia praecox may be a “precocious senility” caused by the premature atrophy of the gonads.
The prospect that changes in the testicles were pathogenic was intriguing to asylum physicians who were frustrated with the intractability of dementia praecox. They considered the possibility that there was an intimate relationship between spermatozoa and the cells of the cerebral cortex of the brain. Undischarged spermatozoa, they hypothesized, were reabsorbed into the bloodstream and carried to the brain, bathing it in the very lecithin, cholesterin and phosphorus that were the chief constituents of brain tissue. If the testicles of asylum patients were pathological, then such secretions were compromised, adversely affecting the brain and causing dementia praecox. Following that logic, a reasonable therapeutic response by asylum physicians was to inject their dementia praecox patients with testicular extracts, or to administer any one of the many popular nostrums, such as Brown-Séquard Elixir [see Organotherapy]. The results, however, were far from satisfactory.
The hypothesis, though, remained intriguing and asylum physicians had another therapeutic strategy consistent with it: vasectomy. The organotherapist Charles-Édouard Brown-Séquard, whose elixir had failed to ameliorate the symptoms of dementia praecox, had also insisted that vasectomy restored the “senile testicles” of the elderly, thus it may very well do the same for the precociously senile testicles of the patients with dementia praecox. Thus in the early to mid-twentieth century, even as the diagnosis of dementia praecox evolved into that of schizophrenia, vasectomies were performed in any number of asylums in the United States, Great Britain and Europe.
At the Manhattan State Hospital, for example, 100 patients underwent the surgical procedure in the early 1920s. All of them were under thirty years old at the time of admission and had been diagnosed with dementia praecox. The results failed to live up to expectations: seventy-one of the patients showed no mental or physical improvement; seventeen has some physical improvement in that their weight increased and their physical appearance improved; six demonstrated a slight mental improvement characterized by a diminution of combative and impulsive behavior; the remaining six showed a slight degree of both mental and physical improvement. As a result of the study, the asylum physicians were unable to substantiate the claim that vasectomy was of any value in the treatment of dementia praecox.
Early findings such as this did not necessarily dampen the interest that many asylum physicians had in treating dementia praecox with vasectomy. The fact that the therapeutic intervention not just continued but actually revved up in some places as opposed to others suggested that larger and more local eugenical interests may have intersected or even merged. The state of California provided an interesting case study. There was no more vigorous eugenics program, no more vociferous and prominent eugenics promoters, no more thorough cultural saturation of eugenics propaganda, than in the “Golden State.” So effective was its initiative that in the 1930s representatives of the nascent Nazi party sought the advice of the state’s eugenics promoters as to implementing a similar program in Germany.
All of that, in part, may account for why vasectomies were performed on patients with dementia praecox in so many California asylums, without apparent regard for the emerging conclusion that they were therapeutically ineffective. One of those asylums was Stockton State Hospital where a state-wide survey conducted by the Human Betterment Society revealed that its physicians endorsed the procedure. The transcript of a conversation between one of those physicians and a patient who had just been admitted for the second time for nervousness and depression, showed just how smoothly vasectomy had emerged as a therapeutic alternative, for physician as well as patient:
Doctor: You are back again?
Patient: Yes, sir.
Doctor: What was the trouble this time?
Patient: Oh, about the same thing…
Doctor: Have you ever been sterilized?
Patient: No.
Doctor: You had better let us operate on you while you are here.
Patient: That will certainly be all right with me and my wife also.
Doctor: We will do that then.
Patient: Doctor, will that bring better composure to the nervous system?
Doctor: It is supposed to, it has in a number of cases, we do not guarantee it, but in a number of cases it has had marked beneficial effects. It cannot hurt you and does not interfere with your sexual life in any way…
Patient: I will be very much obliged to you, sir [Braslow, 64–65].
It is estimated that between 1910 and 1950, Stockton State Hospital physicians performed vasectomies on more than 1,500 patients, but with few therapeutic benefits. At the Sonoma State Hospital, in contrast, the therapeutic value of the procedure was never really considered. It was here that vasectomy was used in its most eugenical form—as a measure of social control. Founded as a state hospital in the late nineteenth century, the Sonoma State Hospital originally confined mentally disabled children and adolescents. With the passage of the state’s eugenics law, however, with its generous definition of “mental defective,” the asylum was transformed into a “revolving operating room” (Kline, p. 53). People were committed for social and moral violations, such as alcoholism or petty vice crimes, sterilized within days, and discharged days later. Sonoma State Hospital, according to best estimates, sterilized more “mental defectives” than any institution in the world.
In states that had passed eugenic sterilization laws, but that had less vigorous promotion of them, asylum patients were more fearful of the procedure. One of them, Marion Marle Woodson, who under the pseudonym “Inmate, Ward 8” published a memoir of his years as a patient in the Eastern State Hospital in Vinita, Oklahoma, described the impact of state’s sterilization law on his fellow patients:
The patients on the receiving ward are in seething unrest. The two thousand men and women in the institution are in a foment. I suspect that this is true in every asylum in the state…. The spectre of sex sterilization has been thrust over us. The legislature has passed and the governor has signed a measure permitting the desexualization under certain circumstances, of any male of female inmate who is too aged to procreate. And the patients are frightened, wrought up, angry and muttering. They know little about the law, therefore they are the more frightened…. They gather in knots and discuss the fate which may be hanging over them. But they do not do it where the attendants can hear. They are afraid to do that.… And so the fears, the loneliness, and the near hopelessness of the Locked-ins have an added terror [Inmate, Ward 8, p. 112].
Whether vasectomy was intended to be used to relieve the suffering of insane patients or to protect society from social and moral degenerates was not always evident. That said, it is estimated that in the United States alone more than 9,000 vasectomies were performed between 1900 and 1940 on patients confined to state asylums.
A procedure if not developed by, certainly popularized by, David Yellowlees, superintendent of the Glasgow Royal Asylum in Scotland, which involved the surgical insertion of a silver wire ring into the foreskin of the penis, making it impossible to masturbate without pain or injury. Like many asylum physicians in the late nineteenth century, Yellowlees was influenced by the work of the Swiss physician Samuel Tissot who had posited that by increasing the peripheral circulation, the act of masturbation dangerously rushed blood to the brain and that ejaculation had a more debilitating effect on the nervous, circulatory and digestive systems than losing forty ounces of blood. And like most asylum physicians of that era, Yellowlees witnessed his male patients masturbating, leading him to the conclusion that the act was not only a cause of insanity, but also one of its effects. Curing insanity, then, required preventing masturbation.
Yellowlees’s conclusion certainly had the backing of some distinguished asylum physicians. Jean-Étienne Esquirol of the Salpêtrière Asylum in Paris, France, earlier had argued that masturbation caused insanity, not via a sudden rush of blood to the brain but by the depletion of blood from the brain, and that unless it could be prevented it would be ”an insurmountable obstacle to cure” (Esquirol, p. 388). On that latter point William Ellis, the superintendent of the Hanwell Asylum near London, England, agreed, as did the revered German reformer Wilhelm Griesinger, albeit with some hesitation. He suggested that the secrecy and shame surrounding the act of masturbation contributed more to insanity than the act, itself. David Skae, resident physician at the Royal Edinburgh Asylum, agreed as well, and was the first to propose a new category of insanity—masturbatory insanity—to be added to the categories of mania and melancholia.
Whether they considered it a cause and/or an effect of insanity, or a distinct clinical category, asylum physicians were frustrated in both preventing and treating masturbation. They tried blistering the penis or smearing it with croton oil, shocking the spine or restraining the hands, increasing the exercise of the patient in question or altering his diet, but all to no avail. Surgical procedures such as castration were discussed, and almost always rejected. So in the late nineteenth century when Yellowlees suggested the minimally evasive procedure of wiring, there was considerable interest in the procedure.
Yellowlees surgically inserted wires into the penises of twelve of his patients with what he declared were good results. Not only did the wiring prevent masturbation, but the surgical process itself, in his opinion, seemed to have a strong moral effect on the consciences of his patients, one of whom wept when he learned that the wire eventually would be removed once he had learned the proper habit of self-restraint.
Richard Maurice Bucke, superintendent of the Provincial Asylum for the Insane in Hamilton and later the London Asylum, both in Ontario, Canada, tried the procedure on twenty-one patients specifically selected “as belonging to a class in which the habit seemed to some extent a cause of the insanity” (Shortt, p. 126). Case records show that the patients, most of whom were laborers or farm workers, were all in their early twenties and, with one exception, were single. Their diagnoses upon admission varied: twelve had been diagnosed as manic, four as melancholic, three as imbecilic, one as demented; the remaining patient, for reasons not explained, was undiagnosed.
While Yellowlees had reported no pre- or post-surgical complications for his patients, Bucke could not claim the same. Many of his patients resisted the procedure, several developed serious infections; for one reason or another, eight of the patients had to be wired twice, and three underwent three separate procedures. And while Yellowlees described a “good” outcome, Bucke did not. The casebooks show that of the twenty-one patients, only two showed “marked improvement” and three “slight improvement.” The rest remained unchanged. On the basis of this trial, Bucke, who had taken on the task with enthusiasm, asserting that “a good many cases could be relieved and cured which are now hopeless” (Warsh, p. 59), was forced to reconsider his position. Not only did he think wiring was insufficient to the task of preventing masturbation, but he questioned whether masturbation could be considered the sole cause of insanity in the first place.
Experiments in wiring were conducted in a number of British, European and American asylums in the late nineteenth century, but with disappointing results. A concomitant sea-change in opinion about the cause-and-effect relationship between masturbation and insanity caused many asylum physicians to reject their own theories and the therapeutics they had recommended, or used.