The internal or external application of water in any of its forms—liquid, ice or vapor—as a therapeutic treatment.
The use of water to treat insanity dates to antiquity. Celsus, Galen and Hippocrates, among other physicians, prescribed its use not just for the relief of physical ailments but for the mental disorders they were presumed to have caused. When asylums were but few and far between, physicians often treated insane patients with what usually was a staggering array of therapeutics that included some type of application of water.
Daniel Oxenbridge was a case in point. The Puritan physician plied his trade in London in the early seventeenth century and treated a number of insane patients in their homes. His journals, anonymously published many decades later, detailed his treatment of one Mrs. Miller, aged twenty-four, the wife of a well-to-do cloth merchant, who had been insane for a couple of years. Hardly parsimonious in his treatment, he bled, purged and vomited her, as was de rigueur in that era, made her swallow copious quantities of apple cider and a concoction of borage, endive, succory (chicory), fumitory and even more apples. He shaved her head and applied to it the warm lungs of lambs, sheep and pigeons, and then, in what she must have reveled in as relief, he bathed her head in warm water infused with rosemary, sage, lavender and betony (mint). He plunged her feet nightly into warm water to dispose her to sleep, and as time passed and the weather warmed, he placed her in a bath of lukewarm water where she remained for hours at a time. Although his cure of her hardly could be attributed to water alone, the case demonstrated the same kind of therapeutic use of it as is found in the case notes and texts of such eminent physicians as Robert Burton and Richard Napier, contemporaries of Oxenbridge.
Despite the weight of history and the imprimaturs of such distinguished physicians, hydrotherapy or hydropathy was generally not incorporated into the therapeutic regimens of early asylums, at least not in the form that easily would have been recognized by its bygone proponents. Water was used in them not so much to achieve some therapeutic end in and of itself, but more as a means to terrify, subjugate and punish [see Salutary Fear]. Thus, asylum patients were ducked, drenched and nearly drowned during much of the eighteenth and early nineteenth centuries—hydrotherapeutic methods, if indeed they could be so termed, that left little question as to their intent.
Over the years, however, sometimes elaborate and always expensive hydrotherapy suites and buildings were being constructed in asylums around the world, signaling a change in attitude in favor of the therapeutic, as opposed to coercive, potential of water. While there may be many reasons for this, three are especially noteworthy. The first springs from an unlikely source—the significant influence of a Silesian peasant by the name of Vincent Priessnitz. As a boy he had witnessed a deer drag itself to a stream and submerge its injured limb in the cold water; it did so day after day until its strength returned. Deeply moved by what he believed was both the healing and the spiritual property of water, Priessnitz assumed the role of folk healer, treating villagers’ aches and pains with cold water immersions and compresses. He healed himself, as well. In 1816 he was run over by a wagon loaded with oats. The physician who examined him declared that if he lived, he most surely would be an invalid for the remainder of his life. Priessnitz set out to heal himself when the physician’s poultice of herbs stewed in wine failed to relieve his pain. He leaned over a chair and held his breath in what he mistakenly believed was a successful effort to realign his fractured ribs, and then applied cold water compresses, changing them every few hours. After ten days he declared himself cured although, as a matter of interest, he wore wet compresses around his chest to relieve the pain for the remainder of his life.
His remarkable recovery secured his reputation among laypeople as a “water-doctor” and among qualified physicians as a quack. The hydrotherapeutic clinic he built in his home, however, was lauded by the Imperial Commission sent to investigate it, and Priessnitz was given a license to practice “hygienic remedies,” an honor that had never before been bestowed on a layperson. Among the many patients who took the “water cure” by subjecting themselves to cold baths, showers and wet packs, and drinking copious amounts of cold water, were physicians who were curious about its curative claims. Most left impressed; some were evangelical in their zeal about the cure, thus it was not long before hydrotherapeutic clinics, often known simply as “hydros,” were being built across Europe. The patients who flocked to them, most of them quite well-to-do, were suffering not only from the aches and pains of work and life in a rapidly industrializing society, but from the mental strains and stresses that were produced by modernization. It would not have been unusual in the mid-nineteenth century to find a “nervous” patient following an arthritic one into a hydro’s cold shower room.
Second, the putative success of the water cure in ameliorating mental distress garnered the attention of asylum physicians. Faced with stinging criticism that their tried and true “heroic” methods of treatment—bleeding, blistering, purging, vomiting [see Counterirritation; Depletive Therapy]—were not only feeble but dated, they were interested in modernizing their approach. And by using water in less threatening ways than their predecessors, they were able to claim some therapeutic success. Hydrotherapeutic applications soothed and calmed the manic, stimulated and invigorated the melancholic, and improved the general physical health of patients while checking the spread of communicable diseases and freshening the odor of overcrowded asylums in the bargain. Although certainly well suited for coercion and, to be frank, sometimes still boldly used for that purpose alone, by the mid-nineteenth century hydrotherapy more often was being used as a therapeutic substitute for the mechanical restraints, “heroic” interventions and befuddling drugs of old.
In his travels, Frederick Peterson of the Hudson River State Hospital for the Insane in New York was quite taken with how widespread the use of hydrotherapeutics had become in asylums around the world. He commented,
[F]or the insane in Germany, Holland, France, Belgium, Italy, and Austria in the winter of 1886–1887, I was surprised to find how universally hydrotherapy was employed in the treatment of certain conditions of insanity, and with what excellent results; and in a visit to the new insane asylum in Athens, Greece, in 1892, I was astonished to note how well equipped a hydrotherapeutic establishment it possesses, although in a country we are disposed to consider somewhat out of the track of modern progress [Peterson, p. 371].
Had he traveled to Mexico, Peterson would have been just as surprised. San Hipólito Asylum for the Insane was established in 1566, the first asylum of its kind built in the Americas. Almost from the start, however, its compassionate mission was undermined by ideological conflicts between the Catholic Church which had founded it, the wealthy benefactors who funded it, and the often poorly trained physicians who ran it. The overcrowded asylum fell into horrible disrepair, its patients neglected, underfed and often abused by coercive applications of water—the bath of surprise and forced immersions in tubs of cold water. By the 1880s, just about the time that Peterson was visiting European asylums, San Hipólito had placed itself on the “track of modern progress” by transforming its custodial function into a therapeutic one with the installation of a rather elaborate hydrotherapy suite with showers, douches and tubs used to treat anything from melancholy and mania to hysteria and hypochondriasis.
Modern asylum medicine, after all, required modernized facilities and, it might be added, modernized facilities made the practice of modern asylum medicine possible. When patients were being nothing more than bled and shackled, purged and leg-locked, there were few reasons for improving asylums, save for the construction of wings and outbuildings to accommodate the ever-increasing patient census. The therapeutic, as opposed to coercive, use of water required specialized facilities and trained staff, the building and hiring of which provided the opportunity to transform asylums from hopeless and antiquated institutions into hopeful and modern ones.
The costs of adding hydrotherapeutic facilities were considerable. A 1902 report from the Government Hospital for the Insane, later known as St. Elizabeths, in Washington, D.C., where 1,199 patients in the previous year had been treated with 22,210 baths, estimated an outlay of $3,000 to build a hydrotherapeutic facility in a single ward, and $36,000 to $40,000 to build one in a new and separate building. It also advised that each facility be staffed with skilled operators or specially trained attendants, adding significantly to personnel costs.
Such costs, it was argued, would be offset by the benefits of the therapeutic use of water. The 1907 Biennial Report of the Illinois Public Board of Charities provided an interesting glimpse into the rather peculiarly unbalanced structure of this argument that was being presented in many asylums around the world: costs were being calculated in cold financial terms; benefits in impressions, observations and hopes.
To begin, the report framed the argument by visually linking the modern asylum with modernized therapeutics. The report’s frontispiece has two series of photographs, one titled “The Old Way,” the other “The New Way.” The former is of chains, straitjackets, restraining chairs, and a bottle ominously labeled “stupefying drug”; the latter is of bathtubs, showers and footbaths. Determined to bring the “New Way” into its state asylums, the Public Board of Charities estimated the costs of constructing hydrotherapeutic facilities as $290,000, a cost that would be offset, it argued, by the significantly increased cure rates that would “relieve the state of the care of such patients” (p. 251). To bolster its benefit analysis, the report offered testimonials by American asylum physicians already experienced in the therapeutic applications of water. The tributes illustrated what was being touted as a modern remedy whose benefits far exceeded its costs:
From our experience here I am inclined to the belief that no other therapeutic agent is so valuable in such an institution. We expect by the aid of hydrotherapeutic measures to practically do away with all forms of restraint whatever, either mechanical or chemical [p. 13].
The various methods in which water must be applied makes necessary a certain amount of apparatus…. All this involves, in its installation, a certain outlay, yet it seems to me the state has no right to deny this proved means of greatest utility and curative power to its wards, especially when its economic value in restoring health and sanity is considered [p. 254].
Your legislature must permit this step of progress to be made or be left behind and see your insane hospitals discreditably trailing along in the rear [p. 255].
I have observed with great interest that hydrotherapy has won a prominent place in the therapy of the insane and that in the most progressive hospitals it is substituted for injurious hypnotics and narcotics … no matter how expensive the hydrotherapeutic apparatus may be, its use is always profitable [pp. 256–257].
Physicians always had relied upon declarations and anecdotes like these to justify the coercive uses of water in the early years of asylums. It was, in fact, the oft-repeated story originally told by the Flemish physician and chemist, Jean Baptiste van Helmont in the mid-seventeenth century, of a carpenter who was cured of his insanity when he escaped his captors by leaping into a deep pond and nearly drowning, that gave reason for the uses of the bath of surprise and ducking—those greatly fearsome and feared coercive uses of water. Modern asylum medicine, however, had to be based on sounder stuff, and it was the science that built up around the therapeutic uses of water that is the third reason for the widespread and enthusiastic use of hydrotherapeutics in asylums.
Neither a researcher nor a scientist, Priessnitz had kept no records of the thousands of patients who took his water cure; he had published nothing, and he had never addressed his contemporaries in a professional meeting. But he had a devotee who did. Wilhelm Winternitz, an Austrian medical student, conducted extensive research for his dissertation on the patients who took Priessnitz’s water cure. He measured their pulses and took their temperatures before and after treatments; he took plethysmographic readings to measure the accumulation of blood in the parts of the body exposed to particular treatments. He theorized that the temperature stimulant of water not only acted on the organs proximate to its administration, but on nerve points that affected other organs, as well as glands and muscles, through the neural pathways of reflex arcs. An ice pack on the foot, he hypothesized, indeed would affect the brain.
Graduating as a neurologist, Winternitz founded his own hydrotherapy establishment in the popular resort town of Kaltenleutgeben in the southern Vienna Woods where he treated nearly 13,000 patients over a quarter of a century. While doing so, he carried on his research and published extensively on the therapeutic uses of water, and was admitted to the medical faculty of the University of Vienna as a private docent for hydrotherapy. It could be convincingly argued that hydrotherapy was the first asylum therapeutic whose rationale was derived from rigorous adherence to the scientific method, albeit that little of that research used insane patients as subjects, and indeed it was this modern approach to therapeutics that asylum physicians were eager to embrace. For his research and work, Winternitz is referred to as the “father of scientific hydrotherapy,” a sobriquet that reveals that this therapeutic not only was empirically and theoretically grounded, but that it constituted a discipline, of sorts, that asylum physicians could be taught, as well as a technique in which they could be trained.
Winternitz had his own devotees who furthered scientific hydrotherapy. Among them was Simon Baruch. It was through his tireless advocacy that American asylum physicians, many of whom were skeptical at first, were eventually convinced of the efficacy of hydrotherapy. A general practitioner with no experience in treating insanity, Baruch nonetheless meticulously documented the experiences and the research of asylum physicians around the world who were skilled in its use. Among them, was the American asylum physician Frederick Peterson whose appeal to “modern progress” was a clarion call for a new and different approach to asylum therapeutics. Like Winternitz, Baruch was given an academic position. As professor of hydrotherapy at Columbia University’s College of Physicians and Surgeons, he assured that the future generation of asylum physicians were schooled in the theory and research of hydrotherapy in the treatment of insanity.
With credentials such as this, it would be reasonable to expect that hydrotherapy would have had a long and vital tenure as an asylum therapeutic. By the 1920s and certainly for several decades after, however, the expensive hydrotherapy facilities were being re-purposed for the new shock therapies [see Shock Therapy] that were making even stronger claims of scientific legitimacy and bolder promises for cures. And even after those therapies had all but run their ultimately disappointing course, hydrotherapy did not return as a therapeutic. Thorazine and other neuroleptic drugs that came into asylum use in the mid-twentieth century provided an easily administered, low cost alternative to the showers, baths and douches that were once hailed as markers of modern asylum medicine.
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The practice, especially popular in the Scandinavian countries and France, of bathing patients in the sea. Sea bathing was said to have considerable advantages over other types of cold water bathing:
Sea bathing is usually preceded by some exercise, a walk or ride to the beach; it is accompanied by some muscular exertion—struggling against the waves, or, in the more robust, by attempts to swim: with others, again, the whole affair is attended by a dread of danger which powerfully affects the nervous system, and causes hurried breathing, palpitation, and increased rapidity of circulation. The immersion also is in a dense fluid largely impregnated with salts, by which the skin is sensibly stimulated and even irritated. This surface is, besides, actively impressed by the movement of the waves impinging on it, and causing a kind of massage. Add to these, exposure at one time to often a cool and keen wind from the sea, and at another to the full blaze of the meridian sun, and we can readily conceive that sea bathing presents a more complex problem for solution than the mere use of a cold bath [Bell, p. 399].
In Denmark, sea bathing was used with great enthusiasm. At Stk. Hans Asylum, most of the 700 patients were bathed daily between late May and early October. In the opinion of the superintendent, “the beginning of convalescence, or at least essential improvement in both body and mind [could be dated] from the day when the patient began strand bathing” (Lechworth, p. 211). It was also reported that the daily promenade of patients from the asylums to the fjords had additional beneficial therapeutic effects.
Beach or strand bathing was part of a therapeutic regime that idealized rural life. The move of Stk. Hans Asylum from the city of Copenhagen to the Bistrupsgaard Manor overlooking the Roskilde Fjord, for example, was predicated on the assertion that the patients soon would “emulate the pure and innocent customs of the locals, and fall into the natural rhythms of sound sleeping and healthy eating” (Stevenson, p. 29). Fresh air, long walks and bathing in the cold water of the fjord were considered antidotes to the stresses of city life that either caused or contributed to insanity.
The rural idyll also was reflected in Harald Selmer’s prize-winning essay on the topic of “On the General Principles to Be Adopted in the Treatment of the Insane,” submitted in a contest sponsored by Philiatria, an association of young physicians. Selmer, a physician at Stk. Hans, set out a plan for a model asylum that would treat the insane with dignity by providing refuge, employment and recreation in a pleasant and healthy rural setting. The essay prompted the Danish government to establish the Jütland Asylum in Aarhuis in the mid-nineteenth century and to name Selmer its first superintendent. The asylum was purposely built close to the sea so that its patients would benefit from beach or strand bathing.
Although the Wards Island Asylum was in close proximity to the Atlantic Ocean, patients were not taken to the sea, rather, the sea was brought to them. Under the superintendency of Alexander MacDonald, a 220 by 30 foot open air bath was cut out of the rocks at the southern tip of the island; a sluice allowed the water of Hell Gate, a narrow tidal strait in New York City’s East River, to flow into it. On his mid-nineteenth century tour of the asylum, British physician Daniel Hack Tuke saw as many as 200 patients bathing in the two-and-a-half feet deep sea water “to their heart’s content” while “evidently enjoy[ing] their immersion immensely” (Tuke, 1885 p. 63).
The drinking of an hourly pint of cold water for several continuous days or weeks. Cold water ingestion was promoted by Austrian physician Leopold Avenbrugger for the cure of suicidal propensity. If, during the course of the treatment, the patient remained pensive and taciturn, Avenbrugger also recommended the sprinkling of cold water on the eyes, forehead and temples until the patient “becomes more gay and communicative” (Burrows, pp. 449–450).
In the early nineteenth century the prevailing theory, elaborated by Jean-Étienne Esquirol, the prominent medécin ordinaire at the Salpêtrière Asylum in Paris, France, was that suicidal propensity was the result of either a “delirium of the passions,” set off by personal crises that extinguished free will, or a chronic pathological obsession in an otherwise healthy mind. It was that latter explanation, referred to as suicidal monomania, to which Avenbrugger subscribed. The received wisdom at the time was that monomania was an organic disorder, originating in the stomach, thus he reasoned that the copious consumption of cold water would stimulate the functions of the stomach and the liver, dilute stomach acids, lessen appetite, distend the blood vessels, and remove toxins from the body.
A proto-sociological challenge to this theory was thrown down by Jean-Pierre Falret, chef de l’hospice at the Salpêtrière Asylum who posited that suicidal propensity was neither the result of the delirium of the passions nor of monomania. Rather, he argued that it was a an act of free will that had been influenced by both the predisposing causes of heredity, age, gender, education and temperament, and the indirect causes of romantic, financial and/or domestic problems. Interestingly, he also recommended cold water ingestion as a treatment, but expressed some skepticism that it would be effective for any patient who already had not made significant progress towards full recovery.
The streaming of cold water down the coat sleeves of the patient so that it descended into the armpits and down the trunk of the body. Recommended by Benjamin Rush, “the Father of American Psychiatry,” and physician to the Pennsylvania Hospital, the cold water pour was used as one method of last resort to “establish a governance over deranged patients … in order to prevent their destroying their clothes and the furniture of their cells, as well as to punish outrages upon their keepers and upon each other” (Rush, p. 182).
The tight wrapping of a patient in a cold wet sheet or blanket. The cold wet pack is said to have been invented by Vincent Priessnitz, the innovator of hydrotherapy and was brought into asylum use in the mid-nineteenth century by C. Lockhart Robertson of the Sussex Lunatic Asylum in Hayward’s Heath, England. Controversially, it remains in use in some asylums to this day. Robertson described the method of its use as follows:
A piece of mackintosh cloth is laid over a mattress, and a folded blanket laid over that. An ordinary sheet is then wrung out of cold water and laid on the blanket. On this the patient is laid on his back, and the sheet is rapidly wound round him so as to include the arms in it folds. The blanket is then tucked over the body, and three or four other blankets laid over these. There is often a little shivering at first, but this passes off as the sheet gradually warms and the blood so determined to the surface [Robertson, p. 267].
Particularly suited for the treatment of what were referred to as the “feverish symptoms” of mania—hot head, rapid pulse, increased respiration, hot and dry skin—Robertson left the patient in the cold wet pack for an hour or more, at which time the patient was removed, rubbed with a dripping wet sheet, drenched with several pails of cold water, and then rewrapped in another cold wet pack. This process, Robertson pointed out, had to be repeated either several times over a long period, or even during the course of a single day before its soothing and sedative effect was noted. He described a case of a young blacksmith whose mania was cured by the administration of the cold wet pack after other treatments had failed:
Arrived under strong personal restraint…. The symptoms of mania are well marked; there was general perturbation of all the mental powers, with noise and violence; the expression of countenance wild … face flushed.… [O]rdered to be packed every two hours, with dripping sheet after. This was continued all day, and at night he was placed in the padded room. This treatment was continued during the 12th March; that night he slept five or six hours. On the 13th March he could, for a few seconds, collect his thoughts, and the violent symptoms were subsiding. This packing was continued once a day, with two cold pails after, for a week, by which time he was calm and quiet in mind, though still much confusion of intellect.… The packing was then discontinued…. On the 26th November he was discharged cured [p. 270].
Beyond conjecturing that the cold wet pack reduced the “feverish symptoms” of mania, Robertson did not elaborate upon its physiological action. Physicians with specialties other than asylum medicine however did. Max Schüller, a Berlin surgeon, used the cold wet pack in experiments on trephined rabbits and found that within two hours of its application, it contracted the cerebral blood vessels, lessening the blood supply to the brain, slowed the pulse and respiration rate, and increased the quantity of lymph in the brain, thus hastening sleep. Mary Putnam Jacobi, an American obstetrician, went on to describe how the respiratory, circulatory and heat regulatory centers then were excited, resulting in a dilation of the cutaneous vessels and an increase in body temperature. The skin, as a result of two hours in a cold wet back, became so filled with blood that steam arose when the blankets were removed from the patient. These combined long-term physiological effects, she argued, increased perspiration, urination and defecation, thus relieving the body of impurities and toxins.
The use of the cold wet pack was rationalized on the basis of empirical studies and controlled observations. As a result, its recommended use was extended beyond mania to cases of hysteria, alcoholism, general paresis (syphilis), melancholy and neurasthenia, as well as to general restlessness, agitation and insomnia. Its potential for abuse, most particularly for use as a mechanical restraint [see Mechanical Restraint] rather than as a hydrotherapeutic, however, was noted. After investigating allegations of abuse of the cold wet pack, the Lunacy Commission in 1873 placed restrictions on its use and recategorized it as a mechanical restraint. In the face of the still powerful non-restraint movement, British asylum physicians grew increasingly reticent to use it. By the early twentieth century, it had all but disappeared from the armamentarium of British asylums.
At the same time and in the United States, however, the conclusion that the cold wet pack was a mechanical restraint was vigorously rejected. Rather, it was accepted and so enthusiastically used as a hydrotherapeutic that one physician commented that “the [asylum] packroom is the true bedlam of modern psychiatry” (Rowland, p. 333). The method and mode of its application, however, varied considerably. A 1936 survey of seventeen asylums found that the recommended duration of the cold wet pack varied from twenty minutes to six hours, and the temperature from 48° to 80° F. Other variations also were evident more than a half century later in a retrospective audit of the files of forty-six patients who had been treated with the cold wet pack over a three year period of time at a single asylum. The patients received anywhere from one to more than fifty applications; the majority experienced “calming effects” that were not further described and a few found the treatment so soothing that “they became addicted and required a behavioral modification plan to be weaned” from it (Ross, et al., p. 244).
In regards to that last finding, the cold wet pack was not always feared by patients. Some, such as William Seabrook, actually found it pleasant. The journalist, who had admitted himself into the Bloomingdale Asylum in New York City for alcoholism and depression, wrote this about his cold wet pack experience:
They [the attendants] fixed the bed so it wouldn’t soak through to the mattress, then laid me straight and naked on the bed with my arms pressed along my sides like a soldier lying at attention and began swathing me, rolling me one side and then the other, in tight wet sheets, so that the weight of my body rolling back would pull them smoother and tighter, over and over again…. I was flat on my back. Except that my head stuck out and lay comfortably on a pillow. I was the mummy of Rameses. I couldn’t bend my elbows or knees. I couldn’t even double my fists. My hands were pressed flat. I couldn’t move a muscle…. This was the famous “pack.” … After a while my mind began to work and I discovered that I liked it…. I remembered theories that we all have a subconscious longing to be back in the womb—that we remember subconsciously how nice and safe and warm it was…. I went lax presently and was beginning to sweat. I sweated, time passed, and the tension was gone and the jangling nervousness disappeared too, faded slowly as it does under a strong soporific. I was soon as peaceful as a four month fetus [Seabrook, p. 43].
The “longing to be back in the womb” underlies the controversial contemporary use of the cold wet pack on institutionalized autistic children in France. The therapeutic was brought to France in the 1970s by American psychiatrist Michael Woodbury who had been affiliated with the Chestnut Lodge Asylum in Rockville, Maryland, where packing was routinely used. It was embraced by French psychiatrists whose understanding of autism was strongly influenced by Freudian theory. Most notable among them was Pierre Delion, head of Child Psychiatry at the University Hospital in Lille, who suggested that while wrapped in the cold wet pack the child, whose autism was the result of either cold or cloying mothering, undergoes a regression and re-experiences the safe and secure fetal environment. Used widely throughout France to integrate the senses and reduce self-harming behaviors, the use of the cold wet pack was featured in a 2011 documentary film titled The Wall (Le Mur), which critically interrogated this psychoanalytic approach to autism. The film, which was posted on the internet, caused an international uproar.
The treatment of autistic children in France, 75 percent of whom are institutionalized and few of whom ever attend school, had been the subject of criticism from international advocacy and human rights groups for a number of years, but it was the treatment of the cold wet pack that both accelerated and politicized the controversy. While acknowledging that there is scant empirical evidence for the efficacy of packing, French psychiatrists argued that it often produced spectacular results; they, and a number of psychiatric organizations such as the World Association of Psychoanalysis, called for its continued use. Parents’ groups and international human and disability rights organizations, such as Autism Rights Watch, declared it barbaric and called for its elimination. A consensus statement published by eighteen internationally recognized experts on autism declared the treatment unethical, adversative to the “evidence-based practice parameters and treatment guidelines” of other countries, and oppositional to children’s “basic human rights to health and education” (Amaral & Rogers, p. 191). In early 2012 Prime Minister François Fillon called for a new national plan on autism that will bring France in line with the standards of practice and care of other Western countries; a month later, the French government specifically came out against packing.
The lowering on a hammock of a restrained patient into a tub where a series of valves and temperature gauges assured there was a continuous flow of 95° to 110° F. water. The tub was then covered with a canvas sheet or wooden cover with a hole for the head of the patient. The patient usually remained in the tub for eight to twenty-four hours before the sedative effect on the nervous system was experienced.
Various theories were proposed for the efficacy of the treatment. Some physicians argued that the continuous hot bath eliminated toxic impurities from the body by stimulating the excretory function of the kidneys and the skin; others that it lowered the pulse and blood pressure and raised respirations; and others still that it relieved the “congested brain” by warming the blood and soothing the nervous system. Regardless of the theory, physicians around the world used the continuous hot bath with zeal, and cited case after case where it ameliorated, even cured, the restlessness, agitation and confusion associated with mania.
One of those cases was Daniel D., a thirty-year-old who was committed in the early twentieth century to the Pennsylvania Hospital for the Insane. Described in admission notes as “garrulous, vituperative, restless, noisy, and hostile in manner” (Hinsdale, p. 173), he was placed in the continuous hot bath where he remained for five days, at which time his mania completely receded. He was released as cured.
In Sweden, the continuous hot bath was an often relied upon treatment. One nurse described the treatment as it was carried out at Västra Marks Hospital:
A canvas sheet was placed over the tub…. It happened on one occasion that patients could live in there for three weeks at a time in the bath. They slept in the bathtubs, too. We fed them in the bath and held the drinking glass up to their mouths…. They peed and defecated in the water, of course…. Some patients became calmer from it, they really did! It exhausted them. That was the reason why they had to lie there like that. They were so very restless. They spat on us. The names they called us! [Svedberg, p. 29].
The death of a patient while in the continuous hot bath in a Swedish asylum in 1922 brought both criticism and defense of the treatment, just as deaths, usually from scalding, had brought in other countries around the world. In the United States, William Alanson White, the distinguished superintendent of the Government Hospital for the Insane, later named St. Elizabeths, in Washington, D.C., excoriated his colleagues for their reliance on the continuous hot bath as a therapeutic. He argued that the risks to the patient were considerable, not just from the temperature of the water, but from the length of exposure to it, and the restraints that kept the agitated patient from splashing, pulling the plug, or tearing the canvas cover. He concluded that if asylums would do away with this “crude and useless device that is nothing more than a makeshift and an excuse for lack of exertion,” then more effort would have to be placed on interacting with disruptive patients with patience and intelligence (White, 1916, p. 482).
The continuous hot bath was known as the refractory bath in France, and the waterbed treatment in Denmark. In most asylums around the world, it was used until the mid-twentieth century.
The placing of a patient in a tub of tepid water, often for several hours, while a cold affusion was applied to the head. The method of application varied, from cold wet towels wrapped around the head, jugs of cold water poured on the head, ice bags placed on the head, to a cold spray from a douche pipe directed at the head. The continuous warm bath with application of cold to the head was deemed to be more efficient in reducing the plethora of blood in the brain than the tepid or warm bath alone.
The sedative and soothing effect of this treatment was so pronounced that asylum patients often requested it. The risk that the continuous warm bath with application of cold to the head would either agitate or debilitate the patient, however, required that its application be carefully monitored.
A steady stream of cold water falling from a hose or pipe held or fixed in place above the head of the restrained patient. The douche became a popular feature of the hydrotherapeutic regime in asylums during the nineteenth century and well into the twentieth. The diameter of the douche hose or pipe, and its distance to the head of the patient had significant implications: a small hose held a few inches from the head was deemed to have a decidedly tonic effect and was usually reserved for the melancholic or otherwise morose patient; a large hose, perhaps one to two inches in diameter, held a few feet above the patient’s head tended to produce shock, faintness, vomiting and physical exhaustion and was recommended for the raving maniacal patient.
The douche also acted morally, as a means of repression, since most patients greatly feared it. Most asylum physicians, in fact, conceded that whatever efficacy it had was due more to the shock and fear it produced than the percussion of cold water on the head, and therefore greatly circumscribed its use so as to avoid any impression of punitiveness. A notable exception to that rule was François Leuret, principal physician at the Bicêtre Asylum in Paris, France, who had a dubious reputation for substituting “the continuous but more painful blow of a torrent of water … for a shower of blows from the stick” (Bucknill & Tuke, p. 661).
The douche. This rather low-tech contraption poured a steady stream of cold water on the patient’s head through a pipe approximately one inch in diameter, while the patient reclines in a bath, the cover of which can be seen on the left. The device was portable and was devised by Domenico Gualandi of the Hospital for the Insane at Bologna, Italy, probably in the early nineteenth century (A. Morison [1828]. Cases of mental disease. London: Longman and Highly).
American asylum physician Pliny Earle visited the Bicêtre in 1838, and described in detail the repressive use of the douche by Leuret:
Dr. Leuret showed the bathing room, and explained his use of douche for mental and moral disciplines, which appears to me injurious. The scene of this treatment contained about a dozen bath-tubs, over each was a douche-pipe with a capacity for a three-quarter-inch stream. In two tubs we saw patients, each kept from leaving the tub by a board fitted to his neck where he sat, as a man stands in the pillory. One was a robust man, subject to varying hallucinations, who now thought himself the husband of the widowed Duchess of Berri, and had been permitted the day before to have writing materials on condition that he would not write such vagaries as that he was a favorite of the exiled Bourbons and of Louise Philippe. He had written, however, his usual absurdities about the Duke of Bordeaux, Charles X., etc. Dr. Leuret, with this letter in his hand, reminded the patient of his promise, read him the nonsense he had written, and asked him if he still believed that. “Oui, Monsieur.” “Give him the douche,” said Dr. Leuret to the attendant, who at once turned the cock and discharged the stream on the madman’s head. He screamed and writhed, and begged to have it stopped. It was checked; and he was asked, “Do you still believe you are the intimate friend of Charles X.?” “I think I do.” “Let him have the douche.” He again floundered, shouted and begged for mercy. “Well, are you the chum of Charles X. and the Duke of Bordeaux?” “I—I presume so.” “Give him the douche once more.” In this way, sometimes with argument and sometimes with the cold stream, the doctor labored for half an hour to break up his fantastic notions. At last the patient gave in, and his tormenttor gave him a lesson to be learned for the next day.
Turning to the other man in his tub, Dr. Leuret said he had yesterday refused to do a task assigned to him, leaving the work untouched. He then asked the man why he had neglected to work. “To tell the truth, Monsieur, I did not feel any special desire to work.” This was said with a jocose leer which almost made us laugh. “Well, will you work hereafter when you are told?” Reflecting an instant, with the same comic air he said, “Parole d’honneur, I will not work.” “Give him the douche,” said Dr. L. The effect of the stream was now instantaneous. Like a child who is whipped, he cried, “I will, I will!” The douche was then stopped, and orders given that he should do the task before night [Sanborn, pp. 95–96].
Leuret believed that the cause of insanity was not yet, and perhaps never would be, known, therefore its treatment demanded the “reasonable use of all means which influence directly the mind and the passions of the insane” (Leuret, p. 156). Many of his contemporaries argued that the cause of insanity was an as yet unidentified lesion on or in the brain and that treatment, therefore, had to be directed at the body. The vituperative debate these two opposing views created waged during much of the later nineteenth century, not only in France, but around the world. The douche, arguably the one hydrotherapeutic most easily adaptable to either therapeutic or coercive purposes, was central to that debate.
The pouring of as many as forty to fifty buckets of ice cold water from a distance of ten to fifteen feet above, unto the patient’s head. The pouring was done either by hand or by what became increasingly complicated series of pulleys and winches that raised and tipped the buckets. Drenching was strongly advocated by Ernst Horn of the Berlin Charité Hospital and was used there and in some other German asylums into the mid-nineteenth century. Horn argued that drenching
calms and soothes the insane; it cools the head made feverish by congestion of the blood; it makes unruly patients docile and orderly; it enables the dumb to speak; it changes the outlook of those bent on self-destruction; it awakens self-consciousness in the motionless melancholic obsessed by his brooding; it has a salubrious effect on imbecile patients; and in many instances it contributes to the maintenance of calm and order in its role as an instrument for shocking and punishing patients [Kraepelin, p. 65].
Some of Horn’s German colleagues agreed that drenching was an effective punishment of the intransigent patient. Even the reformer Ernst Pienitz, superintendent of the Sonnenstein Asylum in Pirna, used it occasionally, but only when accompanied by “a certain ritual exhortation and admonition” (Kraepelin, p. 65). Most of his colleagues, however, disagreed that drenching was an effective therapeutic. The superintendent of the Siegburg Asylum, Maximilian Jacobi, related that in one German asylum he had visited, 300 buckets of ice cold water had been poured over the head of one patient over several successive weeks, without ameliorating a single one of his symptoms.
A variant of the cold wet pack, it was administered to a patient who stood in a tub of approximately twelve inches of 100° F. water. The sheet, which had been dipped in 75° F. water was then wrapped around the patient and tucked in at the neck and the legs. Two or three basins of 60° F. water were then poured over the head and shoulders of the patient; each was followed by several minutes of vigorous rubbing and slapping of the patient’s sheeted body by the physician or nurse. Upon leaving the tub, the sheet was removed and the patient was dried with a warm towel.
The sedative effect of the drip sheet, which American neurologist S. Weir Mitchell proclaimed was a “remedy past praise,” was found to be efficacious as a treatment of hysteria, neurasthenia, psychoneurosis and melancholia (“Drip Sheet,” p. 25). It was used in North American asylums well into the twentieth century.
A bucket positioned above the restrained and often blindfolded patient that slowly and steadily dripped cold water on a single spot on the forehead. Used extensively in French and German asylums in the mid-nineteenth century by devotees of the “somatic school” that posited organic causes of insanity, the dripping machine was used most often to treat persistent nervous headaches and insomnia, secondary symptoms of the congestion of blood in the head that was thought to have caused the insanity.
In the mid-nineteenth century Russia was divided into states, each with its own “Yellow House,” or asylum. The dripping machine may have been used in many of them, but certainly was at Poltava, a small asylum with just twenty patients who slept on straw covered floors and were daily subjected to the dripping machine, more as punishment than for therapy.
Interestingly, the dripping machine was better known throughout history for causing insanity than for treating it. As early as the fifteenth century, the Italian jurist Hippolytus de Marsiliis observed how a steady drip of water could hollow out a stone, and concluded that the same process, if directed to the forehead of a person, would cause insanity. In the eighteenth century the term “Spanish water torture,” referencing a method of torture used during the Spanish Inquisition, was used to describe the device, but by the early twentieth century, the term “Chinese water torture” came into parlance, perhaps as a result of one of escapologist Harry Houdini’s tricks in which he was suspended by his feet in what he called a “Chinese water torture cell,” actually a steel cabinet, while it was being quickly filled with water. Regardless of its moniker, the dripping machine long has been more intimately associated with torture than with treatment.
A modification of the douche, it was administered by placing the thumb over the nozzle of the hose or pipe, breaking the jet of usually cold or cool water into a fan-shaped stream. On its own, the fan douche had few beneficial effects, and therefore was used as an adjunct to other types of hydrotherapies.
More high-tech versions of the douche, depicting from left to right: the rain bath or shower, the steady pour on the head, and the fan douche on the head and neck (courtesy of the Wellcome Library, London).
The application of moist heat via a large square piece of woolen flannel or a sponge that had been dipped in boiling water and wrung out. The action of fomentation was similar to that of a poultice, in that it relieved tension by increasing the circulation in the part of the body, usually the abdomen or spine, to which it had been applied. Because fomentation lost its heat quite rapidly, the flannel or sponge had to be changed every fifteen to twenty minutes.
At times, counterirritants [see Counterirritation] such as turpentine were added in an effort to draw out impurities, or narcotics such as laudanum or poppies to produce sedation. The poppy fomentation, as the latter was referred to, was prepared by boiling a half a pound of deseeded poppy heads in four pints of water, and then dipping the flannel or the sponge into the strained liquid.
On occasion, dry fomentation was used as an asylum treatment. This involved the application of a hot brick wrapped in flannel, or of a heated bag of salt or bran, to the abdomen or spine of the patient. In addition to its sedative effect, the dry fomentation was thought to relieve indigestion, thus increasing the appetite of the patient.
A needle spray administered through a perforation in the sitz bath tub. The liver spray was directed at the upper right section of the abdomen, in the general direction of the liver. By drawing blood to the surface of the body and stimulating the flow of bile secretions, the liver spray relieved the liver and the intestines of the stasis that caused constipation.
Whether due to poor diet, poor general health, or large doses of opiates, chronic constipation was a problem peculiar to many asylum patients. Since the amount of putrefaction in the organs was thought to influence both temper and temperament, the liver spray was deemed a necessary adjunct to other hydrotherapeutic methods.
A tepid bath into which five or six handfuls of crude mustard were dissolved. The mustard bath was enthusiastically endorsed by Samuel Newington of Ticehurst House Private Asylum in East Sussex, England, who had found it effective in the treatment of severe cases of mania. He described a patient, Mr. W., who had been brought to Ticehurst in a straitjacket while being further restrained by attendants. Despite repeated doses of opium, Mr. W. did not sleep for nearly a week; he was restless, excited and talkative. He was placed in a mustard bath where he remained for thirty minutes, and was “perfectly red upon being taken out” (Newington, 1865, p. 73). Over the next eight days he had six of these baths, and at the end of two weeks was released to his family.
The mustard bath was believed to lower body temperature and decrease blood circulation, however the risk of skin irritation and even superficial burns to the body was considerable. Although infrequently used as an asylum therapeutic, those physicians who did use it significantly decreased the duration of the mustard bath, from the thirty minutes recommended by Newington, to ten minutes with cloths protecting the patient’s genitals.
Multiple horizontal sprays of water, under twenty to thirty pounds of pressure, from nozzles that surrounded the body. The needle spray was administered while the patient stood in a iron box or in an otherwise enclosed shower. Valves allowed for the regulation of water temperature. The needle spray most often was used as an adjunct to other forms of hydrotherapy, most notably the spinal douche.
It did have its own independent therapeutic effect, however. Although the needle spray did not lower body temperature, it did dilate the superficial blood vessels and had both a tonic and a sedative effect on the patient. At St. Elizabeths Hospital in Washington, D.C., the needle spray was a favorite hydrotherapeutic for staff and patients alike. Staff found it easy to administer and patients enjoyed it.
What might have been the prototype of the needle spray used at Hôpital Sainte-Anne in Paris, France, decades earlier, did not elicit such a positive response. American physicians touring the asylum observed patients standing in the middle of hoops of metal pipes, approximately one inch in diameter, that had been perforated with small holes through which jets of water sprayed out. “It seemed to us a frightful ordeal through which to pass,” one of them wrote, “and from the contortions and grimaces of the patients we infer it was regarded in the same unfavorable light by them” (California Commission in Lunacy, p. 179).
A variant of the cold wet pack, the girdle was a linen compress, soaked in 60° F. water, folded several times over and placed on the patient’s abdomen. It was secured there by a flannel that was wrapped around the patient’s trunk and fastened behind the back.
Some version of the girdle had been used in German folk medicine for a century before it found its way into German asylums where it was considered an effective treatment of any number of symptoms, including mania and melancholy. One of its proponents was Karl Neumann whose mid-nineteenth century treatise on hydrotherapy enthusiastically described its use, both in insane asylums and in the hydro spas that were popular in his native Germany. An anonymous English physician who reviewed his book, however, was not nearly so impressed. He dismissed the alleged beneficial effects of the girdle on nothing more than the “principles of hocus pocus” (“Dr. K.G. Neumann,” p. 73). Regardless, the girdle was used in asylums throughout Europe.
At the McLean Asylum in Boston, Massachusetts, the girdle was a particularly favored treatment for the female patient suffering from hysteria, neurasthenia or psychoneurosis, all of which were considered related to the female reproductive system. Theorizing that the abdominal skin had the most immediate reflex reaction with the abdominal viscera, the cold and the mild pressure of the girdle on the abdominal region was thought to ease cramping and “uterine restlessness,” as well as regulate and relax the genital organ’s function. The girdle was used there and in many other American asylums as late as the mid-twentieth century.
A double linen cap either dipped in cold water or with shards of ice placed between its folds, or a bladder or clay cap filled with ice. The nightcap was placed on the shaved head of the patient to reduce irritation and fury, and to induce sleep. Its use was predicated on the theory that what generally was referred to as “mania,” was caused by a plethora of blood in the brain. In the words of Joseph Mason Cox, medical superintendent of Fishponds, a large private asylum near Bristol, England, that excess produced “grotesque and incongruous catenations of thought, while the sense of sight, hearing, and feeling are morbidly affected” (Cox, p. 27). It also caused the patient “to retain heat with great tenacity” (p. 120), a symptom that could be easily relieved through the application of the nightcap.
To equalize the circulation of blood through the body, many physicians took the advice of Achille-Louis-François Foville, medical superintendent of the Saint-Yon Asylum in Rouen, France, and immersed the patient’s feet or entire body in warm water while wearing the nightcap. Foville recommended the patient be kept in the warm bath for as long as two to three hours, and for many as two to three times a day, observing that anything less would increase, rather than decrease, agitation. He claimed so much success with this treatment that he boldly declared, “la folie est curable.”
The nightcap was used in asylums throughout the world during the nineteenth century. Its use far outlasted the “plethora” theory of madness that had given rise to it in the first place.
The pouring of pails of water of any temperature, or of alternating temperatures, over the head and shoulders of a patient who was kneeling, crouched over or restrained in a bath tub. The height from which the water fell was thought to moderate the intended effect, thus water poured from a short distance was considered more stimulating than water poured from a longer distance. The pail douche often was given just before bedtime, and its nightly administration over a period of two to three weeks was found particularly effective in easing the symptoms of melancholia and advanced dementia.
It had a decidedly punitive use, as well. At the Bicêtre in Paris, France, principal physician François Leuret used the pail douche to punish refusal to participate in the therapeutic regime he had set out. He described one such case, that of a patient named Mr. Dupré, a former army officer, who had adamantly refused his order to write the history of his own life:
I now determined to employ my last and strongest arguments. I had the patient carried into the bath-room, undressed, and placed in a baignoire; two pails of water thrown over his body. On his promise to write, he was allowed to dress, but when dressed, he refused to keep his word. He was again placed in the bath, and four buckets of water poured over him. He again persisted he would write, again dressed, and again broke his promise; eight pails were then ordered to be brought, and when he saw them ranged before him, and had become convinced that I was likely to carry out my threat, he gave up further resistance, and devoted the rest of the day to writing his life in all its details [Tuke, 1858, pp. 551–552].
The pail douche was used in many European, British and American asylums well into the early twentieth century.
The direction of a forceful jet of 60° to 80° F. water for as long as ten continuous minutes at the genital area of the patient who was seated on a box or stool with an opening at the center. The pelvic douche was used primarily to relieve the plethora of blood and the hyperesthesia believed to be contributing causes of hysteria in women. The therapeutic was used in many asylums around the world.
By the time hydrotherapy had become the peerless remedy for almost all types of insanity in the mid-nineteenth century, the canonical assumption that hysteria was a uniquely women’s affliction, a consequence of the wandering womb, had been successfully challenged by prominent French asylum physicians, such as Pierre Briquet of the Hôpital de la Charité and Jean Martin-Charcot at the Salpêtrière Asylum. Hysteria in men was assumed to have the same origin in the nervous system as that of women, and their symptoms—paralyses, limb contractures, seizures and hemianesthesias—were identical to women’s, although more likely to be set off by physical, rather than emotional, traumas. The latter point is an important differentiation, and one that helps account for the fact that the pelvic or perineal douche was much more often administered to women than men: physical traumas were transient events that left their traces in the bodies of otherwise strong and reasonable men; emotional traumas were enduring events that left their traces in the bodies of otherwise weak and irrational women. Men, therefore, were thought to be able to “get over” hysteria, while women had to be treated for it.
While the pelvic douche was not often administered to hysterical men, it was to men whose insanity was thought to be either the cause or the effect of excessive masturbation. Maximilian Jacobi, director of the Seigburg asylum near Bonn, Germany, described in detail the case of J.R., who had been committed to the asylum in the early nineteenth century for restlessness, aggression and “vehement expressions of the will and propensities” (“Dr. Jacobi,” p. 4). After dismissing an irregular excitement of the nervous system as the cause of his insanity, Jacobi determined that J.R. had been “excessively addicted to masturbation” (p. 4) since he was a boy. The plan of treatment was complicated, and involved a spare diet, active employment in the open air, sleeping in a straitjacket or camisole [see Mechanical Restraints] while being watched over by an attendant and, especially, cold douches on the perineum. The treatment regime was successful; J.R. refrained from masturbation for several months, and was released from the asylum.
The placing of a restrained patient into a tub of continuously flowing 50° to 70° F. water; the patient typically remained in the tub for several continuous hours. The prolonged cold bath was said to have a sedative effect on the nervous system by contracting the capillaries and drawing the blood into the body and to the heart. Upon removal from it, the patient often was wrapped in a warm blanket until color had returned to the face and the lips were no longer blue. It was during this warming phase that the patient experienced the tonic effect of blood rushing back to the surface of the skin. This “perceptive shock to the nervous system” (Tuke, 1892, p. 118), however, had to be used repeatedly to produce lasting sedative benefits to the manic or agitated patient.
Michael Viszanik, medical director of continental Europe’s oldest asylum for the insane, the Narrenturm, colloquially called the “Fools’ Tower,” in Vienna, Austria, claimed remarkable success with what he referred to as the cold water cure, stating that fully one-third of his patients were cured by it, and it alone. American physician Pliny Earle, who not only visited the Narrenturm, or the “Babel-Tower,” as he dismissed it, but methodically reviewed its annual reports, argued that this remarkable cure rate could be attributed to the fact that all cases of delirium tremens and many of febrile delirium that had been admitted into the general hospital were immediately transferred to the Narrenturm and then conveniently rediagnosed as insanity. These disorders, which Earle argued were not insane at all, would have been quickly cured by Viszanik’s cold water cure.
The risks to patients of the prolonged cold bath were considerable. And patients feared it. Clarissa Caldwell Lathrop, who had been institutionalized at the Utica Asylum in New York, described the deaths of two women who had been subjected to it:
Two women met their death from a “soak,” as it was called, of five hours in cold water. One of these, a Mrs. S., had never evinced the slightest indication of insanity beyond a depression natural to her imprisonment. She was a bright, refined little woman, and was pronounced sane and was to go home if she would sign a certain paper, which she protested frequently she would not sign as it disposed of her property in a way she did not approve. Finally, she did sign the paper, and directly after signing it a “soak” was prescribed for her. She died within a day or two. The other lady, a Mrs. J., was placed in the “soak” in a “camisole,” a garment which rendered her perfectly helpless, and she died shortly afterwards [Lathrop, p. 207].
The prolonged cold bath was used well into the twentieth century. Frances Farmer, a well-known actress who had been involuntarily committed to the Western Washington State Hospital for the Insane in the mid-twentieth century was subjected to repeated prolonged baths which she loathed but that had their desired therapeutic effect. She vividly described the experience in her memoir:
The trustee …steered me… into a small room with three bathtubs. Before I could organize myself, the trustee had taken down three canvas straps from the hook on the wall and looped one around my chest, pinning my arms against my sides until my breath was cut short. The second was buckled around my thighs, the third around my ankles…. They picked me up, one by the ankles, the other by the shoulders and dropped me into the empty tub, bruising my spine…
The first crash of icy water hit my ankles and slipped rapidly up my legs. I began to shake from the shock of it, screaming and thrashing my body under the sheet, but the more I struggled, the more I realized that I was helplessly restricted in a frozen hell…
For the next twenty-four days I was depersonalized in hydro. The physical pain, the spiritual injury, the mental torture mashed one day into another, until all thoughts hinged on either being in or out the tub. Nothing else existed.… Hydro was prescribed for a three hour duration, but seldom did the treatments terminate on time, and the endless hours in cold water attacked my bowels and bladder. Lying in the water, with my nerves and system violated, knowing that my [menstrual] blood and waste were mingling with it, offended and grieved my spirit beyond description. My femininity was mauled, my power to reason or struggle vanished. I simply existed in chilling confusion.
I was unnaturally calm at the end of three weeks, for I had been systematically de-energized. All personality was washed away and all that was left was a water-logged robot.
I had been tamed [Farmer, p. 173].
The placement of a patient in a tub of 104° to 115° F. water to which salt had been added. The patient was then vigorously rubbed for eight to ten minutes with salt crystals that had been dampened in the tub water until the body glowed, and then was rinsed with warm water. The salt glow bath had a tonic effect and was most often prescribed for cases of melancholia.
The rapidly alternating sprays of cold and hot water shot through a pressured hose and directed at the back and the trunk of the patient. The Scotch douche was valued for its tonic and thermal effects on the body.
In his annual report to the Ohio legislature, O.O. Fordyee, medical superintendent of Athens State Hospital, described the use and the benefits of the Scotch douche in some detail:
One of our favorite treatments is the modified Scotch douche, which is given as follows: Beginning at about 98 F., and gradually rising to 110–120° F., and covering a period of three or four minutes, then suddenly drop to about 70° and apply momentarily…. It is best to begin with ten or fifteen pounds of pressure and gradually increase with the tolerance of the patient to thirty of forty pounds, or even more…. I regard its use, given in connection with a preparatory treatment, such as a salt glow, wet sheet pack, tub bath, or cabinet bath, the most active hydriatic tonic we have, and recommend its extensive employment in the convalescent, dementia praecox, functional neurosis, depressed states of manic depressive insanity after the patient has reached the state of subjective sufficiency, and, in fact, whenever a tonic agent is indicated. It is tonic, alternative, revulsive and calmative, and it good for anyone [Fordyee, p. 22].
By the mid-twentieth century, the use of hydrotherapy had gone out of vogue in asylums around the world and few asylum physicians shared Fordyee’s enthusiastic declaration that the Scotch douche was “good for anyone.” In his memoir of his psychiatric rotation at Manteno State Hospital near Chicago, Illinois, in the mid-twentieth century, Harvey Widroe’s reaction reflected the new attitude that the Scotch douche was less therapeutic than it was punitive:
[T]he door to the [Scotch douche] room burst open, admitting two burly attendants dragging a large man, thrashing and screaming, struggling against the straight jacket that bound his arms to his body…. Within almost no time at all, he was tightly secured to the metal post at the end of the room opposite the fire hoses. Aimed directly at him, the hoses were turned open full blast, and high pressure streams of water hit him from different angles. Assaulted by forceful torrents, he cursed and threatened for a minute or two and then began screaming and moaning. After a very long five minutes he slumped to the floor, now a silent and limp rag doll…. After a five minute interval the hoses were turned on again even though the patient appeared to have become docile.
It may have made difficult patients more manageable, but I realized that this inhuman procedure was not treatment. This was torture! [Widroe, pp. 14–15].
The subcutaneous injection once every five to eight days, of an approximately 700 gram dose of diluted and cold-sterilized sea water that had been collected at least thirty-five miles from the shore. Lauded as a cure for everything from melancholia, to dementia, to epilepsy, sea water injection typically produced chills, thirst, loss of appetite, insomnia, weakness and slight nausea that lasted one to two days, followed by a gradual increase in improvement that culminated several days later in restoration, if not recovery.
French biologists, most notably Réne Quinton, promoted the therapeutic in the early twentieth century, based on two premises: that insanity was the result of some peculiar, but unidentified, toxin that infected the brain, and that sea water was 98 percent identical to blood. They hypothesized that by bathing cells in the plasma of sea water, in which all minerals on earth were concentrated, they would be purified and, if they had not already been irreparably damaged, restored to proper functioning. Quinton elaborated on the theory:
Man is a marine animal by descent (like all animals). Now, in order to render to the human organism its primitive environment, which a long line of descent has modified, it is feasible to place it (the organism) in sea water, or its original environment. It is easy enough to admit that if infection is really the point of departure of mental maladies, it (infection) may be combated by marine serum, because using that means makes it possible to wash out the toxins which clog and destroy the central brain cells as rust, if allowed to rest upon the steel, clogs and ruins machinery, and that it may be possible to renew the strength of the brain cells by placing them in sea water [“Virtues of Sea Water,” p. 496].
Quinton was an unabashed evolutionist and, in fact, often was referred to as the “French Darwin.” It actually was his argument that sea water was the “original environment” of cells that provoked the strongest reaction, even from physicians who were willing to entertain his toxin theory of insanity. One of them, an anonymous American reviewer of Quinton’s book titled, L’eau de Mer Milieu Organique, struck an uneasy compromise between belief and science by reminding readers that “the action of sea water is not divine…. Sea water is not the creator of human life, and therefore diseased brains… may be recuperated by the water of the sea, but not re-created if dead” (“Virtues of Sea Water,” p. 496).
While Quinton and his colleagues demonstrated considerable success both in France and in Egypt in treating diarrhea, athrepsia and cholera in infants, and psoriasis and eczema in adults with sea water injections, the extent to which the insane recuperated at all was a matter of some contention among those French and Belgian asylum physicians who were experimenting in the early twentieth century with its use. Interest in sea water injection to treat insanity waned considerably over the years as a result. Despite a post–World War II revival of interest in the use of a vast range of products derived from Quinton’s Plasma, such as isotonics, hypertonics, nasal and dermo-sprays in health spas and alternative medicine clinics in Europe and North America, there was no concomitant revival of interest in treating insanity with sea water injection or any of the derivative products.
A modification of the douche, that delivered water through a rose-shaped nozzle in the form of a spray rather than a stream. The advantages of the shower bath over the prolonged bath were considerable, and guaranteed its steady implementation in asylums around the world. Because the water did not remain in contact with the body, the shower bath produced an initial shock to the patient, the recovery from which required a greater, and more restorative, expenditure of physiological energy than that required by the prolonged bath. The descending water also assured that the patient did not have prolonged contact with his or her own dirt and disease. Cheaper to construct than a bath tub and, because it used less water, cheaper to use, the shower bath was considered an efficient and effective asylum therapeutic for both mania and melancholia.
It was not always a safe therapeutic, however. When first used in European asylums, the shower bath subjected the patient, who was unaccustomed to such an ablution, to twenty to thirty continuous minutes of rapidly descending water. The risk of death from shock was unexpectedly high.
The 1856 death of a pauper patient by the name of Daniel Dolley, confined in the Surrey County Lunatic Asylum in south London, and the vigorous defense of the shower bath as a therapeutic by Charles Snape, the physician who had ordered it, illustrates how risk was imagined and negotiated in an asylum. Dolley had been subjected to a twenty-eight minute shower bath that had put him a “state of vital depression”; upon his removal, he was administered a two grain dose of tartaremetic (Winslow, p. 1). He died shortly after. Snape was indicted for willful negligence, unskillful and unscientific treatment that caused Dolley’s death. The grand jury, however, threw out the indictment and Snape was reinstated to his position in the asylum. The reinstatement left unresolved the larger question as whether the shower bath could be considered “a safe, efficient, judicious, and curative process of treatment” (p. 2). The nature of the shower bath, in this case, was a matter of dispute. A civil engineer, hired by the Commissioners in Lunacy who were involved in the case, had estimated that an average of twenty gallons of water per minute fell on Dolley; a civil engineer hired by Snape had estimated that it was no more than four-and-a-half gallons per minute. While the exact nature of the shower bath remained unresolved, the larger issue of the risk asylum physicians should take in treating the insane prompted considerable debate. Snape argued that:
The science of medicine in all its branches will ever be a science of unusual difficulty and doubt, from the necessity of treatment being based upon “surmise”; and, after all, he is the ablest practitioner who guesses most correctly, and assumes most justly the real seat and nature of the disease to be grappled with. But it is still “surmise”; and if in the treatment of bodily ailments there be so much doubt, how much greater is the doubt in references to mental disease? [Winslow, pp. 4–5].
The reaction to this statement was swift. “The profession of medicine would indeed be reduced to a very low ebb, and the practitioner of this exalted art would be in a humiliating position,” Forbes Winslow argued, “if the noble science which he cultivates and practices were based upon ‘guesses,’ ‘assumptions,’ and ‘surmises’” (Winslow, p. 5). Yet even Winslow, an expert on insanity and a vocal critic of the inhumane treatment of the insane, acknowledged that the specialization of asylum medicine was being practiced in the absence of a complete understanding of insanity, and with the hope that “fresh resources” eventually will cure it. Snape had defended the shower bath as one of those “fresh resources,” and had castigated his fellow asylum physicians for not taking the risk in using it.
In the end, the Lunacy Commission ruled that the duration of the shower bath should not exceed three minutes, that it should not be used punitively, and that tartar emetic should not be administered after it. The larger, and more pressing, scientific and philosophical controversy over the state of asylum medicine, however, was left unresolved.
In the United States, the shower bath was an integral feature of the public health and hygiene movement. Simon Baruch, a physician who went on to become a professor of hydrotherapy at Columbia University’s College of Physicians and Surgeons, was the driving force behind the building of public bath houses in New York City, and the first institutional shower bath in that city’s Juvenile Asylum. His passionate promotion of the therapeutic drew the attention of Amariah Brigham, medical superintendent of the Utica State Hospital in upstate New York who set up a shower bath facility in the former bakery on the asylum grounds in the late nineteenth century. The facility had four rows of eight feet high showers with nickel-plated brass nozzles that sprayed seven-and-a-half gallons of water per minute at twenty-five pounds of pressure.
With its growing use in asylums around the world, the shower bath was subjected to recommendations beyond that concerning its duration. It was proposed that it be administered only in the morning at least an hour after breakfast, in that its tonic effect was likely to interfere with sleep if administered later in the day or in the evening. To prevent fainting, it was advised that the patient sit on a stool or lean forward from a standing position so that the water descended on the neck, rather than the head. A vigorous rubbing of the patient with a coarse towel or flesh brush was recommended after the shower, and was to be followed by gentle exercise. The shower baths of various duration, pressure and temperature were used in asylums around the world until the mid-twentieth century.
A small tub of approximately 98° F. water in which the patient sat so that only the pelvic portion of the body was submerged, while the legs were bent over the rim of the tub. Originally, the sitz bath was prescribed for the female patient whose insanity was thought to be caused by, or resulted in, dysmenorrhea or amenorrhea. By congesting the blood vessels in the pelvic viscera, the sitz bath stimulated the flow of menstrual blood. The treatment usually commenced two to three days before the expected menstrual period and continued for a week; it often was repeated the following month.
Invented by Karl Wilhelm Ideler of the Berlin Charité Hospital in the early nineteenth century. The spinal douche directed a jet of cold water against the patient’s spine for several continuous minutes. Ideler, a proponent of what was then called the “psychic school” of thought that took a philosophical approach to insanity, viewing it as a result of moral failings, argued that the spinal douche was effective in disciplining the patient to the norm of reason, thus it was effective both as punishment and a therapeutic.
Upon his visit to the Berlin Charité, British physician William F. Cumming was quite taken aback by the use of this “cruel remedy” which he described in detail:
This cruel remedy is resorted to on alternate days in every case, male and female, when its use is not contraindicated by complications of epilepsy, phthisis, or paralysis; and it is administered in the following manner:—
Between 10 and 11 A.M. the patients are placed singly in an empty bath, furnished with a formidable array of straps and buckles, to secure them during the torture. A small jet of cold water is forced out of a pump by the combined strength of four men, against the spinal column, along which it is made to play for the space of two minutes. The victim is then released, and his place occupied by another. My [host] acknowledged to me that the pain of this discipline was excessive. He had himself made trial of it, and with all his resolution could hardly support it for thirty seconds. On my remarking on the cruelty of the practice, he said, that many of the patients, notwithstanding their great dislike to the douche, derived much benefit from its use, and confessed that they felt better and more comfortable on the days of its application than on the intervening days [Cumming, p. 18].
During his tour, Cumming came across no other German asylum in which the spinal douche was, or had been, used. In fact, most asylums physicians dismissed it out of hand, relegating it to the imaginings of a “clever and enthusiastic man, whose better judgment was in this instance warped by a favourite theory” (Cumming, p. 19). The comment could be read both as a condemnation of the spinal douche as a therapeutic, and of the German psychic school of medicine that by the time of Cumming’s visit had been usurped by a biological approach to insanity.
Although Cumming was quick to conclude that the spinal douche only was used at the Berlin Charité, it was in fact used in asylums throughout Europe as well as the United States. In fact, it was used with such therapeutic enthusiasm at the Salpêtrière Asylum in Paris, France, for the treatment of hysteria, that it was known there as the Charcot Douche, after the legendary neurologist and chief physician, Jean-Martin Charcot. It was at the Salpêtrière that Charcot aimed a jet of 45° to 60° F. water, at twenty to thirty pounds pressure, at a small section of the hysterical patient’s spine for less than thirty seconds. While far from the only therapeutic used in the treatment of hysteria at the Salpêtrière, the spinal douche was touted as a method of stimulating the nervous system and redistributing nervous energy through the body. The Charcot Douche now is used in spas, especially in Eastern Europe, rather than in asylums, although for the same purpose.
The spinal douche also was used in American asylums, but with some variation: the jet was of warm water or of pulsating cold water, the duration was only a few seconds, and it typically was used in combination with other hydrotherapy therapeutics.
A contested treatment in which the restrained patient was lowered in a hammock into a tub where there was a continuous flow of 85° to 95° F. water. The tepid bath, usually several hours in duration, was recommended by a number of physicians for the treatment of recent onset mania or melancholia. Joseph Mason Cox, medical superintendent of the Fishpond Asylum near Bristol, England, claimed much success in treating mania by enticing the patient into a tepid bath that had been infused with rosemary or other aromatic plants; John Thurnam, resident physician at the York Retreat in northern England, claimed the same success in treating melancholia when mild stimulants such as soap or salt were added. At the Salpêtrière Asylum in Paris, France, the weekly, and sometimes daily, tepid bath was the preferred treatment for hysteria. It was there that Etienne-Jean Georget found the tepid bath particularly useful for diminishing the excitement, dissipating the tension, and calming the nervous organs of the hysterical patient.
In the United States the most prominent proponent of the tepid bath was Simon Baruch. As a visiting physician to St. Elizabeths Hospital in Washington, D.C., he made sure it became a significant feature of the asylum’s hydrotherapy program. Between 1923 and 1924 alone, nearly 109,000 tepid baths were given to 4000 patients at this federal asylum.
Some detractors, however, found it difficult to comprehend the rationale for using a tepid bath at all, reasoning that since water temperature was below body temperature, the bath “does not raise the temperature of the body, and can give rise to no reaction, and cannot affect the circulation in the central nervous ganglia” (Tuke, 1892, p. 118). Taking an even more dismissive attitude, Philippe Pinel, physician of the infirmaries at the Hospice of Bicêtre near Paris, France, argued that the tepid bath produced such debilitation that it risked rendering the patient incurable.
A continuous flow of 160° to 190° F. steamy air that circulated through a tiled room in which the patient sat. The purpose of the Turkish or hot air bath was to cause intense perspiration that softened the skin, increased circulation, and encouraged deep and refreshing sleep. The Turkish bath, or Haman, long a tradition in Middle Eastern culture as well as a therapeutic in that region’s asylums, was introduced in Great Britain by David Urquhart. A diplomat who had traveled extensively through the Middle East, Urquhart not only wanted to popularize that region’s culture, but address both the personal hygiene and health concerns of the British people. To that end, he built a Turkish bath at the St. Anne’s Hill Hydropathic Establishment near Blarney, Ireland, in the mid-nineteenth century. An immensely popular component of what became known as “the water cure,” the Turkish bath was thought to cure everything from cancer to baldness.
Thomas Power, resident physician of the nearby Cork District Lunatic Asylum, speculated that the Turkish bath might also cure insanity. He had one constructed and reported with great enthusiasm the results of the first 124 patients who had been treated by it: ten had been cured and released; two had been cured, released, but relapsed; fifty-two had improved significantly; sixty, most of whom had been long-term patients of the asylum, remained unchanged. On the basis of these data, Power ventured that cure rates would double if all asylums administered Turkish baths to patients.
In addition to its curative effect, Power found that the Turkish bath had one other decided advantage: it all but eradicated the noxious odor of the insane. He, along with many of his colleagues, theorized that the peculiar and disgusting stench of the insane was “exhaled from the skin and its minute glands and follicles” and that it must have arisen from “an unhealthy state of the blood, which must exercise a deleterious influence on the system generally, and on the organs connected with operations of the mind in particular.” The Turkish bath, he reasoned, removed the “vitiated humours and other secretions and probably cures the diseased and tainted system where other means have failed” (Power, p. 3).
In the wake of this report, Turkish baths were installed in asylums across Great Britain. Urquhart designed a magnificent panopticon style bath for the Colney Hatch Asylum, the largest in the country, but financial constraints significantly altered its scale. Nonetheless, medical director Edgar Sheppard, reported that eight of the ten patients to whom it was first administered were cured and released. The case of one of those patients who was released as cured after two months of institutionalization and several Turkish baths, was presented as follows:
W.S.N., 30 admitted 1865, with delusions, aural hallucinations, great depression of spirits, and impaired memory. Received a great shock two months ago by the death of his only child. He thinks the child has been taken away by women, and will be restored to him. Complains of constant pain in his head and of sleepless nights, when he fancies the child is under the bed. At times is quite confused and stupid; bowels costive, tongue furred, skin harsh and dry…. Was taken to the Turkish bath, temperature 180°. In about twenty-five minutes the patient was bathed in profuse perspiration; expressed satisfaction and enjoyment, pain in the head being the only drawback…. Dropped asleep in the cooling room, where animated conversation was going on, fifteen minutes after reclining on the couch, and woke up decidedly relieved. Said his skin felt as it never felt before—soft, supple, and clean. Went to bed at 8 p.m. without an opiate, and slept soundly to 5 a.m. on the following morning [Sheppard, pp. 75–76].
Although Sheppard saw no drawbacks to the Turkish bath, some of his British colleagues did. John Bucknill was not particularly impressed with its therapeutic outcomes at the Devon County Asylum where he was medical superintendent. He wrote that the Turkish bath was “more calculated to improve the health of chronic and incurable patients than to act remedially on those whose malady is recent and curable, or at most that its role will be to supplement methods of treatment which are capable of being applied more constantly” (p. 744). He, just as other skeptics, was inclined to worry that if the Turkish bath was used too often it would become “a luxurious and wholesome habit rather than a remedy” (Buknill & Tuke, p. 744).
With the construction of municipal water systems, the Turkish bath became part of the hydrotherapeutics of a number of asylums around the world. Charles Shepard, a public health physician, was its most prominent promoter in the United States, arguing that this simple and inexpensive therapeutic purified the blood and relieved its congestion in the brain. He was instrumental in the building of a facility in the New York City Asylum for the Insane where 2280 Turkish baths were administered in 1873 alone.
Over the decades since its introduction in the Cork District Lunatic Asylum, enthusiasm over the Turkish bath waned as the claims of its curative power were challenged. By the mid-twentieth century, and with the advent of Thorazine and other neuroleptic drugs, the administration of the Turkish bath all but disappeared as an asylum therapeutic.
The subjection of the body of the patient to the action of steam in a closed chamber. The vapor bath was used in some asylums less as a specific therapeutic for insanity than for the relief of physical complications, such as rheumatism or dropsy (edema), experienced by many asylum patients. The 120° F. temperature did not produce the sedative effect of the Turkish bath and therefore was considered less exhausting to the patient.
The therapeutic lowering of body temperature for a prolonged period.
Influenced by the writings of the ancient medical authority Hippocrates, eighteenth and early nineteenth century asylum physicians applied ice packs to the shaved heads of their patients. Hippocrates had posited that if patients were covered with mud, the parts of their bodies that dried first were the warmest, and where there was excessive heat, there was disease. For early asylum physicians insanity was a disease of the brain, therefore a perfectly sensible therapeutic intervention was to cool the heads of their insane patients.
Cooling techniques proliferated during the nineteenth century. The British physician George Mann Burrows, for example, suggested that in addition to ice packs, drops of ether, diluted alcohol, or a mixture of spirits, vinegar and water would produce a “calming and even soporific effect in violent mania” (Burrows, p. 595). Asylum physicians also sprayed their patients with cold water douches, forced them to swallow pints of cold water, wrapped them in cold wet sheets, and restrained them in cold baths in order to relieve the “feverish” symptoms of their insanity [see Hydrotherapy]. They also swung them to and fro on hammocks while pouring cold water on their heads [see Rotation, Oscillation and Vibration], and plunged them into vats of cold water to gather up their senses [see Salutary Fear].
It was, in fact, the plunging of insane patients into cold water that was cited by McLean Asylum physicians John Talbot and Kenneth Tillotson as a precedent for inducing hypothermia in patients with schizophrenia. At that time, the early 1940s, hypothermia was being used to treat some forms of cancer as well as drug addiction, and although it was much too early to determine its effectiveness in either case, the two physicians were determined to use it to treat the asylum’s most intractable patients. They began with ten patients. Each was sedated with a barbiturate and a muscle relaxer, and wrapped in a Therm-O-Rite blanket, also known as a “mummy bag,” through which the physicians circulated a refrigerant. A stomach tube pumped glucose into each patient and a rectal thermometer transmitted body temperature readings every other minute. So wrapped, the patients, whose body temperatures dropped an average of 15° F, stayed in a hypothermia-induced stupor for as long as sixty-eight continuous hours.
The patients had been chosen for their failure to respond to other therapeutics, such as insulin and metrazol, yet several reacted to the induced hypothermia with either a “persistent and reassuring modification of the mental picture,” or with a “temporary or quasi-permanent” modification (Talbot & Tillotson, p. 123). The physicians presented the case of S.R., a sixteen-year-old who had been diagnosed with catatonic schizophrenia, as an example of one of the four patients for whom the treatment’s effects were positive and enduring. After the hypothermia treatment, during which his body temperature dropped to 92° F, he became quiet, polite and friendly. His hallucinations and “queer ideas” disappeared, and after several months he was discharged as cured (p. 122). One of the three additional patients for whom the effects were temporary was H.M., a thirty-nine-year-old woman who had been diagnosed with paranoid schizophrenia a decade before. She was wrapped in the Therm-O-Rite blanket until her body temperature dropped to 74.6° F. The treatment left her “less aggressive for a few days,” but she regressed to her pretreatment condition before the end of the week (p. 119).
Two more of the patients in this trial run of therapeutic hypothermia were not at all affected by the treatment. Talbot and Tillotson hypothesized they may have experienced an “irreparable morphological damage to the central nervous system” as a result of having had schizophrenia for some time (p. 126) and that that had rendered them resistant to the treatment. The remaining patient, a forty-eight-year-old man who was kept in a hypothermic stupor for fifty continuous hours, died of circulatory collapse as his body temperature rose from 80° F to 92° F towards the end of the treatment.
On the basis of this initial trial with ten patients, Talbot and Tillotson believed therapeutic hypothermia held out a “modicum of hope” in the treatment of schizophrenia (p. 126), particularly that of relatively short duration. That “modicum of hope,” however may have been too tiny to make hypothermia a really promising intervention for most asylum physicians. Its risks were considerable. A temperature of 95° F is required for normal metabolism and bodily functions and the reduction required by the therapeutic literally brought patients to a state of near-death. The consequences such a state could have for patients were considerable. Two Longview State Hospital physicians found that out when they initiated their own version of what they called “refrigeration therapy.” Douglas Goldman and Maynard Murray chose sixteen patients whose schizophrenia was intractable from the Cincinnati, Ohio asylum. They placed them, already packed in ice, into cooled cabinets, kept them refrigerated for as long as forty-eight continuous hours, and dropped their body temperatures to 84° F. Three of the patients died of pneumonia, and most of the others suffered a variety of physical complaints, including serious lung infections. None demonstrated any lasting change in schizophrenic symptoms. The physicians conceded “with a sense of keen disappointment” that refrigeration therapy did not meet expectations (Goldman & Murray, p. 165).
Nor did it meet the expectations of Thomas Hoen and his colleagues at the Central Islip State Hospital in New York. They administered therapeutic hypothermia to thirteen patients diagnosed with schizophrenia, rapidly reducing their body temperature to 85° F at which time the refrigerating machine was turned off. In most cases the temperature dropped another three degrees over the following hour before slowly rising. Although the use of the therapeutic gave Hoen and his colleagues some insight into the physiological consequences of induced hypothermia, the clinical results were not significant.
Hoen and his colleagues hypothesized that it was not the therapeutic but the patients that were the problem in attaining good outcomes. They conjectured that hypothermia might very well be more effective with patients who had a better prognosis than the intractable schizophrenics for whom the therapeutic originally was designed. In fact, James Spradley and M. Marin-Foucher had already given that a try. The Trenton State Hospital physicians had treated thirty patients variously diagnosed with schizophrenia, manic-depression, involutional psychosis, and psychosis with mental deficiency, wrapping them in Therm-O-Rite blankets to maintain steady body temperatures of 90° F for anywhere from forty-eight to seventy-two continuous hours.
One patient, a twenty-eight-year-old woman who had been diagnosed with manic-depression, not only improved remarkably but rapidly; she was discharged a month after her hypothermia treatment, her anxiety, anorexia, and flights of ideas gone completely. Fourteen more patients improved enough to be released as well; the remaining patients all showed improvement, although the term “improvement” remained undefined and unmeasured.
Spradley and Marin-Foucher were optimistic about the outcomes and predicted that the curative power of induced hypothermia would be boosted if patients could only be kept longer than seventy-two hours in frozen sleep without the significant risk of vascular damage. Although they acknowledged that there were “a multitude of other details to be solved” (Spradley & Marin-Foucher, p. 238), they concluded that the possibilities offered by hypothermia “appear to be unlimited” (p. 238).
None of that possibility was realized. The few asylum physicians who induced hypothermia in their patients were faced with lackluster outcomes, and were never able to develop a scientific rationale as to why the therapeutic was not working or, for that matter, why it should have worked in the first place. With the exception of a few sporadic attempts to test its efficacy, induced hypothermia all but disappeared as an asylum therapeutic by the mid-twentieth century.
In the end, though, it may have been something else that hastened its disappearance. Writing just four years after the end of World War II, and three years after the Nuremberg trials of Nazi physicians, Spradley and Marin-Foucher had cited the Dachau experiments in which concentration camp prisoners were subjected to freezing conditions as precedent for the therapeutic use of hypothermia with asylum patients. Although quick to condemn the experiments as “iniquitous attempts …inspired by the perverted mind of Heinrich Himmler” (p. 235), they just as quickly lauded them as “the most complete investigations in the bio-physiological field” (p. 235). This curious acknowledgment left Spradley, Marin-Foucher and other asylum physicians practicing hypothermia, or interested in doing so, vulnerable to invidious comparisons, and that most surely hastened the disappearance of the therapeutic from asylum practice.
Beam, A. (2001). Gracefully insane: The rise and fall of America’s premier mental hospital. New York: PublicAffairs.
Burrows, G.M. (1828). Commentaries on the causes, forms, symptoms, and treatment, moral and medical, of insanity. London: Thomas and George Underwood.
Goldman, D., and Murray, M. (1943). Studies on the use of refrigeration therapy in mental disease with report of 16 cases. Journal of Nervous and Mental Disease, 97, 152–165.
Hoen, T.I., Morello, A., and O’Neill, F.J. (1957). Hypothermia (cold narcosis) in the treatment of schizophrenia. Psychiatric Quarterly, 1, 696–702.
Spradley, J.B., and Marin-Foucher, M. (1949). Hypothermia: A new treatment of psychiatric disorders. Diseases of the Nervous System, 10, 235–238.
Talbott, J.H., and Tillotson, K.J. (1941). The effects of cold on mental disorders. A study of ten patients suffering from schizophrenia and treated with hypothermia. Diseases of the Nervous System, 2, 116–126.
The physical and social separation of a patient from the rest of the asylum population.
Isolation was, and arguably still is, the leitmotif of insanity. In the pre-asylum era the insane often were confined in the attics and cellars of their own homes, present in a physical sense, yet absent from the daily interactions of their family members. Such was the case in Ireland, as an example, in the decades before the building of the first asylum:
There is nothing so shocking as madness in the cabin of the Irish peasant, where the man is out laboring in the fields for his bread and the care of the woman of the house is scarcely sufficient for attendance on the children. When a strong man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin, not high enough for the person to stand up in, with a crib over it to prevent his getting up. The hole is about five feet deep, and they give this wretched being his food there, and there he generally dies [Letchworth, p. 172].
Those without families often were left to wander the countryside alone, begging for food and shelter. Some were even licensed to do so. In England, insane patients who had gained a modicum of their senses while in the care of London’s Bethlem Asylum were released to fend for their own. Their left arms adorned with an armlet of tin that was the official “license” that distinguished them from the “sturdy beggars” who were otherwise fit and able to work, they drifted around the country, begging for food and for drink that would be poured into the hollowed out ox horn they had strung around their necks.
Even in the almshouses, poor houses, workhouses and hospices that sprung up to separate the destitute, disabled and disorderly from rapidly modernizing society, the insane were often separated from other residents. Then, if they were particularly difficult to manage, they were further separated from each other by confinement in solitary pens, stalls and purpose-built “lunatic boxes.”
The nineteenth century boom in asylum construction might be understood as having resolved that leitmotif of isolation. After all, it was in these institutions that the insane were congregated. Yet, by reading history against the grain, asylums as brick-and-mortar institutions also could be understood as perpetuating isolation. Consider their locations. It is a fact that there were plenty of urban asylums; centrally situated, only walls, fences and gates isolated their patients from the sociability of daily interactions and the hustle and bustle of daily commerce. Yet, the majority of asylums were built as far from urban centers as possible. Essential to the Kirkbride Plan that guided the construction of public asylums in the United States, for example, rural locations were essential to the regime of moral treatment [see Moral Treatment]. As Thomas Kirkbride himself declared:
It should never be forgotten, that every object of interest that is placed in or about a hospital for the insane, that even every tree that buds, or every flower that blooms, may contribute in its small measure to excite a new train of thought, and perhaps be the first step towards bringing to reason, the morbid wanderings of a disordered mind [Kirkbride, p. 47].
Kirkbride, no stranger to insanity as he was the superintendent of the Pennsylvania Hospital for the Insane, was not just waxing rhapsodic on the rural idyll, but also suggesting that isolation of insane patients from the stresses and strains of their familiar lives was therapeutic. So therapeutic was this isolation from “precipitating influences”—families, work, social interactions —thought to be that asylum physicians with perhaps a soupçon more imagination than Kirkbride whimsically proposed that asylums should isolate the insane from everything familiar by becoming, themselves, completely unfamiliar. Such was the desire of François Emmanuel Fodéré, then physician to the Marseille Lunatic Asylum in France:
I would like these [asylums] to be built in sacred forests, in steep and solitary places, amid great upheavals, like the Grande-Chartreuse…. It will often be useful for the latest arrival to be brought down by machines, for him to traverse ever new and astonishing places before he reaches his destination; the ministers of these places should wear special costumes!…Phantasmagoria and the other resources of physics, music, water, lightning, thunder, etc., would be used by turns…[Asylums must] offer to the senses of the insane objects entirely different from those to which they were accustomed, new faces, other furnishings, other sites, other manners, a total change, finally, in all the objects that surround them [Fodéré, p. 215].
That was nothing more than ripe imagining, but the fact remained that the geographic and social isolation of asylums also made possible the therapeutic control of insane patients, impressing upon them what the French asylum physician Philippe Pinel termed “the deep and durable conviction of [their] dependence” (Pinel, p. 105). To that end, isolation also was used behind the walls of brick-and-mortar asylums as a therapeutic intervention. The dingy cells, dark pits and padded rooms became the sites of uncontested medical power: social contact, food, light, space, temperature, activity were controlled within their walls to achieve therapeutic ends.
As is true with many therapeutics, reputation tarnished with age. In the twentieth century and beyond isolation was used less frequently and the conditions of it were improved considerably. Patients were confined in what was being referred to as “limited containment suites,” and their health, both mental and physical, was carefully monitored on a daily basis. But a new phrase had been introduced in many countries in contemporary times, one that would have been foreign to asylum physicians of the past but that would have captured the concerns that occasionally were being voiced about isolating patients in cells and strong rooms. That new phrase is “human rights.” It signifies a different understanding about insanity and more particularly about those who experience it. Patients in many countries no longer suffer a civil death with their confinement, but have rights that are both protected and enforced by law. In the United States, for example, both federal and state legislation mandate that isolation only be used in emergencies to protect asylum staff and other patients; while laws do not cap the consecutive days patients can be so detained, or at least allow for exceptions if they do, they do require that physicians approve each twenty-four hour segment.
During the latter part of the twentieth century, the deinstitutionalization initiative in the United States, Great Britain and much of Europe decanted most asylum patients into communities and created a new model of community-based care. In many poor and developing countries, however, the asylum-based model persists to this day, and it is in those countries that isolation as a therapeutic strategy cum social control mechanism cum torture device cum expression of indifference is also being recast as a human rights issue. The advocatory efforts of Disability Rights International has brought to light the plight of asylum patients in Paraguay, for example, by exposing the isolation of two adolescent males in cells containing only wooden benches and holes in the floor as latrines. Although each had been allowed four hours every other day in an outdoor pen littered with garbage and human excrement, they had remained in isolation cells for more than four years. Other Paraguayan asylum patients shared their plight. The organization’s exposure of the continued use of isolation led to a 2005 agreement with the Paraguayan government to release patients confined in the country’s asylums and to integrate them into newly developed community-based service networks.
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The subterranean cells of the Salpétrière and the Bicêtre Asylums, respectively. The cells of the Paris, France, asylums were notorious. Tiny and dank, with straw-covered planks for sleeping and sitting attached to the wall, they were lit by small holes over the doors through which food was passed to the patients who were likely also to be chained, fettered or restrained in an iron collar [see Mechanical Restraints]. The basses-loges were particularly loathsome in that they were on the same level as the sewer system; when the Seine River swelled with rain, sewer rats made their way into the cells and bit the restrained patients.
An early eighteenth century visitor to Paris described the “cry of the hospital” that sometimes emanated from the patients held in the basses-loges of the Salpétrière:
Sometimes, in the middle of the night, the residents … would hear a clamor rise up, a sort of savage groaning at regular intervals. It was the cry of the hospital. Held in, suppressed for months, the energy and fury that filled the souls of the poor creatures would slowly increase and then burst forward…. This cry of alarm coming from the place produced in us a terrifying feeling [Micale, p. 708].
The cells at both asylums were demolished in the early nineteenth century under the superintendency of Philippe Pinel.
A windowless asylum room, with or without furniture, in which intractable patients were confined. The dark was a subject of some controversy among early asylum physicians. Some insisted that insanity could be caused not by the dark, per se, but by the fear of it. William Perfect, a physician who owned a private madhouse in the English market town of West Malling, for example, presented the case of a respectable and genteel young seminarian who was so terrified of the dark and the prospect that his mischievous classmates would confine him in it, that he “lost his reason, and has never since emerged from a state of the most deplorable idiot” (p. 357). Other asylum physicians worried that the dark exacerbated the confusion and aggression of maniacal patients in particular; yet others, still, believed it calmed, perhaps cured, even the most unmanageable patients by reducing distractions and encouraging silence. Among the latter was the American physician Benjamin Rush who in the early nineteenth century used four dark chambers, approximately ten feet square in size and fronted by heavy doors with small bolted hatches through which food could be passed. He explained the effect of the dark on maniacal patients at the Pennsylvania Hospital:
Solitude is indispensably necessary in [mania]. The passions become weak by the abstraction of company, and by refraining from conversation. For this reason, visitors should be excluded from the cells and apartments of highly deranged people, and there are times in which the visits of a physician, and of the cellkeeper or nurse, should be as seldom and short as are consistent with the proper treatment and care of the patient…. Darkness should accompany solitude in the first stage of [mania]. It invites to silence, and it induces a reduction of the pulse, by the abstraction of the stimulus of light, and by the influence of fear, which is naturally connected with darkness [Rush, pp. 189–190].
Confinement in a dark chamber was not at all considered inconsistent with the principles and practices of moral treatment [see Moral Treatment], as long as patients were not further restrained by straitjackets or chains. At the York Retreat, so intimately associated with moral treatment that its name was synonymous with it, patients in the throes of mania were confined in chambers that the residing physician preferred to describe as “gloomy,” rather than dark, so that they “may not be affected by the stimulus of light or sound; such abstraction more readily disposing to sleep” (Tuke, p. 164). And at the asylum in Ghent where Joseph Guislain introduced moral treatment to Belgium, maniacal patients were confined in dark chambers often for weeks at a time until they calmed and became more amenable to the therapeutic regime.
The “color cure” [see Color Cure] offered a serviceable alternative to dedicated dark chambers in overcrowded asylums around the world. At the Juliusspital in Würzburg, Germany, physician Aton Müller painted the walls of a room black; while the room could be used for any patients, when the window also was shuttered, the most furious of them became tranquil. Black rooms, promoted as particularly suitable for female patients with hysterical insanity, also were found in a number of asylums across the United States, including the Wards Island Asylum in New York City, and at the Peoria Asylum for the Insane in Illinois where its superintendent, George Zeller, distinguished himself as a proponent of the color cure as an adjunct to moral treatment.
Yet no matter how vigorously the dark chamber was rationalized as a more humane alternative to the straitjacket or chains it could never distance itself from the pits and cells in which the insane were confined before moral treatment became de rigueur. The investigation into the Dixmont Asylum near Pittsburgh, Pennsylvania, in the late nineteenth century illustrated what was the often considerable difference between the rhetoric of moral treatment and the reality of managing the insane. Katie Fondelier, an “acutely insane” young patient with a talent for escape, had been found dead in a dark chamber. It was less the cause of her death than the reason for her confinement—therapeutic or punitive—that led to the grilling of asylum physicians and staff by state representatives as the transcript of the inquiry revealed:
Q. Doctor, you have testified here this morning in regard to Katie Fondelier, that Katie was not put in a dark room for punishment.
A. No, sir.
Q. What was she put there for?
A. She was put in for—more when she came back—when she was brought back to the hospital, she was brought back in a paroxysm. She was acutely insane, had an acute attack, and was very much excited, noisy, boisterous in manner, and also tearing her clothing, destructive of furniture and clothing, and all window glass. About the window glass, I don’t know whether she ever broke any, but she was destructive of furniture. She broke two chairs, and, taking all these things into account, we knew she would escape if she could, and for these reasons we put her in a dark room.
Q. She had escaped?
A. Yes, sir.
Q. Isn’t it true she had escaped and been recaptured, and that the purpose of placing her in such confinement was that she could not escape again, and for that reason you placed her in a dark room?
A. No, sir; because we could not keep her in the hall. She was too excitable to be kept in the hall. She had excited all the patients around her.
Q. Why not put her in her own room?
A. Her own room had just an ordinary window, and I was afraid to.
Q. So that you were afraid she would break out the glass and commit suicide?
A. I thought it was best to put her in a dark room where she would be more quiet. I know by putting patients in a dark room that way it has done a good deal of good [Committee of the General Assembly, pp. 404–405].
Just a couple of years later, an exchange of letters between the Michigan State Board of Corrections and Charities and the superintendent and board members of the Upper Peninsula Hospital for the Insane in Newberry illustrated not only how quickly the very term “dark chamber” conjured images of patient abuse and punishment, but just how much it unsettled the goal of enlightened asylum medicine:
Letter from the Board of Corrections and Charities: The Board was surprised to find that dark rooms in which no windows were provided (regular dungeons), had been planned for inmates. No such means for the easy though cruel, restraint of troublesome patients, by attendants could meet the approval of this Board, and it would therefore urgently recommend to your honorable board that such dark rooms near the dining rooms in each story be thrown into and made a part of the dormitory adjoining them.
Reply from the chairman of the asylum building committee: In regard to the dark rooms will say that this board never intended them for places of punishment. These rooms were placed in the hospital department of the institution as a means of treatment for certain classes of patients, a means the most humane and beneficial known to science for these cases. We have no places or modes of punishment. These rooms are designed for new lines of medical treatment, and when your honorable board fully understand their use and the benefits that will follow I do not think they will object to them…. This is an era of progress and if we cannot advance in the treatment of the insane by all known methods, we should cease to try to employ medical men.
Reply from the Board of Corrections and Charities: I am instructed to say in reply that this Board did not say in its communication, and regrets that it was so understood, that your board intended the dark rooms for places of punishment.…That the temptation to use them would be great, and that such temptation would be yielded to at times, is beyond question with this Board in the light of past experience. We would respectfully suggest that the ‘”new lines of medical treatment’” which the eminent alienists of your board propose to adopt, be so planned as to prevent, as far as possible, the old and still existing attempts of attendants to make their official actions as easy as may be, when not under the eye of the medical superintendent or one of his assistants [Michigan State Board of Corrections and Charities, pp. 67–69].
The use of the dark chamber in American, British and European asylums certainly ended in the twentieth century with the introduction of Thorazine and other major anti-psychotic drugs, and in response to patients’ rights initiatives. But in other countries, the use continues into contemporary times. Argentina provides an example. Its first asylum was established in 1876 and founded on the principles of moral treatment that slowly eroded under the familiar pressures of overcrowding and underfunding. By 2004, there were more than 25,000 patients in teeming public asylums that were in considerable disrepair. Investigations conducted by Disability Rights International and the Center for Legal and Social Studies documented egregious human rights violations behind the closed doors, and focused most critically on the use of dark chamber isolation. Patients in one of the country’s psychiatric penal units, for example, were confined in filthy, hot chambers that measured four by six feet and had no toilets, ventilation or light. Some had been so confined for months, either to protect themselves or others from harm, or to observe them before placing them in the wards. At the Colonia Montes de Oca, the national asylum, physicians strenuously defended the use of the dark chamber as a means to make easier the work of the few attendants on staff by isolating the most distracting and disruptive patients from the larger patient population. That dark chamber isolation often has been found to exacerbate symptoms and arrest any progress towards rehabilitation or cure, was ignored in the name of bureaucratic efficiency until a scathing report was filed by the investigating organizations. That report, coupled with the advocacy work of a number of human rights activists and organizations, led to significant and continuing asylum reform. In 2007 Argentina became the first country to ratify the United Nations Convention on the Rights of Persons with Disabilities, and passed Mental Health Law #26.657 that, in part, protects the rights of asylum patients from abusive treatment, including confinement in the dark chamber.
The suppression of visits from family and/or friends. Although a few asylums, such as the original Bethlem (or “Bedlam”) in London, England, and the Salpêtrière in Paris, France, were exceptions, historical encounters between asylum and place more often meant that asylums were built at some geographic distance from centers of population. This was especially true in the United States. Between the mid- to late nineteenth century scores of public asylums were being built across the country not only according to the “moral architecture” blueprint of Thomas Kirkbride, chief physician at the Pennsylvania Hospital for the Insane in Philadelphia, but in deference to his moral treatment plan as well. Built in secluded and tranquil places, the asylums were far from the social and moral influences that Kirkbride believed caused insanity [see Moral Treatment], not to mention the hereditary one. For most asylum physicians of that age, the prospect that insanity indeed was hereditary in nature, placed them in a tense relationship with the “dangerously contaminated pool(s) of lunacy and dementia” that were their patients’ families (Kelm, p. 181).
Away from public and even political scrutiny, the geographic isolation of asylums allowed their superintendents and physicians to exercise a patriarchal power over their patients. But that power was far from hegemonic. Even from a distance, sometimes in fact a great distance, families and friends attempted to mediate and negotiate the treatment of their loved ones, as these letters to asylum superintendents illustrate:
Please sir, is my wife any better since she last wrote me. Please ask her if she would like to see me or her sisters. Please give me her answers in her own words….
Doctor, I have this day sent a letter containing a picture to Mrs. L. As I was her most intimate girlfriend please let me know how she receives it and if she recognizes the face. I take much interest in her and sincerely hope you can benefit and help her [de Young, p. 134].
When families and/or friends did visit, they did so according to asylum rules; they came at designated times and days, congregated in designated places within the asylum walls or on the grounds and under the watchful eye of staff, and conversed about designated topics so as to not further excite or disturb their loved ones. The potential for visitors to upset institutional order and its therapeutic agenda was a pressing concern for asylum superintendents and physicians. And for good reason. Occasionally visitors uncovered ugly realities, and in doing so made the private troubles of asylum life into public issues. Such was the case for the sisters of a Helen H. who had been committed to the scandal-plagued Provincial Hospital in British Columbia, Canada in 1913. There, they found her restrained in a straitjacket and severely bruised from a beating by a female attendant. They demanded to see the superintendent, Charles Edward Doherty, who acquiesced to their insistence that she be discharged, although he made it clear that he did so against medical advice. The sisters then contacted the Provincial Secretary and demanded an investigation into the treatment of patients at the asylum; their adamancy was dismissed by Doherty as evidence of the insanity that Helen apparently also had inherited. In the end, no investigation ensued, if only because Helen had been returned to the asylum by her family who found themselves once again unable to care for her. Upon her re-commitment, Doherty received a letter signed by the Provincial Secretary insisting that the family’s complaints were to not adversely affect Helen’s future treatment at the asylum.
Asylum superintendents and physicians debated for some time about whether to restrict or refuse visiting. But it was Jean-Martin Charcot at the Salpêtrière Asylum in Paris, France, who triangulated the issue: at the apex was the powerful asylum physician with superior expertise and knowledge; at the base, the inferior patient at one angle, the family at another, and a wide distance between them. The asylum physician’s influence on the family, then, was necessarily as strong as it was on the patient, but because the family also influenced the patient, it was his obligation to restrict or refuse their visits. All of this, of course, was therapeutically rationalized as being in the best interest of the patient, and was given the label “isolation therapy.”
Isolation therapy was part of the treatment regime at the Salpêtrière where the “Napoleon of Neurosis,” as Charcot enjoyed being called, treated a large number of women patients who had been diagnosed with hysteria. Upon admission, he refused to allow their families to visit. It was not until the patients’ often astonishing array of hysterical symptoms slowly abated over the ensuing weeks, months or years, that he allowed only occasional visits.
In one of the twenty-five clinical lectures he delivered on the nervous system, Charcot defended isolation therapy by relating a detailed story of its success. The case was that of a fourteen-year-old anorexic girl, “bordering on hysteria,’ who was starving herself to death. The girl’s distraught father had begged Charcot to come to their home in Angoulême in southwestern France to treat her. Charcot demurred, and told the father to bring his daughter to Paris, “place her in one of our hydrotherapeutic establishments. Leave her there, or at least when you go away make her believe that you quitted the capital, inform me of it, and I will do the rest” (Silverman, p. 279). Weeks later, an Angoulême physician, familiar with the family, informed Charcot that the girl indeed had been admitted to such an establishment, but that she was still refusing food and was close to death. The father had not contacted Charcot, he revealed, because he and his wife refused to leave their dying daughter.
Charcot visited the establishment only to come across the tall, emaciated girl with her drooping head, weak voice and cold extremities. “There was indeed every reasons to be uneasy,” he told his colleagues, “very uneasy.” He continued:
I took the parents aside, and after having addressed to them a blunt remonstrance, I told them that there remained, in my judgment, but one chance of success. It was that they should go away, or pretend to go away, which amounted to the same thing, as quickly as possible…. They went immediately. Their acquiescence was difficult to obtain in spite of all my remonstrances. The father especially failed to understand how the doctor could require a father to leave his child in the moment of danger. The mother said as much, but I was animated by my conviction. Perhaps I was eloquent, for the mother yielded first, and the father followed, uttering maledictions, and having I believe but little confidence in the prospect of success.
Isolation was established; its results were rapid and marvelous. The child, left alone with the nun who acted as nurse, and the doctor of the house, wept a little at first, though an hour later she became much less desolate than one would have expected. The very same evening, in spite of her repugnance, she consented to take half a little biscuit, dipped in wine. On the following days she took a little milk, some wine, soup, and then a little meat. The nutrition became improved, progressively but slowly.
At the end of 15 days she was relatively well. Energy returned and a general improvement in nutrition, so far that at the end of the month I saw the child seated on a sofa, and capable of lifting her head from the pillow. Then she was able to walk a little… and 2 months from the date of the commencement of the treatment she could be considered as almost completely cured [Silverman, p. 298].
Eulogized by his former student Sigmund Freud as a “visuel” who had little interest in talking to his hysterical patients and even less in listening to them, Charcot nonetheless conversed with the girl he had successfully treated, who reaffirmed the hierarchical underpinnings of isolation therapy:
As long as papa and mamma had not gone—in other words, as long as you had not triumphed (for I saw that you wished to shut me up), I was afraid that my illness was not serious, and as I had a horror of eating, I did not eat. But when I saw that you were determined to be master, I was afraid, and in spite of repugnance I tried to eat, and I was able to, little by little [Silverman, p. 298].
Charcot’s influence, in the matter of isolation therapy as in all, was considerable, and the therapeutic was widely used in France into the twentieth century. In fact, it became so associated with him that the American neurologist S. Weir Mitchell took umbrage. In 1875 Mitchell had developed the rest cure [see Bed Therapy], a treatment for neurasthenics, most of them women, that entailed several weeks of isolation. To correct the widespread impression that isolation therapy was Charcot’s brainchild, he challenged the famous asylum physician and, in doing so, staked a claim for the inventiveness of American medicine:
Charcot is quoted as claiming for its use … precedence of invention [but I cannot] find proof of this in his books. He was given to such claims, and I have twice before suffered in like manner at his, Charcot’s, hands. I think it just, less on my account than to American medicine, that I a little protest [Mitchell, p. 2034].
A cylindrical pit, large enough to accommodate a single patient, dug into the basement floor of an asylum and covered with a heavy metal grate, or a makeshift wooden stall constructed in the basement and fronted by a metal grate. As the French word “oubliette” suggests, the strong room was a “forgotten place” used in the nineteenth through early twentieth centuries in asylums around the world to confine violent and otherwise unmanageable patients, and most likely for centuries before asylums were established. One such oubliette, then called a fool’s pit, was observed in a Munich general hospital decades before an asylum was constructed in that German city:
In the hope of seeing wide, light rooms, I entered the cellar; instead of fresh, healthy air a repugnant vapour hit me and instead of dry cleanliness I met damp dirtiness. No separate and free-standing beds, but human stalls made of wooden slats were to be seen. These areas were the pits. The overseers of the fool’s pits were called the strikers [Hippius, Möller, Müller & Neundörfer-Kohl, p. 3].
An asylum room with cushioned walls and floors into which refractory or suicidal patients were placed. The origin of the padded room has been attributed to Johann Heinrich Ferdinand von Autenrieth, professor of medicine at the University of Tübingen in Germany in the early nineteenth century. Although he had little contact with insane patients, Autenrieth’s writings greatly influenced the therapeutic regimes of German asylums where padded rooms, their walls and floors covered with rubber stretched over cork chips, first appeared.
In the emerging era of moral treatment [see Moral Treatment], many British asylum physicians found padded rooms to be viable alternatives to coercive methods of mechanical restraint [see Mechanical Restraints]. Padded rooms were introduced into the basement wards of London’s Bethlem Asylum, better known as Bedlam, in 1844. Visiting physician Sir Alexander Morison described their design and purpose and offered a few caveats about their use:
In almost every case of excitement, seclusion in a padded room, as it is called, will be found to be sufficient. This consists of a small room padded with cushions, stretched on a frame-work of wood, and stuffed with horse-hair or cocoa-nut fibre, and having the floor covered in the same way. In [Bethlem] the padded rooms are lined with a composition consisting of India-rubber and cork; but although possessing the advantage of being more easily cleaned, I prefer the first mentioned, as I consider them to be too hard, so that a resolute maniac, if so determined, might easily inflict injuries upon himself, by throwing himself against the walls. As light is often a source of great irritation, so darkness is a powerful auxiliary in obtaining quiet, and preventing the renewal of raving. But we should as speedily as possible ascertain that darkness does not beget real terror.
Many, besides the ignorant and superstitious, have an unaccountable dread of being left in the dark; and the worst consequences might follow, by their being so treated. Although we cannot enforce too much the employment of soothing means to calm and restrain the violent and mischievous insane,—still, if these entirely fail (and especially when the patient is in a condition to be sensible that his conduct has called for marks of disapprobation), these become necessary [Morison, pp. 397–398].
If Morison seemed somewhat hesitant about using padded rooms to soothe the “resolute maniac” and the “violent and mischievous insane,” his rival John Conolly was far from it. At the forefront of the non-restraint movement, Conolly was determined to render “both mechanical restraints and muscular force unnecessary” for the control of even the most refractory patients at the nearby Middlesex County Asylum, better known as the Hanwell Asylum (Conolly, p. 44). It was there that Conolly not only unhesitatingly used the bare rooms that were padded from floor to ceiling with cocoa-nut fiber enclosed in ticking and illuminated by whatever light came through wire blinds across the windows, but set out strict guidelines to prevent their misuse:
The seclusion and the reasons for it, are always immediately reported to the superintendent or physician, and, in the case of female patients, to the matron also. The ward is visited from time to time by these officers, and an accurate knowledge of the state of the secluded patients is obtained by means of an inspection plate or covered opening in the door of the room. The patient is not left to suffer from thirst or hunger, nor are his personal state and cleanliness unattended to; nor is he allowed to remain in seclusion longer than his excited state requires. A written report of each instance of seclusion, and of its duration, is sent to the physician at the close of each day, and copied by him into a book which is inspected at every meeting of the Committee. Thus are obtained all the advantages of seclusion, without any abuse of it [Conolly, p. 460].
The padded rooms, in Conolly’s opinion, soothed and quieted distressed patients, but their “cure commenced” before they were even coaxed or carried into them. Because they were subjected neither to mechanical restraints nor muscular force the patients, he argued, were more inclined to trust their best interests were being served; the timely introduction of “good tempered” attendants (p. 47), offering food and drink after they had calmed, drew patients to the inevitable conclusion that they were under good and kind care. He offered the case of a twenty-four-year-old woman in support of his contentions. In a state of “violent excitement” (p. 111), she was convinced she would be burned alive for some real or imagined sin and had to be carried into a padded room. Then,
the tranquility and the solitude at first appeared to surprise her. She got up, and walked around the room as if to examine it; then lay down again, and became quiet and composed. It was some hours before she became quite calm enough to take a little food, and by this time the appearance of the attendants scarcely seemed to alarm her. After three days careful nursing and management she had quite gained enough confidence in them, and it was practicable to remove her to a bed in the infirmary. She recovered and was released weeks later” [Conolly, p. 113].
As a therapeutic innovator of some repute, Conolly’s promotion of padded rooms had considerable influence on asylum medicine in Great Britain. Heralded as an “all important aid to the Modern System of humane treatment” (Arnold, p. 184), they could be found here and there along the six miles of corridors that wound through Colney Hatch, the newly built asylum in north London that, with 3500 patients, was the largest in Europe. Conolly’s influence was felt in the Commonwealth of Australia where the addition of padded rooms at the Adelaide Lunatic Asylum in the mid-nineteenth century was praised as the first enlightened step towards moral treatment. And it was felt as far away as Egypt, then under British rule. At the Cairo Lunatic Asylum, the only asylum in that country, five padded rooms were constructed and filled with leather cushions stuffed with vegetable horse hair and palmetto from Algiers. Although so effective in calming maniacal patients that the heavy neck chains that once had held them to the walls were no longer needed, straitjackets or camisoles were still on hand. Despite the assessment of the British asylum superintendent that “healthy-minded Egyptians are very like grown-up children, and when insane are almost invariably quite easy to manage” (Sandwitch, pp. 485–486), occasional mechanical restraint still was required.
Colonial condescension aside, the Cairo Lunatic Asylum illustrated one of the incongruities of padded rooms: they could not always replace mechanical restraints entirely. Sometimes, in fact, they were used in conjunction with them. In the United States where their use was relatively infrequent, Clifford Beers, a university student who would go on to be the founder of the American mental health hygiene movement, described in his bestselling memoir his confinement in a padded room while also restrained in a strait-jacket:
The [padded room] I was forced to occupy was practically without heat., and as winter was coming on, I suffered intensely from the cold. Frequently it was so cold I could see my breath. Though my canvas jacket served to protect part of that body which it is at the same time racking, I was seldom comfortably warm; for, once uncovered, my arms being pinioned, I had no way of rearranging the blankets [Beers, pp. 133–134].
Beers’s experience revealed another incongruity of padded rooms. Conolly’s rigid regulations for their therapeutic as opposed to punitive use aside, they invited abuse. Conolly’s influence most likely did not extend to Russia where asylums, also known as “dollhouses,” a perversion of the German “Tollhaus,” and later as “yellow houses,” had not been used to confine the insane until the late eighteenth century. Small, poorly run, and cruel, the use of padded rooms also known as “isolators,” to torture as much as treat, was common.
Some British asylum physicians pointed out the definitive incongruity of padded rooms and that was that they were, in fact, little more than capacious versions of the straitjackets and camisoles they were designed to replace. That position was taken by George M. Robertson, physician-superintendent of the Royal Edinburgh Asylum, also known as Morningside:
I place [padded rooms] … in the same category as mechanical restraint, which is only resorted to most exceptionally and in the direct necessity. Of course, it is possible to say that if mechanical restraint be necessary and does good in one case for one day in 100,000, that to that extent the practice is desirable. A similar limited desirability may be claimed for the padded room…[I]t is a form of treatment handed down to us from the past, and had its origin in, and was adopted from, the jails. It became naturalized in the madhouses one hundred years ago because these institutions were not mental hospitals, but prisons for the insane.
I venture to say that no medical student from the hospitals or graduate, seeing the practice adopted for the first time, but feels more keenly its prison-like characteristics with compassion for the individual subjected to it, than a realization of its medical and therapeutic blessings…[T]he sight of a patient locked up in a room will never fail to create an impression, often indelible, on a layman visiting an asylum for the first time. The impression is never favourable, and its always accompanied by sympathy for the unfortunate sufferer [Robertson, pp. 195–196].
In a concluding statement that was more disturbing for its prescience than its condemnation, Robertson went on to warn that padded rooms very well could become “magnified in importance and in frequency of employment out all semblance of the truth” (p. 196) in the eyes of the public for whom asylums were unsettling and insanity unnerving. Indeed, padded rooms, just like the straitjackets they were meant to replace, are to this day associated in the public imagination with the brutal and unenlightened treatment of the insane.
The isolation of patients from all human contact and in total silence for a period ranging from several days to several weeks. Developed by the Swiss born psychiatrist, Otto Binswanger, who at the start of World War I was a professor at the University of Jenna in Germany, psychic abstinence treatment was administered to soldiers suffering from the most severe manifestations of shell-shock. Often disparagingly referred to as “war hysterics,” “tremblers,” or “war neurotics,” these soldiers were a source of considerable shame not only to the German body politic, but to psychiatrists such as Binswanger who lionized war as an antidote to the degenerating forces of modernity. War also was glorified as a test of manhood. According to Binswanger:
In the course of the last year and on the outbreak of the war, I have been treating a whole series of young men with weak nerves: anxious, timid, vacillating, weak-willed individuals whose consciousness and feelings were determined only by their own ego and who exhausted themselves in complaints about their physical and mental pain. Then the war came. Their morbid sickliness fell away from them at a stroke, they reported for service—and all have so far proved their worth [Kaufman, p. 128].
By the end of the first year of the war, however, nearly 112,000 German soldiers had been diagnosed with what eventually came to be known as shell-shock, and treating them was a daunting challenge to physicians. Binswanger, taking inspiration from the at-home rest cure for middle class neurasthenic women developed in the United States by S. Weir Mitchell, isolated his soldier-patients in single rooms [see Bed Therapy], demanded complete silence and forbade any human contact. Patients who violated the strictures of psychic abstinence treatment were deprived food. Only the most severe cases of shell-shock were subjected to this disciplinary therapy, and Binswanger claimed a 66 percent success rate.
An even higher rate of success was claimed by his colleague Ernst Kretschmer who, after the war, would serve as a founding member of the General Medical Society for Psychotherapy. Kretschmer isolated his shell-shocked soldier-patients in darkened rooms at the Württemberg Hospital and visited them once daily; no other staff were allowed to enter the rooms. The patients were confined to their beds and activity, indeed movement in general, was forbidden. Positing that such “boring to death” treatment, as it came to be called, would calm the patients’ frayed nerves, Kretschmer found that the symptoms of shell-shock—the trembling, tics, stutters, stumblings, as well as the disturbing impairments of the senses—improved in one to two weeks, and disappeared in four to six weeks.
A room that isolated uncontrollable or self-injuring patients from the larger asylum population. The solitary cell usually was quite well lit and ventilated, and often was furnished with a bed or pallet for sleeping; patients placed in it typically were not further restrained. That was the case at the Het Dolhuys (The Madhouse) in Haarlem in the Netherlands, where fourteen solitary cells, known as “dolcellen,” were built for the insane patients who in the sixteenth century joined the lepers already isolated there. Each of the cells was approximately four feet wide by four feet long, and nearly six feet in height, had a stone floor and walls, a barred inner door and a heavy wood outer door. Hot stones were placed between the doors in the winter to provide some heat for the patient who slept in a small wooden crib and had a bucket for bodily wastes. An iron hatch, approximately one foot square, was built into the wall above the cell and could be opened to provide light and air.
Solitary cells were used in asylums around the world, but not without a great deal of discussion and debate about the exigencies of their use. For reformers determined to introduce moral treatment into asylums that had relied on chains, cuffs and straitjackets to control and subjugate patients, solitary cells offered in equal measure a caring intervention and an opportunity for cruel abuse. The prominent French asylum physician Jean-Étienne Esquirol, pondered that dilemma. While acknowledging that solitude “exercises a mysterious power which reestablishes the moral forces that have been exhausted by the passions,” (Esquirol, p. 78), he nonetheless warned that “it is not easy to determine the period at which isolation should cease. To prevent abuse, extreme caution and tact are requisite. Here, experience is slow to decide” (p. 78).
Indeed, the duration of solitary cell confinement in French asylums was the subject of a broadside by the British physician C. Lockhart Robertson, whose career included the superintendency of the Sussex County Asylum, the presidency of the Medico-Psychological Association, and Visitor to the Chancery lunatics. Lockhart, who was known for his unbridled criticism of patient abuse, discovered in his tour of French provincial asylums that in one of them two patients, diagnosed with nymphomania, had been confined in solitary cells for two years. He attributed that “barbarous” practice to the bureaucratic interference of lay governors and, above all, of “stupid old réligieuses” (“The Restraint System,” p. 443), and called on more enlightened French colleagues to “insist such scandals shall cease to disgrace France” (p. 443).
The use of the solitary cell was the subject of scandal and not just in France. In the late nineteenth century a tavern keeper named Heinrich Mellage in Iserlohn, Germany, published a pamphlet that detailed how he rescued Alexander Forbes, a Scottish priest, from Mariaberg Asylum where he had been involuntarily confined for more than three years. Written in hyperbolic prose, the pamphlet detailed the abuses of patients at the private Catholic asylum, including long periods of confinement, after having been stripped naked, in unheated solitary cells. The pamphlet, 39 Monate bei gesundem Geiste als irrsinnig eingekerkert [“39 months of a sane man’s imprisonment as insane”] was widely read by a public ghoulishly fascinated not only with insanity and its commitment, but by the vindictively applied label of insanity by incompetent physicians and the prospect of false commitment. The pamphlet did not go unnoticed by the asylum or the state that, in a joint action, brought a libel suit against Mellage. His nine day trial, covered by both the international press and by psychiatric journals and communiqués, ended in his acquittal, prompted asylum reforms, and mounted a vituperative public backlash against asylums and their physicians. Forbes, the alcoholic, explosively violent and unrepentantly “un-priestly” priest who was the subject of the pamphlet, was released from Mariaberg after having been certified as sane by a consulting physician.
The abuse at Mariaberg was considerable, and certainly not limited to the solitary cell. But the fact that such a cell, so reminiscent of the unenlightened past, was still being used stood in stark contrast to the wide-sweeping German asylum reforms that had been put into place by such notable theorists as Wilhelm Griesinger, and into practice by such asylum physicians as Oscar Wattenberg at the State Hospital in Lübeck. It was there that Wattenberg had abolished completely the use of the solitary cell, and did so “on principle”:
One can sense, that it [i.e. the isolation of patients] is not as it should be, it is an open sore that one does not like to put a finger on. That must change! We have to use the sharp knife of humanity for this putrid wound and cut it from the core. We have discontinued the use of strait-jackets, we have invented the agricultural colony, the family care and the open door system, we have reduced the use of isolation cells—why don’t we totally abolish them? [Ptok & Dilling, p. 321].
For asylum physicians in other countries, as eager as their German colleagues to jettison “the ballast of [their] sinking public image” (Engstrom, p. 69) while at the same time controlling their asylums, misunderstandings about the continued use of the solitary cell had to be adamantly confronted. Such was the case at the Newcastle-Upon-Borough Lunatic Asylum in northeast England in the late nineteenth century, when visiting members of the Lunacy Commission criticized the use of the solitary cell by stating, “we cannot but express a hope that by care and perseverance some other and less objectionable means may be adopted in the management and treatment of cases of the descriptions now under consideration” (Committee of Visitors, p. 12).
Medical superintendent R.H.B. Wickham offered a strong rejoinder by reminding the Commission that the patients confined in solitary cells were “objects of terror to the well-disposed patients, and the feelings of the quiet and orderly” (p. 15). He further emphasized that while the Commission had counted more than 3,000 hours of seclusion cell use, the majority of that total actually reflected the repeated use of the cell over time for a small number of particularly difficult patients. One of those, a homicidal male, was secluded sixty-nine separate times for a total of 700 hours; another an acutely manic female, thirty-eight times for a total of 353 hours. That said, Wickham somewhat reluctantly agreed to “almost entirely” relinquish the use of the seclusion cell despite disagreeing with the Commission that its use was “wrong, inhumane, or retrograde” (Committee of Visitors, p. 16).
A room, usually with a reinforced or a double door and grates on the window, to confine violent or self-injuring patients. Often disparagingly referred to as an oubliette, the strong room in fact was considerably less oppressive; patients usually were allowed to remain clothed and seldom were further restrained. A strong room typically was well lit, aired and heated in the winter months, but additional features were matters of both planning and pride. At the Sonnenstein Asylum, housed in a castle overlooking the river Elbe near the German city of Dresden, the floor of the strong room was brick and heavily varnished so bodily excretions and odors would not be absorbed, an innovation that was consistent with its status as Germany’s first moral treatment asylum. At the West Riding Pauper Lunatic Asylum in Wakefield, England, the thirty strong rooms had silicate-covered walls and flush-paneled doors that opened outward to they could not be blocked by patients. Similar design novelties could be found in asylums across the United States although some, such as a county asylum in Pennsylvania that replaced the easily damaged plaster walls with sheets of tin, were put into place more out of necessity than any pretense of promoting moral treatment.
Coverings strapped or otherwise secured over the face, or placed around or in the mouth, to prevent speaking, screaming, spitting and biting.
Upon a visit to Bethlem, England’s first insane asylum, a visitor observed:
It seems strange that anyone should recover here: the cryings, screechings, roarings, brawlings, shaking of chains, swearing, frettings, chafings, are so many, so hideous, so great, that they are more able to drive a man that hath his wits, rather out of them, than to help one that never had them, or hath lost them, to find them again [Ackroyd, p. 619].
That observations was made in the early seventeenth century when Bethlem held thirty-one insane patients in a dark and dingy building designed to hold just twenty-four. Over the years the asylum, originally located on a patch of ground between two open sewers, would become better known as “Bedlam,” the Cockney contraction of “Bethlem,” and a word synonymous with noise.
In that sense, “Bedlam” was typical of early insane asylums. But it was not just the often impenetrable noise that was considered both the consequence of insanity and the cause of it that was problematic. It was also the fact that patients sometimes ingested inappropriate things—the straw or mattress ticking of their beds, the dirt on the floor and the grounds, even their own feces—ripped their clothes with their teeth, spit, and bit themselves, each other, as well as attendants and asylum physicians. Case notes such as this one from the files of the Hampshire County Lunatic Asylum in southern England could be found in any mid-nineteenth century asylum anywhere in the world: “Attacked … the Charge Attendant of his ward whilst on the seat of the W.C. Tried to bite off his nose & ear & to gouge out his eyes, and did bite him about 11 places but only superficially” (Carpenter, p. 126).
Hampshire was a provincial pauper lunatic asylum, holding patients who had spent months, perhaps years, in workhouses under often execrable conditions; they were and most likely always had been, poor, and many were uneducated, even illiterate. But insanity was a great leveler. Once in the throes of it, class distinctions blurred and pauper and private asylums alike were plagued by the same problems of discipline and danger. This was evident from the case files at the Bloomingdale Asylum in New York City. The private asylum catered to the well-to-do and was a model of moral treatment [see Moral Treatment]. Rules were posted on the walls of the elegant Federal style brownstone building, encouraging patients to engage in civilized comportment: no screaming, spitting or biting was allowed. But in the throes of insanity, such rules were meaningless and their violation posed as much of a problem of management as it did in any pauper or public asylum, as this case illustrated:
Miss--- was admitted to Bloomingdale Asylum, December 7, 1888, in her third attack of insanity. Her age was 23 years…. Her case pursued a course of increasing violence and excitement, at the height of which her actions were most violent, destructive, filthy, abusive and insulting to those around her…. The first entry in her case records state that she was admitted in an excited state, singing, striking, and biting.…[S]he acknowledges that she is very bad, but again glories in being so, and says the best thing she has done since she came here was to bite a patient. She never loses an opportunity to bite or strike [Lyon, p. 109].
While mechanical restraints [see Mechanical Restraints] could deter patients from biting, they could not silence screaming; and while isolation [see Isolation] could mute the screaming, it could not deter the biting and self-injury. Sedatives such as opium, morphine, chloral and bromide were used to calm boisterous and aggressive patients, but in some nineteenth century asylums, particularly in Europe, masks, toggles and gags were valuable additions to the therapeutic armamentarium. In significantly modified versions, masks of some kind or another were in use well into the twentieth century.
Ackroyd, P. (2000). London: A biography. London: Vantage.
Arnold, C. (2008). Bedlam: London and its mad. London: Simon & Schuster.
Brown, A.R. (2010). Reform and curability in American insane asylums in the 1840s. Constructing the Past, 11, 12–29.
Carpenter, D.T. (2010). Above all a patient should never be terrified: An examination of mental health care and treatment in Hampshire 1845–194. Doctoral Dissertation, University of Portsmouth. Portsmouth, UK.
Farrell, L. (1995). Some things never change. British Medical Journal, 311, 634.
Giles, H.H. (1888). The insane, and the Wisconsin system for their care. Madison, WI: Democrat Printing Co.
Heinroth, J.C.A. (1975/1818). Textbook of disturbances of mental life. Baltimore: Johns Hopkins University Press.
Lyon, S.H. (1895). Dual action of the brain. New York Medical Journal, 62, 107–110.
Meranze, M. (1996). Laboratories of virtue: Punishment, revolution, and authority in Philadelphia, 1760–1835. Chapel Hill: University of North Carolina Press.
Millingen, J.G. (1842). Aphorisms on the treatment and management of the insane. Philadelphia: Ed. Barrington & Geo. D. Haswell.
Szasz, T. (2010). Coercion as cure: A critical history of psychiatry. New Brunswick, NJ: Transaction Publishers.
Tuke, D.H. (1882). Chapters on the history of the insane in the British Isles. London: Kegan Paul, Trench & Co.
Webster, J. (1852). Additional notes on provincial asylums for the insane in France. Journal of Psychological Medicine, 5, 124–139. 229–255.
A well cushioned leather mask with openings for the eyes and nostrils, and with a tight leather strap that was slipped under the chin. The mask was designed by Johann Heinrich Ferdinand von Autenrieth, professor of medicine and founder of the inpatient clinic at the University of Tübingen in Germany in the early nineteenth century. Although he had little direct contact with insane patients, his writings had a significant, albeit brief, influence on their treatment, particularly in Germany. Autenrieth identified with what was known as German Romantic Psychiatry, a movement that emphasized the quasi-mystical nexuses between psychiatry and philosophy, and that posited psychic, rather than somatic, origins of insanity. In the manner of his colleagues in that movement, Autenrieth posited that insanity was tantamount to passion unrestrained by free will, thus therapeutics should restore the will of insane patients through the benevolent tyranny of iron-clad discipline. He wrote:
The doctor can never sufficiently impress upon himself and others the fact the insane are identical in more respects to stubborn, ill-mannered children and, like them, require stern (not cruel) treatment…. Is not the treatment of mental patients frequently comparable to the education of children? Every finding indicates that comparison is apt [Szasz, p. 77].
How apt that comparison was in practice was evident in the case of Autenrieth’s most famous patient, the lyric poet Friedrich Hölderlin whose metaphysical influence on the development of the philosophical movement known as German Idealism was considerable. Physically and mentally exhausted, the poet was taken in the early nineteenth century by friends to Autenrieth’s clinic where he was administered the standard course of stimulants and sedatives, immersed in baths of cold water [see Hydrotherapy], wrapped in a straitjacket [see Mechanical Restraints] and, when his outbursts were intolerable, fitted with Autenrieth’s mask. Silenced, but not improved, he was later discharged as incurable and taken in by a local cabinet-maker with whom he lived quite peacefully until his death, thirty-six years later.
Although one of the leaders of the German Romantic movement in psychiatry, Johann Christian August Heinroth, went out of his way to disabuse asylum physicians of their concern that the Autenrieth mask was cruel, since its aim, he argued, was “to produce one of the most healing restrictions” (Heinroth, p. 294), the mask was never well accepted nor widely used. That said, modifications of the mask found their way into asylums in Europe. At the Ospedal San Lazzaro in northern Italy, for example, what was variously referred to as the “cap of silence” or the “helmet of silence,” a leather cap with a heavy chin strap held in place by a strap buckled behind the head, was used well into the nineteenth century to silence loud patients. In its tour of provincial English asylums around that same time, the Lunacy Commission came across similar leather caps with mouth-closing chin straps. Most of these were in storage, and the Commission was assured that they had not been used for many years. And although John Minson Galt, the superintendent of Eastern State Hospital in Williamsburg, Virginia, dismissed the mask in all of its versions as “merit[ing] but little confidence” (Galt, p. 181), it occasionally was used until the mid-nineteenth century in some American asylums as well.
A locked metal frame that fit over the head with an iron bit approximately two inches long and one inch wide to press down on the tongue. The brank was used in the Middle Ages to punish and humiliate women who were “common scolds,” that is, who talked shrewishly, gossiped and nagged, hence the early term for the device was the “scold’s bridle” or “gossip’s bridle,” or “witch’s bridle.”
In a mid-nineteenth century series of lively lectures, replete with quotes from early English poets and dramatists and illustrated with hand drawn pictures, T.N. Brushfield told his audiences that branks had been used as late as decades before in Scottish and some provincial English asylums to silence loud patients. His claims on that point were considered questionable at the time, although he insisted he had found a brank in storage at the Cheshire Lunatic Asylum, where he was medical superintendent, and had been told by an elderly patient that years before she had been forced to wear one to silence her loud screams.
A horseshoe-shaped iron pallet that was inserted into the mouth and that pressed down the tongue. The gag had chains on each end that were drawn tightly towards the jaws and then fastened behind the head with a lock. The gag had wide use in a variety of disciplinary institutions, including jails, prisons and even in the military, and was the subject of occasional investigations and official inquiries, especially when its use resulted in death. It also was used in asylums around the world as late as the early twentieth century.
A simple cotton cloth tied over the mouth of the patient to prevent talking and screaming. The muffle was used in eighteenth century asylums.
A piece of pear-shaped hardwood placed in the mouth of the patient and secured at the back of the neck by leather straps attached to a crossbar. Johann Christian August Heinroth, professor of medicine at Leipzig University in Germany, urged asylum physicians to use the device, which many had considered cruel, for its ability to bring refractory patients into submission, if not silence:
Since the oral cavity of the patient is more or less filled by this instrument, the patient can obviously utter no articulate sounds, but can still utter stifled screams, which is the more undesirable as the patient has to make a greater effort to do so; except that he might grow tired of this effort and become quiet…. Just as badly brought up children, or rather spoiled children, given vent to their malice through screaming, and thus enjoy themselves, so unruly patients give vent to their rage and obstreperousness by screaming and roaring if they cannot do so in any other manner, and tend to scream more the more they are forbidden to do so. If they are prevented from screaming, they lose their only remaining weapon and must finally acknowledge their total impotence [Heinroth, p. 294].
It was Heinroth who suggested that because Autenrieth’s mask did not prevent the patient from opening his or her mouth, that the pear be used in conjunction with it to assure silence.
A bowl-shaped devise made of quite tightly woven wire or fabric mesh, fitted over the head of the patient and secured around the neck with a leather strap that was locked behind the head. The mask did not prevent the patient from talking, but did prevent biting, tearing clothes with the teeth, spitting, or eating objectionable substances. Although an American physician who was touring provincial French asylums in the mid-nineteenth century was quite taken aback by the site of patients, both male and female, wearing wire masks, such masks were in occasional use in asylums throughout Great Britain, Europe as well as in the United States into the twentieth century.