Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century [Reprint 2019 ed.] 9780520917934

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Mental Ills and Bodily Cures

MEDICINE AND SOCIETY Andrew Scull, Editor This series examines the development of medical knowledge and psychiatric practice from historical and sociological perspectives. The books contribute to a scholarly and critical reflection on the nature and role of medicine and psychiatry in modern societies. l.

Robert Castel, The Regulation of Madness: Origins of Incarceration in France. Translated by W. D. Halls 2.

3.

John R. Sutton, Stubborn. Children: Controlling Delinquency in the United States, 1640-1981

Andrew Scull, Social Order/Mental Disorder: Anglo-American Psychiatry in Historical Perspective 4. Ian R. Dowbiggin, Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth-Century France 5.

Denise Jodelet, Madness and Social Representations. Translated by Tim Pownall, edited by Gerard Duveen

6. James W. Trent, Jr., Inventing the Feeble Mind: A History of Mental Retardation in the United States 7.

Steven G. Epstein, Impure Science: AIDS, Activism, and the Politics of Knowledge

8. Joel Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century

Mental Ills and Bodily Cures Psychiatric Treatment in the First Half of the Twentieth Century

Joel Braslow

UNIVERSITY OF CALIFORNIA PRESS Berkeley Los Angeles London

University of California Press Berkeley and Los Angeles, California University of California Press London, England Copyright © 1997 by The Regents of the University of California

Library of Congress Cataloging-in-Publication Data Braslow.Joel T., 1959— Mental ills and bodily cures : psychiatric treatment in the first half of the twentieth century / Joel Braslow. p. cm. — (Medicine and society : 8) Includes bibliographical references and index. ISBN 0 - 5 2 0 - 2 0 5 4 7 - 2 (cl : alk. paper) 1. Mental illness—Treatment—United States—History—20th century. 2. Mental illness—Physical therapy—United States—History—20th century. 3. Mind and body. I. Title. II. Series. [DNLM: 1. Mental Disorders—therapy. 2. Therapeutics—history—United States. Wi ME6490 v. 8 1997 / WM 1 1 AAi B8c 1997] RC480.5.B725 1997 6i6.8g'i—DC21 DNLM/DLC for Library of Congress 96-39469 CIP Printed in the United States of America 1 2 3 4 5 6 7 8 9 The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984©

For Christine

CONTENTS

FIGURES

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TABLES

ix

/

xi

ACKNOWLEDGMENTS

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Introduction to the Psychiatric Body

xiii

/

i

1. Institutional Therapy: Context, Background, Structure

/

14

2. Discipline or Therapy: Patients, Doctors, and Somatic Remedies in the Early Twentieth Century

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33

3. In the Name of Therapeutics: Sexual Sterilization as Psychic Cure

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4. Neurosyphilis, Malaria, and a New Therapeutic Rationale

71

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54

5. Where the Mind Ends and the Body Begins: The Practice of Electroconvulsive Therapy / 95 6. Surgery as Discipline: Lobotomy at Stockton State Hospital 7. Discipline Gendered: Women and the Practice of Lobotomy CONCLUSION NOTES

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REFERENCES INDEX

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171

777 / 233

275

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125 152

FIGURES

1. Stockton Resident Patient Population, 1910—1955

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21

2. Resident Patients per 100,000 of the General Population, 1 9 1 0 — 1 9 5 5 3. Statewide Sex Distribution of All Admissions, 1 9 1 0 — 1 9 5 0 4. Sterilization at Stockton State Hospital, 1935—1950

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/ 69

5. Articles on Malaria Fever T h e r a p y Listed in Index Medicus, 1 9 1 7 - 1 9 5 7 / 77 6. Disease Categories of Patients Treated with EST, 1 9 4 4 - 1 9 5 4 , C o m p a r e d to Disease Prevalence of Resident Patients at Stockton State Hospital, 1949 / 103 7. Diagnosis at the T i m e of L o b o t o m y at Stockton State Hospital, 1 9 4 7 - 1 9 5 4

/

141

8. Overcrowding at Stockton State Hospital, 1946—1955

ix

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755

24

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22

TABLES

1. Selected Items Made by Patients in Occupational Therapy at Norwalk State Hospital, 1928—1930 / 30 2. Cumulative Sterilizations of Mental Patients in California and the United States, 1907—1951 / 5 6 3. Classification Criteria for Positive and Negative Descriptions of Neurosyphilitic Patients Made by Patton State Hospital Physicians

/

8y

4. Characteristics of 129 Neurosyphilitic Patients Admitted between 1910 and 1950 / 88 5. Positive and Negative Descriptions Made by Physicians of 129 Neurosyphilitic Patients Admitted between 1910 and 1950 / 89 6. Stated Condition at Discharge as Determined by Physicians of 129 Neurosyphilitic Patients Admitted between 1910 and 1950

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90

7. Positive and Negative Descriptions Made by Physicians of 79 Neurosyphilitic Patients Who Died Prior to Discharge

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8. Gender and Diagnostic Distribution of Patients Treated with EST 9. Sex Distribution of Lobotomy Patients

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10. Multiple Lobotomies and Sex Distribution

xi

154 /

154

91 /

118

ACKNOWLEDGMENTS

In 1988, as I was nearing the end of my psychiatry residency, Dora Weiner allowed me to assist her in teaching a course on the history of psychiatry. Her encouragement led me to undertake this project, which in its early form was my doctoral dissertation. I am very grateful to those scholars who guided me early on. Regina Morantz-Sanchez alerted me to the importance of gender. Her insistence on clarity of argument and prose have, I hope, found their way into this book. My intellectual debts to Mario Biagioli and Martin Shapiro are enormous, and their contributions may be found throughout this work. There are two scholars who deserve my greatest thanks. My thesis adviser, Robert Frank, whose methodologic sophistication and exhaustive knowledge of medical history have been indispensable, helped me to ask and try to answer why physicians, in the name of therapeutics, did what they did. Kenneth Wells has been, and continues to be, my closest mentor. Without his intellectual and emotional support this project would have been impossible. There are many individuals who graciously read and commented on various parts and versions of the text. Though I was unable to attend to all their comments and suggestions, I am grateful to Arthur Kling, Lisa Rubenstein, Marvin Karno, Louis J. West (who also came up with part of the tide), Vernon Rosario, and Robert Edgerton. Christian Zacher and Robert Bjork were especially helpful with issues of style. I especially want to thank Andrew Scull. He provided crucial encouragement when I first began this project and was invaluable in helping me transform this project from a dissertation into a book. I also thank Stanley Holwitz, Michelle Nordon, and Sheila Berg at the University of California Press for bringing this book to fruition. My deepest thanks belong to my wife, Christine Schneider. As a psychiatrist, she has subjected many of the ideas contained herein to the concerns xiii

xiv

ACKNOWLEDGMENTS

o f a practicing clinician. We have h a d i n n u m e r a b l e discussions o n what it m e a n s to be a psychiatrist, a n d the insights c o n t a i n e d h e r e i n are owed, in large part, to these dialogues. My two sons, Seth a n d Sam, t h o u g h m a k i n g this work h a r d e r to finish, also deserve heartfelt thanks f o r " h e l p i n g daddy work o n his b o o k . " I also want to thank the California D e p a r t m e n t o f Mental Health f o r givi n g m e access to patient medical records. William DeRise a n d Kathy Stye were especially g e n e r o u s with their time a n d advice o n h o w to locate materials. A t Patton State Hospital, William Summers, Sheila Fossum, a n d Nikki Batres provided invaluable assistance in finding patient records. A t Stockton, Mary A n n e Purlmutter was most helpful. This work w o u l d n o t have b e e n possible without the g e n e r o u s support o f a postdoctoral fellowship f r o m the U C L A / R A N D C e n t e r f o r Health Policy, the U C L A R o b e r t W o o d J o h n s o n Clinical Scholars P r o g r a m , a n d the prog r a m ' s director, R o b e r t B r o o k . I also t h a n k the U C L A N e u r o p s y c h i a t r i c Institute R e s e a r c h C e n t e r o n M a n a g e d C a r e f o r s u p p o r t i n g this p r o j e c t . T h i s p r o j e c t was also s u p p o r t e d in p a r t by a V A H e a l t h Services a n d Research G r a n t a n d the Sepulveda V A H e a l t h Services a n d Research Field P r o g r a m C e n t e r f o r the Study o f Healthcare Provider Behavior. M o d i f i e d parts o f this b o o k have a p p e a r e d earlier, as follows: "Punishm e n t o r T h e r a p y : Patients, D o c t o r s a n d S o m a t i c R e m e d i e s in t h e Early T w e n t i e t h C e n t u r y , " Psychiatric Clinics of North America 1 7 ( S e p t e m b e r 1994): 4 9 3 - 5 1 3 ; " T h e Effect o f T h e r a p e u t i c Innovation o n Perception o f Disease a n d the Doctor-Patient Relationship: A History o f General Paralysis o f the Insane a n d Malaria Fever Therapy, 1910—1950," American Journal of Psychiatry 152 (May 1 9 9 5 ) : 6 6 0 - 6 6 5 , copyright 1995, the A m e r i c a n Psychiatric Association, reprinted by permission; "In the N a m e o f Therapeutics: T h e Practice o f Sterilization in a California State Hospital," Journal of the History of Medicine and Allied Sciences 5 1 (January 1996): 2 9 - 5 1 . My thanks to the publishers f o r granting permission to r e p r o d u c e copyrighted material. C h a p t e r 4, in slightly d i f f e r e n t f o r m , also appears as " T h e I n f l u e n c e o f a Biological T h e r a p y o n Doctors' Narratives a n d Interrogations: T h e Case o f G e n e r a l Paralysis o f the Insane a n d Malaria Fever Therapy, 1 9 1 0 - 1 9 5 0 , " in Bulletin of the History of Medicine 70 ( 1 9 9 6 ) : 5 7 7 - 6 0 8 . Finally, I wish to thank t h e C a l i f o r n i a Institute o f T e c h n o l o g y f o r permission to q u o t e f r o m the E. S. G o s n e y Papers a n d R e c o r d s o f the H u m a n B e t t e r m e n t F o u n d a t i o n , B o x 12.8, Archives, California Institute o f Technology, Pasadena, California.

Introduction to the Psychiatric Body July g, 1943. Patient has had 12 electric shocks, resulting in 8 grand mat and 4 petit mal attacks. She has shown some improvement such as she is more concerned about her appearance than she was before. She is not as impudent and sarcastic as she has been on the ward. She claims that the reason she has not gotten along at home is because her husband is rather neglectful of her by leaving on weekends, she having to take care of the children and the house. At present she says she feels well but there are two things that are worrying her and she is afraid of One is the electric shock treatments, she is morbidly in fear of them and worries a day or two before she gets them. The other is the operation that she is going to have performed for sterilization. If those two things could be eliminated she believes that she may make good if given a chance. For those reasons the examiner is discontinuing the electric shock treatments for the present to see what improvement the patient will make now. — PHYSICIAN,

MENDOCINO

STATE

HOSPITAL

Hounded by alien and menacing voices, Jane Lomax was first admitted to Mendocino State Hospital in the early 1930s.1 Though she initially fought her fate as a psychiatric patient, Jane responded quickly to her doctors' ministrations, which consisted primarily of numerous applications of mummylike "wet sheet packs" and hours of hot "continuous baths," treatments collectively known as hydrotherapy. After a brief application of this rigorous regimen, Jane's doctors discharged her as "cured." She relapsed in early 1943, and her husband returned her to the hospital. With a nearly brandnew electroshock machine at the ready, Jane's doctors instituted a course of shock treatments and, just in case she eventually might return home to her husband, recommended that she be sterilized. As the July g note suggests, her physician was not impervious to her pleas that the planned interventions on her body be halted. Despite having had the husband's permission to sterilize her and to continue the shock treatments, the doctor acquiesced to her wishes, saving her, for the time being, from the scalpel and further convulsions. Unfortunately, her condition worsened. By late 1947 a psychiatrist described her as "silly, childish and stupid" and changed her diagnosis from manic depression to dementia praecox, hebephrenic type. Dementia praecox, one of the most hopeless diagnoses that could be stamped on a patient, justified her new geographic location on a neglected back ward for i

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the chronically disturbed. By this time her doctors had all but given up any hope of her recovery. Though they reinstituted electroshock, they had no illusions that this might result in a permanent cure. Instead, they used electroshock to quell her frequent attacks on patients and attendants. In fact, she eventually received well over one hundred treatments. On January 18, 1950, Jane's husband agreed with her doctors that cure might be found in a direct attack on her frontal lobes through a newly introduced and scientifically proven surgery, prefrontal lobotomy (indeed, just a few months earlier the Nobel Prize had been awarded to its inventor, Egas Moniz). Though admittedly radical, lobotomy offered the possibility of subduing her increasingly "shock resistant" behavior. However, she failed her screening interview for lobotomy. "Answered questions poorly," the interrogating physician wrote. "Appeared actively hallucinated. Enough response to indicate she had marked deterioration of an organic nature, lobotomy contraindicated." She progressively withdrew from those around her, retreating into her own private and, no doubt, lonely world. In December 1956 her physician noted, "The patient sits and grins, and gesticulates, making unintelligible replies.... Her daughter has requested one of the ataraxic drugs. Although there is not much hope of improvement, in view of her deterioration and her long hospitalization and no response to ECT [electroconvulsive therapy], we will try Thorazine." A short while later, Jane's doctor decided that after nearly a quarter century of hospital life she should be released to a board and care home. Whether years of madness had simply worn her out or the new antipsychotic drugs had done their job, Jane's violence had finally been vanquished. One of the doctor's last notes in the medical record, written in the mid-1960s, updated her progress in the nursing home: "The patient is reported clean, but does not w o r k . . . . She is friendly, grins, grimaces, and gesticulates. Typical schizophrenic. . . . She grins delightedly when asked questions, such as does someone want to kill you?" Each intervention that Jane's doctors employed or contemplated reaffirmed the intimate relationship they saw between her soma and her psyche. Whether they wrapped her in wet sheets, immersed her in warm tubs of water, sliced her fallopian tubes, or sent electrical current coursing through her, they deemed her body the main route to curing her troubled mind. The history of biological psychiatry was also inscribed on her body with these multiple interventions, for Jane underwent nearly every major somatic therapy created between the 1900s and the 1950s. The premier remedies of the first half of this century included hydrotherapy and sterilization beginning in the 1900s and 1910s, malaria fever therapy in the 1920s, shock therapies and lobotomy in the 1930s, and antipsychotic medications in the early 1950s. With varying degrees of enthusiasm, doctors

INTRODUCTION TO THE PSYCHIATRIC BODY

3

c o n t i n u e d to use all o f these treatments t h r o u g h the 1950s. It is also worth n o t i n g that as o n e moves forward in time, these interventions spiral closer a n d closer to the interior o f the brain. F r o m merely applying water to the skin with hydrotherapy to the severing o f frontal lobe axons with l o b o t o m y to, finally, giving medications that putatively act at precise neurotransmitter sites, the brain increasingly took center stage as a source o f disease a n d a site o f cure. T h e aim o f this b o o k , then, will b e to m a p the history o f this psychiatric body a n d its cures over the first half o f the twentieth century. T h i s history, while possessing intrinsic interest, b e c o m e s all the m o r e important given the current d o m i n a n c e o f biological psychiatry within the psychiatric profession a n d p o p u l a r culture. We n e e d turn only as far as television talk shows a n d best-seller lists to b e c o n v i n c e d that somatic therapies have p r o f o u n d l y i n f l u e n c e d t h e way in w h i c h A m e r i c a n c u l t u r e u n d e r stands psychic distress a n d its cure. T h e latest psychopharmacological solution to gain notoriety has b e e n what are k n o w n collectively as the serotonin selective reuptake inhibitors. T h e s e are relatively new antidepressant medications, the oldest a n d best k n o w n o f w h i c h is f l u o x e t i n e (better k n o w n by its trade n a m e , Prozac). W h e t h e r lauding or c o n d e m n i n g this latest technology a n d its widespread use in America, works such as Listening to Prozac, Prozac Nation, a n d Talking Back to Prozac intentionally or unintentionally pay h o m a g e to the almost mystical p o w e r o f this antidote to psychological suffering. 2 Peter Kramer, a u t h o r o f Listening to Prozac, writes, Is Prozac a good thing? Asking the virtue of Prozac may seem like asking whether Freud's discovery of the unconscious was a good thing. Once we are aware of the unconscious, once we have witnessed the effects of Prozac, it is impossible to imagine the modern world without them. Like psychoanalysis, Prozac exerts its influence not only in its interaction with individual patients, but through its effect on contemporary thought. In time, I suspect we will come to discover that modern psychopharmacology has become, like Freud in his day, a whole climate of opinion under which we conduct our different lives.3 T h o u g h o n e m i g h t q u i b b l e with K r a m e r ' s assertion that f l u o x e t i n e has b e c o m e the symbolic equivalent o f the unconscious (one n e e d only think o f lobotomy, the last N o b e l P r i z e - w i n n i n g psychiatric remedy, to be less sang u i n e about fluoxetine's longevity into the new m i l l e n n i u m ) , he does capture o u r current fascination a n d desire to move away f r o m the immaterial m i n d to the c o r p o r e a l brain. T h e psychiatric profession has aided a n d abetted this cultural e m b r a c e o f the brain a n d biological interventions; f o r psychiatrists themselves, over the last few decades, have veered sharply away f r o m psychoanalysis a n d psychological ways o f u n d e r s t a n d i n g toward a somatic a p p r o a c h to psychiatric

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disorder and its treatment. Even a superficial perusal of the leading psychiatric journals underscores the eclipse of talk therapies and the importance of biological psychiatry—in terms of both the theoretical understanding of disease and its treatment. 4 Adding an exclamation mark to this growing trend, President George Bush and the United States Congress in 1989 declared that the 1990s would be the "decade of the brain." Organized psychiatry has met this declaration with more than a modicum of enthusiasm. 5 However, this turn has its critics, most of whom would not be classified as antipsychiatrists. For them, the legitimacy of psychiatry or psychological healing is not at issue but rather the hegemony of a biological vision of human behavior. Accordingly, they have argued that the scientific content of this ilk of psychiatric knowledge and practice is flawed at best and inconclusive regarding biological causation of nearly all psychiatric disorders. This way of viewing the mind and its disorders, they argue, is a form of reductionist determinism that is more of an ideological justification of the existing social order than scientific fact. 6 I, too, am critical of an exclusive devotion to biological psychiatry and see this book as, in part, a critique of physical solutions to psychological distress, for in it we will see the particularly pernicious consequences of locating the cure of psychic and behavioral disorder in patients' bodies. However, my aim is not to expose these practices as either "unscientific" or ineffectual. Science was and is historically and socially contingent, and to hold physicians of the 1900s to the 1950s up to a late twentieth-century ideal standard of science would be ahistorical and meaningless, except as an exercise in demonstrating the "progress" of current practice. Two useful concepts for understanding my point of view are efficacy and effectiveness. Derived from clinical epidemiology, effectiveness refers to how well a particular remedy performs in everyday clinical practice, while efficacy refers to how well a treatment does under controlled circumstances in clinical studies. Efficacy closely parallels what one would call a treatment's scientific basis. For the most part, I will take a given remedy's efficacy for granted. I make this odd statement (since few currently would be foolhardy enough to suggest that treatments such as insulin shock, lobotomy, and malaria fever therapy are efficacious) with a caveat or two. I do not mean that a particular remedy would be deemed efficacious today. By late twentieth-century standards, none of the treatments with the exception of electroshock therapy would hold up under scientific scrutiny. During their heydays, however, most of the therapeutic practices that are the subject of this book generally conformed to standards that constituted legitimate evidence for efficacy. 7 Leaving efficacy aside, then, my aim will be to explore the ways in which doctors and, to a lesser extent, patients constructed and reacted to what they judged to be effective remedies. In fact, this is a central theme of the

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5

book and goes to the heart of therapeutic practices, whether psychiatric or medical. While the determination of efficacy generally goes on behind the ordinary practitioner's back, he or she actively creates the treatment's effectiveness. A naive realist might object by arguing that a patient's biology and the physiological effects of the treatment account for what we think of as effectiveness. But what are we to make of the fact that doctors will use a remedy effectively for many years, and then, sometimes quite suddenly, that remedy becomes transformed, by a strange alchemy, into the therapeutic equivalent of fool's gold? Whether dethroned by additional scientific evidence or a new treatment, the now-discarded remedy undergoes reinterpretation by its practitioners. What they once thought were biological effects they now disparagingly attribute to their (or, more commonly, their predecessors') past ignorance and find that the old treatment no longer works and believe that it never "really" did. It is not that biology has suddenly changed. Rather, what has changed is the way doctors construct effectiveness. I am not arguing that therapeutic effects are entirely socially constructed. Instead, I am suggesting that whatever biological consequences a particular therapy has are mediated by and interpreted through the way doctors see disease and its cure, which are themselves determined by therapeutic practice. Looked at in this way, the "biological effects" of a treatment, though obviously important, assume a less important role in understanding the effectiveness of a particular remedy. This act of constructing and perceiving an effective therapy requires that doctors create a kind of rough-and-ready "therapeutic rationale" through which they can interpret their patients' signs and symptoms in the context of the proposed intervention.8 Acting as a conceptual filter, a therapeutic rationale organizes what physicians see as disease and its cure. In this way doctors structure signs and symptoms into treatable disease. Thus, for practitioners, disease and its treatment form an almost inseparable unit that mutually legitimates and reinforces the other's existence. Assuming a treatment "effectively" eradicates these signs and symptoms, both the reality of disease and the effectiveness (and thus "goodness") of the treatment are gloriously affirmed in the eyes of the doctor. With the somatic therapies of the first half of this century that this book explores, therapeutic rationales varied as different sites on the psychiatric patient's body became the loci of various treatments. My focus on therapeutic practices is part of a growing trend among historians. This interest was perhaps accelerated by Charles Rosenberg's lament in 1977 that most historians "have always found therapeutics an awkward piece of business" and "on the whole, they have responded by ignoring it." 9 Rosenberg himself has made significant contributions to our understanding of early nineteenth-century medical therapeutics. For early nineteenth-century physicians and patients, various treatments mediated a

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INTRODUCTION TO THE PSYCHIATRIC BODY

shared belief between d o c t o r a n d diseased r e g a r d i n g the nature o f illness. 1 0 M o r e recently, J o h n Harley Warner's The Therapeutic Perspective has provided a richly t e x t u r e d a c c o u n t o f o r t h o d o x physicians a n d their therapies in nineteenth-century A m e r i c a . 1 1 His work relies heavily o n medical records, w h i c h allow h i m to e x p l o r e the local c o n t e x t o f treatment practices. As his work illustrates, a doctor's professional, social, a n d intellectual identity is central to what a d o c t o r does to his or h e r patients. 1 2 W h e r e a s t h e r a p e u t i c s has o f t e n figured centrally in a c c o u n t s o f nineteenth-century psychiatry, the history o f twentieth-century somatic therapies, as A n d r e w Scull suggests, is "in its infancy." 1 3 T h e r e are two short studies o f limited value that deal exclusively with psychiatric therapies, o n e by W i l f r i d J o n e s a n d the o t h e r b y j . F. C a d e . 1 4 A l t h o u g h h e is primarily conc e r n e d with policy questions, Gerald Grob, in his n u m e r o u s works o n American psychiatry, does occasionally deal with biological therapies o f the twentieth century, p r o v i d i n g b a l a n c e d a n d u s e f u l , a l b e i t short, a c c o u n t s o f c o m m o n l y d e p l o y e d interventions. 1 5 W h i l e b e y o n d the c h r o n o l o g i c a l scope o f this work, Judith Swazey provides an informative a c c o u n t o f the history o f c h l o r p r o m a z i n e ( T h o r a z i n e ) . 1 6 N o w that a new g e n e r a t i o n o f antipsychotic d r u g s are b e i n g i n t r o d u c e d w h i c h show p r o m i s e o f g r e a t e r e f f i c a c y a n d f e w e r side e f f e c t s than c h l o r p r o m a z i n e a n d m e d i c a t i o n s d e v e l o p e d in its wake, perhaps we will see m o r e critical histories o f these o l d e r drugs. 1 7 T h o u g h f o c u s i n g o n l o b o t o m y , Elliot V a l e n s t e i n ' s Great and Desperate Cures is the most extensive published a c c o u n t o f twentieth-century biological therapies in psychiatry. 1 8 Understandably, given the terrain that his work covers, Valenstein's a c c o u n t contains a large dose o f m o r a l outrage. However, this same laudable stance fundamentally flaws his account. O n the o n e h a n d , h e sees practices such as l o b o t o m y as "bizarre a n d obsolete"; o n the other, h e does not fruitfully identify the m e a n s by w h i c h the "bizarre" was m a d e t h e r a p e u t i c a n d e f f i c a c i o u s f o r t h e m a n y physicians w h o readily d e p l o y e d these remedies. W h i l e he sees the rise o f l o b o t o m y n o t as an aberrant p h e n o m e n o n b u t as a "part o f the mainstream o f m e d i c i n e , " h e presents a mainstream that seems simply too alien a n d grotesque in its application o f science to have relevance as a m o d e r n cautionary tale. In the e n d , Valenstein claims that the necessary prophylactic to such unhealthy medicine is more, perhaps soberer, medicine: "It is essential that we minimize the h a r m caused by p r e m a t u r e claims o f cures, by u n b r i d l e d ambition, a n d by uncritically enthusiastic p r o m o t i o n . This e n d can be a c c o m p l i s h e d only by establishing p r o c e d u r e s f o r testing innovative t h e r a p i e s b e f o r e they are broadly u s e d . " 1 9 In contrast, J a c k Pressman's s o o n to b e p u b l i s h e d P h . D . dissertation, "Uncertain Promise: Psychosurgery a n d the D e v e l o p m e n t o f Scientific Psychiatry in America, 1 9 3 5 - 1 9 5 5 , " provides a history strikingly different f r o m

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7

Valenstein's.20 Clearly the most exhaustive history of lobotomy, "Uncertain Promise" argues for the importance of psychosurgery in the development of controlled clinical trials and lobotomy's "symbolic" function in the psychiatric profession's attempt to end its isolation from scientific medicine. Focusing on a broad range of annual reports, Pressman tries to show how lobotomy helped state hospital superintendents deal with the pressing clinical problem of the chronic mentally ill patient. 21 However, Pressman's account transforms lobotomy from a procedure of bizarre excess to a crucial part of psychiatry's scientific maturation: "It was precisely through numerous lobotomy investigations and extensive conferences that psychiatrists learned important principles of experimental design, confronting problems that could not be foreseen but had to be experienced." In his desire to avoid "characterizations [that] anachronisticallyjudge past efforts by current standards of scientific medicine," his account becomes, at times, simply a chronicle of psychiatric progress without critical regard for the consequences. 22

To uncover how doctors and, to a lesser extent, patients constructed their therapeutic world, this work relies heavily on patient records from California state hospitals. If one wished to study elite psychiatric culture, these archives would have little to recommend them. Most doctors at these institutions produced no scientific publications and practiced their craft in relative obscurity, although by the late 1930s increasing numbers of researchers from the University of California used the state hospitals as study sites. Records from these asylums, however, provide a remarkably clear window through which to observe how ordinary doctors and patients struggled, often with each other, to control and create meaning out of despair and madness. While my focus shifts between several institutional locales, depending on the therapeutic intervention in question, I have mined most extensively records at Patton State Hospital, located about sixty miles east of Los Angeles, and Stockton State Hospital, about fifty miles south of Sacramento. Since the case records from these two institutions provide the flesh and bones of my account, a short description of these documents might be helpful. Throughout the first half of this century the structure of the medical records remained constant. They commonly contained the following: transcripts of court proceedings to determine insanity, which most often included testimony from family members and police officers; a typed admission history usually three to ten pages in length; typed physician progress notes whose entries varied in frequency (daily to several per decade) and length (a single sentence to several pages); family questionnaires asking for

8

I N T R O D U C T I O N TO T H E PSYCHIATRIC BODY

the supposed cause of the insanity; letters to and from the patient; and verbatim transcripts of patient interviews. Although all the contents of the case records help create a detailed picture of state hospital culture and practice, the transcripts of patient interviews offer perhaps the richest yield. These interviews were produced in what were called "clinical case conferences." With a stenographer at the ready, physicians convened these conferences on a patient's admission, when a new treatment was u n d e r consideration, when a particularly perplexing clinical problem needed ferreting out, and when the patient was considered for discharge. Several staff physicians and often the hospital superintendent participated in questioning the patient. The presenting doctor would then dismiss the patient so that the staff members could discuss the interview and any necessary interventions. The interviews and the ensuing discussions allow us a vivid, if brief, glimpse of psychiatric practice and discourse and allow us to reconstruct the intersection of therapies, perceptions, and the doctor-patient relationship. Eventually heeding Erwin Ackerknecht's "plea" to pay closer attention to what doctors actually did, historians increasingly have f o u n d medical records to be a vital source by which to go beyond the peer review literature and explore the ways in which medical knowledge was implemented and reinterpreted in actual practice. 2 3 Nancy Tomes's work on Thomas Kirkbride and the Pennsylvania Hospital is a model study that relies heavily on patient records in its reconstruction of nineteenth-century asylum life from doctors' and patients' points of view.24 Other notable studies of nineteenthcentury psychiatric and medical practices liberally using patient records include Anne Digby's Madness, Morality, and Medicine, Ellen Dwyer's Homes for the Mad, and Warner's The Therapeutic Perspective.25 Not surprising, given thorny issues of patient confidentiality, few have had the opportunity to mine the rich archives of twentieth-century hospitals. Joel Howell's work on the introduction of a variety of medical technologies (such as X-ray machines and blood tests) into the New York and Pennsylvania hospitals, Cheryl Warsh's study of the Homewood Retreat in Ontario, and Elizabeth Lunbeck's examination of the Boston Psychopathic Hospital are notable exceptions. 26 It should be emphasized that the clinical narratives on which these histories (as well as my own) are based do not provide privileged access to "what really happened." In the case of California state hospital records, they were penned (or dictated) by doctors and had a variety of legal and bureaucratic functions. Most important for our purposes, they also served as doctors' collective diaries on medical life and were crucial in the construction of their clinical knowledge. 27 Thus they are best for revealing doctors' subjective realities. However, any inferences we make about how patients felt or the nature of the interactions between doctors and patients must take into

INTRODUCTION T O THE PSYCHIATRIC BODY

account the fact that first and foremost these records were created by and for physicians. Even the verbatim transcripts are not pristine "true" accounts, for the doctors' very presence, not to mention their often interrogating, adversarial style, colored their patients' responses. 28 Imbalances of power permeate these records in which authorial and real power over bodies and freedom was in the hands of the doctors. How somatic therapies reflected, reinforced, and embodied this imbalance of power between doctor and patient is another central theme explored here. Tomes suggests that historians should "move beyond the treatment-incarceration dichotomy." 29 While understandably wanting to move the history of psychiatry away from the excesses of the antipsychiatrists of the 1960s and 1970s, Tomes does point to the close alliance between treatment and control, which I believe is at the heart of many psychiatric practices of the twentieth century. Of course, this is all the more apparent in state hospitals where most had little choice in their fate as patients, the vast majority being hospitalized against their will. This indissoluble link between control and cure was summed up by a patient involuntarily committed to Stockton State Hospital in 1951: "The authorities placed me in the hospital. They thought I was sick. I believe it is immaterial; that the important thing is effect a cure to get me out of here." 30 The experience of being handcuffed, taken by police car, and then locked behind the walls of Stockton could not help but underline for this patient that incarceration was central to his cure. But involuntary hospitalization was only the beginning of a long journey into a land of both therapeutics and corporeal discipline. This relationship between discipline and therapeutic practice crops up throughout the book, and I use the phrase "therapeutic discipline" to convey three related meanings of this close interconnection. 31 The first is that therapies embodied specific sets of knowledge and scientific practice. The second is that somatic therapies were a means of corporeal control, a way of disciplining or eradicating undesirable/diseased behaviors via the body. Simply put, somatic therapies were ideal technologies for controlling irascible, resistive, incorrigible, destructive, disruptive, or violent patients. The third is that doctors saw these methods of control as unassailably therapeutic. These physicians "scientifically" and "therapeutically" disciplined their patients' bodies and minds with hydrotherapy, electroshock therapy, lobotomy, and clitoridectomy. With the exception of clitoridectomy, contemporary science legitimated all of these practices. "The new methods of power," to use a comment by Michel Foucault, were "not ensured by right but by technique, not by law but by normalization, not by punishment but by control." 32 Foucault's remark applies to our topic in that we will see how the social and cultural world constructed and

IO

INTRODUCTION TO THE PSYCHIATRIC BODY

was e m b e d d e d in psychiatric t h e r a p e u t i c s . In state hospitals w h e r e a patient's classification a n d p l a c e m e n t within them d e p e n d e d o n his or h e r behavior, the social world o f these institutions was e t c h e d especially deeply in somatic therapies that aimed at therapeutic discipline. A final t h e m e that threads its way t h r o u g h this b o o k is the m a n n e r in which these various remedies i n f l u e n c e d the interactions between doctors a n d patients. Analyzing the verbatim dialogues between would-be healers a n d the sick, I show how the doctor-patient relationship c h a n g e d with shifting therapeutic rationales a n d disciplinary objectives. However, the phrase "doctor-patient relationship" should b e a p p r o a c h e d with caution. As we will see, these were very h u m a n relationships. Doctors c o u l d be caring, spiteful, indifferent, cruel, or even loving. Patients, t h o u g h , were not passive. They, too, loved, hated, destroyed, a n d complied. 3 3 W h i l e the patients' voices are present t h r o u g h o u t this work a n d prevent us f r o m taking an overly sanguine view o f twentieth-century psychiatric therapeutics, we n e e d to r e c o g n i z e that they are o f t e n thin, barely a u d i b l e voices. Even w h e n heard, they are almost always refracted t h r o u g h the doctors a n d their interrogations. T h o u g h based o n transcripts o f a sixteenthcentury inquisition, Carlo Ginzburg's reconstruction o f ordinary peasants' c o s m o l o g y p o s e s similar m e t h o d o l o g i c a l difficulties. 3 4 L i k e the strange beliefs o f the benadanti witches, given voice only t h r o u g h the mediation o f the inquisitors' questions, o u r access to the patients' o f t e n fantastic beliefs c o m e s f r o m their interrogations by their physicians. As G i n z b u r g points o u t in a later work, while we may emotionally identify with the accused, intellectually we identify with the literate inquisitors, representatives o f the domi n a n t c u l t u r e o f w h i c h we are a part. 3 5 W h e t h e r they b e inquisitors a n d witches o f the sixteenth century or psychiatrists a n d patients o f the twentieth century, we are c o n f r o n t e d with similar tensions. I feel this tension acutely f o r professionally I am ambivalently a m o n g the ranks o f the inquisitors. I am a practicing psychiatrist, teaching psychiatric residents a n d medical students how a n d w h e n to prescribe the latest antidepressant a n d antipsychotic medications. In the n a m e o f therapy, I also deprive patients o f their f r e e d o m , f o r c i n g them (sometimes sedated or in h a n d c u f f s ) into the hospital. Scholars have increasingly r e c o g n i z e d that one's "countertransference" to his or h e r research affects not only the sorts o f questions asked b u t also how o n e interprets their sources, and my clinical perspective, n o d o u b t , has c o l o r e d the way in w h i c h I interpret these very intimate a n d p o i g n a n t episodes in the lives o f patients a n d physicians. 3 6 I also w a n t to m a k e a p e r s o n a l observation in this c o n t e x t . It is an early c h i l d h o o d m e m o r y that provides a c o n v e n i e n t c o n d e n s a t i o n o f my relationship to this history a n d my sources. My father, a surgeon, served a brief stint at Camarillo State Hospital in the 1950s. Clearly c o m m i t t e d to his calli n g — f o r h e g e n u i n e l y b e l i e v e d that t h e r e c o u l d b e n o h i g h e r f o r m o f

I N T R O D U C T I O N T O THE PSYCHIATRIC BODY

n

humanitarian service than treating the sick—he often talked about his surgical feats, some of which came from his experiences at Camarillo. O n e of his favorite stories, perhaps because of his brush with fame, recounted Walter Freeman teaching him how to perform a transorbital lobotomy. 3 7 With a certain a m o u n t of flair and drama he described the procedure: " O n e takes a thing that looks just like an ice pick and positions it right above the eye. Using a hammer, the pick is p o u n d e d into the skull. T h e n ping!!! the bone breaks e n o u g h to let the ice pick slide easily into the patient's brain. You then swing the pick back and forth, cutting the nerves that connect to the front of the brain. That's it." For my father, this memory and its recitation reaffirmed his skills as a surg e o n and his belief in himself as a healer; even in spite of lobotomy's infam o u s history, he tells the story with pride. For me, the story was m o r e ambiguous. O n the one hand, I f o u n d myself wanting to identify with him as a physician, and, later on, my decision to become a doctor was motivated by a positive identification with him. O n the other hand, the tale increasingly perplexed me; I wondered how my father's desire to heal coexisted with his performance of this seemingly mutilating operation. T h e following history aims at understanding this contradiction. In the very human and often tragic dramas that lie before us, I try to give voice to both doctors and patients in order to c o m p r e h e n d the meaning of often seemingly incomprehensible and, at times, reprehensible acts.

Chapter 1 provides the institutional context within which doctors and their somatic therapies operated. Focusing on Stockton State Hospital, this chapter describes what life was like in such gargantuan institutions—who lived, worked, and died in them and how the hospitals changed over the first half of this century. As we will see throughout this book, these facts profoundly influenced what doctors counted as disease and its cure. Chapter 2 inaugurates the discussion of somatic therapies and focuses on the use of hydrotherapy from its introduction in the early 1900s to the 1950s. Doctors' use of hydrotherapy marks the earliest twentieth-century use of the body as the primary site of therapeutic intervention for psychiatric distress. In contrast to handcuffs, camisoles, and straitjackets, hydrotherapy demonstrated, for doctors but not patients, that the control of behavior was therapeutic. T h o u g h not commonly thought of as a therapeutic intervention, sterilization is the focus of chapter 3. In this chapter I show how physicians transformed this technology of negative eugenics into a medical therapy aimed at treating individual patients. T h e first Nobel Prize-winning psychiatric intervention, malaria fever therapy, is the topic of chapter 4. Called the "friendly fever" in the popular press, it was the first widely successful treatment for a form of neurosyphilis called general paralysis of the insane. O n e

12

I N T R O D U C T I O N T O T H E P S Y C H I A T R I C BODY

of the few psychiatric disorders with a known etiology, general paralysis was also quite common and usually fatal. Relying on records from Patton State Hospital, I show how this therapeutic intervention drastically changed both the doctor-patient relationship and the way in which doctors and patients perceived disease. Despite the admittedly paradoxical nature of injecting malaria parasites into the blood of patients, this remedy gave rise to some surprising transformations in how doctors described and interacted with their patients. The only remedy currently in use that finds its way into this history is electroshock therapy, the topic of chapter 5. Exploring the variety of therapeutic rationales that doctors used in shocking the patients, this chapter brings us back to Stockton State Hospital, where we will stay for the remainder of the book. I argue that these physicians believed that, despite its status as a somatic therapy, electroshock therapy acted on the mind as much as the body to produce its beneficial effects. Equally effective as a treatment for depression as for uncontrollable behavior, electroshock therapy was used for a host of purposes ranging from corporal discipline to the alleviation of despair. Electrotherapeutic practice charted a complex and tortuous path between discipline, disease, the mind, and the body. Although electroshock therapy traversed a circuitous route connecting psyche and soma, lobotomy directly located psychiatric disease within the brain, creating for physicians at Stockton not only their most biological of remedies but also their most effective means of therapeutic discipline yet. Chapter 6 chronicles the history of lobotomy at Stockton from its introduction in 1947 to its abrupt cessation in 1954. Perhaps a sad consequence of placing too much faith in the body as a source of disease and a site of cure, doctors' use of lobotomy illustrates the extent to which a biological therapy can be a social technology, though for practitioners themselves it was simply a somatic therapy combating a brain disease—far removed from the social world. Locating the cure of behavioral disorders within the brain itself had especially untoward consequences for psychiatric patients, and, as with previous interventions, the institutional setting played a decisive role in determining what doctors deemed disease and its surgical cure. Chapter 7 ends the story of lobotomy at Stockton. In it we will find women's brains and genitalia as especially fertile sites for the surgical application of therapeutic discipline. This book ends with a crescendo of increasingly invasive and destructive technologies of control. Should we hope that these practitioners and their practices were aberrations in the march of medical progress? Certainly if these doctors had acted out of malice and a sadistic desire for control, it would be easier to dismiss them as simply evil. We could be reassured that these physicians and their remedies have little in common with present-day

I N T R O D U C T I O N TO T H E PSYCHIATRIC BODY

13

practices. But this history does not provide us with this solace, for we will find no villains in what follows. Acting in the name of therapy, these practitioners, often with tragic consequences, were bound to ways of seeing and being not of their own choosing. Andrew Scull comments that we "need to ask ourselves what it is that appears to make the mentally ill so vulnerable to therapeutic experimentation—often, as it subsequently transpires, of a singularly harmful sort. " 3 8 We also might ask what it is that makes physicians so capable and eager to mete out such harmful interventions on those whom they are charged to care for. This history o f patients, doctors, and their somatic therapies answers how it comes to be that doctors transform the harmful into the "therapeutic."

CHAPTER

ONE

Institutional Therapy: Context, Background, Structure I like it here. I have had good treatment. — PATIENT,

PATTON

STATE

HOSPITAL

(1937)

Places like this [are] where civilization buries its mistakes. — ANONYMOUS

STOCKTON

STATE

HOSPITAL

PHYSICIAN

(ig22)

On the outside, the individual can hold objects of self-feeling—such as his body, his immediate actions, his thoughts, and some of his possessions—clear of contact with alien and contaminating things. But in total institutions these territories of the self are violated; the boundary that the individual places between his being and the environment is invaded and the embodiments of selfprofaned. — ERVING

GOFFMAN,

ASYLUMS

(1 g6 1 )

Everything done to, for, or around a mentally inpatient in a California hospital can be considered as therapy since therapy is the ultimate purpose of everything done. — FRANK TALLMAN,

DIRECTOR,

OF M E N T A L

CALIFORNIA

HYGIENE

DEPARTMENT

(1952)

Considered together, the four quotations above embody a range of contradictions inherent in state hospital care. The first, spoken by a patient at the end of her hospitalization, reminds us that some patients did in fact find solace in the asylum, despite the popular conception that state hospitals produced more misery than cures.1 The second was penned by an obviously exasperated physician who unintentionally betrayed his ambivalence toward his charges.2 Although he decries society's neglect of the insane, he cannot help but see them as "mistakes" nonetheless. In the third, Erving Goffman outlines the oppressive features of what he called "total institutions." 3 Like prisons, Goffman saw state hospitals as paradigmatic total institutions in which all aspects of daily life are repressively regulated. In contrast to Goffman's point of view, the final epigraph underscores the therapeutic importance that physicians attached to the institutional milieu.4 For them, these "total institutions" were, above all else, "therapeu14

INSTITUTIONAL THERAPY

75

tic." Patient, doctor, social critic, and bureaucrat all described contradictory, though equally true, features of state hospital life that resound throughout this book and that indelibly shaped doctors' use of somatic remedies. Those acts aimed directly at the body are the focus of the remainder of this work; "everything [else] done to, for, or around" the psychiatric patient is the focus of the present chapter. What follows can be thought of as the scaffolding on which doctors and patients constructed the therapeutic building described in the subsequent chapters. To understand the context in which somatic therapies were carried out, I briefly explore the history of the California state hospital system in general and in more depth the history and structure of Stockton State Hospital. A BRIEF H I S T O R Y OF C A L I F O R N I A STATE H O S P I T A L S T h e Euphemia, a British brig captured in the War of 1812, was bought by the city of San Francisco in 1849 to incarcerate the city's burgeoning population of criminals and madmen. T h e Euphemia, however, had a shortlived career as a solution to the city's growing population of insane. By 1851 wharves and other structures had encircled the Euphemia, virtually landlocking the decrepit ship and leading the town council to raze her. Less than a year after statehood, in April 1851, the state legislature established for the physically and mentally disordered three general hospitals located in Sacramento, San Francisco, and Stockton. In 1853 the legislature rescinded state f u n d i n g of general hospitals, leaving this responsibility to the counties, and authorized the hospital at Stockton to care exclusively for the insane, renaming it the California Asylum for the Insane at Stockton. Located eighty miles east of San Francisco in California's largest inland port that supplied the gold mines of California and Nevada, the hospital grew rapidly, so rapidly in fact that in 1875 the state erected an additional asylum in Napa to accommodate the seemingly endless supply of the insane, most of whom were men (consistent with the demographics of late nineteenth-century California where men outnumbered women). 5 T h e Napa institution, located in a rural community about seventy miles north of San Francisco, also quickly overflowed with patients, necessitating the construction of additional asylums: Agnews in 1888, M e n d o c i n o in 1893, Patton in 1893. In the first half of the twentieth century, an additional four hospitals were built: Norwalk in 1916, Camarillo in 1936, De Witt in 1946, and Modesto in 1947. A variety of agencies oversaw these institutions. Initially, they were administered by independent hospital boards. From 1887 to 1920 the

16

INSTITUTIONAL THERAPY

Commission in Lunacy acted as the primary state regulatory agency over these hospitals. The State Board of Charities and Corrections, created by the legislature in 1903, made periodic reports on the conditions and needs of the state hospitals until its dissolution in 1923. In 1920 the Department of Institutions was created to take over the administration of the state hospitals, reformatories, and homes for the blind. In 1945 the Department of Institutions was renamed the Department of Mental Hygiene. 6 T h e history of California's asylums is not unique. Beginning in the late eighteenth and early nineteenth century, states throughout America began constructing insane asylums and, like California, found that the more institutions they built, the more they needed. At the beginning of the twentieth century a total of 131 state-funded asylums were in existence, and by 1941 the number had increased to 181. The number of patients increased even more dramatically, from 1 2 6 , 1 3 7 in 1903 to 4 1 9 , 3 7 4 in 1 9 4 1 . 7 Pauline Carter was one of these patients. Admitted to Stockton in the early 1920s, she spent nearly half of the twentieth century as a patient there. Her history is typical of thousands of patients, and her medical record can help guide us through some of the common features of state hospitalization. So let us follow her into the asylum. PATHS T O THE ASYLUM Born in the desert of the Southwest, Pauline had lived an unremarkable, though dreary, life. Pauline, her older sister, and her mother fended for themselves, long before she would be old enough to recall any memories of the father who deserted them. T h e mother then moved what remained of the family to San Francisco, hoping to build a better life for herself and her young daughters. Unfortunately, Pauline's mother had difficulty supporting her daughters, and Pauline quit school at the age of ten so that she could work to supplement the family's meager resources. After nearly twelve years of factory work she married Jack Carter. While her marriage to Jack liberated her from the drudgery of the factory, she always felt stifled by Jack's mother, who lived with them throughout their marriage. Pauline would complain bitterly that her mother-in-law often found fault with her cooking and housekeeping. Two children, eight years apart in age, also added strain to Pauline's fragile inner equilibrium. In the winter of 1920 Pauline's emotional life inexplicably disintegrated. She became convinced, according to the "affidavit of insanity," that a plot had been hatched by her neighbors to murder her. In retaliation for their evil designs, she not only threatened to poison their infant child but also planned to set their house on fire. Although Pauline would subse-

INSTITUTIONAL THERAPY

17

quently deny these claims, the damage had been done. Jack, frightened she would make good on her threats, filed a "complaint of insanity" with the local magistrate. The affidavit declared her "so far disordered in mind" as to constitute a danger to herself and others. After a warrant on the charge of insanity was issued, she was taken into custody, briefly examined by two physicians, and then formally committed by a superior court judge. Immediately after her commitment, a sheriff handcuffed Pauline and escorted her from the county courthouse to Stockton State Hospital. She was barely thirty years old when she was irrevocably stamped as a psychiatric patient. Throughout the first half of the twentieth century, most patients traveled the same path in their journey to the state hospital. Commitment usually began with someone, most often a family member, filing a complaint of insanity against an individual, which resulted in a magistrate issuing a warrant for the alleged insane. Studying commitments from the County of San Francisco between 1906 and 1928, Richard Fox, in So Far Disordered in Mind, found the following people, in decreasing order of frequency, filing petitions: relatives, doctors, police, friends, neighbors, relief home administrators, charity workers, and employers. 8 In most instances the future patient was then incarcerated while he or she awaited first an examination by two court-appointed physicians and then a trial. The form of detainment varied dramatically from county to county. Counties such as Los Angeles and Santa Barbara provided hospital quarters, either in separate buildings or in specially created wards, staffed by trained nurses. These accommodations provided at least the appearance of medical treatment. At the other end of the spectrum, soon-to-be patients were simply jailed until their eventual commitment in a state hospital. In Sacramento County, for example, although the county hospital had a psychopathic ward, it was simply too small to use, and most potential patients were jailed prior to being taken to Stockton State Hospital. Describing conditions throughout the state in 1916, a member of the State Board of Charities and Corrections wrote, "According to the law, the mentally ill while awaiting 'trial' are entirely in the hands of the sheriff or his representative, and, except in a few counties, patients are actually detained in jails or in worse places, such as basements, attics, out-houses, isolated shacks, etc. These places in many counties were found to be neglected, unsanitary, even filthy, and in several instances bad fire traps. . . . A favorite custom in jails is to put insane patients in the 'misdemeanor tank' to be cared for by such vagrants and petty criminals as happen to be in prison. (The present law passed nearly twenty years ago expressly forbids detention of insane persons in jail)." 9

i8

INSTITUTIONAL THERAPY

As late as 1929 the majority of the fifty-eight counties of California continued to furnish little more than goals for the detainment of the insane. 10 Regardless of where he or she was detained prior to trial, the newly committed patient, often in shackles with steel cuffs or leather restraints, was transported by a sheriff to the state hospital. Echoing the sentiments of most physicians on California's commitment procedures, a physician at Stockton State Hospital, Frederick Marnell, wrote, "It is indeed barbaric that a man who happens to be mentally sick should be arrested and tried in a court of justice as if he had committed a crime, when a man with typhoid fever, who is probably in a worse mental condition than the man arrested for insanity, is picked up without ceremony and taken to the nearest hospital and treated as he should be." 1 1 B E C O M I N G A PATIENT Remember when writing a history you are not taking it for yourself but for the hospital and fifty years hence. R. B. T O L L E R , PHYSICIANS'

MENDOCINO MANUAL

STATE

HOSPITAL

(UNDATED)12

Like all newly admitted patients, Pauline was brought by the sheriff to the receiving and treatment building where she would stay for the first several weeks in her new life as a psychiatric patient. The receiving and treatment hospital, or "R. H." in hospital slang, served as the evaluation and distribution center for new patients. It was built with a $55,000 appropriation from the legislature in the late 1900s and a good bit of patient sweat (for patients did much of the manual labor), and Stockton's superintendent from 1906 to 1929, Fred Clark, envisioned it as the core of the hospital's modern medical regimen. In the 1 9 1 0 Commission in Lunacy Biennial Report, Clark enthused, "The indigent insane receive the same treatment that is accorded the man of means at the most fashionable and expensive health resort. Operating this building has increased the cost of maintaining the institution but eventually it will mean a great saving, as many patients are now able to return to their families after a few weeks' treatment and thereby save the State the expense of maintaining them for months and perhaps years as was formerly the case." 1 3 Unfortunately for Pauline, her "treatment" in R. H. did little to cure her madness despite the efforts of her first physician, Dr. Marnell. Marnell first met Pauline several days after her admission. She did not leave him with a particularly favorable impression of her prognosis. His relatively brief admission history of three single-spaced typed pages (many histories contained up to ten pages of single-spaced typed text) leaves litde doubt that Marnell believed her to be severely disordered, and he found a

INSTITUTIONAL THERAPY

ig

number of clues that pointed toward her madness. First, she disputed all charges on the commitment papers. "She denies," Marnell wrote, "having attempted to poison an infant, says this is the first time she ever heard of it." He added that she "denies threatening to set fire to anything and says she never threatened to harm anyone." Second, she performed badly during the interview, doing little to assist Marnell in his efforts to diagnose her psychic ills: "Patient cooperates poorly in this examination and is confused and irrelevant in her statements." Third, her cognitive abilities, according to the doctor, seemed awry. She was unaware of what city she was in, although she did know that she was in a hospital; she could perform calculations only with extreme effort; and she believed that Columbus had discovered America in 1 3 9 1 . Perhaps the most damning piece of evidence was her complete lack of insight into her predicament. According to Marnell, "She does not think her mind is affected, she did not see any crazy people . . . here." Marnell's and his colleagues' written evaluations changed little over the first half of the twentieth century. Titled "Admission History," "Mental Examination," or "Anamnesis," these documents were meant to display the tentative diagnosis arrived at by the examining physician. The documents contained the following categories: "general behavior," "stream of mental activity," "general mental attitude," "retention," "orientation," "recent past," "family history," "personal history," "present history," "grasp," "calculation," "insight," and "judgment." While these divisions emphasize the scientific and clinical nature of the evaluations, they read more like short, tendentious detective stories. Instead of clues that point to a murderer, though, these narratives contain scattered hints, leads, and suggestions intended to help the reader see the same "truth" as deciphered by the interviewing physician. The stories build to a predictable climax when the physician ends the report with the name of the disease, which, if the history was properly written, should by then be obvious to the reader. Reiterating Pauline's lack of cooperation, Marnell concluded his report with the fruits of his detective work: a diagnosis of manic depression, depressed form. Next, Pauline, like most newly arrived patients, was interviewed in the "clinical conference." In these conferences, which were convened three times a week and attended by most of the doctors and a stenographer, physicians determined the diagnoses of newly admitted patients, the courses of treatment for difficult patients, and whether to discharge patients. The structure of the conferences remained fairly constant irrespective of the doctors' aims. First, the ward physician presented the patient's history, often reading from the chart. Then the patient was escorted in and questioned. Although any of the physicians present might ask questions,

20

INSTITUTIONAL THERAPY

generally only two or three actually participated in the interview. When sufficient information for either a diagnosis or a treatment decision had been gathered, the patient was dismissed and discussion among those physicians present ensued. The conferences ended with a final diagnosis or treatment decision that was typed on the top of the first page of the transcripts of the proceedings. As with physicians today, these state hospital doctors demonstrated a wide range of interviewing styles that were shaped by the exigencies of the interview. Driven by the paramount goal of ferreting out the nature of Pauline's madness, Fred Conzelmann, a ward physician, lost any semblance of rapport with Pauline as she became increasingly exasperated with his queries. Conzelmann: You took milk in your mouth and then spit it back in the nurse's face when you came here? Pauline: I did no such a thing. Conzelmann: You told the doctor. Pauline: You aren't speaking to an idiot, sir. Conzelmann: How about thinking your f o o d was poisoned? Pauline: No, sir, I never thought any such a thing.

The interview went from bad to worse, becoming more like an interrogation, when another doctor demanded, "Whose baby was that you tried to poison?" As Pauline angrily got up from her chair, Conzelmann ordered "Just sit down," and she apparently complied. In the final minutes of the examination, Conzelmann asked, "Do you like your husband?" Underlining her displeasure at the grilling, Pauline replied, "He has a little bit more sense in his questions than you have." I believe that Conzelmann's singleminded aim of arriving at a diagnosis led to this rather disastrous interview in which, above all else, Conzelmann and his colleagues needed to unearth and classify Pauline's madness. This foreshadows a similar process that we will see in subsequent chapters when therapeutic practices, instead of the desire for diagnostic certainty, shape the interactions between doctors and patients. DEMOGRAPHIC

CHARACTERISTICS

Interactions between doctors and patients were profoundly influenced by the fact that there were large numbers of patients but few physicians to care for them. This massive state hospital patient population was characterized by an ever-increasing number of admissions per year. For example, in 1922, the year that Pauline became a patient, there were 555 first admissions to Stockton. Thirty years later the number of Stockton first admissions had nearly doubled to 1,030. 14 To make matters worse, this rise in admissions

INSTITUTIONAL THERAPY

21

Date

Figure 1. Stockton Resident Patient Population, 1910-1955

was not accompanied by a similar rise in discharges so that the total resident population increased rapidly (see fig. 1). 1 5 The total number of patients residing in all of California's state hospitals grew even more quickly than did Stockton's resident population. Between 1910 and 1955 the total resident population increased more than fivefold, from 6 , 8 6 4 t o 36,403. 16 This spectacular growth, however, reflected not an increasing rate of insanity in the Golden State but the boom in its population. This is shown in figure 2, which plots the resident patients per 100,000 of the general population from 1910 to 1955. Despite wide fluctuations with declines after World War I and World War II and a sustained rise during the Great Depression, the rate averaged around 300 patients per 100,000 of the general population throughout this period. 17 T h o u g h four additional state hospitals were built between 1916 and 1947 and wards, cottages, and larger structures were added at existing sites, superintendents were unable to keep up with the burgeoning resident population until the 1950s. In 1910, for example, medical superintendents estimated that 300 to 400 patients slept on corridor floors. 18 Superintendents reported in 1912 that many wards designed to house 40 patients

22

INSTITUTIONAL THERAPY

Date Figure 2. Resident Patients per 100,000 of the General Population, 1910—1955

frequently had as many as 120. 19 "Although we are constantly enlarging our institutions," wrote the State Board of Charities and Corrections in 1918, "we never seem to be able to provide enough room. . . . One of the most depressing sights that meets a visitor is that of long rows of patients, hundreds, perhaps, in number, seated side by side, their chairs often touching, through the long hot summer days, in dark corridors. Such an existence would seem enough to drive a normal person insane." 20 Like patients at the other state hospitals, those at Stockton often found themselves sleeping on cold, hard floors and in drafty corridors. In 1920, 115 patients lived without permanent rooms, usually sleeping in hallways.21 Using a standard of 500 cubic feet of airspace per person, superintendents quantitatively measured this human misery, which they expressed as a ratio of "excess" population to the calculated "normal" or ideal capacity.22 Estimated overcrowding at Stockton peaked in 1937 at 33 percent. 23 A massive postwar spending and construction spree by the state considerably improved conditions so that by 1955 calculated overcrowding had decreased to a mere 1.8 percent. 24 Interestingly, as conditions for patients improved at Stockton, doctors introduced their most invasive and permanently destructive therapeutic interventions. I will have much to say about this in subsequent chapters. As one would expect, patients in California state hospitals tended to be poor. Pauline's family, for instance, was unable to afford the $20 per month that the state charged for hospitalization. Indeed, the vast majority of patients were unable to pay this sum, most being classified on admission as economically dependent or marginal. 25 In contrast to frequently recording

INSTITUTIONAL THERAPY

23

their patients' economic conditions, physicians tabulated their patients' racial classifications only briefly between the late 1940s and early 1950s. During this period the racial composition of the resident patient population roughly approximated that of the general population. 26 This relative indifference to race was due, at least in part, to the fact that a patient's race had scant institutional import (wards were not racially segregated) and no therapeutic significance. Gender turns out to be more complicated than race. Not only did doctors segregate wards based on patients' sex, but, as we will see in chapters 3 and 7, doctors treated women and men differently when it came to sterilization, lobotomy, and sexual surgery. Like race, however, an individual's sex made little difference as to whether or not one was admitted to the hospital, for gender distributions within California state hospitals roughly approximated the state's demographics. As can be seen in figure 3, male admissions outnumbered female admissions throughout the entire first half of the twentieth century. 27 Men also constituted the majority of resident patients. Taking Stockton as a typical example, men comprised 59 percent of the resident population in 1920. 28 The number rose to 61 percent in 1930 and then slipped to 57 percent in 1940 and 55 percent in 1950. 29 The import of these distributions will become clearer as we explore the interface between body, mind, and therapeutics in subsequent chapters. The therapeutic significance of an individual's psychiatric diagnosis varied, depending on the intervention in question. Sometimes diagnosis was crucial (as in the case of malaria fever therapy and lobotomy), while in other instances it was inconsequential (as in the case of hydrotherapy and electroshock therapy). Discussion of these differences will have to await future chapters. For now, let me simply enumerate the most common diagnoses doctors made. These were dementia praecox (or schizophrenia), manic-depressive insanity, general paresis (a late stage of syphilis), and disorders associated with aging (psychosis with cerebral arteriosclerosis and senile psychosis). Dementia praecox and manic-depressive insanity were the most common diagnoses, accounting for 25 to 50 percent of first admissions. 30 In a 1932 California state hospital training manual, manicdepressive insanity was defined as follows: This group comprises mental disorders marked by emotional oscillations and a tendency to recurrence throughout the life of the individual. The manic type is characterized by feelings of well-being, flight of ideas and overactivity. The depressive type manifests a feeling of mental and psychical insufficiency, a despondent, sad or hopeless mood, and in severe depressions, retardation

24

INSTITUTIONAL THERAPY

1910

1920

1930

1940

1950

Date Figure 3. Statewide Sex Distribution of All Admissions, 1 9 1 0 - 1 9 5 0

and inhibition. In some cases it comes on in middle life, may be diagnosed as INVOLUTIONAL MELANCHOLIA. 3 1 " D e m e n t i a p r a e c o x , " the m a n u a l c o n t i n u e d , "develops in individuals leading a seclusive, shut-in type of e x i s t e n c e . " T h e m a n u a l w e n t o n to give the c o m m o n l y a c c e p t e d t a x o n o m y of d e m e n t i a p r a e c o x . They develop peculiar trends of thought, fantastic ideas, with odd, impulsive or negativistic conduct. We have the PARANOID type with delusions of persecution; the CATATONIC type who may be negativistic or mute; the HEBEPHRENIC type showing a tendency to silliness, grimacing, mannerisms in speech and action and the SIMPLE type characterized by defects of interest with the gradual development of an apathetic state without delusions or hallucinations. These patients live in a make-believe world of their own, and it is not unusual to find Napoleon Bonaparte or Julius Caesar working on the garbage wagon or in the pig pen, or Mary Queen of Scotts scrubbing and cleaning in toilet or water section. 32

INSTITUTIONAL THERAPY

25

Given that dementia praecox was considered to be the most chronic and unremitting of psychiatric disorders, it is not surprising that patients of this category predominated as state hospital residents. Statewide, slightly over 50 percent of resident patients had this diagnosis. This proportion changed litde over the years for which data are available. In 1936, 53 percent of patients residing in state hospitals had a diagnosis of dementia praecox, and in 1955 the percentage remained virtually unchanged. 3 3 The diagnostic distribution of resident patients at Stockton in 1949, the only year for which published data exist, was as follows: dementia praecox, 48.9 percent; psychosis with cerebral arteriosclerosis and senile psychosis, 17.7 percent; and manic-depressive psychosis, 4.4 percent. 34 These percentages probably changed only slowly over time, given that the average length of hospitalization was over five years and more than a quarter of the resident patient population was hospitalized for over ten years. 35

DOCTORS A physician in charge of wards is responsible for the proper handling of the patients on his or her wards in all details (this covers use of restraint, seclusion, care of the sick, use of hydro baths, etc.). . . . He shall see that they are properly fed and clothed and afforded entertainment as is possible, and that the work asked of them is suitable to each individual case. . . . He is to use tact and judgment in personal contact with patients and encourage them in every way. R. B. T O L L E R

(UNDATED)3®

Physicians often found it difficult to live up to Toller's exacting standards since a relatively few doctors were charged with caring for thousands of patients. For example, in 1930 there was one California state hospital physician for every 346 patients. Nationwide, the doctor-patient ratio was somewhat better: one physician for every 268 patients. 37 Compared to other California state hospitals and those throughout the United States, Stockton physicians were even more overburdened. Again taking 1932 as an example, seven Stockton physicians cared for more than 3,200 patients, roughly 460 patients per physician. 38 By 1940 an additional five physicians were hired at Stockton, which decreased the number of patients per physician to 366. A decade later the number of patients per physician dropped to 274. Four years later, in 1954, it fell even further, to 247 per physician. 39 Returning to Pauline, we find that her case record reflects this dearth of physicians. At first Pauline's doctor penned monthly notes, though they were short and perfunctory. T h e entry for July 5, 1921, is typical: "Came

26

INSTITUTIONAL THERAPY

here she says on a search warrant—asked why, replies for disturbing people of Manteca—asked if she thinks she were insane, replies 'I most respectfully do not'—denies she disturbed anybody—says she was off her premises only twice in one year—adds 'I was arrested—Citizenship papers—and detention stamps'—thinks her husband is included." 40 From 1922 to 1926 Pauline's physicians did not write a single entry in her record. A brief note in the fall of 1 9 2 6 tells us she is still alive and "very incoherent." The depression and World War II came and went with virtually no mention of Pauline's mental state. Given the overwhelming numbers of patients relative to doctors, Pauline's descent into the chronic class of the insane predictably received scant documentation by her doctors. In the chapters that follow we will see not only the effects that so few doctors had on the doctorpatient relationship but also the way in which this ratio influenced what counted as "good" therapy. Obviously, those interventions that physicians could give quickly and on a mass scale, such as electroshock therapy, were more likely to be introduced and to survive than labor-intensive interventions such as the talk therapies. ATTENDANTS All patients here are to be considered as definitely mentally sick and, therefore, not responsible for their acts. Patients may curse you, spit at you, strike or scratch you, bite or pull your hair. If you are not so constituted that you can accept such treatment from an insane person without retaliation in word or deed, a hospital for the insane is no place for you, and you should find other employment. . . . While the law excuses violence on the part of patients, it does not excuse it on the part of employees. —

R. O.

LEBARON,

CALIFORNIA

STATE HOSPITAL

PSYCHIATRIST

(1 g 3 2 )

4 1

In contrast to physicians and patients, attendants will appear rarely in this book. 42 That is not to say they were incidental to the running of state hospitals or to patients' experiences. To the contrary, "attendants and patients," in Gerald Grob's words, "were in constant contact, and the interaction between them generally shaped the character of the institution." 43 Responsible for the day-to-day management and control of patients, attendants far outnumbered any other class of state hospital employees. In 1930, the first date for which statistics are available, 2 3 3 attendants were employed in direct clinical activities at Stockton State Hospital, giving a ratio of one attendant for every 14 patients (compared to the California average of 13.4). 4 4 If all attendants are considered, including those engaged in nonclinical activities, the average ratio for California state hospitals considered together drops to one attendant for every 1 1 . 3 patients, which compared favorably to the similarly derived national average of one

INSTITUTIONAL THERAPY

27

attendant for every 1 1 . 7 patients.45 Despite the depression, the number of attendants employed in California state hospitals increased more rapidly than did the resident patient population. For example, in 1940 there was one attendant for every 10.7 patients.46 World War II wreaked havoc on the number of attendants in California state hospitals. In 1944 the Department of Institutions budget authorized an attendant-patient ratio of about 10. However, the actual ratio was far above this. Of the 4,283 positions available in the California state hospital system, 704 positions, most of which were designated for attendants, went vacant because of the severe labor shortage in wartime California. 47 Postwar prosperity dramatically improved the situation so that by 1954 the proportion of authorized positions for attendants to patients statewide had fallen to 6.3, and at Stockton to 5.4. 48 Although the actual (compared to authorized) ratios were no doubt higher than these, conditions had nonetheless significantly improved from their wartime low.49 In his perceptive study of the social structure of Stockton State Hospital in the late 1950s, Thomas Scheff observed that attendants saw little difference between control and therapy.50 "The staff," Scheff writes, "found it difficult to differentiate between the rehabilitation and control functions of treatment. A patient who opposed the staff, who wouldn't work or follow orders, was sick and therefore needed treatment. . . . The staff not only spoke as if they were treating the patient for his ills, but generally believed it also." 51 For them, maneuvers that restored order were inherendy therapeutic. This belief in the therapeutic value of control, as we will see in the following chapters, was firmly established and legitimated by physicians themselves and their somatic therapies.

T H E T H E R A P E U T I C S OF DAILY L I F E The efficiency of the ward can be judged to some extent by the number of patients working. Idle patients on a ward is an indictment ofpsychiatric nursing. —R.

B. T O L L E R

(UNDATED)52

State hospitals, places where people were born, lived, labored, and died, encompassed nearly every facet of twentieth-century daily life, and a full description of patients' everyday lives is beyond the scope of this book. 53 Two aspects of hospital existence do bear directly on the relationship between therapeutics and discipline, namely, patient labor and ward structure. Let us first look at the way in which state hospitals structured their wards. Though one could imagine a variety of ways in which doctors could

28

I N S T I T U T I O N A L THERAPY

have organized thousands of psychiatric patients (such as segregating them according to diagnosis), they most commonly assigned a patient to a given ward based on that individual's behavior. Irrespective of diagnosis, a patient's ability to conform to hospital's rules determined his or her location within the institution. This literally transformed a patient's socially desirable or undesirable actions into the physical reality of the ward. By reifying behavior, this ward system sanctioned the control of behavior as the major measure of therapeutic effectiveness. At Stockton, the receiving and treatment hospital acted as a kind of clearinghouse: patients were observed and then assigned to a ward based on how well they had behaved themselves thus far. For example, Pauline stayed there for three weeks before her physician decided that she had gleaned enough information to transfer Pauline to Cottage A (in hospital shorthand, ward C-A), which would be Pauline's h o m e for the next thirty years. Unfortunately for Pauline, ward C-A was a "chronic quiet" ward where few patients were ever expected to recover. Other wards at Stockton included those for the "acutely excited," the "chronically disturbed," the "depressed," and, if their behavior or prognosis merited it, the "convalescing." The ward system also reflected and, sometimes, determined a patient's prognosis. As suggested by Pauline's fate after her transfer to C-A, those sent to chronic wards, even if "quiet and agreeable," as Pauline was often described, had little chance of recovery. Nonetheless, wherever a patient might find himself or herself, the ward system charted the patient's improvement or deterioration as he or she traveled from the acute to the chronic or convalescent wards. Since physicians only discharged patients from the convalescent or "front" wards, this classification scheme and architectural sorting helped enforce "healthy" or compliant behavior in those who wished to leave the hospital. On individual wards physicians enforced compliance and good behavior through a system of gradually earned privileges that they could revoke when necessary. Doctors rewarded their "better patients" by giving them increasing f r e e d o m of movement within the grounds of the hospital. Ground privileges at Stockton ranged from close supervision with groups of patients to complete autonomy during daylight hours. 54 This system of ground privileges was buttressed by the ward system itself. On the "chronically disturbed" wards, patients who had achieved the pinnacle of good behavior were allowed only a couple of hours of free movement around the hospital grounds, while those patients on the f r o n t wards, if they proved themselves to be well behaved, were given complete independence during the day.

INSTITUTIONAL THERAPY

29

Patient labor played an important part in this system of privileges. Those patients who had proven themselves the soundest in mind and hence the best behaved were given the most sought after jobs, which were generally off the wards and required fairly extensive ground privileges. Anywhere between 30 and 50 percent of patients were actively engaged in some form of productive work (called industrial and occupational therapy) either on the wards or in the hospitals' farms and workshops. 55 The workshops included tailor, shoe and harness, sewing and mending, mattress and upholstery, and furniture manufacturing departments. 56 The products of patients' labor were destined primarily for consumption within the hospitals. Table 1 gives a partial list of items made by patients at Norwalk State Hospital between 1928 and 1930. 57 With the help of California's climate and fertile soil, patients also tended large and productive agricultural facilities. For example, by 1955 Stockton had accumulated a total of 1,257 acres, 1,000 of which were devoted to agricultural production. 58 On this land, in addition to caring for pigs, chickens, and cows, patients grew apricots, peaches, grapes, plums, walnuts, almonds, onions, beans, beets, carrots, peas, potatoes, and tomatoes. They also grew a number of field crops such as alfalfa and grain hay.59 Not incidentally, the state realized substantial savings from the patients' labors. For fiscal year 1924-1925, the first year that the value and costs of production were published, Stockton had saved more than $85,000 through its farming operations, a significant figure when compared to an overall budget of nearly $820,000.60 However, the fiscal impact of farming diminished with time, especially after World War II. For fiscal year 19541955 excess production value over expenses was almost $220,000, but Stockton's total budget had swollen to $6,000,000.61 Even though the hospital realized substantial savings from patient labor, doctors do not appear to have coerced them into working. Pauline's doctors, for example, simply noted her inability to work in the canning factory when she became too delusional to leave the ward. Many patients, in fact, eagerly sought out work. Scheff observed that despite the disadvantages a particular job might hold, such as being "tiring and dirty" and paying nothing, work "gave the patient a feeling of accomplishment, of responsibility in holding down a full-time job, and therefore of membership, once more, in society."62 Above all else, doctors believed that patient labor was therapeutic. Harking back to moral therapy of the nineteenth century, superintendents repeatedly emphasized the therapeutic benefits of work. The 1918 State Board of Charities and Corrections Biennial Report laid out the following principles for therapeutic labor.

50

I N S T I T U T I O N A L THERAPY

TABLE i Selected Items M a d e by Patients in O c c u p a t i o n a l T h e r a p y at N o r w a l k State Hospital, 1 9 2 8 - 1 9 3 0 Item Made

Number

Mattresses, single Mattress ticks, single Pillows Rubber sheets Fly swatters Khaki cloth, yards Chairs, fiber, dining room Sheets, unbleached, 6/4 Dresses, gingham Tables, dining room, covered with Gunn linoleum Brooms

471 693 921 233 2,086 2,914 545 11,034 2,385 183 5,515

(a) that work should be carried on with cure as the main object; (b) the work must be interesting; (c) the patient should be carefully studied; (d) that one form of occupation should not be carried to the point of fatigue; (e) that it should have some useful end; ( f ) that it preferably should lead to an increase in the patient's knowledge; (g) that it should be carried on with others; (h) that all possible encouragement should be given the worker; (i) that work resulting in poor or useless product is better than idleness.63 O v e r the n e x t f o u r decades superintendents repeatedly r e a f f i r m e d these principles as their guiding justification f o r patient labor, as illustrated by the following two quotations. T h e first, written by the general superintendent o f state hospitals, c o m e s f r o m the 1 9 2 0 Biennial Report o f the Commission in Lunacy. Occupational therapy has attained an important position in the treatment of mental diseases. Its importance is generally recognized as a means of supplemental treatment. Efforts are made to induce every patient who is physically able to work, to engage in some occupation. Idleness induces introspection, the brooding over troubles, the nursing of delusions. An occupation to which one is adapted awakens a new interest in life and makes a man whose recovery is not to be expected, a better hospital patient, neater, more tractable, arouses an interest in something he likes. Occupation fits a recoverable patient to return to civil life and helps him cope with the difficulties that have to be met with in the struggle for existence.64

INSTITUTIONAL THERAPY

5/

Thirty years later, and with virtually the identical meaning, the Department of Mental Hygiene wrote, It is a well established medical fact that prescribed and purposeful activity, carefully guided, hastens the recovery of patients. Occupational therapy is a great morale builder. It aids in the social and institutional adjustment of the patients, encourages wholesome thoughts and emotions, and re-educates the patients in personal habits more acceptable to society. 65

As this passage makes clear, physicians believed that the therapeutic value of work was a "medical fact." But was patient labor simply a means of exploitation that superintendents clothed in the rhetoric of therapeutics? True, patient labor was intimately determined by institutional needs, and even the superintendents could not separate the social benefits—"more acceptable to society"—from the therapeutic ones—"hastens the recovery." Subsequent chapters will show that the social basis of a practice is entirely consistent with and crucial for a particular remedy's therapeutic status. Biological interventions were as rooted as work therapy in the social life of state hospitals. Institutional exigencies played a starring role in what physicians defined as effective therapeutics, and they provided critical building blocks for the everyday determination by doctors of what made a therapy work. Thus to observe that institutions shaped and, perhaps, benefited f r o m a therapeutic practice, whether it be occupational therapy, lobotomy, or antipsychotic medications, underscores the socially constructed nature of treatment practices. 66

Large numbers of patients, few doctors, an architecture and system of segregation based on behavior, and patient labor provided the skeleton that supported the flesh of somatic therapies. These elements defined the limits and possibilities of what doctors deemed practical and effective therapies. Thus the overwhelmingly large patient population dictated that the most useful and enduring therapies must be susceptible to mass administration. The ward system and patient labor made "disturbed" behavior the central object of disease and cure. For some patients, like Pauline, this was enough to control and, sometimes, cure their madness. Though Pauline was given no somatic remedies, we cannot argue that her doctors neglected to "treat" her. Her very presence within the hospital and its ward system placed her within a disciplinary and taxonomic field that doctors believed medically managed her illness. 67 For Pauline's doctors, her disorder never met their practical rationale for the more invasive therapeutic technologies. In contrast, the behaviors and diseases of many other patients required the

J2

INSTITUTIONAL THERAPY

more potent medicine of somatic interventions such as hydrotherapy, sterilization, malaria fever therapy, shock therapies, and lobotomy. Doctors combined these interventions with the social world of the hospital and twentieth-century American culture to create effective physical cures for diseased minds. It is this brew of hospital culture, psychiatric disorder, and the body that we will now explore.

CHAPTER

TWO

Discipline or Therapy: Patients, Doctors, and Somatic Remedies in the Early Twentieth Century Agnews is now a hospital and not a prison, and the success of the new methods is best shown by the general contented spirit that exists among the majority ofpatients. — STATE

BOARD

OF C H A R I T I E S

AND

CORRECTIONS,

SIXTH BIENNIAL REPORT (1914) Agnews Prison, Jan. 12 th 1918 STOCKING: . . . Seven years ago today, Jan. 12th 1911, I was inveigled from San Francisco to Oakland by the LIES of one ofyour kind, put in a dungeon kept seven days and a charge framed up on me by parties that I never saw or heard of in my life, sent to San Quentin for 3 years and then here for LIFE. Going on five years I have been held here by you hired assassins and murderers, to keep me from proving my innocence. . . . One word in regard to my sanity and you insane Bastard sons of Bastard insane whores you lie—and furthermore you have spent your entire lives destroying men's lives and souls. ... I will die here to gratify your insane lust. — D R . F R E D F.

WEBSTER

We have before us two irreconcilable accounts from the early twentieth century concerning the same institution. The first, penned by a nameless California state bureaucrat, tells us that Agnews State Hospital is a modern treatment facility.1 The second, written by an obviously unhappy patient, tells us that this institution resembles a prison more than a hospital.2 Indeed, Frederick Webster was familiar with both prisons and hospitals. In 1913, having served a three-year prison sentence at San Quentin State Penitentiary for forgery, he was transferred to Agnews State Hospital for the Insane on the charge of madness. He steadfastly maintained that he was of sound mind and that he had been illegally detained. Through the help of Horace Wilson, a member of the hospital's board of managers, Webster appealed to the superior court to prove his sanity. On May 13, 1919, a jury decided that Webster was indeed sane and ordered his immediate release. At his trial, as well as before, Webster accused both doctors and attendants of cruelty toward other patients. He charged them with beating and breaking patients' bones, stealing patients' belongings, and punishing patients with their "so-called" therapies. He also asserted that Leonard Stocking, the 33

34

D I S C I P L I N E OR T H E R A P Y

medical superintendent, had knowledge of these abuses and had tried to hide true causes of death within the asylum, implying that murder as well as mayhem occurred behind its walls. Northern California newspapers such as the San Francisco Examiner followed the sordid tale that Webster told about the Agnews asylum. Although grist for faded, yellow journalism, these charges questioned the core of therapeutic practice. In consultation with Governor William Stephens, the hospital's board of managers convened a special investigation into these very grim allegations. In addition to the five members of the board, the following individuals took part in the official inquiry: two representatives of Governor Stephens from the State Board of Charities and Corrections and the State Board of Lunacy, six attorneys representing the State Commission in Lunacy, Stocking, Webster, and another patient who also claimed to have been held illegally. From June 12, 1919, to June 25, 1919, these individuals interrogated sixty-nine patients, physicians, and attendants and created nearly one thousand pages of testimony. Since the investigators allowed patients as well as doctors to testify, this document gives us a window into early twentieth-century treatment practices, asylum life, and relationships between doctors and patients from the perspectives of both. A central charge against the asylum was that the doctors did not provide medical treatment but instead meted out punishment with various technologies, such as continuous baths and wet packs, that masqueraded as therapies. Thus therapeutic practice had a starring role. What counted as a therapy? How did doctors differentiate between punishment and treatment? How did doctors legitimate their therapies? What did patients consider to be therapeutic? What did they consider to be punishment? Irrespective of whose interest the investigators represented, they wanted answers to these questions. The purpose of this chapter is to examine how ordinary early twentiethcentury physicians and patients attempted to answer the above questions in daily practice. With the decline of moral therapy in the second half of the nineteenth century and the rise of a more somatically based model of psychiatric disorder, the patient's body rather than his or her mind or environment became an increasingly important site of therapeutic intervention. 3 The psychiatric patient's body provided a fertile ground for a host of technologies; some of these were applied to the body's surface and others invaded and destroyed or altered a patient's internal organs. In the early twentieth century, physicians at California state hospitals deployed two very different types of therapeutic discipline, one embodying behavioral control (hydrotherapy, the subject of this chapter) and the other reproductive control (sterilization, the subject of the next chapter). Here I look briefly at the published medical literature on early twentiethcentury somatic remedies, focusing on hydrotherapy as a form of therapeutic discipline. Since published accounts often diverge from everyday

D I S C I P L I N E OR T H E R A P Y

35

practice and are virtually silent when it comes to the patient's voice, I focus on the Agnews investigation and California state hospital records to explore the therapeutic world of the 1910s and 1920s from the point of view of doctors and patients. As we will see, patients perceived and spoke about hydrotherapy and the diseases it treated in a vastly different language from that of their doctors. P H Y S I C A L R E S T R A I N T A N D S O M A T I C R E M E D I E S IN T H E NINETEENTH

CENTURY AND EARLY TWENTIETH

LATE

CENTURY

Throughout the nineteenth century, physicians often debated the place of physical restraint in controlling their patients. Grob has pointed out that the issue of restraint remained one of the most hotly debated issues in nineteenth-century American psychiatry. Near the end of the century, a number of states even attempted to abolish physical restraint altogether.4 In the 1900s and 1 9 1 os restraint continued to be an important issue, although most condemned its use or, at best, saw it as a necessary evil. For example, Charles Wagner, superintendent of the Binghamton State Hospital, wrote in 1903, "Formerly such patients were confined in cells, put in straight jackets, muffs, belts and wristlets or mittens, and otherwise harshly treated: but now all such devices are regarded as barbarous." 5 Whether physicians saw restraint as necessary or not, few argued that it had therapeutic value. Rather, they generally agreed that its value resided in its ability to control recalcitrant and disruptive patients.6 With nearly every new therapeutic innovation, doctors rang the death knell of physical restraint, claiming they no longer had need of such a crude and nontherapeutic intervention. Physicians made this assertion with the introduction of hydrotherapy, the shock therapies, lobotomy, and antipsychotic drugs. However, reports of its death were gready exaggerated. Like an unwanted dinner guest who refuses to leave, restraint remained a necessary, albeit disliked, adjunct to therapeutic practices throughout the first half of the twentieth century. To cite one example from a patient's record at Stockton State Hospital long after the introduction of hydrotherapy, a physician's note in 1942 read, Some years ago (August 1 9 3 7 ) almost killed the Charge Attendant and later attacked and nearly killed a patient and since that time she has been in cuffs and belt and then is fastened to the bed at night.

Nearly five years later, she remained tied to her bed. Noting that the patient had been continually restrained for almost an entire decade, a physician wrote in 1947, She has been kept in restraint and for the past few years has been kept in bed. Even then, when in full restraint in the bed, she has been able to maneuver in such a position that, had there not been others at hand, she would of seriously injured the individual. 7

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D I S C I P L I N E OR T H E R A P Y

O f course, this doctor would not have argued that the woman's life of immobility did anything more than simply prevent her from disrupting the ward and hurting herself or others. Nonetheless, while physicians of the twentieth century never elevated camisoles, cuffs, and straitjackets to the lofty heights of therapy, these devices played a central role in how state hospital physicians defined therapeutics and navigated between cure and discipline. For throughout the first half of this century, and in spite of heaping disdain on physical restraint, doctors ascertained a given remedy's effectiveness by how well it measured up against these simplest methods of bodily control. 8 Asylum physicians also had recourse to numerous drugs with which to calm and sedate their patients. Those developed in the nineteenth century included bromides, chloral hydrate, hyoscine, paraldehyde, sulfonal, and narcotics. 9 Perhaps best known and still used today is chloral hydrate. In 186g the German pharmacologist Oskar Liebreich published the results of his experiments to produce a new form of chloroform that could be taken orally. T h o u g h mistakenly believing that chloral hydrate would be converted into chloroform in vivo, Liebreich correctly predicted that it would have sedative properties. These properties proved quite useful to asylum physicians and general medical practitioners, and they readily accepted the new drug. 1 0 In The Therapeutic Perspective Warner convincingly argues that chloral hydrate played an important symbolic role for the acceptance of laboratory science in medical practice. That chloral hydrate emanated directly from the laboratory, Liebreich's erroneous assumptions notwithstanding, demonstrated the practical fruits of scientific investigation. Chloral hydrate and the laboratory, according to Warner, represented a shift in therapeutic perspective from a medicine rooted in humoralism to one defined by physiology and physiologic norms. Nonetheless, doctors were unable to sustain claims that drugs such as chloral hydrate and subsequentiy developed sedatives were genuine cures for psychic ills. In the late nineteenth century enthusiastic reports often appeared in the psychiatric literature on the effects of particular sedative drugs, but these declarations always proved evanescent. 1 1 For e x a m p l e , describing the effects of hyoscine, an optimistic Thomas Drapes wrote in 1889, "It is incomparably superior to the older sedatives, such as morphine and chloral, and n o n e of the newer ones, in my opinion, approach it in value as a remedy for controlling paroxysms of furious excitement and turb u l e n t maniacal outbreaks." H e a d d e d that "the d r u g has, to a certain degree, a direct calmative influence on ideational disturbance, apart from its sleep producing properties." 1 2 As it did for other sedatives, physicians' enthusiasm f o r hyoscine rapidly waned. T h e English psychiatrist Henry Maudsley wrote in 1895 that "the reports of its successes, when examined, are mostly naive reports of its success, not in curing but in 'quieting the patient.'" 1 3 Indeed, speaking for many physicians, Maudsley argued, "The

DISCIPLINE OR THERAPY

57

purely medical treatment of insanity which is not maltreatment might be comprised within a narrow compass. Drugs can no more directly quell an insane delusion than they can eradicate an envy or abate an ambition." 14 Regardless of their usefulness, drugs also had severe drawbacks such as toxicity and dependency. 15 And, most damning of all for sedatives' classification as remedies, physicians often criticized their use as simply another form of restraint, albeit chemical rather than physical. According to Maudsley, Mechanical restraint, except under surgical necessities, was formerly abandoned, not only because [its] use was sure to become abuse, but because it was deemed better for the patient to let him have the relief and self-respect of pretty free exercise than to keep him tied up like a mad dog . . . but it may be doubted whether its coarse bonds did as much harm as has been done by the finer means of chemical restraint which have been used to paralyse the brain and to render the patient quiet. 16

For psychiatrists of the late nineteenth century, as well as for those of the twentieth century, sedatives and physical restraints occupied the same nontherapeutic space. These drugs, like restraint, and despite their "unwanted" presence, were readily used by state hospital physicians when the need arose. In a Stockton State Hospital medical record a physician wrote in 1925, "Not ill behaved. Eats and sleeps well. He has quieted down at times. He was disturbed last night, given hyoscine, noisy, singing." 17 This physician and his colleagues found hyoscine and other sedatives simply too useful in quieting disturbed patients to abandon their use in the name of therapeutics. Doctors at Stockton used hyoscine as late as the 1960s. Although physicians in California state hospitals continued to use sedatives developed in the nineteenth century, the most commonly used from the 1920s to the 1950s were the barbiturate derivatives. Emil Fischer and Joseph von Mering introduced in 1903 the first barbiturate that produced both sedation and sleepiness. It and its later derivatives were also easy to administer. The best-known therapeutic use of barbiturates was in Jakob Klasi's prolonged sleep therapy. Working under Eugen Bleuler at the Burgholzli, the psychiatric clinic at the University of Zurich, Klasi in 1922 published the results of inducing an artificial sleep lasting six to eight days in schizophrenic patients by using diethyldipropenyl barbiturate of diethylamine. Interestingly, the drug itself was not seen to be curative. Instead, Klasi argued that the patient's experience of prolonged somnolence fundamentally altered the doctor-patient relationship and allowed psychotherapeutic work to proceed. According to Klasi, Now the physician is needed again. The physician as well as the staff members now have the opportunity to present themselves as useful and necessary and

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gain through the treatment the patient's gratitude and confidence. T h e patient is forced to abandon muteness and negativeness, to return to using meaningful words and gestures, and to consider and to adjust to the environment. If the patient establishes contact with the environment and becomes interested and concerned, then after the end of physical depression and succoring, he will not sink again into autistic habits, but become open to experiences. 1 8

Unlike the somatic therapies that we will be examining in detail, Klasi's Dauernarkose exerted its curative effects not on the body itself but by "increasing the accessibility of the patient" to therapies of the mind. 19 Prolonged sleep therapy experienced a rapid rise in popularity in the 1920s only to be replaced by the shock therapies in the mid- to late 1930s. 20 Dauernarkose never made its way into California state hospitals, its use no doubt impeded by a reported mortality rate of up to 6 percent and the large time commitment required of nurses and doctors to monitor the slumbering patient. Nevertheless, physicians did make frequent use of barbiturates for their sedative and hypnotic properties. Patients were often given nightly regimens of pentobarbital and sodium amobarbitol to promote sleep. Occasionally, when a patient became too disruptive during the day, a physician would order that a barbiturate be given earlier for its calming effects. However, despite the usefulness of these drugs, like their nineteenthcentury predecessors they never escaped the negative connotation of chemical restraints. Psychiatrists of the late nineteenth and early twentieth century did have a remedy that they believed did more than simply restrain patients. This "new" treatment was hydrotherapy. Water's medicinal powers had been extolled for centuries, and its use became particularly popular in the nineteenth century. Although nineteenth-century orthodox physicians decried the "water-cure craze" as sectarian quackery, by the end of the nineteenth century physicians had transformed hydropathy into hydrotherapy—a legitimate medical technology.21 For example, a physician wrote in the Journal of the American Medical Association in 1896, It [hydrotherapy] may be considered, in fact, to be a complete materia medica in itself. I think that all those physicians who have advocated its use in the treatment of disease and especially of insanity, will never regret so doing. It has been left, however, to the wisdom of the nineteenth century to unveil the therapeutic use of the Turkish bath . . . for the benefit of humanity. 22

This laudatory intervention was vigorously contrasted with what was seen as the previous generation's unenlightened and, often, barbaric misuse of water. The same author wrote, T h e plunge bath was formerly and sometimes is now substituted for the cold shower. . . . A violent and excited patient is forcibly taken by his legs and plunged head foremost into an ordinary swimming bath. He is not permitted

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the use of his limbs when in the water, but is detained there, or taken out and plunged again into the bath, until the required effect of tranquility is produced. 2 3

Not to be confused with this latter method, the scientific use of water was unequivocally a "treatment" for psychic ills. Physicians deployed water in a number of scientifically sanctioned ways, but two hydrotherapeutic techniques deserve special mention, both because they were the focus of the 1 9 1 9 investigation of Agnews State Hospital and because they were the most frequently employed techniques in California state hospitals. These methods were the continuous bath and the wet sheet pack. 24 The "pack" required little in the way of sophisticated equipment. A sheet was dipped in water ranging from about 40 to 100 degrees Fahrenheit and then the patient was snugly wrapped in it. Very agitated patients were given colder sheets; frail patients were wrapped in warmer sheets. Patients generally remained wrapped for several hours at a time, although, as we will see, this did not always prove to be the case. Attendants often wrapped a blanket around the patient and the sheet. Finally, if the patient resisted the wet pack, the attendant placed a third sheet over the patient and securely tied him or her to the bed. Patients went through several stages while in the pack; first they were cooled, but as time passed the pack began to heat. At Agnews, doctors frequently ordered a rubber sheet to be wrapped around the wet sheet to enhance the heating effects. Not surprisingly, these packs markedly limited a patient's freedom of movement. A doctor during the Agnews investigation conceded that "you will frequently have to restrain a man to put him in the pack," and to "keep him there— you wrap him up like a mummy." 25 Continuous baths required more elaborate devices. The baths most often consisted of a tub with an inlet for hot water and an outlet to drain the water. Attendants placed the patient in a hammock to which he or she was fastened. Attendants then covered the tub and patient with a canvas sheet that had a hole for the patient's head. A series of valves and temperature gauges allowed the attendant to regulate both temperature and water flow. A single treatment could last anywhere from hours to days. Like the pack, patient resistance to the procedure was an ever-present problem. "Take a man that is delirious and put him in the tub and keep him there," according to a doctor at the Agnews inquiry, "and by virtue of his condition he thinks you have got him in scalding hot water, when, as a matter of fact, the temperature is only 92 degrees. That man screams and hollers and swears that you are burning him up alive, and they call you all kinds of names. . . . You simply have to ignore his pleas, that are sometimes heart-rending, and you do your duty by him, and do it in spite of himself." 26 Physicians found this "duty" made easier by their belief in hydrotherapy's scientific credentials, often grounded in experimentation. These credentials were adorned with complex physiological and biological explanations

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for why hydrotherapy effectively treated insanity. Some, for example, asserted that the remedy relieved cerebral congestion through its influence on the peripheral vascular system. 27 Others argued that hydrotherapy helped to eliminate toxic impurities that might cause insanity.28 "It is extremely likely," a physician wrote in explaining the physiology of hydrotherapy, "that the excretory function of the skin and kidneys is stimulated." 29 A body of research based on precise measurement of parameters such as blood pressure, pulse, respiratory rate, and differential blood count lent support to this science.30 The science of hydrotherapy in turn bolstered doctors' belief in the therapeutic value of technologies such as continuous baths and wet packs in spite of the fact that, not unlike "nontherapeutic" devices such as camisoles, straitjackets, and muffs, they severely immobilized their victims. "Hydrotherapy," wrote a physician in 1 9 1 3 , "whether applied in the form of prolonged baths or as wet packs, has a therapeutic effect, which is not to be obtained by mere immobilization of the patient or by restraint." 31 In a refrain echoed with nearly every new psychiatric intervention, physicians argued that hydrotherapy had proven so useful that physical restraint and sedative drugs were fast becoming relics of the past. One enthusiastic practitioner wrote, "If I were placed in the position of having to choose one single modality to meet the exigencies of daily practice in the acute and chronic disorders and diseases of which the human organism is afflicted, I would choose water as my weapon. No single drug, chemical, serum, vaccine, antitoxin possesses such value." 32 The diffusion of scientific hydrotherapy was gradual, largely because proper hydrotherapeutic facilities required substantial capital outlays. In 1896, for example, the eminent neurologist S. Weir Mitchell chastised his psychiatric colleagues on the grounds that too few of their hospitals had provisions for hydrotherapy. 33 Psychiatric institutions only slowly heeded Mitchell's advice, although institutions such as St. Elizabeth's, McLean, and Danvers State Hospital all installed large-scale hydrotherapeutic equipment in the late 1890s. By the 1910s, however, hydrotherapy had become standard practice in state institutions. J . A.Jackson wrote, '"Lunatic asylum' is the proper nomenclature for an institution which has no hydrotherapy outfit; to call such an institution a hospital would be a misnomer and, to say the least, exceedingly out of place." 34 H Y D R O T H E R A P Y IN C A L I F O R N I A

Eager to shed the opprobrium associated with "lunatic asylum," state hospitals throughout California sought to introduce hydrotherapy. By the turn of century California had five state hospitals, and in 1 9 1 6 the state built an additional hospital to accommodate its burgeoning population. Like state

DISCIPLINE OR THERAPY

41

hospitals throughout the country, California's institutions were horribly overcrowded. In 1908, for example, the State Board of Charities and Corrections wrote, "At present, over 400 patients in our five insane hospitals are sleeping in beds laid down on the floor each night, and 360 more in basements, corridors, and other places not made for patients and where patients ought not to sleep." 35 Not withstanding these conditions, hospital superintendents wished to make their institutions modern treatment facilities but believed that the lack of hydrotherapeutic facilities prevented them from doing so. "Our insane hospitals," wrote the State Board of Charities and Corrections in 1906, "have been places for the detention of the chronic insane, and not places for the treatment of insanity as a disease." 36 To remedy this, the state legislature in the late 1900s began making appropriations for superintendents to construct hydrotherapy facilities. In 1907 the state government gave Stockton State Hospital $55,000 to erect a new hydrotherapeutic building and to equip it with the latest devices. Underscoring the hospital's need for this remedy, the superintendent wrote, "The building has been commenced. Until it is completed and installed, insanity can not be treated here by modern methods and appliances." 37 In 1910 the State Board of Charities and Corrections proudly announced, "All of our state hospitals are provided with such cottages, equipped with the best apparatus known to medical science for the treating of insanity. These cottages have been completed during the past year. . . . The people of the State may now expect more and quicker cures than have been possible heretofore." 38 Throughout our journey into therapeutic practices we will explore the medical record to mine the rationales that doctors employed when treating a patient with a particular remedy. Yet, curiously, doctors revealed little in the medical record about their practice of hydrotherapy. Granted, the records tell us that from the 1910s to the late 1930s and early 1940s physicians ordered hydrotherapy—especially in the form of wet packs and continuous baths—more frequently than any other somatic treatment. The records also show how insignificant diagnostic categories were in determining whether to bathe or wrap a patient. An individual diagnosed with dementia praecox was as likely to receive hydrotherapy as a patient with mania. 39 The following excerpt from a patient's record at Stockton State Hospital illustrates what these records can and cannot tell us about the therapeutic use of water. Sept. 20th, 1920: . . . Is noisy at times during the day and at night, but quiet some nights. Receives continuous baths three hours daily. . . . Oct. 7th, 1920: This patient takes hydrotreatment daily. He seems quiet and well behaved—very polite and friendly—feels very much better . . . noisy at n i g h t — h e is loath to admit insanity.

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Oct. 14th, 1920: Conduct g o o d as a rule but is variable—at times he is noisy and yells in a peculiar way. Has b e e n taking hydro treatment which is discontinued this d a t e — h e thumps his chest—walks back and forth on hall at times. . . . No apparent disease insight. 40

As in most state hospital therapeutic regimens, hydrotherapy occupied a prominent place in this patient's treatment. However, the notes leave many questions unanswered. Did the doctor order hydrotherapy because of this patient's noisy behavior? If that is the case, why did the physician continue the treatments on October 7 even though the patient was "very polite and friendly"? Then, inexplicably, the doctor stopped the continuous baths on October 14 despite the patient yelling in a "peculiar way" and thumping his chest. Further, we have no way of determining whether the doctor believed hydrotherapy restrained or treated the patient, or if this was even a relevant distinction for him. Finally, the patient's voice is entirely absent from the record; we do not know, for example, whether the patient resisted the therapy or found it beneficial. There are two probable explanations for why doctors made so little comment about hydrotherapy other than noting its use. First, attendants rather than physicians actually administered the treatments, so that physicians were less likely to spend much time describing their feelings about the treatment and their patients' reactions to it. Second, since physicians readily accepted hydrotherapy as an essential treatment, its use quickly became such an integral part of their daily routine that they saw little need to comment about it. What rationale did physicians have for using hydrotherapy? Did they believe that it treated patients, or merely restrained them? If the former, what exactly did such technologies treat? What did patients think of their doctors' ministrations? To what extent did doctors and patients share a common vision of what constituted treatment? To answer these questions, we need to return to the Agnews investigation. In contrast to the medical record, the investigation provides us with a window into the generally unstated assumptions that underpinned everyday therapeutic practice.

IN T H E M A T T E R O F T H E I N V E S T I G A T I O N OF AGNEWS STATE HOSPITAL

Agnews State Hospital, located in northern California's Santa Clara County, opened in 1888. Throughout much of its early history Leonard Stocking directed the hospital's course as its medical superintendent. Stocking joined the hospital staff as an assistant physician in 1894 and became medical superintendent in 1903, in which post he remained until his death on October 29, 1931. He saw the institution through some of its most turbu-

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43

lent times. The San Francisco earthquake of 1906 destroyed nearly all of the hospital's buildings. With an appropriation of over $1.2 million, Agnews was rebuilt in accordance with Stocking's desire to reduce restraint to a minimum. This entailed eliminating bars and screens on windows, assigning patients to wards based on behavior rather than haphazardly, and constructing the most up-to-date hydrotherapeutic facilities to avoid the need for physical restraint. It was the nature of these hydrotherapeutic facilities that lay at the heart of the 1919 investigation. At issue was whether doctors provided medical treatment or simply controlled, restrained, and punished patients in the guise of therapy. The investigation's transcripts give us an unobstructed view of the way hydrotherapy structured doctors' and patients' therapeutic world. Unlike documents of literate patients on which historians have generally focused, these transcripts allow us to hear ordinary and often poorly educated patients describe their mental ills and what they believed would or would not heal their troubled minds. 41 But before we listen to these patients, let us first see how hydrotherapy shaped their doctors' perceptions of disease and its cure. Doctors

Doctors' use of any particular therapy had wide-ranging effects on the way they perceived disease. Instead of acting on an already given disease, each treatment actually structured what doctors counted as signs and symptoms of illness. Thus for every practice doctors constructed a "therapeutic rationale," or a way of understanding disease, that was inseparable from the context of the proposed remedy. Looked at in another way, a particular therapeutic rationale acted as a conceptual filter through which doctors divined health or treatable disease. At Agnews hydrotherapy exerted a profound influence on how doctors viewed psychiatric illness and its cure. "The insane man," one of the experts testified during the investigation, "is a sick man and . . . should be treated for his illness and not be held responsible for his conduct." 42 As innocuous as this statement appears, it signals an important shift in the meaning of "conduct." Previously, as the expert saw it, patients had been "held responsible" for uncontrollable, disruptive, or violent conduct by being subjected to "nontherapeutic" mechanical restraint. The hydrotherapeutic perspective, however, transformed disorderly conduct into a referent of disease that could be treated. Indeed, in order for doctors to believe in hydrotherapy's efficacy, they had to see incorrigible behavior and disease as equivalent categories. O n an everyday level, hydrotherapy allowed physicians to collapse disease and behavior into a single category so that methods that controlled behavior were considered therapeutic.

DISCIPLINE OR THERAPY

Given that good or bad behavior measured disease for doctors at Agnews, they understandably deployed hydrotherapy for many of the same reasons that prompted them to use mechanical restraint. As with mechanical restraint, any disruptive act could be an indication for the pack or continuous bath. T h e ward system, which was itself structured around patient behavior, played a crucial role in this process of defining the acceptable and unacceptable limits of how patients could behave before a doctor saw treatable disease. When a particular patient's actions taxed the already meager resources of his or her ward, he or she often became the object of therapeutic intervention. A staff physician told the investigators that "hydrotherapy treatment was used where patients were excited, very restless and required some measure to produce a soothing affect. It was also used in more acute conditions." 43 Since physicians did not see therapeutic efficacy in simply binding patients' arms and legs with straitjackets and the like, how did they construct effectiveness out of a treatment that distinguished itself from these methods mainly by the addition of water? This issue lay at the heart of the investigators' interrogations of Agnews physicians. To the untrained eyes of the investigators, packs and baths often appeared to be simply newer forms of mechanical restraint, albeit more effective in controlling irascible behavior. In contrast, doctors at Agnews considered the effectiveness of hydrotherapy to be self-evident. That they deemed it therapeutic and constructed an everyday, practical rationale for its deployment reaffirmed it as a remedy, and throughout the investigation they attempted to convince the interrogators of what they saw as an "obvious" truth, namely, the therapeutic value of hydrotherapy. Doctors argued that the hydrotherapy treatments produced visible effects on their patients that provided graphic evidence of its effectiveness.44 This contrasted with the apparent lack of physiological effect seen with mechanical restraint. For example, in comparing the camisole to the continuous bath and wet pack, Glen Meyers, formerly a ward physician at Agnews and currently head of the psychopathic ward at Letterman General Hospital, described the therapeutic effects of hydrotherapy during his interrogation by Leonard Stocking's attorney, Mr. Benson. Mr. Benson: That was one of the chief arguments against the camisole, that it was too convenient? Dr. Meyers: It was very convenient indeed, but the chief argument against it was this, it is certainly not a therapeutic treatment. It is merely an irritating restraint. O f course you may call the continuous bath or the pack a restraint if you wish, but it is therapeutic treatment given for a certain reason. A patient is never quieted by a camisole; he is simply restrained. The patient is quieted by the continuous [bath] and by the pack. . . . O f course the care of the insane is a very exhausting occupation and it is most

DISCIPLINE OR THERAPY

45

convenient if one is a little bit tired or irritated, to put the patient in a camisole instead of using some other more humane and therapeutic method. 45

This effect of quieting the patient fundamentally altered how these physicians perceived aberrant behavior and its control. They no longer saw such behavior as requiring shackles and straitjackets but as disease amenable to therapeutic intervention. Another way in which doctors constructed an effective treatment out of hydrotherapy was their assertion that it had largely made mechanical restraint unnecessary. To underscore this fact, physicians repeatedly told the investigators that hydrotherapy had replaced the crude mechanical instruments of control. One of the ward physicians, Dr. E. W. Mullen, reported, "We now use the hydro baths in place of restraint for quieting patients Since 1 9 1 6 when we changed our method of treatment we have been able to get along without restraint."46 Underscoring the significance of this change, Stocking asked rhetorically, "The pack and the continuous bath, the hydro treatment, is not only a means of handling patients but it is a method of treatment? . . . And it requires more care and attention than a patient in the straight jacket, or camisole?" 47 The expert witnesses called to testify on the institution's behalf agreed with Stocking and his physicians that the ideal institution had replaced physical restraint with the modern treatment methods of hydrotherapy. "The modern treatment is more and more to eliminate restraint. . . and to eliminate the need for restraint by cold packs and by hydro therapy."48 That hydrotherapy was not simply a newer form of physical restraint was a point repeatedly emphasized by doctors of Agnews, for if hydrotherapy was to be considered a genuine therapy, it could not be viewed as a mere substitute for mechanical devices. As Dr. Mack, a ward physician, asserted with a healthy dose of circular reasoning, it was the therapeutic value of the pack that made it much more than a mere surrogate for mechanical restraint. Mr. Benson: Did you ever have occasion to use the camisole instead of the pack? Dr. Mack: Well, as I said before I don't recall the pack being used on that ward at that time very much. Mr. Benson: If they had used it, would it be used as a substitute for the camisole? Dr. Mack: Certainly not. The pack is a method of treatment.49

One could imagine that Mack had used the pack in instances when he might have previously used the camisole. However, since the pack was a "method of treatment" while the camisole simply restrained, he saw no inconsistency

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in denying that one was a substitute for the other given what was for him this vital difference, despite a similarity in aims of the two technologies— namely, the control of patients' bodily movements. Even if these distinctions between restraint and therapy might appear dubious to us, for Mack and his colleagues this difference defined their identity as physicians, an identity they believed to be grounded in efficacious and scientific practices. For physicians at Agnews there was a final and, perhaps, most important difference between hydrotherapy and mechanical restraint. Doctors readily conceded that vindictive attendants could easily punish patients with devices such as camisoles, straitjackets, and handcuffs. They were, after all, simply devices of bodily control and discipline. In contrast, physicians believed that since packs and baths were "treatments," it was almost unthinkable that they could be used to punish patients. Mr. Benson: Dr. Mack is the cold pack used as a means of restraint or has it some value as a treatment? Dr. Mack: It has a value, yes. Mr. Benson: Then it is not used as punishment and restraint? Dr. Mack: No. 5 0

When asked if doctors used the pack as punishment, V. H. Podstata, former superintendent of Elgin State Hospital and the Dunning Institution of Illinois, succinctly tried to put the matter to rest: "No, it [the pack] quiets the patients. It couldn't very well be used as punishment. I consider punishment only something that tortures, and a pack couldn't be torture if it has a soothing effect." 51 Doctors contended that requiring a written order for its application not only bolstered the status of hydrotherapy as a medical treatment but also diminished the aura of punishment that the baths and wraps sometimes engendered. According to Meyers, We had very strict instructions, which were given to the nurses that it was a therapeutic treatment and not punishment; that when an excited patient was placed in a pack, for instance, we explained to that patient that he was placed in that pack because he was excited and because the pack would quiet him and that it was not for any other reason. . . . The attendants were instructed never to give a pack without the order of the physician. 52

A renegade attendant might disregard the doctors' "strict instructions," which the physicians easily conceded was an ever-present, but regrettable, reality in an institution such as Agnews. "If any of the attendants are caught doing it, putting it on without orders," declared Mullen, "we consider that just cause for a discharge." 53 Thus if systematic abuse had occurred or if one asserted that Agnews' therapies had been inherently abusive, one would have to question the physicians' credibility as they, not the attendants, controlled therapeutic practices. Yet in the 1910s doctors' intentions were

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47

nearly unassailable. According to Eva Reid, chief psychiatric "clinicist" at the University Hospital, San Francisco, and instructor in psychiatry at the University of California, "I can't imagine a physician using a cold pack as discipline. If a physician wished to punish a patient, which is almost unthinkable, he could use much easier and better methods than the cold pack which takes a great deal of time and trouble." 54 And indeed, none of the investigators suggested that Agnews' doctors willfully abused their patients. However naive the content might appear to late twentieth-century sensibilities, scientific evidence also played an important role in the therapeutic rationale that these doctors employed with hydrotherapy. Reid explained that hydrotherapy "is the only scientific treatment for the acute excitement of the insane that has yet been discovered." Echoing the published literature, she went on to describe its physiologic effects: "Packs act by increasing the elimination by the skin, helping to rid the system of toxins and poisonous matter in the constitution." Furthermore, hydrotherapy brings "blood to the surface and relieve[s] the congestion in the brain and spinal cord, which in most cases seems to cause the excitement." 55 H. C. McClenahan, who had worked in the State Lunatic Asylum in Austin, Texas, and who at the time of the investigation had a private practice in neurology and psychiatry, provided a similar rationale for the remedy's beneficial effects. That Stocking imported these experts to give long discourses on the scientific nature of hydrotherapy to the lay investigators testifies to the importance, at least rhetorically, of physiologic explanation in the everyday practice of hydrotherapy. The concatenation of these various ways in which doctors described their use of hydrotherapy constructed its everyday therapeutic rationale. T h e most salient feature of this rationale was the way in which doctors incorporated discipline and control into a therapeutic regime. More than simply a matter of semantics, the control of bodies became therapeutic at the moment this control became scientifically legitimated and recalcitrant behavior became disease. As a shorthand, I will call this collapsing of control into cure "therapeutic discipline," of which much will be said in subsequent chapters. Patients

As if from a strange land and speaking in an alien tongue, patients spoke of disease and its cure in ways that bore scant resemblance to the therapeutic rationale of their physicians. This analogy of languages does not, however, capture the difference in power that the physicians' words had over their charges. "The difficulty in listening to the testimony of an insane patient," according to one of the testifying physicians, "is this, by virtue of the patient's condition he is not able to separate the things that occur from the things that he hears and the things that he feels and the things that he reads

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and the things that he thinks and the things that he dreams." 5 6 For these doctors, the nature of insanity made it axiomatic that when patients defied their doctors' wisdom they were reaffirming their madness. Indeed, Stocking and his lawyers subjected patients who had made accusations against the hospital to intense scrutiny in the hope that their insane ramblings would undermine their allegations. For example, Martin J u d d , who had lived in the hospital since 1 9 1 4 , accused attendants of beating and choking him and other patients. To impugn the veracity of his accusations, Stocking called forth J u d d ' s delusions. Stocking: Do you and God have any partnership in detective work, the detective business? . . . Mr. Judd: God Almighty. He learned me a trick that he kept secret from everybody else because he understood I had the ability and was willing to do what he wanted me to do.. . . Stocking: You told me once that you had an understanding with God, which was a private matter between you and God, and you wouldn't tell the Burns people how you did it? Mr. Judd: That is what the bible tell you. Nobody knows God but me and nobody believes him, only me. I am talking for God when I am talking to you. 57 J u d d ' s boast that he was one of God's detectives, which was artfully encouraged by Stocking, did not enhance the credibility of his testimony. Since behavior, rather than delusions, determined whether doctors bathed or wrapped a patient, it mattered little who helped J u d d in his detective work. That he had "no disease insight" reflected not so much his refusal to abandon his grandiose delusion but his inability to see his behavior as disease needing treatment. Put another way, J u d d and many patients like him were incapable of speaking their doctors' language of disease and therapy. Thus the terrain that counted most f o r hydrotherapy—the status of behavior—proved the most contentious. Whereas doctors saw behavior as the sine qua non of treatable disease, patients did not necessarily see their behavior as either pathological or in need of treatment. Although extreme, Webster's charge that "the rules of the institution are that when a man shows any trace of sanity he is choked or beaten until they beat it out of him" reflected many patients' experiences, especially when their perceptions of sanity, insanity, treatment, and punishment clashed with those of their doctors. 58 Consistent with their inability to apprehend in their behavior signs and symptoms of disease, patients saw little qualitative difference between the various instruments that wrapped, bathed, c u f f e d , and tied them down. These were f o r them simply methods of corporeal control and little else. So seeing only a motley assortment of techniques and contraptions linked not by therapeutics but by discipline, patients sometimes described these interventions as diabolical instruments of torture and at other times praised

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49

them. For example, caught on a rare positive note, Webster admitted that hydrotherapy could be of benefit. When asked if the pack should ever be given, he replied that "in a great many instances they are very good, very good things, a very good treatment." 5 9 However, Webster and his fellow patients also excoriated the Agnews staff for the way in which they used hydrotherapy. E. H. Stoldt, a patient at Agnews for four years, gave his version of torment by wet pack: "They put the blanket, the two blankets across the bed, and they get two rubber sheets and put that across, and then they get a cold sheet. I think they use two and make him lie in that, bring the sheet around him first and then the rubber sheets and put the blankets over him." He added that the attendants "dipped [the sheets] in cold water." 6 0 Webster believed the pack to be "far more brutal" than the straitjacket: "They strap you down to a wire mattress. . . . They cover them up with a wet blanket, a cold wet blanket and leave them there anywhere from three to four to twenty-four to forty-eight hours, or until they take all the life out of them. That is the usual treatment here now." 61 The continuous bath fared litde better than the pack in many patients' accounts. "Two fellows came in, hop-heads, dope-heads and they gave one of them what you call a continuous bath," recalled J . L. Doak, a patient who believed that Dr. Stocking had illegally deprived him of his freedom. Doak continued, I had a room right next to it for a couple of nights and during the day they brought him in and gave him this continuous b a t h . . . . I don't know his name, they put him in there and had a canvass over this bath-tub where just their head sticks out and then they turn the water on and one man turns the water on and another man watches the patient. . . . Smith was giving this man this bath and . . . was making the water so hot that the fellow would holler and the other man would choke him until his tongue held out of his mouth so long (indicating) , 6 2

He ended by saying that "the next day they took him out to the morgue, poor fellow." Irrespective of the truth of this incident, Doak was clearly afraid o f the baths, a sentiment echoed by many patients. Like Doak, patients not only were frightened by the baths and packs but also felt that the attendants used these therapies to abuse and punish them. That patients saw a continuum of restraint allowed a patient such as Webster to rant against the abusive nature of hydrotherapy and, without a sense of inconsistency, to agree with his physicians that it could be a "very good treatment." Seeing a progression from treatment to brutality, a former patient, Jens Jensen, described his view of hydrotherapy. Gentlemen, I always told the Doctors I like those packs. When you are placing those packs like men, then those packs, in my estimation at least, to me, I felt

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Date Figure 4. Sterilization at Stockton State Hospital, 1935—1950

d e p a r t m e n t consistently placed sterilization a l o n g with insulin shock therapy and, later, electroshock therapy a m o n g the available medical therapies. In 1946 they d e m o t e d sterilization f r o m its standing as a "therapeutic activity" b u t reinstalled its "therapeutic" status in 1 9 4 7 , only to take it away permanently in the 1950s. 5 2 In the Biennial Report o f 1 9 5 0 - 1 9 5 2 they dealt with the issue directly: "Because it c a n n o t be considered a 'treatment' this proc e d u r e will b e c o n s i d e r e d in a n o t h e r section o f the r e p o r t . " 5 3 Distancing the practice f r o m its e u g e n i c history, the report c o n t i n u e d , Quite a few questions about sterilization in our mental hospitals are asked each year by those who are interested in the study of eugenics. The answer is always that in those few cases where sterilization seems indicated, the ultimate therapeutic benefit to the patient is the chief concern of the medical staff of each hospital. In certain patients, both mentally ill and mentally deficient, sterilization is indicated because only a borderline adjustment is being made and the possibilities of parenthood with the attendant responsibilities would be too much of an emotional stress. In other patients there is a history of either pregnancy or parenthood previously having been a major factor in the mental illness—sufficiently so to justify sterilization. 54 By 1 9 5 9 the n u m b e r o f sterilizations p e r f o r m e d annually in California state psychiatric institutions h a d d r o p p e d to twelve. 5 5

Stretching to the limit our credulity as to what o n e m i g h t consider a mental cure, the history o f sterilization demonstrates doctors' capacity to transf o r m the most n o x i o u s o f social concerns into medical ones. This transform a t i o n u n d e r w r o t e t h e " s u c c e s s f u l " i m p l e m e n t a t i o n o f sterilization in

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California, although, of course, it initially depended on a small group of eugenic reformers and legislators to enact the sterilization laws. As the experience of other institutions in California as well as elsewhere attests, these laws alone did not translate into mass sterilizations. Stockton's program of large-scale sterilizations "succeeded" because physicians believed it did more than simply render their patients incapable of reproducing. Rather than accept eugenic principles as a rationale for surgery, these doctors remade sterilization into a therapeutic procedure aimed at solving what they believed to be their patients' individual needs. Interestingly, the transience of therapeutic sterilization for men suggests that the male body, unlike the female body, was not a particularly durable site of psychiatric cure. I will have more to say about this in later chapters. Hydrotherapy and sterilization provided two differing therapeutic strategies that were played out in California state hospitals between the 1910s and the 1950s. On the one hand, hydrotherapy embodied remedies meant to control "diseased behaviors." As we will see in the ensuing chapters, physicians at Stockton State Hospital reevaluated the relationships among disordered behavior, psychiatric disease, and the psychiatric body as they developed more effective means of corporeal control. With these means, state hospital physicians increasingly saw psychiatric disease simply as a matter of diseased brains and bodies. On the other hand, sterilization suggests that not all biological remedies need to control behavior to be seen as efficacious. In the mid- to late 1920s physicians at California state hospitals introduced a new remedy known as malaria fever therapy. This new technology was aimed specifically at hidden disease pathogens rather than the control of patients' observable behavior. By completely expunging behavior as a criterion for treatment and a measure of effectiveness, doctors created a markedly different way of seeing disease, the diseased patient, and the doctor-patient relationship.

CHAPTER

FOUR

Neurosyphilis, Malaria, and a New Therapeutic Rationale

What are we to make of our current fascination with biological psychiatry, in terms of both models of causation and therapeutic practice? Many have argued that biological psychiatry has succeeded in recent years simply because biological treatments are efficacious. It is a contention that assumes biology can be kept neatly away from the contaminating influence of culture, and vice versa. But already we have seen this argument thrown into serious doubt with therapeutic sterilization and with hydrotherapy, both of which possessed and then over the course of a few decades lost "biological," hence "therapeutic," potency. Since the history of psychiatry is strewn with onetime successful somatic treatments that investigators later have shown to be of dubious value, is it possible that a given practitioner's assertion that a therapy works has little to do with that therapy's "biological" effects? A doctor's determination that a treatment works was (and is) a social act between healer and patient so that "nonbiological" relationships were (and are) an inseparable part of the effectiveness of a somatic treatment. Only in retrospect, when scientific evidence turns against a particular treatment, does a practitioner awaken with a new clarity of vision; a trick of almost magical proportions turns a vaunted biological treatment into a social product of an unenlightened past. I think, however, that we have much to learn from these failed forays into somatic therapeutics for they hint at fundamental ways in which doctors construct effective therapies. 1 This chapter examines the effect of a once wildly successful and subsequently abandoned biological therapy—malaria fever therapy—on doctors' perceptions of disease as well as on their relationships with their patients. Malaria fever therapy was used extensively by psychiatrists throughout the 71

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world between the 1 9 2 0 s and 1940s as a remedy f o r general paralysis of the insane. My central aim is to explore the ways in which this new technology transformed physicians' narratives and interrogations of their neurosyphilitic patients. To this end, I have based much of this story on patient medical records from Patton State Hospital, which is nestled in the foothills of southern California's San Bernardino Mountains. 2 Patton, opened in 1 8 9 3 , was the first of three state hospitals in the rapidly growing southern half of the state. Records f r o m this hospital, like those f r o m Stockton, contain, a m o n g other items, verbatim transcripts of patient interviews. As these records illustrate, the introduction of malaria fever therapy led to a dramatic c h a n g e in physicians' descriptions and interrogations of their patients, leading them to see their patients in a more positive light than they had prior to the availability of this remedy. This finding underscores the fact that therapies do more than simply address disease processes. This episode in psychiatric history has three virtues to r e c o m m e n d it. First, unlike most previous or even subsequent psychiatric disorders, general paralysis of the insane conformed to the ideals of scientific medicine by having a known biological cause, syphilis. In this respect the contrasts to hydrotherapy and sterilization are obvious. Second, malaria fever therapy gave psychiatrists of the 1 9 2 0 s their first widely successful and scientifically acknowledged somatic treatment. Third, since psychiatrists largely abandoned malaria by the 1950s and general paralysis is now a rarity, we have the anthropologic distance that helps us to avoid inserting our own perceptions of the disease and its treatment into the story. PARESIS: ITS NATURE AND CAUSE General paralysis of the insane, or more simply paresis, is a tertiary form of syphilis that appears ten to twenty years after initial infection. T h e disorder has both neurologic and psychiatric manifestations. Prior to the advent of penicillin, the disease led to psychosis and an agonizing death. Although it was u n r e c o g n i z e d as a distinct illness b e f o r e the nineteenth century, patients with symptoms similar to those of general paresis were described by Thomas Willis in the late seventeenth century and by J o h n Haslam in the late eighteenth century. However, Antoine-Laurent Bayle has been credited as the "discoverer" of the disease because of his observations in 1 8 2 2 that the particular constellation of psychic, physical, and neuropathological features constituted a single disease entity. 3 While they described a disease with protean and unpredictable manifestations, nineteenth-century physicians believed that paresis often led from a subtle "perversion" of the patient's disposition to a maniclike insanity marked by extravagant "delusions." T h e final psychological manifestation was dementia with "rapid and complete mental decay." 4 Simultaneously,

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subtle neurologic signs and symptoms eventually led to frequent seizures, paralysis, and incontinence. "I have known it to continue for seven years," wrote W. A. F. Browne in 1875, "but the e n d is generally reached m u c h earlier. Whatever the history, that end appears to be inevitably death." 5 Given the many clinical guises that paresis took, physicians diagnosed the illness with certainty only at autopsy. They f o u n d that cerebral inflammation and destruction were particularly characteristic of patients afflicted with general paralysis of the insane. Doctors increasingly believed, in the seventy years after the initial description of paresis, that brain lesions led to the mental and physical symptoms, but the question of what caused the brain lesions remained hotly debated. Nineteenth-century physicians proposed a number of causes for paresis, which included painful psychological experiences, overwork, anxiety, intemperance, and physical trauma. 6 Yet curiously, practitioners associated paresis with venery long before they had conclusive evidence for its syphilitic origin. For example, in 1877 a physician wrote, "Wives or mistresses of paretics, when they are not reticent upon the subject, tell stories of extreme sexual ardor, and of acts of coition repeated with astonishing frequency; and in these wives and mistresses there is a certain appearance of animal vigor and sensuality which I have c o m e to look upon as a diagnostic sign almost as valuable as is the appearance of the paretic himself." 7 In 1857 the Scandinavians Johannes Friedrich Esmark and W.Jessen first suggested that syphilis might cause paresis, and with increasing frequency throughout the latter half of the nineteenth century, many physicians agreed with this formulation. 8 By the turn of the century psychiatrists, armed primarily with statistical correlations between paresis and past syphilitic infection, confidently asserted that syphilis was the essential cause of the disease. 9 In 1904 Emil Kraepelin emphatically claimed, "We can to-day declare with the greatest certainty that syphilitic infection is an essential for the later appearance of paresis." 1 0 D e v e l o p e d in 1905, the Wassermann complement-fixation test allowed physicians to test for the presence of a past syphilitic infection in the spinal fluid of patients. T o g e t h e r with Hideyo N o g u c h i and J. W. Moore's discovery of spirochetes in paretic brains in 1913, this technology conclusively proved the long-held belief in the connection between sexuality and paresis. By yielding its secrets paresis provided somatically oriented psychiatrists of the early twentieth century with their paradigmatic disease. Not only did the psychological manifestations appear to have a visible basis in lesions of the brain, but a biological cause of these lesions—syphilitic spirochetes— had been found. Perhaps mental disorders such as mania and dementia praecox were not far behind in divulging their organically based mysteries. "DementiaParalytica [general paralysis]," wrote Kraepelin in 1913, "forms one of the best recognized of diseases . . . which psychiatry, indeed even

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medicine itself, has produced." 1 1 Echoing sentiments felt by many of his colleagues, Edinburgh psychiatrist T. S. Clouston claimed that paresis held "one of the chief keys of our future knowledge of brain and mental diseases." 12 While the illness symbolized many physicians' beliefs in a somatically based model of mental disorder, it also presented a major clinical challenge for late nineteenth- and early twentieth-century asylum keepers. In Europe, for example, some institutions reported that up to 45 percent of their male patients suffered from this disease. 13 In America physicians reported lower, although substantial, rates of paresis. In the 191 os approximately 20 percent of first admissions of male patients in New York state mental hospitals had a diagnosis of paresis, a figure that did not decline until 192 5. Women were less likely to be admitted with paresis and had an admission rate approximately one-third that of male paretics. In the United States as a whole about 9 percent of all first admissions during the 1930s had the diagnosis of general paralysis. 14 In California state hospitals neurosyphilitic admissions rose to about 13 percent until 1933, when the rate began to fall slowly.15 In spite of the advancing knowledge of the etiology of paresis, and its high prevalence, doctors' efforts to halt its fatal course proved futile. They used douches, cold packs applied to the head, mercury, blistering of the scalp, venesection, leeching, sexual abstinence, and holes drilled into the skull. Needless to say, the therapeutic outcome of these remedies was not heartening. 1 6 In 1909 Paul Ehrlich discovered Salvarsan (arsphenamine), which soon supplanted mercury as the treatment of choice for primary syphilis. Physicians attempted various methods of injecting the paretic with Salvarsan, such as intracranially and intraspinally. But even Salvarsan and, later, Neosalvarsan had little effect on the deadly progression of the disease. 17 WAGNER V O N J A U R E G G AND MALARIA FEVER THERAPY In June 1 9 1 7 Julius Wagner von Jauregg, a professor at the University of Vienna Hospital for Nervous and Mental Diseases, first used malarial fever therapy for the treatment of general paralysis. T h e treatment that he devised entailed inoculating the paretic with malaria-infected blood. Once infected, the paretic experienced fevers of up to 106 degrees Fahrenheit, which signified that the therapy was working. Indeed, the medical profession and the public believed the therapy worked so well that Wagner von Jauregg received the Nobel Prize in 1927, the first psychiatric researcher accorded this honor. 1 8 Sparked by scattered clinical case reports of spontaneous remissions of insanity after a fever, Wagner von Jauregg had developed a keen interest in the relationship between psychiatric disorder and febrile illness for several decades prior to his 1917 "discovery." In 1887 he published his first work

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on the relationship between fever and mental disorders, an article that combined a current review of the literature with his own observations on the effects of fever in psychiatric disorders. 19 He concluded that fevers were indeed beneficial in treating a whole host of psychiatric disorders, including "melancholy, manic states and acute mania." 20 Significantly, he mentioned general paresis only in passing as a possible candidate for fever therapy. Throughout the 18gos Wagner von Jauregg treated numerous psychiatric disorders with a variety of fever-producing agents. He first attempted to create fevers by injecting his psychiatric patients with erysipelas but finally settled on the newly discovered tuberculin. Realizing that many psychiatric patients inexplicably recover regardless of what is done for them, he had problems assessing the efficacy of his treatment, although he found that patients with general paresis appeared to have the most lasting remissions. He recalled in 1935, "Many therapeutic successes were observed in patients who fell in diagnostic groups which have a high percentage of spontaneous recoveries. It was therefore difficult to evaluate the exact effect of this treatment method. Among the apparently cured patients, however, were a few cases of general paralysis. This was something unusual and attracted my attention. From this time on the main interest was focused on general paralytic patients." 21 From the 1900s onward Wagner von Jauregg focused exclusively on the effects of fever on general paresis. First using tuberculin and then Alexandre Besredka's typhus vaccine, he frequently created fevers above 102.2 degrees Fahrenheit. Initially, he combined tuberculin with mercury inunctions. Later, with the development of Salvarsan and then Neosalvarsan, he combined this specific antisyphilitic treatment with his fever treatment.22 However, Wagner von Jauregg's fever therapy never gained wide psychiatric acceptance during most of the 191 os, nor was he himself particularly pleased with his results, and he postulated that a more effective means of creating fevers was necessary. In the summer of 1 9 1 7 , while treating a soldier infected with tertian malaria, Wagner von Jauregg believed that he had found the ideal febrifacient and proceeded to inoculate nine paretics with this soldier's blood. In 1 9 1 8 he reported a remarkable success rate: 67 percent improvement in treated patients. 23 Four years later he reported that three of them were "actively and efficiently at work." 24 The same three patients were again said to be working seven and a half years later. 25 After having inoculated more than two hundred patients, Wagner von Jauregg reported in 1922 that fifty patients had had complete remissions.26 By 1935 he proudly stated, "The malaria strain of September 1 9 1 9 has been maintained up to the present day—more than 16 years—in continuous human passage. I do not know of any other strain in the world which has been used for so many years." 27

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FEVER THERAPY: T E C H N I Q U E , THEORY, AND J U S T I F I C A T I O N

The technology of malarial therapy changed little in the thirty-five or so years of its existence. Prior to inoculating a patient with malaria-infected blood, the proper strain of malaria had to be obtained. The standard strain used was Plasmodium vivax, otherwise known as benign tertian malaria, although P. malariaesufficed for those patients who were immune to P. vivax. Physicians avoided using P. falciparum, the highly malignant form of malaria. They obtained their initial malaria strain either from a patient incidentally infected or from a vial of infected blood sent from another institution.28 Physicians devised a number of methods for infecting patients. Wagner von Jauregg rubbed infected blood on superficial scarifications and made subcutaneous injections of several milliliters of infected blood. Others tried to inoculate paretics by using mosquitoes that had previously fed on infected patients.29 By the early 1920s the accepted method of inoculation was intravenous injection of several milliliters of malaria-infected blood into the paretic. 30 After inoculating their first patient, physicians maintained their malarial strains indefinitely by transmitting the infection from paretic to paretic. Although intravenous routes remained the method of choice from the 1920s to the 1950s, some more "innovative" practitioners devised other techniques. One such procedure involved "injecting into one or both frontal lobes 3 to 5 c.c. of a mixture of equal parts of malaria blood and tetanic antitoxin." 31 This author reported an 81 percent cure rate with his form of the treatment. While some observed that infecting one paretic with the blood of another paretic "offends the esthetic sense of many individuals," few openly disapproved of the practice. 32 "Since no evidence of superinfection has been reported," one group wrote, "we followed the practice of others in not hesitating to use the blood of patients having general paralysis in inoculating cases of tabes or cerebrospinal syphilis."33 William A. White expressed opposition to this prevailing attitude. He objected to this method because he feared medical complications might result from using the blood of one paretic to infect another paretic with malaria. 34 Once inoculated, the paretic's malarial infection followed a predictable course. The incubation period generally lasted about a week, followed by the onset of chills, nausea, and malaise. These symptoms heralded the beginning of the fever. The fever usually peaked at about 106 degrees Fahrenheit and lasted several hours, and the temperature then slowly returned to normal. The fever and chills recurred about every other day. After approximately twelve bouts of fevers and chills, patients received quinine sulfate to terminate the infection. Just before administering the quinine, doctors often removed two to six milliliters of blood to inoculate another patient and to begin the cycle over again. 35

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160 140 120 100 80 60 40 20 m

0 S

O C O < D O > ( M « O C O t - ^ - f » - O C O < D N N N N r t n n ^ ' t T f i f l m i n 0 ) 0 ) 0 ) 0 ) 0 ) 0 ) 0 ) 0 ) 0 ) 0 ) 0 ) 0 ) 0 )

H

Date Figure 5. Articles on Malaria Fever Therapy Listed in Index Medicus, 1917—1957

T h r o u g h o u t the w o r l d investigators r e p l i c a t e d W a g n e r v o n J a u r e g g ' s results. In a review o f the literature u p to 1 9 2 6 researchers r e p o r t e d the following results based o n thirty-five studies: 27.5 p e r c e n t full remissions, 26.5 p e r c e n t i n c o m p l e t e remissions, a n d 46 p e r c e n t n o i m p r o v e m e n t or d e a t h . 3 6 T h r o u g h o u t the 1930s a n d 1940s psychiatrists c l a i m e d similar results. 3 7 Consistent with c o n t e m p o r a r y m e d i c a l research, n o n e o f these was a r a n d o m i z e d controlled trial a n d most were historical case studies. M a l a r i a f e v e r t h e r a p y s p r e a d rapidly t h r o u g h o u t E u r o p e a n d N o r t h America. A t St. Elizabeth's Hospital in Washington, D.C., Watson Eldridge inoculated America's first malaria fever patient in D e c e m b e r 1922. 3 8 Subsequently, most U.S. institutions b e g a n u s i n g malaria in treating g e n e r a l paralysis: New York State Psychiatric Institute, Ward's Island, in J u n e 1923; the Mayo Clinic in 1924; a n d the University o f Michigan Hospital Clinic in 1925. 3 9 Figure 5 illustrates the diffusion a n d scientific interest g e n e r a t e d by this n e w t r e a t m e n t . T h e ;y-axis indicates the total n u m b e r o f articles o n malaria fever therapy listed in Index Medicus f o r each year. 40 Interest p e a k e d in 1929, shortly after the awarding o f the N o b e l Prize, a n d then progressively d i m i n i s h e d . In 1 9 4 3 J o h n F. M a h o n e y p u b l i s h e d his f i n d i n g s that penicillin effectively treated syphilis, a n d a small flurry o f articles subsequently a p p e a r e d which c o m p a r e d the efficacy o f malaria a n d penicillin. 4 1 Nonetheless, malaria c o n t i n u e d to b e the treatment of c h o i c e until the late 1940s a n d early 1950s. Even as late as 1963 Francis Walshe, in Diseases of the Nervous System, mentions that some doctors c o n t i n u e d to use fever therapy for g e n e r a l paralysis. 42 Researchers p r o p o s e d a n u m b e r o f explanations f o r the efficacy o f fever therapy. In contrast to the so-called specific antisyphilitic remedies such as

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Salvarsan and mercury, fever acquired the designation "nonspecific," and some believed that it acted through general physiological mechanisms rather than having a specific antitreponemal effect. For example, Wagner von Jauregg believed that infectious diseases such as malaria "weakened" the "hemato-encephalic" barrier, thus allowing specific agents, such as Salvarsan and mercury, to enter the central nervous system. 43 Others believed that by creating a "hyperleukocytosis" with malaria, the paretic patient's "resistance" was increased, 44 although, if this was the case, they were at a loss to explain why other substances produced an elevation in white blood cells without having a similar therapeutic effect. 4 5 Still other researchers believed that the malaria infection increased antibody formation and hence increased immunity against the spirochete. 46 Many investigators believed that the high temperatures killed the syphilitic spirochete, a theory supported by experimental findings. In 1919 two European researchers, F. Jahnel and R. Weichbrodt, successfully demonstrated the heat sensitivity of syphilis when they placed syphilitic male rabbits with scrotal chancres in an oven heated to 105.8 degrees Fahrenheit for thirty to sixty minutes at a time. After several days, the heat had destroyed the spirochetes. 47 During the 1920s American investigators replicated these basic findings.48 Irrespective of whether it was the heat or a more general physiological response that brought about therapeutic efficacy, most physicians believed that the production of a fever in the patient was crucial to the success of the remedy, and, based on this, physicians in the late 1920s began to create artificial devices for producing fevers. 49 These machines fabricated fevers in a variety of ways. For example, some psychiatrists utilized shortwaves generated by two condenser plates with the patient sandwiched in the middle. Other machines included air-conditioned cabinets, infrared and carbon filament light cabinets, and electric blankets. 50 Although psychiatrists during the 1930s and 1940s frequently debated the relative merits of either artificial or malarial fever therapy, no one treatment gained universal hegemony. 51 Overall, malaria remained the most frequently used febrifacient, largely because of its ease of administration. 52

N O N M E D I C A L C O N S T R U C T I O N S OF NEUROSYPHILIS AND FEVER THERAPY T h e voluminous twentieth-century medical literature on syphilis and general paralysis and its treatment provides us with few clues as to how malaria fever therapy may have affected the ways in which doctors perceived the syphilitic patient. An examination of more general cultural attitudes might provide some guidance. In his social history of syphilis in the twentieth century, No Magic Bullet, Allan Brandt suggests that public attitudes toward

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those infected with syphilis changed little during the first half of this century. 53 Despite increasingly useful medical therapies and public health efforts during World War I and the 1930s, "venereal disease remained . . . a symptom of social decay and sexual evil." 54 Further, a review of the popular literature on malaria fever therapy from the 1930s and 1940s demonstrates that the advent of this remedy did little to alter the public's perception of the syphilitic as an evil sinner. Articles in newspapers and magazines such as the New York Times, GoodHousekeeping, Scientific American, Hygeia, Readers Digest, Newsweek, and Popular Mechanics depicted neurosyphilitics in highly value-laden, moralistic terms, calling them "maniacal syphilitic victims," 55 "wretched maniacs," 56 "those whose sins it rewarded," 5 7 and "doomed human derelicts." 58 Dubbed the "friendly fever," malaria was often portrayed as a fitting punishment for those afflicted with syphilis. According to Paul de Kruif, the widely read popularizer of medical knowledge, in an article apdy titled "The Pale Horror," "Give your paretics the right kind of malaria . . . and, though it burned them, the whole bodies of these paralytics seemed cleansed by the malaria fire. Thin, washed out by the terrible fever, they . . . began to turn into new people." He noted afterward "how sorry they now were for the silly acts they'd done when they were crazy." 59 Although physicians, as part of this larger cultural milieu, may have seen the syphilitic in this value-laden context, it is possible that actual practice and local experiences differed markedly from the published accounts, as an examination of a specific institution and its doctors shows. GENERAL PARESIS AND MALARIA FEVER THERAPY IN PATTON STATE H O S P I T A L To explore the effect of malaria fever therapy on doctors' and patients' perceptions in everyday practice, we turn our gaze to a typical state hospital in southern California, originally named the Southern California Asylum for the Insane when it admitted its first patient in 1893. In 1927 the California State Legislature changed the name to Patton State Hospital. Like Stockton State Hospital, this institution contains a particularly rich and complete archive of all patient medical records since its opening. Also, as with Stockton medical records, these have the following: transcripts of court proceedings to determine insanity, family questionnaires asking for the supposed cause of the insanity, admission histories, progress notes, and transcripts of patient interviews. As our exploration of these records will show, malaria fever therapy brought about radical changes both in the way in which doctors saw their patients and in the doctor-patient relationship. These changes are especially apparent when we compare the therapeutic world of general paresis before and after introduction of malaria in the spring of 1928. These two

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separate worlds will be described in turn. We will see at the end of this chapter that it is a comparison that also lends itself to quantitative assessment. Before embarking on this examination, a few general features of Patton State Hospital should be kept in mind. Material and medical conditions for individual patients probably worsened, or at best stagnated, over much of the period that we will consider. For example, the patient population steadily rose throughout the forty years between 1910 and 1950. In 1910 Patton had a resident patient population of 1,372; by 1950 that population had swelled to 4,128. 60 For most of the period studied, the number of treating physicians and attendants simply could not keep abreast of this burgeoning patient population. T h e Great Depression and World War II further exacerbated the staff and material shortages endemic to Patton. While these factors affected state hospitals throughout the country, California was particularly hard hit. In 1940, for example, California state hospitals had one physician per 301 patients compared to one per 245 in Illinois, one per 183 in Massachusetts, and one per 160 in New Jersey. 61 Against this background of an abundance of patients and a scarcity of resources, Patton's administration remained remarkably stable. From 1912 to 1925 John Reily ran the hospital as medical superintendent. Following a prolonged illness, Reily relinquished the post to his first assistant, G. M. Webster, who remained at this position until 1946. Emphasizing that little would change with his new administration, shortly after assuming leadership of the hospital Webster wrote that "the remainder of the medical staff and the heads of departments are unchanged. There has been no question of the loyalty of any of these or their interest in the hospital." 62 Finally, it is worth noting that physicians' armamentarium changed little during most of the period in question. Between 1 9 1 0 and 1941 Patton physicians introduced essentially no new therapies (other than Salvarsan and malaria), and they relied primarily on those developed in the late nineteenth and early twentieth century. These therapies included various forms of hydrotherapy, sedatives, mechanical restraint, and sterilization. In 1941 Patton physicians, with the help of California Institute of Technology scientists, began experimenting with a newly constructed electroconvulsive machine but did not begin to use this new technology on a wide scale until the mid-1940s. 63 Thus steadily worsening conditions and the lack of general therapeutic change provide the context in which Patton physicians attempted to treat their neurosyphilitic patients.

Premalaria Era General paralysis of the insane was one of the most frequent diagnoses Patton physicians made. For example, in 1921 neurosyphilitics accounted for 20 percent of first admissions, second only in frequency to those with a diag-

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nosis of manic-depressive psychosis. 64 Significantly, virtually no paretic patient voluntarily admitted himself or herself to Patton for treatment, and prior to the introduction of malaria nearly all patients with general paresis were involuntarily committed. That patients did not willingly admit themselves to Patton for treatment is not surprising given the level of pessimism that premalaria era physicians expressed regarding the treatment of paresis. Although they began using Salvarsan and Neosalvarsan in the late 1910s or early 1920s, physicians had little trust in these arsenicals. Shortly after a patient's admission, the doctor usually initiated a six-week course of weekly intravenous injections of either Salvarsan or Neosalvarsan. The doctor occasionally instituted another series of injections a year or so later. Since the vast majority of paretic patients died before discharge, physicians rarely had the opportunity to start a third course of injections. Reflecting his exasperation and helplessness over Elizabeth Kuper, a forty-three-year-old woman whom he described as "noisy" and "very untidy," a physician wrote, "4-14-1923. Neo-salvarsan discontinued as patient is too disturbed and disease too far advanced for her to derive any benefit from further treatment." 65 Doctors' doubts regarding their ability to treat syphilitic patients pervade the medical records of those admitted before the introduction of malaria therapy. A close examination of these premalaria era records, however, reveals more than simply a gloomy outlook on the part of physicians. We find that doctors perceived their neurosyphilitic patients in ways that reflected both their therapeutic nihilism and the prevailing cultural meaning of syphilitic infection. In the premalaria era, doctors often characterized their syphilitic patients in pejorative ways. In records with admission dates between 1910 and 1927,1 found that doctors often used the following adjectives: "lazy," "silly," "childish," "obscene," "vile," "vulgar," "stupid." Doctors commonly employed these adjectives to describe integral characteristics of their patients that functioned independently from the physicians' relationships with the patients. For example, in 1 9 1 9 a physician wrote the following about Jose Gonzales, a fifty-year-old laborer who had neurologic and psychiatric manifestations of paresis: "Habit disorderly. Manner stupid. Dull and stupid . . . continually looking for a chance to get away from the institution . . . a deteriorated [patient] who is very indifferent. . . . So lazy that he has to be left on the ward; will occasionally help with the work a little if the attendants keep after him." 6 6 Note that from the context of this passage, "dull," "stupid," and "lazy" are unchanging and perhaps unchangeable states. These adjectives define Jose's essence. Premalaria era physicians did occasionally make favorable comments about their patients, although usually in a backhanded way. Here is an example from 1916: "In the clinic the patient was happy and good natured; talked about his looseness of moral character with considerable aplomb,

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thought nothing whatever of it." 67 Typical of his counterparts, this physician c o m b i n e d a relatively c o m p l i m e n t a r y attribute, " g o o d natured," with a modicum of virtuous reproach, "looseness of moral character." T h e moral character of patients was often questioned and explicitly cond e m n e d by their physicians, a finding not surprising given the cultural association of syphilis with moral turpitude. T h r o u g h o u t the 1910s and 1920s doctors expressed righteous indignation over their patients' p r e s u m e d depraved behavior, describing them as "morally loose," "immoral," and "sexually irregular." T h e following extract f r o m the record of a w o m a n admitted in 1923 exemplifies the way in which doctors saw moral deficiencies in their syphilitic patients: "An extremely vulgar paretic . . . [who] has led an immoral life. Had been treated for syphilis. I think her j u d g m e n t is better than her behavior. This is the place for her." 68 Doctors not only saw syphilis as a sign of moral corruption but also believed it signified that paretics lacked control over their sexual urges, necessitating close observation even while in the hospital. Describing a thirty-two-year-old woman w h o was receiving Salvarsan for her paresis and a permanganate douche for a gonorrheal infection that gave her an "extremely foul body odor," a doctor wrote the following in 1921: "So far as can be observed there is absolutely n o change in her condition mentally or physically, not withstanding, her husband, w h o is very sentimental and visits frequently, imagines otherwise. W h e n he visits her it is necessary to keep him and the patient u n d e r close observation,"69 Like many of his colleagues, this doctor believed that paretic patients'—or, perhaps, by association, their spouses'—carnal desires could easily overpower them. A l t h o u g h I am primarily c o n c e r n e d with how doctors perceived their paretic patients, it is worth noting that families often believed that syphilitic infection was simply too morally repugnant to acknowledge openly. In all family questionnaires f r o m the premalaria era records that I reviewed, when asked for the cause of his or her loved one's insanity not a single family m e m b e r c o u l d bring himself or herself to admit to the possibility of syphilitic infection. Writing in 1923 in response to the doctor's questions regarding her brother's alleged past syphilitic infection, a patient's sister wrote, "Regarding the blood test for the dread disease, you mention—that I cannot say anything about. IfJack was ever afflicted with it I do not know, for I was the youngest sister and nothing like that would ever have b e e n discussed in my hearing, and you can understand that in a family circle anything like that is usually tabooed." 7 0 Note that the sister could not even bring herself to mention the word syphilis, calling it instead the "dread disease." She then reassured Jack's doctors that he was "too clean minded" to be infected with syphilis. Finally, she theorized as to the "true" causes of Jack's psychic problems, which included head trauma, worry, family troubles, and a "high-strung" constitution that ran t h r o u g h the family. Like

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most premalaria era family members, Jack's sister found these much more morally acceptable causes than syphilis. Consistent with seeing paretics as immoral, degenerate transgressors, doctors often dealt with these patients as though they were objects to be acted on, defined by their disease rather than their subjectivity. T h e manner in which Patton physicians meted out their remedies illustrates this objectification of the syphilitic patient. For example, doctors never asked a patient's permission to initiate a particular treatment. After deciding that his patient suffered from general paralysis, a doctor wrote, "This deteriorated paretic . . . will be given neo-salvarsan." 71 As far as one can discern from the medical record, this patient's doctor gave her no choice in her treatment. If doctors did discuss treatment with their patients in the premalaria era, such conversations were never recorded.

Malaria Era During the spring of 1928, Patton doctors received their first vial of malariainfected blood. By June 1932 these physicians had inoculated 154 patients and produced a total of 1,526 chills. 72 More than simply a new technology to combat a recalcitrant disease, these malaria plasmodia were associated with a fundamentally altered perception of the neurosyphilitic patient. We find, f o r example, that the nature and frequency of negative comments changed. Doctors made relatively fewer negative comments, and those they did make implied more of an interaction between doctor and patient, albeit at times a rocky one. Terms such as "belligerent," "quarrelsome," "sarcastic," or "unreasonable," rare before 1928, imply a greater degree of interaction between doctor and patient than the static ones used in the premalaria era. Let me illustrate by the following example: "She stayed a few hours and was very dissatisfied; crying and d e m a n d i n g she be allowed to leave. . . . Patient appeared to be very unreasonable, perhaps mild deterioration." 7 3 T h e doctor saw this potential malaria fever patient as "unreasonable" not because of any inherent quality she possessed but because she refused his suggestions. It is noteworthy that he allowed her to leave without forcing her to undergo fever therapy, although he obviously had the last word. Whereas faint praise was bestowed on premalaria era patients, in the malaria era doctors wrote less ambivalently about their syphilitic patients. In the 1910s and 1920s doctors often paired positive comments with negative descriptions, but physicians in the malaria era increasingly described their patients by using only positive attributes. This is exemplified by the following extract: "November 10, 1931. Patient is pleasant and agreeable; is an excellent worker; gives no t r o u b l e . . . . Is happy to remain h e r e . . . . [ A p p r e ciates everything that is being done for him." 7 4 Furthermore, physicians wrote empathic and generous descriptions of their malaria-treated

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A NEW T H E R A P E U T I C R A T I O N A L E

patients—portrayals absent in the 1910s and 1920s. Taking an active interest in Evelyn Brice's world, her doctor wrote in 1941, "She is industrious and takes care of the flower garden. . . . She has been raising many flowers and takes good care of them, also does very nice needle work. . . . [I] s especially fond of her cat, goes to all entertainment." In 1935, a few months before inoculating Evelyn with malaria, her ward physician sympathetically observed that she "is somewhat unstable and emotional and will require considerable attention to make her feel at ease." 75 In fact, with malaria era syphilitic patients, unlike previously, physicians often expressed and recorded interest in their patients' emotional well-being. Concerned about a patient's reaction to the untimely death of his wife, a physician wrote, "Patient's son called up; stated his mother had just died and wondered if he would be allowed to take the father to the f u n e r a l . . . . It was finally decided that the son come to the hospital Sunday and notify the patient of the death of his wife, and if his reactions are satisfactory he should be allowed to take him for the day." 76 As we saw, Americans from the 191 os to the 1940s saw syphilis as a sign of moral failure, and this attitude pervaded doctors' descriptions of patients in the premalaria era. Providing us with further evidence that fever therapy altered perceptions, malaria era physicians only occasionally accused their syphilitic patients of immorality. Further, in contrast to the virtual silence of families in the premalaria era about the origins of the disease, families after 1928 became increasingly candid about syphilitic infection, and family questionnaires returned in the malaria era often cite syphilis as the cause of their loved ones' difficulties. This transformation in the way doctors described their patients points to a more fundamental change in the doctor-patient relationship. Malaria fever therapy allowed physicians to engage their patients in a new type of therapeutic dialogue, wherein therapy became a mutually agreed on course of action instead of one unilaterally decided on by the doctor. Indeed, that these physicians entered into a dialogue at all with their syphilitic patients marks a major departure from their previous relationships with them. Thus, instead of forcing patients to be treated against their will, as with the use of Salvarsan and Neosalvarsan, doctors asked patients if they wanted to u n d e r g o fever therapy. T h e following doctor-patient interaction, transcribed in 1937, illustrates this. Patient: Good morning. Doctor: Do you want malaria?

Patient: Well yes, I want anything to make me better. Thank you very much. 77 Despite this patient's involuntary status, her doctors, at the least, were willing to ask whether she wanted the treatment.

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One could suppose that these doctors had such an anemic faith in the effectiveness of the remedy that it mattered little to them whether patients agreed to the inoculations. This, however, was not the case. Patton physicians enthusiastically embraced the new treatment. In describing his institution's experience with fever therapy, the medical superintendent wrote, "There were practically no deaths, an improvement was apparent in nearly every patient, and in some sufficiently marked so that we felt justified in discharging the patient as recovered, a possibility unhoped for in the days before this treatment became routine." 78 Nonetheless, when patients did refuse inoculations, physicians acquiesced to their wishes, as the following 1933 dialogue between the superintendent, Webster, and a recently admitted patient, Harold Miller, indicates. Dr. Webster: I think it is a mistake f o r y o u to g o h o m e w i t h o u t taking malaria. . . . D o n ' t you want to have the malaria? Patient: N o t exactly m e but both of us. . . . My p e o p l e that passed away have passed away with fevers, typhoid and malaria and she is afraid of it and so am I. . . . I would prefer to g o h o m e . Dr. Webster: Write the wife and tell her of o u r ideas regarding treatment, if she wishes to sign his "death warrant" all right [he can leave]. 7 9

In spite of believing that the fever could save Harold's life, Webster reluctandy accepted his decision. This passage is emblematic of the transformation that malaria fever bought about in the way doctors saw their paretic patients. No longer seeing them as objects to be manipulated, doctors listened to and acted on their patients' desires, even when doing so contradicted their own therapeutic belief system. The malaria era also signaled a transformation of neurosyphilitic patients' attitudes toward state hospitalization and their treatment. Although almost unheard of prior to the 1930s, neurosyphilitics began to voluntarily seek admission to California state hospitals specifically for malaria fever therapy. In 1930, for example, 242 patients voluntarily went into California state hospitals, yet only about 40 of them had a diagnosis of neurosyphilis.80 By 1945, 974 patients voluntarily sought admission to California state hospitals, 420 with a diagnosis of neurosyphilis. 81 It is noteworthy that many of these voluntary patients exhibited no symptoms of general paresis and had only a positive spinal Wassermann. A variety of paths led a patient to "voluntarily" admit himself or herself into the hospital. One common path was through the Selective Service System. If a positive spinal Wassermann was detected during the induction physical examination, the individual was strongly encouraged to undergo fever therapy at the local state hospital. In other instances the family physician implored the individual to go to the state hospital when he or she tested positive for antibodies against syphilis in the spinal fluid. Whatever

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A NEW T H E R A P E U T I C R A T I O N A L E

path taken and gentle coercion applied, patients, in the main, appear to have genuinely wanted the treatment, as the following dialogue between a recently admitted man and his doctor exemplifies. While his wife staunchly opposed inoculation with malaria, the patient persisted. Patient: I want the malaria, that is about all I can tell you. . . . I had three lawyers come to me in the court and tell me I did not have to come here if I did not want to and I wanted to come and get the treatment. Doctor: Patient is anxious to have malaria and up to the present time his wife has not been willing to sign the permit. We are to write her that we are going to give the malaria. 82

Shortly thereafter the doctors inoculated him with the malaria parasite, in spite of the wife's refusal. This example shows not only that this patient took an active role in therapeutic decisions but also that state hospital doctors could and did listen to their patients' wishes—especially when it reinforced their own therapeutic outlook. In contrast, I found no evidence that premalaria era patients requested any form of therapy. For many patients, malaria treatment was a terrifying and physically brutal experience. According to one patient, "I had an awful time with the malaria. I thought I was going to die for sure with the chills." 83 Nevertheless, they often expressed heartfelt gratitude to their doctors after the chills and fevers had subsided. When asked by his doctors how he felt, a patient replied, "I have felt bad until I had malaria," but after the fevers, he went on to say, "when twenty years old I never felt better. " 84 Obviously agreeing with his patient's assessment, the doctor discharged him from the hospital six weeks later as "recovered." In this case, as in most other cases, the shared belief in a successful therapy allowed doctor and patient to agree on a course of action and then allowed them to agree on what constituted therapeutic success, which even affected patients' perceptions of the institution itself. In the words of a woman admitted in the 1930s and who wished to remain in the hospital a while longer, "I like it here. I have had good treatment." 85 Quantitative

Descriptive

Results

I have attempted to show that malaria fever transformed doctors', patients', and possibly their families' attitudes toward neurosyphilis. My argument has been based on a content analysis of medical record extracts, a method admittedly subject to selection bias. Although this qualitative method has yielded a portrait of general paralysis and its treatment, a quantitative approach based on random sampling and systematic chart review provides further confirmation of my findings. To this end, I systematically selected 130 patient records that had admission dates between 1910 and 1950. I chose random start dates for each year and, starting from each chosen date,

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87

3 Classification Criteria for Positive and Negative Descriptions of Neurosyphilitic Patients Made by Patton State Hospital Physicians

TABLE

Positive

Excellent/industrious worker Does very nice work Good helper Excellent/good/likable patient Pleasant/enjoyable/friendly Good-natured/gets along nicely/always has a smile Intelligent/considerable insight Obedient Well-poised

Negative

Lazy Immoral/profane Silly/childish Obscene/vile/vulgar Obnoxious/sullen/not friendly Sarcastic/belligerent/agitator/ quarrelsome Stupid/foolish Disobedient Unreasonable

examined the first two records that had a diagnosis of neurosyphilis. I oversampled patient records with admission dated between 1920 and 1936 to focus on the early effects of the treatment's introduction. One hundred twenty-nine records were available for review. From this sample, there were 50 premalaria era patients (patients who either died or were discharged prior to the summer of 1928) and 79 malaria era patients, 46 of whom received fever therapy. The method of analysis consists of quantitative and descriptive comparisons of medical records before and after Patton physicians began using malaria. After reviewing approximately 200 neurosyphilitic records from both Patton State Hospital and Stockton State Hospital, I constructed the classification scheme as shown in table 3. Then, using the randomly selected sample from Patton State Hospital, I categorized all statements in the chart as positive, negative, or neutral, in accordance with criteria set forth in the table. I also devised a chart abstraction form to tabulate patient characteristics (sex, age, race, etc.) and symptoms, therapies used, and patient condition at discharge as described by the physicians. As can be seen from table 4, I divided the sample into two groups. The first group consists of 50 patients who were discharged or died before the summer of 1928 (the date Patton doctors began using malaria fever therapy) . The second group consists of 79 patients who were discharged or died after the summer of 1928. I then further subdivided the malaria era group into those who did not receive malaria fever therapy and those who did receive it. In all groups, most were middle-aged white men. It is worth noting that while men predominated among those treated with malaria fever, the number of men thus treated was nearly identical to the prevalence of

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TABLE 4

Characteristics of 129 Neurosyphilitic Patients Admitted between 1910 and 1950 Premalaria Era, 1910-1927 (N = 50)

Characteristic

Age White Male Neurologic symptoms Psychiatric symptoms

Mean

43

N

Malaria Era, 1928-1950 Total (N = 79)

% Mean

45

(N = 79)

No Malaria (N = 33)

N

% Mean

62 56

78 71

50

Malaria (N = 46)

N

% Mean

27 23

82 70

42

N

%

35 33

76 72

33 41

66 82

44

88

61

77

26

79

35

76

38

76

59

75

29

88

30

65

male neurosyphilitics, suggesting little or no gender bias in the use of this remedy. Furthermore, the great majority had neurologic symptoms such as a positive Romberg sign, ataxia, or tremor. Patients in all three groups also experienced delusions or disorientation. Table 5 shows the percentage of medical records containing negative and positive descriptions by doctors of their patients. As can be seen, doctors made many more positive comments about their malaria era patients than about their premalaria era patients (53% vs. 20%). Comparing records within the malaria era, doctors made many more positive comments about their malaria-treated patients than about those not treated with malaria (70% vs. 30%). Conversely, physicians made many fewer negative comments about their malaria era patients than about their premalaria era patients ( 2 8 % vs. 5 0 % ) . Comparing records within the malaria era, doctors made fewer negative comments about their malaria-treated patients than about those who did not receive malaria (24% vs. 3 3 % ) . Although these figures suggest that malaria treatment did alter how doctors described their syphilitic patients, they also raise questions. Foremost among them is that they depend on the vagaries of an admittedly variable medical record. In some instances doctors wrote long descriptions of their patients, while in others they merely recorded vital statistics. For a reliable quantitative measure, we need an aspect of the medical record that appears uniformly throughout the period in question. Patton doctors' determination of patient outcome fulfills such a requirement. Throughout the period of the 191 os to the 1940s the hospital administration required that for each patient's stay in the hospital the physician make a judgment of the patient's

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89

t a b l e 5 Positive a n d Negative Descriptions Made by Physicians of 129 Neurosyphilitic Patients Admitted between 1910 a n d 1950 Premalaria Era, 1910-1927 (N= 50)

Malaria Era, 1928-1950 (N = 79) Total (N= 79)

No Malaria (N = 33)

Malaria (N = 46)

Description

N

%

N

%

N

%

N

%

Positive Negative

10 25

20 50

42 22

53 28

10 11

30 33

32 11

70 24

r e s p o n s e to t h e hospitalization a n d t r e a t m e n t . This d e t e r m i n a t i o n was r e c o r d e d in t h e final p r o g r e s s r e p o r t , w h e r e t h e physician assessed t h e patient's condition at discharge a n d used o n e of the following categories: "recovered," "improved," " u n c h a n g e d o r worse," "dead." A l t h o u g h these are n o t necessarily objective reports (except f o r the category "dead"), they d o provide us with a direct m e a s u r e of d o c t o r s ' perceptions of p a t i e n t outcomes. By c o m p a r i n g the premalaria era to the malaria era assessments f r o m the r a n d o m l y selected sample, we find that physicians clearly believed in the effectiveness of this new technology (table 6 ) . Premalaria era physicians perceived little i m p r o v e m e n t in their paretic patients, discharging only 4 p e r c e n t of t h e m as "improved." In sharp contrast, doctors in the malaria era p e r c e i v e d entirely d i f f e r e n t o u t c o m e s , d i s c h a r g i n g 4 0 p e r c e n t of t h e i r paretic patients as e i t h e r " i m p r o v e d " o r "recovered." Fever t h e r a p y also may have i n f l u e n c e d how doctors saw paretics n o t treated by this therapy; they discharged 15 p e r c e n t of these patients as "improved." T h e m a r k e d differences in d e a t h rates between the premalaria era a n d malaria era certainly must have r e i n f o r c e d physicians' belief in malaria's effectiveness. Alternative

Explanations

I have a r g u e d that malaria fever therapy t r a n s f o r m e d b o t h how doctors a n d patients perceived disease a n d their relationships with each other. Let us now entertain some alternative explanations f o r these changes in the medical record. For example, o n e could argue that patients in the malaria era were less psychotic a n d physically debilitated t h a n p a t i e n t s in t h e premalaria era, a n d , as a consequence, doctors r e s p o n d e d m o r e positively to t h e i r m o r e r o b u s t m a l a r i a e r a patients. As table 4 shows, m a l a r i a e r a patients h a d slightly fewer neurologic symptoms (77%) than did premalaria era patients (88%). Although this would suggest that malaria era patients

po

A NEW THERAPEUTIC RATIONALE

TABLE 6 Stated Condition at Discharge as Determined by Physicians of 129 Neurosyphilitic Patients Admitted between 1910 and 1950 Premalaria Era, 1910-1927 (N- 50)

Malaria Era, 1928-1950 Total 79)

(N-

No Malaria (N = 33)

(N = 79) Malaria (N = 46)

Stated Condition

N

%

N

%

N

%

N

%

Recovered / improved Unchanged Dead

2 6 41

4 12 82

32 6 37

40 8 47

5 2 24

15 6 73

27 4 13

59 9 28

might have been healthier, the records require cautious reading. For these physicians, a diagnosis of paresis often structured and determined what they saw when they examined a patient. For example, if they believed a particular patient suffered from paresis, they found signs and symptoms that confirmed this diagnosis, and this was especially true of subtler neurological signs. If the spinal Wassermann proved negative, signs such as a positive Romberg suddenly disappeared. What doctors saw cannot be separated easily from what they believed. When they admitted a paretic patient who they thought could be helped by malaria fever therapy, these physicians saw a healthier patient, one who could withstand the demands of intense fevers and chills. However, we can partially control for the degree of illness of patients both before and after the introduction of malaria by looking more closely at those patients who died. It is not unreasonable to assume that those who died during hospitalization before and after the introduction of malaria were roughly equivalent in terms of health status. Table 7 compares positive and negative descriptions of those patients who died. As can be seen, even those sick enough to die of their disease in the malaria era were described more positively and less negatively than similar premalaria era patients who died before discharge. Doctors made more positive comments about their malaria era patients who died than their premalaria era patients who died ( 3 8 % vs. 14%). Within the malaria era records, those patients treated with fever therapy were more likely to be described positively than those who did not receive fever therapy ( 6 2 % vs. 25%). In contrast, doctors made fewer negative comments about their malaria era patients who died prior to discharge than their premalaria era patients who died prior to discharge ( 3 5 % vs. 4 8 % ) . Within the malaria era records, those patients treated with fever therapy were less likely to be negatively described than those who did not receive fever therapy ( 3 1 % vs. 3 8 % ) . Thus, assuming that those patients

A NEW THERAPEUTIC RATIONALE

91

TABLE 7 Positive and Negative Descriptions Made by Physicians of 79 Neurosyphilitic Patients Who Died Prior to Discharge Malaria Era, 1928-1950

Premalaria Era, 1910-1927

11

11 -u.

Total

(N = 37)

No Malaria (N = 24)

Malaria (N = 13)

Description

N

%

N

%

N

%

N

%

Positive Negative

6 20

14 48

14 13

38 35

6 9

25 38

8 4

62 31

who died in both the premalaria era and the malaria era had roughly similar degrees of physical pathology, the results shown in table 7 suggest that the changes in perception were independent of the patient's physical condition. O n e also could suppose that institutional factors at Patton could have led to these changes in doctors' perceptions of their patients. However, since working conditions most likely worsened during the depression and since the hospital's administration remained stable, these factors are unlikely explanations for the increasingly h u m a n e care of paretic patients after 1928. Changes in societal attitudes toward sexuality and syphilitic infection could also have brought about the changes that we have observed. However, Brandt's study of syphilis in the twentieth century as well as popular literature from the 1930s and 1940s on fever therapy suggest that syphilitic infection continued to represent moral failure and that the "friendly fever" was believed to be an apt punishment for this failure. For these reasons, cultural attitudes are unlikely causal factors for the changes in the doctors' perceptions of paretic patients. Are these medical records a reliable source for assessing physicians' attitudes? As is well known, the medical record can be unreliable as a source of objective clinical information. I have attempted to see the world of general paresis and its treatment through doctors' and, to a lesser extent, patients' very subjective eyes. The question of objective validity, although important, is not pertinent to our exploration of perception. Nonetheless, we can question whether Patton physicians' charts accurately reflected their clinical perceptions. For example, did these physicians disingenuously claim—possibly for administrative reasons—that patients had recovered when in fact they had worsened or remained unchanged? Indeed, some of their appraisals deserve to be viewed with skepticism. In the progress note just before a patient's escape from the hospital, for instance, a doctor wrote the following: "June 2, 1921. Patient has been working in the shoe shop for some [time], but his work is unsatisfactory and he is to be left in on the ward;

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hears voices but is unable to speak an intelligent word in English and is quite rambling and incoherent; noisy in reaction to his hallucinations." 86 Several months after his unexpected escape from the hospital, the superintendent discharged him as recovered. Records such as this are exceptional; physicians' progress notes and patient interviews appear to confirm discharge assessments. The next case exemplifies the more typical instance in which these physicians seem genuinely convinced that their malaria-treated patients had recovered. Believing himself to be the president of the United States and threatening to kill his brother and wife, a thirty-nine-year-old carpenter was taken by ambulance to Patton on April 27, 1945. On finding he had treponemal antibodies in his spinal fluid, his doctors diagnosed him as having general paralysis and several months later inoculated him with malaria. By the fall of 1945 they felt he had sufficiently improved to consider discharging him. The following interview occurred on October 2, 1945. Doctor: You h a d malaria? Patient: Yes m a ' a m . I took it easy too. Doctor: You didn't have a very bad time of it? Patient: No, m a ' a m . 17 chills. Doctor: D o you feel recovered? Patient: O h yes. 87

The physicians agreed with him, noting that his "physical and mental health have remained good" and that "he appears to be emotionally stable," and discharged him as recovered. It is significant that the patient also believed himself to be recovered. Finally, it is also possible that malaria might have been incidental to these changes in attitude. For example, although greatly accelerated by the experiences of World War II, the psychiatric profession of the 1920s and 1930s had begun drifting slowly away from more somatically oriented models and toward more socially and environmentally determined explanations of psychiatric disease. O n e could argue that this shift created a generational change in psychiatrists' attitudes toward their patients, leading them to treat their nonparetic patients in a less objectified manner, by, for instance, encouraging patients to participate in treatment decisions. However, with the exception of sterilization and occasionally electroconvulsive therapy, I found no evidence that physicians invited their patients to participate in treatment decisions. A similar situation prevailed at other California state hospitals, as is illustrated by the following extract from a Stockton State Hospital medical record. T h e second series of shock treatment was b e g u n on O c t o b e r 30, 1944 a n d terminated on D e c e m b e r 2 8 , 1 9 4 4 . A t the b e g i n n i n g o f the treatment this patient

A NEW THERAPEUTIC RATIONALE

93

was very excited, noisy, violent and at times destructive. She was resistive, mute, negativistic and confused. . . . After the 10th treatment she again began to improve slightly and at the end of shock therapy showed some improvement, but was still excited, talkative and at times threatening and negativistic.88

This passage suggests that this woman's physicians did not (and, perhaps, could not) enter into a therapeutic dialogue with her as they did with their malaria era syphilitic patients. Armed with a therapeutic regimen that acted to quell her violent and destructive behavior, her physicians were forced to treat—and perhaps perceive—her as an object to be manipulated and acted on. One could speculate that since her behavior rather than a specific disease pathogen, like the treponemal spirochete, was the target of the remedy, there was litde likelihood that doctor and patient could agree on a particular therapeutic regimen. I have intentionally avoided making an argument for or against the efficacy of fever therapy. As researchers performed no randomized clinical trials (our late twentieth-century "gold standard" for proof of efficacy), we cannot answer this question with any degree of certainty. Nonetheless, in actual practice malaria fever therapy was dramatically effective in altering, for doctors and patients, the meaning of disease and the nature of the doctorpatient relationship. With a therapeutic regimen that held out little hope for success, premalaria era physicians saw their neurosyphilitic patients as "hopeless," "immoral," and "stupid" paretics—objects to be acted on. And patients played a reciprocal role, compelled into the hospital by force of law and often made to accept the meager ministrations of their doctors. Perceptions of both doctors and patients not only mirrored each other but also reflected their belief, or more accurately, lack of belief, in premalaria treatments. The advent of malaria therapy restructured patients' and doctors' perceptions of themselves and each other. Not only did these physicians believe that they could act decisively against the syphilitic spirochete, but their belief in its efficacy allowed them to write more sympathetically about their patients and, perhaps, to care for them in a less objectified and more humane way. Furthermore, this new technology not only allowed patients voluntarily to seek hospitalization, but permitted even those who were there against their will to become active participants in their treatment. Indeed, it is possible that shared belief and the altered relationship brought about by changes in perception created malaria fever's apparent biological success. When a patient admitted in 1940 asked his doctor, "Will you help me? Do I have to suffer a lot? Do I have to be afraid?" malaria fever allowed the doctor to answer compassionately, "Yes I can help you and you do not have to be afraid." 89

A NEW T H E R A P E U T I C RATIONALE

Though therapeutic sterilization allowed physicians to flirt with the possibility of divorcing therapeutics from behavior, the practice of malaria fever therapy decisively made this separation real by shifting the object of psychiatric pathology from disorderly conduct to a disease pathogen, syphilitic spirochetes invading the tissues, blood, and brain. In contrast to behaviors that were vulnerable to differing interpretations, doctors and patients easily agreed on the meaning of a positive Wassermann and the necessary therapeutic course that such a finding entailed. Though this history suggests that biological solutions to mental ills may have salutary effects on patients and doctors, this interpretation should be made cautiously. This history could, and probably should be, read not as the triumph of biology but as the triumph of hope, and of a desire to heal and be healed. Further, the fate of neurosyphilis and its treatment suggests that when psychiatrists devise remedies that forsake their place as disciplinary technologies, the illnesses they ameliorate lose their status as psychiatric diseases. Thus neurosyphilis is no longer within the purview of psychiatrists but o f neurologists and internists.

CHAPTER FIVE

Where the Mind Ends and the Body Begins: The Practice of Electroconvulsive Therapy A good talking to would do more good than insulin. — PHYSICIAN,

STOCKTON

STATE HOSPITAL

(1942)

I don't know doctor, it's—I had the electric shocks and that's the greatest thing ever happened in my life. I am telling you, that's the greatest thing that ever happened to me. — PATIENT,

STOCKTON

STATE HOSPITAL

(1950)

She improved in two weeks and did well for 3 wks. but in recent weeks she has been a "zombie. "Is in restraint and resistive... . She had about noEST's in recent years. She did well with EST and will probably get more. — PHYSICIAN,

STOCKTON

STATE

HOSPITAL

(1956)

We have before us three seemingly irreconcilable quotations involving the practices known collectively as shock therapy. In the first, an exasperated and condescending doctor says that his patient needs a "good talking to" instead of the proposed remedy, insulin shock therapy. 1 For him, words were not only a legitimate intervention, they also possessed as much potency as insulin. In the next quotation, a patient can barely contain his enthusiasm for the electrically induced convulsions that he had recently experienced. 2 He willingly submitted to the shocks, and even asked his doctors for more. T h e final quotation portrays an entirely different scene. Bound by cuffs and a camisole, this woman fought to no avail against her doctors' ministrations.3 Despite, and often because of, her resistance physicians at Stockton eventually would give her more than one hundred fifty electroconvulsive treatments during her six-year sojourn at the hospital. The aim of this chapter is to understand the meaning of these various representations of shock therapy. Introduced into California state hospitals in the late 1930s and early 1940s, the shock therapies provided psychiatrists with their first new remedy since the introduction of malaria fever therapy in the 1920s. Like 95

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