The Proceedings of the 19th Annual History of Medicine Days Conference 2010 : The University of Calgary Faculty of Medicine, Alberta, Canada [1 ed.] 1443849537, 9781443849531

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The Proceedings of the 19th Annual History of Medicine Days Conference 2010

The Proceedings of the 19th Annual History of Medicine Days Conference 2010: The University of Calgary Faculty of Medicine, Alberta, Canada Edited by

Lisa Petermann, Kelsey Lucyk and Frank W. Stahnisch Advisors to the Editors: David Hogan Gilaad Kaplan Margaret J. Osler (†)

Peter Toohey

Mark Humphries

Diana Mansell

Melanie Stapleton

James R. Wright, Jr.

Previous Editors: 1999-2006: William A. Whitelaw 2006-2008: Melanie Stapleton Founded by: Peter J. Cruse

The Proceedings of the 19th Annual History of Medicine Days Conference 2010: The University of Calgary Faculty of Medicine, Alberta, Canada, Edited by Lisa Petermann, Kelsey Lucyk and Frank W. Stahnisch This book first published 2013 Cambridge Scholars Publishing 12 Back Chapman Street, Newcastle upon Tyne, NE6 2XX, UK British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Copyright © 2013 by Lisa Petermann, Kelsey Lucyk, Frank W. Stahnisch and contributors All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-4438-4953-7, ISBN (13): 978-1-4438-4953-1

CONTENTS

List of all Presenters and their Academic Affiliations ................................ xi Preface and Acknowledgements ............................................................... xiii List of Images ........................................................................................... xix List of Tables ............................................................................................ xxi Applications of Science to Medicine A Poisoned Sleep: How Curare Revolutionized Anaesthesiology .............. 3 Esther Kim History of Nursing Medical Refugee Nurses in Britain, 1933-1945 ........................................ 25 Tashia Scott History of Public Health Placating the British: The Contagious Diseases Act in Canada................. 45 Caitlin Dyer A Scourge No More: The Portrayal of the WHO Smallpox Eradication Program in the North American Media (1967-1981) ................................ 61 David Harnett Illness and Disease in History The History of the Tainted Blood Scandal in Canada: Where Does the Responsibility Lie? .............................................................................. 79 Holly Ann Garnett and Meghan Ann Garnett

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Contents

Combating Sleeping Sickness: A Glance at the Development of Trypanosomiasis Treatment in Colonial Africa .................................. 101 Rosalind Ashton The Role of Pharmaceutical Companies in the Medicalization of Mental Illnesses ................................................................................... 115 Boluwaji Ogunyemi Stigma and Gender A Leper by No Other Name: Perpetuating Stigma in Medical Discourse ................................................................................................. 129 Angelique Myles History of Neurology and Psychiatry Oral History of Dr. C. Chan Gunn and His Neuropathic Theory: IMS ... 153 Chris Noss Recalling the Forgotten: Dementia Care Facilities and Programs in Alberta from 1900-1950 ...................................................................... 213 Riana Downs Eugenics in Alberta: the Lasting Effects ................................................. 239 Allison Barr Editorial Note .......................................................................................... 251 A Family Point of View: Negotiating Asylum Care in Alberta, 1905-1930 ................................................................................................ 253 Geertje Boschma Appendix 36 Abstracts of presentations (in alphabetical order) at the conference (either with no submission of a formal manuscript for publication or rejection following to the peer-review process). Waters and Syrups: the Deconstruction of Eighteenth-Century British Medicinal Recipes for Modern Applications ........................................... 280 Katherine Allen

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Borrowing Authority: Finding Nova Scotia’s Place in the Eugenic Discourse ................................................................................................. 281 Leslie Baker Getting the Blood Out of Your Boots: The Medical Adventure of External Counter Pressure ................................................................... 282 Brydon Blacklaws Plastic Surgery in World War I Today: The Pedicle Flap ....................... 283 Curtis Budden With Yellow Signals Burning Bright, Ill Winds Bring Fevers in the Night: The Secrets of Partridge Island, Canada’s First Quarantine Station ................................................................................... 284 Anna Davies “In Great Mercy Delivered:” Medical and Theological Understandings of Pain in Early Modern England ............................................................ 285 Adam Fowler Keeping Healthcare Afloat: The Lady Anderson Journals of Dr. Robert Dove, 1936-1938 ..................................................................................... 286 Shaina Goudie “Married to Angels and Among Lovely People:” The Hadamar Mass Murderers and Their Farewell Letters in the Shadow of Death ............... 287 Christiane Grieb From Sinner to Saint: Dr. Norman Bethune ............................................ 288 David Zhifei Han A License to Kill: The Merciful Murders of Dr. John Adams ................. 289 Charles Ho Societal Response to Choreomania in the Middle Ages .......................... 290 Sanjna Miriam John The Willowbrook Hepatitis Studies: Ethical Improprieties in Medical Research and the Need for a Universal Professional Standard ................ 291 Yasir Khan

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Contents

Lessons Learned from Medical Eponyms: Never Swear Faithfulness “With Every Waking Breath” .................................................................. 292 Ashley Kim Acupuncture: Journey into the West........................................................ 293 Erin Knight The Mandate to Heal: Jewish Medical Ethics, An Historical Perspective............................................................................................... 294 Jacinda Larson A Cloak of Secrecy: Transplant Tourism in China.................................. 295 Caroline Lee Responding to the Plague: the Development of Saint Roch as a Plague Saint ...................................................................................... 296 Clinton Lewis The Historical Development of the Cuban Health Care System ............. 297 Jessica Moe From Radioactivity to Radiation Therapy: How Saskatchewan Cancer Policy Influenced the Canadian Health Care System .............................. 298 Mathew Mossey ‘Messing with Genetics’: Perspectives on Synthetic Biology from the Organic Consumers’ Association.............................................. 299 Daniela Navia, Sibat Khwaja, and Niklas Bobrovitz Measuring Midwifery: Models and (Miss)conceptions ........................... 300 Vanessa Nelson Out from Under the Gaze: Foucault and False Dichotomies ................... 301 Tyler Peikes Life on the Edge: the Surgical Residency................................................ 302 Ian Pereira Apollo’s Arrows: the Decisive Influence of Disease on all Aspects of Warfare in Antiquity ........................................................................... 303 Stephen Pow

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The Bus, the Plane, and the Blind Briton: the Unique History of the Evolution of Charitable Eye Care.................................................. 304 John Doan Ali Qazalbash Radioactive Queers: Diagnosing and Pathologizing Homosexuality in Canada’s Cold War.............................................................................. 305 Frances Reilly Reagan, Regulation, and the FDA: The US Food and Drug Administration’s Response to HIV/AIDS, 1980-1990 ............................ 306 Lucas Richert Immigrant Filipino Nurses in Western Canada from 1950-2000: An Oral History Study ............................................................................. 307 Charlene Ronquillo Eugenics and Changing Notions of Women’s Bodies in Twentieth Century Alberta ....................................................................................... 308 Amy Samson How Descartes’ Mind-Body Dualism Will Affect your Visit to the Doctor Today ................................................................................. 309 Carly Scramstad The Summers of Fear: A History of the Polio Epidemic in Manitoba..... 310 Davinder Singh Medical Certainty: A History of Evidence and Authority in Medicine ... 311 Christopher Smith “She Exhibited Masculine Protest:” The Canadian Medical Association Journal and the Embodiment of Femininity During Canada’s Baby Boom, 1946-1966 .................................................................................... 312 Heather Stanley Medicalizing MacDuff: Cesarean Sections, Gender Relations, and the Roots of Obstetrics in Late Medieval Europe ............................. 313 Helen Vradelis

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Contents

A War of Words: The Contentious History of Chiropractic in North America ................................................................................................... 314 Andrew Weiss Historical Investigation of Canada’s Cord Blood Banking System ......... 315 Jacqueline Willinsky Indexes Listing of Names ..................................................................................... 317 Listing of Places ...................................................................................... 321

LIST OF ALL PRESENTERS AND THEIR ACADEMIC AFFILIATIONS

Rosalind Ashton ..........................................................Dalhousie University Leslie Baker ...................................................... University of Saskatchewan Allison Barr ................................................................ University of Alberta Brydon Blacklaws .......................................................Dalhousie University Curtis Budden ..............Memorial University of Newfoundland & Labrador Anna Davies ................Memorial University of Newfoundland & Labrador Riana Downs .............................................................. University of Calgary Caitlin Dyer ................................................................ McMaster University Adam Fowler .................................................... University of Saskatchewan Holly Ann Garnett ...................................................... Nipissing University Shaina Goudie .............Memorial University of Newfoundland & Labrador Christiane Grieb.......................................................... University of Calgary David Zhifei Han ..................................................... University of Manitoba David Harnett ..............Memorial University of Newfoundland & Labrador Charles Ho .................................................... University of Western Ontario Sanjna Miriam John ....................................................... Queen’s University Ashley Kim................................................... University of Western Ontario Esther Kim .................................................................. University of Calgary Erin Knight .............................................................. University of Manitoba Jacinda Larson ............................................................ University of Calgary Clinton Lewis ............................................................. University of Calgary Angelique Myles .........Memorial University of Newfoundland & Labrador Matthew Mossey .............................................. University of Saskatchewan Vanessa Nelson .......................................................... University of Calgary Chris Noss ..................................................................... Queen’s University Boluwaji Ogunyemi.....Memorial University of Newfoundland & Labrador Tyler Peikes ............................................................. University of Manitoba Ian Pereira..................................................... University of Western Ontario Stephen Pow ............................................................... University of Calgary John Doan Ali Qazalbash .............................................. Queen’s University Lucas Richert .............................................................. University of London Charlene Ronquillo ................ University of British Columbia at Vancouver Amy Samson .................................................... University of Saskatchewan

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List of all Presenters and their Academic Affiliations

Tashia Scott ....................................................... Oxford Brookes University Carly Scramstad....................................................... University of Manitoba Davinder Singh ........................................................ University of Manitoba Christopher Anthony Smith ......................................... Memorial University Heather Stanley ................................................ University of Saskatchewan Helen Vradelis ................................................................. McGill University Andrew Weiss ............................................................ University of Calgary Jacqueline Willinsky ..................................................... Queen’s University

PREFACE AND ACKNOWLEDGEMENTS

This book is the second volume in a new, peer-reviewed series of Proceedings Volumes from the Calgary History of Medicine Days conferences with Cambridge Scholars Publishing. The History of Medicine Days are two-day Nation-wide conferences held annually each spring at the University of Calgary in Alberta (Canada), where undergraduate and early graduate students from across Canada, the United States, United Kingdom and Europe give paper and poster presentations on a wide variety of topics from the history of medicine and health care. The selected 2010 conference papers, which are assembled in this volume, particularly comprise Applications of Science to Medicine, the History of Nursing, and essays on the History of Public Health along with topics from Illness and Disease in History. Further content areas such as Stigma and Gender and the History of Neurological Theory, include papers with interdisciplinary perspectives on history, such as anthropology and medicine, from two extended summer research projects from a medical student (Chris Noss, Queens) and a health sciences student (Riana Downs, Calgary), as well as from four history graduate students, Allison Barr (Edmonton), Caitlin Dyer (McMaster), Holly Garnett (Nipissing), and Tashia Scott (Oxford-Brookes) from the United Kingdom. Professor Geertje Boschma, a renowned nursing and public health historian at the University of British Columbia at Vancouver (UBC) and past President of the Canadian Association for the History of Nursing, gave the 2010 keynote address at the conference. Her topic “From a Family and Community Point of View: Rethinking Institutional Mental Health Care in Alberta, 1905-1975” was based principally on an earlier article published in the Canadian Bulletin of Medical History (CBMH).1 With the permission of the author and editors-in-chief of CBMH, this article appears as a full reprint in this volume, to represent the 2010 keynote address. In 2010, the invited keynote lecture was given as a cosponsored event together with the Calgary Institute for Population and Public Health (CIPPH) and the Calgary History of Medicine Society (CHOMS), for which the organizers of this event had been very grateful. 1

Geertje Boschma, “A Family Point of View: Negotiating Asylum Care in Alberta, 1905-1930,” Canadian Bulletin of Medical History 25 (2008): 367-389.

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Preface and Acknowledgements

This volume also includes the abstracts of all 2010 conference presentations and has further been illustrated with diagrams and images pertaining to the various topics from the history of medicine as they are assembled here. The development and fruition of this series, as in the past, has depended strongly also on the editorial and review involvement as well as the volunteering work of the eight advisors to the editors as well. Very unfortunately and sadly, however, during the production process to these 19th HMDs Proceedings, a very important member of the advisory board passed away after a short but serious period of illness. Dr. Margaret (“Maggie”) J. Osler (1942-2010) was a Full Professor in the Department of History and an Adjunct Professor in the Department of Philosophy at the University of Calgary, as well as an Adjunct Professor in the Department of History and Classics at the University of Alberta. She was sixty-seven years old when she passed away on September 15, 2010, and for everyone in her vicinity her passing came all too soon. The tragedy of her death, of a leading historian of the ‘Scientific Revolution’ and the relationship of ‘Science and Religion,’ has been a great loss to the local community in the History and Philosophy of Science at the University of Calgary, as well as for the work with the HMDs Proceedings series. Her erudite and stimulating work counts among the best of scholarship in her field, seeing that it had evolved and continued to explore the works of I. Bernard Cohen (1914-2003) and Thomas S. Kuhn (1922-1996). Both had eroded the fundamental assumptions of a historyof-ideas-style historiography of science and medicine in the vein of Russian-French philosopher and historian of science, Alexandre Koyré (1892-1964). Moving the picture of the scientific revolution further towards illuminating the underlying irrational, metaphysical and even mystical presuppositions that ground the Renaissance and the Early Modern Period in non-negligible forms, Maggie Osler’s publications represent a most important step with regard to the bigger picture of the advancement of science. She was a highly productive scholar and effective teacher, and will be remembered by her colleagues and students as such. Born December 1942 in New York, Osler attended Swarthmore College in Pennsylvania where she received her B.A. degree in Philosophy in 1963. She then moved to Indiana University for her graduate studies where she earned her M.A. degree in History and Philosophy of Science in 1966–during the turmoil of the Civil Rights Era. In the midst of the enthusiastic learning environment fostered by the faculty and graduate students at Bloomington, Osler perfected her historical skills. Amongst many future student generations she would become known for her broad

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understanding of scientific content and social context. Probably the most decisive period was marked by her PhD work entitled John Locke and Some Philosophical Problems in the Science of Boyle and Newton with the late historian of science Richard S. Westfall (1924-1996). In an almost seamless transition, after receiving her PhD, Maggie assumed a position in History and Philosophy of Science at Oregon State University. Quite determined, she drove to the other side of the continent with her car filled with just the necessary boxes of clothing and books. In 1970, she then acquired a continuing position in History at Harvey Mudd College, California, and has since had her primary affiliation with departments of history at Wake Forest University, North Carolina (19741975) and the University of Calgary (1975-2010). For thirty-five years she stayed there, rising through the ranks of Assistant to Full Professor. She also assumed an Adjunct Professorship in the Philosophy Department (1998) and in History and Classics at the University of Alberta (2002). Over the many decades of service to the University of Calgary, Osler taught countless undergraduate students from very diverse fields. She is remembered as a generous preceptor to undergraduates and also a demanding supervisor to the graduate students, both in her home department as well as in other university settings. Quite a number of her supervisees continued on at other colleges and became academic teachers in History, Philosophy and History and Philosophy of Science programs. Counted among her most outstanding local contributions are the launch of the History and Philosophy of Science Program and the Program for Science, Technology and Society at the University of Calgary; she took great pride in these, and we must hope that this institution continues their support in the future. Her research particularly comprised the history of the scientific revolution, such as: magic, science and religion; science in the 17th century and the mechanical philosophy from the 17th to the early 19th century. In addition to her book Divine Will and the Mechanical Philosophy: Gassendi and Descartes on Contingency and Necessity in the Created World (1994),2 she published as co-editor (with John Hedley Brooke) a themed-issue on Science in Theistic Contexts in Osiris (2001).3 As a single editor, she produced Rethinking the Scientific Revolution

2

Margaret J. Osler, Divine Will and the Mechanical Philosophy: Gassendi and Descartes on Contingency and Necessity in the Created World (Cambridge: Cambridge University Press, 1994). 3 John Hedley Brooke, Margaret J. Osler, and Jitse M. van der Meer (eds.), Science in Theistic Contexts: Cognitive Dimensions, vol. 16 Osiris (Chicago: University of Chicago Press, 2001).

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(2000),4 and recently another monograph with Johns Hopkins University Press: Reconfiguring the World: Nature, God, and Human Understanding from the Middle Ages to Early Modern Europe (2010).5 This book has been printed in Baltimore, Maryland, the city of her childhood that she had loved so much. Amongst her many other distinctions, Osler received the Science and Religion Course Prize from the Center for Theology and the Natural Sciences at the University of Berkeley (1999), was invited to give the Stillman Drake Lecture of the Canadian Society for the History and Philosophy of Science (1996), and the Richard S. Westfall Lecture at Indiana University (1999). She served as the Secretary and a Member of the Council for the History of Science Society (HSS), as well as on the advisory boards of Isis, the Journal of the History of Philosophy and Science and Religion around the World (eds. John Hedley Brooke & Ronald L. Numbers). She joined HSS early in her career and became a member of the British Society for the History of Science, the Canadian Society for the History and Philosophy of Science, the International Society for Science and Religion, and the American Society for Eighteenth-Century Studies. Her numerous scholarly involvements in societies, programs and institutions throughout North America and Europe demonstrate deep engagement in her field and a great capacity to make scholarly friends worldwide. In recent years, Osler was also closely involved with an early modern philosophy group at the Dipartimento di Filosofia dell’Università di Lecce. Upon her return to Calgary, she frequently spoke of the warm and studious atmosphere in Italy. In the middle of the many plans that Professor Osler had was the idea to bring more international scholars to the University of Calgary, and see a comprehensive graduate program emerge in the History and Philosophy of Science, Medicine and Technology. In concord with her local colleagues and friends, we hope that these plans will rise to life in future decades.6 During the month after her death, the idea has emerged in the University of Calgary Department of History to create an endowed undergraduate scholarship in support of a student in European History and the History of Science in honour of her name and lasting contributions to the History and 4 Margaret J. Osler (ed.), Rethinking the Scientific Revolution (Cambridge: Cambridge University Press, 2000). 5 Margaret J. Osler, Reconfiguring the World: Nature, God, and Human Understanding from Middle Ages to Early Modern Europe (Baltimore: Johns Hopkins University Press, 2010). 6 Cf. Frank W. Stahnisch, “Professor Margaret J. Osler (1942-2010),” The British Journal for the History of Science 44 (2011): 115-118.

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Philosophy of Science community in Calgary. It is with great coincidence and pleasure that the work of Dr. Osler’s last supervised student was published in the previous edition of this volume, The Proceedings of the 18th Annual History of Medicine Days Conference, 2009 (2012). Lina Roa, an undergraduate student from the Bachelor of Health Sciences Program, who has gone on to pursue her medical studies at McGill University in Montreal, researched an historical topic on William Harvey (1578-1657) and produced a paper that she contributed to this 2010 volume (published in 2012), entitled “Aristotle’s Influence on Harvey’s Discovery of the Circulation of the Blood. In the current Proceedings Volume (from the 2010 conference), the abstracts from all presenters at the conference are included in a special Appendix, so as to comprehensively document the activities, discussions, oral and poster presentations at the Calgary History of Medicine Days. This year, 41 students from thirteen universities–University of Saskatchewan, Queen’s University, University of Alberta, Memorial University of Newfoundland, University of Calgary, University of Western Ontario, Dalhousie University, McMaster’s University, University of Manitoba, University of British Columbia, McGill University, University of London, and Oxford Brookes University–gave oral or poster presentations during the two-day event held on March 12-13, 2010. We are very grateful that following to the peer review process the number of 10 manuscript contributions could be included in this volume.7 Throughout the 2010 conference, research enthusiasm, oratory and A/V competence of the speakers were of a very high quality. The conference audience was not only magnificently entertained, but the local and national delegates contributed to a highly stimulating and engaging discussion throughout the whole event. The proceedings editors are grateful to all participants for their active contributions and support, which helped to make this academic conference a great success. Both the publication of the Proceedings Volumes and the organization of the Calgary History of Medicine Days would not have been possible without the continued substantial financial support from Associated Medical Services in Toronto and the Alberta Medical Foundation in Edmonton.

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All of the contributions in these proceedings, for which the volume editors have received explicit Copyright Transfer Forms and Author Consent Forms, will also be made available online through the University of Calgary Internet Repository dSpace: History of Medicine Days Community Homepage: https://dspace.ucalgary.ca/handle/1880/47439.

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In addition, we want to thank Vitaid Ltd. for their donation to the conference, the Calgary Institute for Population and Public Health, and the Faculty of Medicine at the University of Calgary for their continued support. We also extend our warm thanks to Beth Cusitar for her important additional editorial help before the manuscript was finalized. Frank W. Stahnisch Lisa Petermann Kelsey Lucyk (University of Calgary, November 13, 2012)

LIST OF IMAGES

1-1 Strychnos toxifera ................................................................................. 9 1-2 Structure of d-tubocurarine and related alkaloids ............................... 11 1-3 Relief map of distribution of curare discoveries in Central and South America .............................................................................................. 12 1-4 Harold Randall Griffith ...................................................................... 14 1-5 Anesthesia Record of the First Patient to Receive Curare .................. 19 1-6 Plaque Commemorating the First Use of Curare in Anaesthesia ....... 21 2-1 Volume of the DSM-I ....................................................................... 118 3-1 Dr. Chit Chan Gunn .......................................................................... 154 3-2 Matchstick Test for Trophic Edema.................................................. 210 3-3 Peau d’Orange Appearance of Trophic Edema ................................ 210 3-4 Skin Roll Test for Trophic Edema .................................................... 211 3-5 Pilomotor appearance in neuropathy................................................. 211

LIST OF TABLES

1 2 3 4

Entries in the DSM by year of publication......................................... 117 Summary Chart of Chronological Findings, Alzheimer’s .................. 235 Example of spreadsheet used in data collection................................. 236 Number of Admissions to Alberta Hospital Ponoka by Age, 1912-1916 .......................................................................................... 270

APPLICATIONS OF SCIENCE TO MEDICINE

A POISONED SLEEP: HOW CURARE REVOLUTIONIZED ANESTHESIOLOGY ESTHER KIM

SUMMARY: The discovery of modern anesthetics in the 1840’s revolutionized surgery and gave birth to the new specialty of anesthesiology. The single greatest advancement in the specialty since its beginnings is the introduction of muscle relaxants. The first important muscle relaxant used as an adjuvant to anesthesia was curare. It was first used by Canadian anesthesiologist Dr. Harold Randall Griffith (1894-1985) and his resident in anesthesiology, Enid Johnson Macleod (1909-2001), on January 23, 1942 in Montreal, Quebec. Dr. Griffith’s experiment was especially interesting and controversial because he applied a substance that had up until that time been considered a poison. Curare was used by the indigenous people of South America as a deadly arrow poison for centuries before it was first encountered by European explorers to the Americas starting in the 1500’s. Although curare initially assumed a notorious reputation for its deadliness, its application to anesthesia gave it a more noble purpose. As a muscle relaxant, curare helped to reduce the amount of anesthetic needed for procedures, and it rendered patients immobile, making them easier to operate on. Curare was the first in a long line of muscle relaxants that revolutionized anesthesiology and led to improvements in surgery and decreases in surgical mortality. However, along with the benefits, physicians soon discovered some negative side effects of muscle relaxants that continue to be an issue today. Such disadvantages of muscle relaxants include allergic reactions to the drugs and an increased risk of anesthesia awareness in the patients, as well as a traumatic state where a patient is awake during the procedure but cannot communicate this fact to the medical staff due to paralysis. This paper explores the history behind the discovery of curare, and it also traces the development of anesthesiology from its origins until today, while maintaining a focus on the impact of curare and other muscle relaxants on this particular specialty discipline in medicine. KEYWORDS: Anesthesiology; Anesthesia; Anesthetics; Curare; Muscle Relaxant; Harold Griffith; Anesthesia Awareness PRECEPTOR: Dr. Frank W. Stahnisch INSTITUTION: University of Calgary

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A Poisoned Sleep: How Curare Revolutionized Anesthesiology

Introduction In today’s era of painless and everyday medical procedures, anesthesia during surgery is often taken for granted. However, modern anesthetics have only been used for a little under two centuries. Prior to their discovery in the 1840’s, surgery was a tortuous ordeal for both patients and surgeons. Sir Benjamin Ward Richardson (1826-1896), a prominent British physician from the nineteenth century, once described surgery without anesthesia by saying, I have heard many [patients] express that if they had known beforehand what the suffering was, and the effects subsequently endured, they would rather have faced death than such a fearful struggle for continued existence.”1

Surgery was done quickly and only as a last resort. The mark of a good surgeon in those times was the ability to complete the procedure as swiftly as possible. British physician Sir Thomas Clifford Allbutt (1836-1925) recalled that during his childhood, “He was the best surgeon, both for a patient and onlooker, who broke the three-minute record in an amputation or a lithotomy.”2 Everything changed with the advent of modern anesthetics in the midnineteenth century. The anesthetic properties of the first three inhalant anesthetics, nitrous oxide, ether and chloroform, were discovered during this time. Nitrous oxide was first used in 1844 as a dental anesthetic in Hartford, Connecticut. A local dentist named Horace Wells (1815-1848) had nitrous oxide administered to him when he underwent a tooth extraction. He was so pleased with the painless procedure that after he had recovered from the anesthetic, he proclaimed “a new era in tooth-pulling!”3 Ether soon followed nitrous oxide with the first public demonstration in Boston, Massachusetts in 1846 by William Thomas Green Morton (1819-1868). The story of ether is shrouded in controversy. Three other individuals, Horace Wells, Crawford Williamson Long (1815-1878), and Charles Thomas Jackson (1805-1880) also claimed the credit for this discovery. Long, a physician from Georgia, had privately used ether in a surgical excision several years before Morton in 1842, but he did not 1

Victor Robinson, Victory Over Pain: A History of Anesthesia (New York: Henry Schuman, 1946), 78. 2 Ibid., 79. 3 Geoffrey B. Rushman, Nicholas J.H. Davies, and Richard Stewart Atkinson, A Short History of Anaesthesia (Oxford: Butterworth-Heinemann, 1996), 10.

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publish his results until 1849 after Morton had already convinced the world of ether’s usefulness. Jackson was a chemist and geologist who taught Morton and gave him chemical advice during Morton’s initial experiments with ether. This later led to disputes between the two men regarding who deserved credit for the introduction of ether.4 Wells had also been a teacher to Morton at one time, and they ran a dental practice together briefly. Wells always believed that he should be credited with the discovery of anesthesia, since he used nitrous oxide before Morton used ether, and he also claimed to have used ether for anesthesia first.5 Interestingly, all four men met tragic fates and did not obtain much benefit, financial or otherwise, for the discovery of ether. The third anesthetic, chloroform, was introduced in 1847 by Scottish obstetrician James Young Simpson (1811-1870). Simpson greatly advocated chloroform for use in obstetrics. His work was controversial at the time, because religious institutions claimed that women were ordained by God to experience pain during childbirth. To provide relief from pain would be to go against God’s will. Simpson countered this argument with his own religious beliefs and theological reasoning. He said, for example, that in the Bible in the book of Genesis, “God caused a deep sleep to fall upon Adam, and he slept: and he took one of his ribs, and closed up the flesh instead thereof.” Thus, Simpson claimed that God was the first anesthetist, so therefore the deliverance of pain for mothers in labour could not be morally wrong.6 Later, the arguments against using anesthetics in childbirth were laid to rest when Queen Victoria of England (1819-1901) used chloroform during the births of two of her children. These initial three inhalant anesthetics forever changed surgery into a safer and more effective practice. They paved the way for other better anesthetics to follow, and they led to the birth of the specialty of anesthesiology.

Anaesthesiology’s Early Days In its early years, anesthesiology was far from being an exact science. Nitrous oxide, ether and chloroform were all administered by inhalation, and the manner in which they were given was also not pharmacologically standardized. Practitioners would dab some liquid anesthetic onto a 4

Ibid., 14. Robinson, Victory Over Pain, 105. 6 Ibid., 204. 5

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A Poisoned Sleep: How Curare Revolutionized Anesthesiology

handkerchief and hold it over the patient’s nose so that the patient would breathe in the fumes and be rendered unconscious. Due to the inexact nature of this method, however, terrible side effects and even death could result in such medical settings, if a practitioner happened to administer a dose incorrectly.7 The first physician to specialize in anesthesiology was English physician Dr. John Snow (1813-1858). He likewise was the first to standardize the use of the anesthetic substances and calculate exact doses that were required for safe and effective anesthesia. Snow thus emerged as one of England’s leading anesthesiologists in the late 1840’s and 1850’s, a position which found him administering chloroform to Queen Victoria at the birth of her son Prince Leopold (1853-1884) on April 7, 1853 and her daughter Princess Beatrice (1857-1944) on April 14, 1857. These medical treatments forever settled the controversy over whether obstetrical anesthesia was morally acceptable in Victorian society. Dr. Snow was a remarkable man who made great advancements in two budding specialties. In addition to laying the foundations of anesthesiology, Snow also carried out extensive research into the cholera epidemics of the time, and he established epidemiologically that cholera was transmitted through contaminated water. Snow’s work with cholera sparked the development of the early field of social medicine (public health) and medical epidemiology.8 Snow’s research in anesthesiology mainly focused on how anesthetics affect the body and how to administer them safely and effectively. He was also very interested in why chloroform caused death and how this could be prevented. In his last book On Chloroform and Other Anaesthetics, which was published posthumously in 1858, Snow described all of the fatal cases involving chloroform that had been documented up until then. He thereby noted that in most cases, “death took place by cardiac syncope, or arrest of the action of the heart,” while in the rest of the cases; death was attributable to respiratory arrest.9 Snow’s careful research in calculating safe doses of anesthetics proved to be invaluable to improving patient safety under anesthesia. Snow also wrote numerous casebooks in which he 7

Rushman, Davies, and Atkinson, A Short History of Anaesthesia, 20. David A. E. Shephard, John Snow: Anesthetist to a Queen and Epidemiologist to a Nation (Cornwall, Canada: York Point Publishing, 1995), 10. 9 John Snow, On Chloroform and Other Anaesthetics: Their Action and Administration (Tokyo: Iwanami Book Service Center, 1997; original edition London: John Churchill, New Burlington Street, 1858), 217. 8

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meticulously recorded all the details of every anesthetic administration that he oversaw. He left a legacy emphasizing the importance of pharmacological standardization and patient safety which many anesthesiologists after him would follow. Dr. Victor Robinson (18661947), a physician and medical journalist, eloquently summarized Snow’s anesthetic accomplishments when he wrote, “It is justly said of him [John Snow] that he made the art of anesthesia a science.”10 Chloroform and ether remained the mainstays of anesthesia for decades after John Snow’s era. Despite the fact that very few new anesthetic agents were discovered for a time, much progress was made during the early twentieth century in the more technical areas of the specialty. Anesthesiologists became more skilled at controlling patients’ respiration during surgery by using endotracheal intubation and ventilator machines in intensive care units and operation theatres. Some new agents were also discovered during this time. Ethylene and cyclopropane gradually became more popular than the older drugs due to better safety profiles.11 By the 1940’s anesthesiology had come a long way from its origins in the previous century. Despite anesthesiology’s positive impact on surgery and its progress in the early twentieth century, using anesthetics during operations was still not without its problems. Although patients would be unconscious and free from pain during procedures, their muscles would continue to twitch and move involuntarily, creating many difficulties for surgeons performing delicate operations such as abdominal and thoracic procedures. The only way to induce muscle paralysis at the time was to increase the concentration of the anesthetics administered, but this had negative effects on patient safety, since at high doses the inhalant anesthetics could become cardiac as well as respiratory depressants.12 Even at high doses of the anesthetic, an adequate level of muscle relaxation could not always be achieved for the more delicate procedures. This is where a notorious poison called curare made its mark on medicine through a Canadian anesthesiologist, Dr. Harold Randall Griffith (1894-1985). Griffith was the first to successfully use curare in anesthesia, which he did in Montreal in 1942. This display of medical and scientific ingenuity revolutionized the practice of 10

Robinson, Victory Over Pain, 219. Richard Bodman and Deirdre Gillies, Harold Griffith: The Evolution of Modern Anaesthesia (Toronto: Hannah Institute & Dundurn Press, 1992), 10. 12 Archibald Ross McIntyre, Curare: Its History, Nature, and Clinical Use (Chicago: The University of Chicago Press, 1947), 193. 11

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A Poisoned Sleep: How Curare Revolutionized Anesthesiology

anesthesiology, and in fact many historians, such as Dr. J. Earl Wynands (b. 1930?) of the Canadian Anesthesiologists Society, divide the history of the specialty into “before and after Griffith.”13 To gain an appreciation for the significance of Griffith’s contribution to anesthesiology and surgery, one first needs to understand the history of curare a bit better, along with the events leading up to Griffith’s landmark experiment.

Curare’s Background and History Curare is a poison grown from several different plants in the jungles of Central and South America. It has been known to the native peoples of these areas for centuries as an arrow poison, which they used to hunt and kill their prey and enemies. The word curare actually does not describe one specific compound, but it is a term used by the natives to designate a varied group of arrow poisons. These include extracts from the vine-like plants Strychnos toxifera and Chondodendron tomentosum.14 Curare can be prepared by combining young bark of curare-vine with crushed roots and stems and mixing them with snake venom. The principle chemicals in curare are the alkaloids curarine and tubocurarine.15 The first documented European contact with the poison occurred in 1595 during English explorer Sir Walter Raleigh’s (1552-1618) expedition to the Orinoco River in the Amazon. Raleigh later wrote a book in 1596 called Discovery of the Large, Rich, and Beautiful Empire of Guiana where he detailed his experiences in the Amazon region.16 European explorers quickly learned that a mere scratch with a poisoned arrow could kill a person within minutes by paralyzing all of their muscles, most importantly the muscles of respiration. The cruelest thing about the poison – since the times of its discovery – was that victims remained completely conscious during the phase of agony, as they died from respiratory paralysis, since curare does not cross the blood-brain barrier.17 13

J. Earl Wynands, “Anesthesia Greats: Harold Randall Griffith,” Canadian Anesthesiologists’ Society (June 1998): http://www.cas.ca/. (Accessed December 31, 2009). 14 Cf. Frank W. Stahnisch, Ideas in Action. Der Funktionsbegriff und seine methodologische Rolle im Forschungsprogramm des Experimentalphysiologen François Magendie (1783-1855) (Muenster: LIT Press, 2003), 158-215. 15 Charles Czarnowski, “Curare and a Canadian Connection,” Canadian Family Physician 53 (September 2007): 1531. 16 McIntyre, “Curare: Its History, Nature, and Clinical Use,” 13. 17 Czarnowski, Curare and a Canadian Connection, 1531.

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Although curare fascinated Europeans and North Americans for centuries, it was not carefully studied until eccentric English explorer Charles Waterton (1782-1865) brought back samples of curare extract from the Amazon in the early nineteenth century. Charles Waterton worked with Benjamin Brodie (1783-1862), a prominent English surgeon, to show that the paralyzing effect of curare was temporary and that a victim could survive if artificial respiration was maintained during paralysis.

1-1 Strychnos toxifera. Archibald Ross McIntyre, Curare: Its History, Nature, and Clinical Use (Chicago: The University of Chicago Press, 1947), 39.

Waterton and Brodie demonstrated this in 1814 by keeping a donkey, which had been poisoned with curare, alive by performing a tracheotomy

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A Poisoned Sleep: How Curare Revolutionized Anesthesiology

and using a pair of bellows to pump air into the donkey’s lung. Once the poison passed from the donkey’s system, the animal recovered, which showed that curare did not necessarily have to be fatal. Waterton named his donkey “Wouralia,” which is the native word for curare.18 Famous French physiologist Claude Bernard (1813-1878) further studied the mechanism of action of curare. In 1844, he injected curare into a frog and showed that direct electrical stimulation of the frog’s muscle caused it to contract, but neural stimulation did not. This showed that curare acted at the junction between nerves and muscles.19 Bernard’s early experiments also led to some continuing experimental investigations by French clinical researchers towards the late nineteenth century, in such conditions as rabies, tetanus, epilepsy and chorea.20 However, at that time there were no standardized curare preparations, rendering the contemporary research qualitative and exploratory in nature, while direct practical applications (of this poison) to medicine were not immediately perceived. More was learned about curare in the first part of the twentieth century. In 1934, English pharmacologist Sir Henry Dale (1875-1968) demonstrated that the protein acetylcholine transmits electric signals from nerve ending to muscle causing it to contract. He also discovered that curare blocks nicotinic acetylcholine receptors, which produces the paralyzing effect. In doing so, Dale described the mechanism of action of curare. In 1935, Harold King (1887-1956), a biochemist at Wellcome laboratories in England, isolated the active ingredient in crude curare from the Chondodendrom tomentosum plant. He named the alkaloid compound “d-tubocurarine.”21

18

Ronald D. Miller et al., Miller’s Anesthesia, 7th ed. (Maryland Heights, MO: Churchill Livingstone, 2009), 25-27. 19 Ibid. 20 Abram Elting Bennett, “How ‘Indian Arrow Poison’ Curare Became a Useful Drug,” Anesthesiology 28:2 (March-April 1967): 446-452; esp. 446. 21 Richard Bodman and Deirdre Gillies, Harold Griffith: The Evolution of Modern Anaesthesia (Toronto: Hannah Institute & Dundurn Press, 1992), 58.

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1-2 Structure of d-tubocurarine and related alkaloids. Archibald Ross McIntyre, Curare: Its History, Nature, and Clinical Use (Chicago: The University of Chicago Press, 1947): 63.

According to American psychiatrist Dr. Abram Elting Bennett (18981985), curare had little medical application prior to 1940. He wrote that: Lack of knowledge, varying potency and preparations having toxic impurities produced inconstant results; many thought the drug was lethal thus too dangerous for clinical use.22

This all changed in the late 1930’s when curare started being extracted and purified in large quantities from the Amazon for experimental use in medicine. In 1934, American explorer Richard Cochran Gill (1901-1958) first procured curare from the jungles of Ecuador. He returned in 1938 for a second expedition, during which he established a base in the upper Amazon for supplying large amounts of crude curare to the scientific community for research purposes.

22 Bennett, “How ‘Indian Arrow Poison’ Curare Became a Useful Drug,” 446-452; esp. 446.

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A Poisoned Sleep: How Curare Revolutionized Anesthesiology

1-3 Relief map of distribution of curare discoveries in Central and South America. Richard Bodman and Deirdre Gillies, Harold Griffith: The Evolution of Modern Anaesthesia (Toronto: Hannah Institute & Dundurn Press, 1992), 59.

Gill was able to acquire his steady supply of the substance from the natives of the region, because he had their trust. In general, the “medicine men” of the native tribes guarded their secrets and did not make their drugs and poisons known to foreigners.23 The first to show a keen interest in curare was Bennett, who felt that it might have some application to his psychiatric patients who at that time were offered quite drastic shock therapies, such as insulin coma and electroconvulsive shock treatments. Since there was no commercial preparation of curare available until the 1930’s, Bennett had Gill turn the crude material over to Dr. Archibald Ross McIntyre (b. 1902) of the Department of Pharmacology at the University of Nebraska so that McIntyre could standardize the drug. McIntyre’s preparation was used until 1939 when Gill gave his entire supply of curare to the American pharmaceutical company E. R. Squibb and Sons. This company worked to further refine the drug chemically and to determine its pharmacological properties. Within a few months, Horace Holaday (1914-1997) at the Squibb Institute for Medical Research, New Jersey in the United States, developed the “rabbit head drop test.” In this test, enough curare was given to a rabbit to cause its head to drop, and the amount that achieved this effect helped to standardize doses of the crude

23

Miller, Miller’s Anesthesia, 25-27.

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extract. E. R. Squibb and Sons named their new curare drug “Intocostrin®,” which was finally ready to be marketed.24 The first medical use of curare was then also in electroconvulsive therapy, which is the practice of using electrical stimuli on the brain in order to treat psychiatric conditions such as depression and schizophrenia. The problem with electroconvulsive therapy at the time was that despite its usefulness, it would trigger severe convulsions in the treated patients, which often resulted in bone fractures and dislocations. In the 1930’s, the incidence of serious fractures of the extremities was as high as 1.5 to 2 percent, the incidence of dislocations was 17 percent, and the incidence of compressive spinal fractures was even 43 to 51 percent. Many preventative measures, such as spinal anesthesia, had been tried, but none of them worked effectively to prevent fractures.25 Bennett had the idea of using curare to paralyze the muscles in his patients at the Bishop Clarkson Memorial Hospital in Omaha, Nebraska, so that the therapy would not cause convulsions, thereby reducing the incidence of injury. He first used McIntyre’s early preparation, and then the more refined drug Intocostrin in his electroshock patients in 1939 with very positive results. Bennett noticed substantial drops in fracture rates, and he also found that the drug was relatively safe to use from a respiratory standpoint when administered in low doses. He promoted its use to the American Medical Association at their annual meeting in New York City in 1940.26 It was not long after this that Dr. Lewis H. Wright (1894-1974), an anesthesiologist consultant with E.R. Squibb and Sons, suggested the use of curare as an adjuvant to anesthesia during surgery to Canadian anesthesiologist Dr. Harold Griffith in Montreal.27

24

Bodman and Gillies, Harold Griffith, 58. Bennett, “How ‘Indian Arrow Poison’ Curare Became a Useful Drug,” 446-452; esp. 447. 26 Ibid., 448. 27 J. Earl Wynands, “Anesthesia Greats: Harold Randall Griffith,” Canadian Anesthesiologists’ Society (June 1998): http://www.cas.ca/. (Accessed December 31, 2009). 25

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AP Poisoned Sleep:: How Curare Revolutionized R A Anesthesiology y

Haroold Griffith h’s Early L Life

1-4 Harold R Randall Griffith. J. Earl Wynan nds, “Anesthesiia Greats: Harold Randall ociety, June 1 998, http://ww ww.cas.ca/, Griffith,” Caanadian Anesthhesiologists’ So (accessed Deccember 31, 20009).

Dr. Haroold Griffith iss considered to be one off the most weell-known Canadian annesthesiologissts of all timee for his manny contributio ons to the fields of phhysiology, aneesthesiology and intensivee care manag gement of clinical patiients. He wass born in Mon ntreal, Quebeec on July 25, 1894 to parents of Irish and Sccottish ancestry. His fatheer, Alexanderr Griffith (1864-1936)), was a physsician and wo orked at the M Montreal Hom meopathic Hospital onn Mount Royaal. At that tim me, conventioonal medicinee was not always reliaable, and hom meopathy had more credibiility than it does d now, particularly as homoeopaathic hospitalls frequently offered health h care to largely undderserved urbban neighbou urhoods. In ffact, people felt that homeopathyy bore a greeat resemblan nce to the eemergence off modern serology, beecause both approaches a pro omoted the pprinciple of “llike cures like.”28 A vaaccination woorks by giving g a small dosee of the same toxin t one wishes to bbe protected from, so proponents of hhomeopathy saw s great similarities bbetween vacccinations and the homeopat athic principlee of using dilute formss of toxins to cure diseasess. Alexander G Griffith and eventually e his son Harrold learned and practiced d both conveentional mediicine and homeopathyy.

28

Bodman annd Gillies, Haroold Griffith, 15.

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In 1910, Harold Griffith enrolled at McGill University in order to study for a combined arts and medical degree. He was in the middle of his medical degree when World War I broke out, and in 1914, Griffith signed up for the 6th Field Ambulance of the Canadian Expeditionary Force. He believed the war would only last a few months, but he ended up spending the next four years away at war in Europe. Griffith had his first experience with administering anesthetics on the battlefields in France when he was asked to pour chloroform on a mask for one of the injured soldiers. He was involved in the emblematic battle of the Canadian forces at Vimy Ridge in the North Pas-de-Calais region from April 9-12, 1917, and for his bravery he was awarded the Canadian Medal of Military Velour. After Vimy Ridge, Griffith joined the Royal Canadian Navy with the rank of temporary probationer surgeon. He left the navy in the fall of 1918 and returned to Montreal just in time for the horrendous influenza epidemic also known as the “Spanish Flu.” Upon arriving back in his home country, Harold Griffith quickly settled back into his classes and graduated from medical school at McGill University in 1922. He married his childhood sweetheart Linda Aylen, and then went to the United States for a year where he received a doctorate of Homeopathic Medicine from the renowned Hahnemann Medical College of Philadelphia in 1923.29 Griffith became involved in synthetic anesthesiology very early in his career, when applying new analytical knowledge in chemistry to physiology and medicine. As a medical student, he entered a paper in the McGill Medical Society Senior Prize Competition of 1922, in which he was awarded the second prize. His paper emphasized the importance of monitoring vital signs and controlling respiration in patients under general anesthesia. In this paper Griffith also described the infancy state of the discipline of anesthesiology at the time, while especially focusing on the limited number of available agents. He stated, for example, that “the general anaesthetics in common use in this country [Canada] are ether, chloroform and nitrous oxide-oxygen.”30 There were not many other options than these original anesthetics, of which ether and chloroform had dangerous side effects. In those days, there was no formal anesthesiology residency training program to specialize in for a medical graduate, so after his final year at 29

Bodman and Gillies, Harold Griffith, 24-30. Maltby, J. Roger and David A. E. Shephard, eds., Harold Griffith: His Life and Legacy (Toronto: Canadian Anaesthetists’ Society, 1992), 27.

30

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A Poisoned Sleep: How Curare Revolutionized Anesthesiology

McGill, Griffith first began to work as a general practitioner. However, he abandoned general practice by 1933 to focus on studying and practicing anesthesiology. He became Chief of Anesthesia at the Homeopathic Hospital (now called the Queen Elizabeth Hospital – “the QEH”) in Montreal in 1923 and served in that position until 1959.31 Although Griffith worked at the Homeopathic Hospital, most of his work dealt with modern medicine, and he only used homeopathic therapy to help those patients for whom medicine had not yet found a remedy. Griffith also had his first teaching appointment at McGill in 1946 and eventually received a faculty position in the Faculty of Medicine. Griffith lived through many exciting changes in medicine during his early years as an anesthesiologist and, over his lifetime, he would make many significant contributions to the field of anesthesiology, the most important of which were his continued experimental investigations with curare.

Harold Griffith and the Lasting Impact of Curare While at the Homeopathic Hospital, Griffith was approached by Dr. Lewis Wright regarding the use of curare for muscle relaxation in anesthesiology. Wright was convinced of curare’s usefulness, since he had read with great interest about Bennett’s foregoing successful use of the substance in the latter’s psychiatric patients at the Nebraska hospital. However, Griffith was at first reluctant to act on Wright’s suggestion due to his personal safety concerns for the patients in Montreal, but later changed his mind by reasoning that if curare did not kill Bennett’s patients, it should also be safe enough to be used in his own patients for limited applications in pre-operative patient preparations. In addition, Griffith further knew that by this point in time, anesthesiologists had already become skilled at managing patients’ respiration under general anesthesia, so he reasoned that: The worst it [curare] can do is to paralyze the patient’s respiration and that is not a very serious concern for anesthetists since we control respiration every day in the operating room.32

31 32

Wynands, “Anesthesia Greats: Harold Randall Griffith.” Bodman and Gillies, Harold Griffith, 60.

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On January 23, 1942, Griffith and his resident Enid Johnson McLeod undertook a landmark experiment: They administered intravenous curare in the form of Intocostrin to a patient requiring an appendectomy. The application of curare in the initial phase of the surgical operation allowed them to safely lower the concentration of the cyclopropane anesthetic being used. The observable results proved to be incredible to them. Due to the temporary paralysis brought on by the curare, the patient’s abdominal muscles were able to relax completely, allowing the surgeon to remove the appendix with greatest ease and unhindered by continuous contractions in the gastrointestinal tract. Griffith and Johnson immediately tried Intocostrin in twenty-four other cases and promptly published their results in the international medical journal Anesthesiology. An excerpt from this paper reads, Every anesthetist has wished at times that he might be able to produce rapid and complete muscular relaxation in resistant patients under general anesthesia. ... It seems to us, as the result of these preliminary clinical investigations, that curare may prove to be a drug which will occasionally be of great value, and will give us a means of providing the surgeon rapidly with excellent muscular relaxation at critical times during certain operations.33

These words would soon prove to be very prophetic. News of Griffith’s success with curare spread like wildfire across North America and Europe. Within years it became the standard practice to administer curare within most surgical procedures. By 1947, McIntyre (the same scientist who standardized the initial curare preparation for Bennett’s experiments) wrote that since Griffith’s experiment, “the use of curare in anesthesia has spread very rapidly and become an established procedure.”34 Some of the surgical cases, in which curare was now used in, included bowel resection, laparotomy and colostomy. Although the use of curare itself eventually fell out of favour due to its side effects on the autonomous nervous system, such as leading to severe hypotension, Griffith’s experiment paved the way for newer and safer muscle relaxants to be used in anesthesiology today. These newer drugs, such as succinylcholine (which was discovered in 1949, by the Swiss-born, Italian physiologist Daniel Bovet, 1907-1992, who later received the Nobel Prize 33

Harold Griffith, “The Use of Curare in General Anesthesia,” Anesthesiology 3, no. 4 (July 1942): 418-20. 34 McIntyre, Curare: Its History, Nature, and Clinical Use, 193.

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A Poisoned Sleep: How Curare Revolutionized Anesthesiology

for this work), all work in a similar manner to curare by blocking the neuromuscular junction. Most of the drugs used today are synthetic agents that lack the autonomic effects of curare, and the safest ones tend to be in the steroid class, such as pancuronium, vecuronium and rocuronium.35 The introduction of muscle relaxants starting with curare into anesthesiology is considered by many to be one of the most important advances in this clinical research field since its late beginnings in the 19th century. Muscle relaxants allowed anesthesiologists to use smaller and safer amounts of anesthetics, and they enabled surgeons to expand their range of possible procedures. They also improved operating conditions and outcomes of surgery for patients. The practice of using muscle relaxants as a pharmacological adjuvant to anesthetics later became known as balanced anesthesia.36 In addition to making surgery easier, muscle relaxants also completely changed the anesthesiologist-patient relationship. In the past, a patient could often be expected to wake up at certain intervals from inhalant anesthesia without any intervention, once the anesthetic wore off. However, the introduction of muscle relaxants induced respiratory muscle paralysis in patients, which made it became imperative for anesthesiologists to actively control the respiration of their patients throughout the surgery by using intensive care techniques such as intubation and artificial respiration. As a result, the complexities and responsibilities of the anesthesiologist’s role expanded greatly, which also led to an explosion in the number of training programs all over the world.37 After Griffith’s success with curare, he continued to work tirelessly for the improvement of the specialty. During World War II, for example, Griffith trained numerous military physicians, who were to be deployed with their troops overseas, in how to administer anesthetics in the context of trauma surgery. He was also very influential in organizing the earliest formal anesthesia training programs and professional societies in Canada, while organizing for instance the Resident Training Program in Anesthesia and in his role as the inaugural Professor and Chairman of the Department of Anesthesia at McGill University in 1951. Griffith organized the Society of Canadian Anaesthetists in Montreal in 1940, which likewise was the precursor to today’s Canadian Anesthesiologists’ Society; and he also 35

Miller, Miller’s Anesthesia, 7th ed. Charles Czarnowski, “Curare and a Canadian Connection,” Canadian Family Physician 53 (September 2007): 1531-1532. 37 Bodman and Gillies, Harold Griffith, 65. 36

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served on numerous other organizations and committees, contributing internationally to the organization of the World Federation of Societies of Anaesthesiologists (WFSA) from 1951 to 1955. In addition to his achievements as a medical and science educator on various national and international programs and committees, Griffith also established the first recovery room in Canada in 1943, which formed part of the expansion of the anesthesiologist’s role by making the specialist more involved in patients’ complete peri-operative care process.

1-5 Photograph of the anaesthesia record of the first patient to receive curare. Richard Bodman and Deirdre Gillies, Harold Griffith: The Evolution of Modern Anaesthesia (Toronto: Hannah Institute & Dundurn Press, 1992), 61.

For all of Griffith’s contributions to medicine during his life, he was awarded numerous honours, most notably his appointment to the Order of

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A Poisoned Sleep: How Curare Revolutionized Anesthesiology

Canada in 1974.38 Through his incessant and dedicated work, his scientific ingenuity, and through his long-term experimental explorations of curare, Harold Griffith had also greatly contributed to the development and establishment of the specialty of anesthesiology.

The Dark Side of Muscle Relaxants: Anesthesia Awareness Despite the incredible benefits muscle relaxants brought to the field of anesthesiology, these drugs were not without their disadvantages. As with all drugs, there are side effects and the possibility of allergic reactions. However, the major negative consequence of muscle relaxants is anesthesia awareness, which is the state of being awake intra-operatively, but at the same time being completely paralyzed and unable to communicate this verbally or through limb movement to the operating room staff. It is estimated that the occurrence of this phenomenon in Canada is around 1:1,000 to 1:3,000 in all performed anaesthesias. It is nevertheless methodologically very difficult to calculate exact numbers, especially since anesthesia awareness can occur on a wide spectrum from patients’ waking up briefly during the procedure to having the terrifying experience of being fully conscious and feeling the large pains of the surgical procedures and operations. The incidence of this most extreme end of the spectrum is however much rarer, while estimates regarding this appalling physiological occurrence range from 1:50,000 to 1:100,000.39 The most extreme consequences of anesthesia awareness can include post-traumatic stress disorder. According to the American Society of Anesthesiologists’ (ASA) Closed Claims Database and Anesthesia Awareness Registry for 2010, the two main causes of anesthesia awareness are “light anesthesia and anesthetic delivery problems.”40 Some people are more predisposed to experiencing anesthesia awareness because of their physical state. In emergency situations where a victim has lost a 38

Wynands, “Anesthesia Greats: Harold Randall Griffith.” Angela Mulholland, “‘Awake’ Exaggerates Anesthesia Awareness: Doc,” CTV.ca, November 28, 2007 (http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20071128/anesthesia_ 071128/20071128?hub=TopStories). (Accessed January 31, 2010). 40 Christopher D. Kent, “Awareness During General Anesthesia: ASA Closed Claims Database and Anesthesia Awareness Registry,” ASA Newsletter 74:2 (2010): 15. 39

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significant amount of blood, the patient may have unstable vital signs that do not allow an adequate amount of anesthetic to be used. Some patients are genetically resistant to anesthetics, and some people acquire resistance through environmental factors such as heroin addiction. In other cases, non-standardization of anesthesia machines or problems with machinery may cause an incorrect dose of anesthetic to be administered.41 Although the incidence of anesthesia awareness is rare, it is a physiological phenomenon, which can have devastating health consequences, instilling a great need in anesthesiologists to be vigilant about the prevention of such averse events in the operating room and intensive care units at all costs.

1-6 Plaque commemorating the first use of curare in anaesthesia. Richard Bodman and Deirdre Gillies, Harold Griffith: The Evolution of Modern Anaesthesia (Toronto: Hannah Institute & Dundurn Press, 1992), 62.

41

Mulholland, “‘Awake’ Exaggerates Anesthesia Awareness: Doc.”

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A Poisoned Sleep: How Curare Revolutionized Anesthesiology

Conclusion The field of anesthesiology has risen to great importance in medicine since the end of the 19th century, because it facilitates painless, successful surgery and has supported the development of ever more complex surgical approaches throughout the last century. Without modern anaesthetics, the scope of surgery would indeed be severely limited as compared to what could be accomplished today. One of the most central advancements in this medical specialty since its origins has been the introduction of muscle relaxants, starting with curare (from its earlier uses in experimental physiology in the beginning 19th century) in 1942. This has helped to reduce anesthetic requirements, increase the scope of surgery, improve operation conditions, and decrease morbidity and mortality for patients worldwide.42 Despite the small risk of anaesthesia awareness related to muscle relaxants, the benefits mostly outweigh the risks, giving rise to standard practice in anesthesia and surgery today. The introduction of muscle relaxants not only had a beneficial impact on surgery as a whole, but it also helped to markedly expand the role of the specialty of anesthesiology. When the Canadian physician Dr. Harold Griffith administered the first dose of curare in Montreal in 1942, he not only gave anesthesiologists a new technique to improve patient outcomes, but he also indirectly sparked a modern and exciting era in the specialty of anesthesiology. Despite all of the technological and scientific advancements which have occurred ever since, it remains important for anesthesiologists to remember that Continual training is needed by the doctors, dentists and nurses and technicians who bring the patient to the gates of sleep through anesthesia. Eternal vigilance is the price of safety in anesthesia. The ancient legend of Sleep [Hypnos] as the twin-brother of Death [Thanatos] gains a new meaning in the slumber of Anaesthesia.43

42

Wynands, “Anesthesia Greats: Harold Randall Griffith.” Victor Robinson, Victory Over Pain: A History of Anesthesia (New York: Henry Schuman, 1946), 320.

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HISTORY OF NURSING

MEDICAL REFUGEE NURSES IN BRITAIN: 1933–1945 TASHIA SCOTT

SUMMARY: It is estimated that there were about 400,000 refugees escaping mainland Europe during the 1930’s many being from Greater Germany and Austria. Of these, over 53 percent of German adult immigrants were women. Many were trained doctors, academics, and professionals or may have owned their own businesses; others were middle class, running homes with domestic staff. Yet when they came to Britain often the only employment open to them was as domestics and sometimes nurses. It is estimated that 20,000 women were employed as domestics and 1,500 were employed or continued training as nurses. This paper seeks to provide an understanding of a much wider PhD project which aims at establishing how many refugees worked as nurses in the United Kingdom, when they came to the British Isles, how their careers came to develop later on, while also assessing their longer terms contributions to British medicine and society at large. It is hoped that a ‘total population’ approach will allow for linkages between different occupations, of which nursing and medicine are significant examples. Furthermore, this project wants to give a voice to a group of neglected people of refugees from Nazism, which has to date not been able to be heard. It also has to be seen how these individuals influenced the modernization process of medicine and health care in the United Kingdom during this period and today. KEYWORDS: Medical Refugees; Nursing, History of; Second World War; Jewish Refugees; Modernization; Women’s History; Immigration PRECEPTOR: Professor Paul Weindling INSTITUTION: Oxford Brookes University

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Medical Refugee Nurses in Britain: 1933–1945

Introduction: Why Refugee Nurses? In spring 1940, over 27,000 foreign or “alien” people were interned in Britain; many had been in the country for years, many for just a few months.1 Of these people, they could be divided into groups: Prisoners of War (POWs), Nazi sympathizers, Fascists, but also mixed in this group were many refugees escaping the Nazi regime: Jews, Communists, Germans, Austrians, Italians and other European denominations. Many of these refugees were middle class, a large number also well educated and professionally minded, and yet when they arrived some could be employed in their chosen career, others had to change. Women are prime examples of this. Women made up 53 percent of all adult immigrants from Germany between 1934-1944;2 many were doctors, academics, professionals or may have owned their own businesses; others were middle class, running homes with domestic staff. Yet when they came to Britain the only employment open to them was as domestics and nurses. It is estimated that 20,000 women were employed as domestics and 1,500 were employed or were training as nurses.3 The historiography of women professionals is still a new topic in the History of Medicine, which has begun to attract more and more attention from many arenas of scholarly research. History of Nursing as a cohesive part of women’s history is yet another area that is increasingly finding its home among researchers and historians. Anne Marie Rafferty, a trained nurse and historian at King’s College London, argues that there are increasing …gender and politically aware perspectives emerging from a cross fertilization of ideas and interdisciplinary and international contact between social historians of medicine, nursing, historians of gender and the politics of welfare.4

1

Bernard Wasserstein, “The British Government and the German Immigration 1933-45,” in Gerhard Hirschfeld, ed., Exile in Great Britain, Refugees from Hitler’s Germany (Leamington Spa-Atlantic Highlands, N.J.: Berg Publishers, 1984), 77. 2 Sibylle Quack, Between Sorrow and Strength: Women Refugees of the Nazi Period, [Publications of the German Historical Institute], November 7, (Cambridge: Cambridge University Press, 2002), 6. 3 Paul Weindling, “Medical Refugees in Britain and the Wider World, 1930 – 1950 [Introduction],” Social History of Medicine 22, no. 3 (2002): 451-459. doi:10.1093/shm/hkp098 4 Anne Marie Rafferty, ed., Nursing History and the Politics of Welfare, (London: Routledge, 1997), 1.

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This linkage between ideologies allows for more in-depth investigation of otherwise unexplored areas of history and the impact that was achieved from a bottom up review of historical perceptions. A prime example of this is refugee nurses; an area that is still largely under-researched yet had a great impact on the perception of nursing in Britain today. There are only two significant papers which have been written on the subject of refugee nurses; there is John Stewart’s article Angels or Aliens? Refugee Nurses in Britain, 1938-42;5 John Stewart, was studying the link between refugee nursing, the London County Council and the Socialist Medical Association. Hilde Steppe, a German historian, in her article “... den Kranken zum Troste und dem Judenthum zur Ehre ...” (~ “Comforting the Patients and Honouring Jewishness”) raised questions about the UK response by examining Jewish nursing in Germany.6 But neither of these papers delved deeply enough into the topic. Internationally, Britain had a key role for the reception, training and distribution of refugee physicians and other health care personnel, as registration of professional qualifications in Britain, also had implications for admission to practice in the dominions and colonies. British policies and regulatory controls were for instance also decisive for admission to Palestine. By many émigrés, Britain was considered important as a first stage for onward migrants and temporary exiles. Other countries accepted many refugees, yet this was done selectively with the main concern going mainly to academics and intellectuals. Therefore, there is also a wealth of studies and material to be found for North America in regards to academic migration. However, in regards to medical migration these studies are few and often quite disparate in their perspective and subject area, especially for the US and Canada. This gives further reason for the development of a historical project on this specific occupational group. The German-Speaking Refugee Nurses project is an expansion of a current project at Oxford Brookes University on larger issues about medical and scientific migration and as such seeks to answer a variety of questions focused on individual refugees and the special group of refugee nurses. For instance,

5

John Stewart, “Angels or Aliens? Refugee Nurses in Britain 1938 to 1942,” Medical History, 47 (2003): 149-182. 6 Hilde Steppe, “... den Kranken zum Troste und dem Judenthum zur Ehre ...,” zur Geschichte der juedischen Krankenpflege in Deutschland, (Germany: MabuseVerlag, 1997).

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Medical Refugee Nurses in Britain: 1933–1945

1. How many European refugee nurses were in the UK in the period 1933-1945? 2. Who were they in terms of origins, age, nationality, previous education? 3. How did they obtain a place to study nursing in the UK? 4. What impact did the knowledge and skills of refugee nurses have on British nursing? 5. How did Britain respond to this influx of nursing experience while also having to deal with a shortage of nurses during this period? 6. How can we determine the extent that the UK health care professions could absorb foreign refugees? 7. How did continental and UK standards in nurse education compare? To answer these questions a new historiographical methodology to researching such significant occupational groups will need to be created. It is important to understand that though little has been done to research refugee nurses, this does not mean that there would be an insignificant amount of historical source material. In fact, the complete opposite can be said; however it is widespread and fragmented. The papers of the refugee organizations are incomplete and those of nursing bodies, such as, the General Nursing Council and the Royal College of Nursing, are largely silent on the subject of refugee nurses and their training. Exploring new sources will be fundamental in determining the place of refugee nurses in the period between 1933 to World War II in overall context of the modernization of medicine and nursing. An example of this would be The Times Newspaper where refugees seeking work in the UK placed many advertisements; also the National Archives will be of significant value as many papers are being continually released from this period. But before this can take place we need to understand where these refugees came from, why did they particularly choose Britain to immigrate to, and of course what happened when they got there. To do this, the current paper will discuss the immigration of refugees into Britain and further, the medical refugee nurses experience, and finally the process of refugees’ internment and also where this historical project will go from here. This paper thus aims to give an understanding of what the aims of the refugee nurses’ project are and where it is at present.

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Immigration of Refugees into Britain It is estimated that there were about 400,000 refugees escaping mainland Europe during the 1930’s many being from Greater Germany and Austria. Refugees from Europe began to arrive from 1933, when Adolf Hitler (1989-1945) took power,7 and it is estimated that between 1933 and the outbreak of war in 1939 more than 50,000 refugees entered Britain.8 Refugees came mainly from Czechoslovakia, Germany, Austria, but could also have come from Italy, Spain, Poland and Norway. About these refugees it can be said that they came from differing backgrounds. Ninety percent of the refugees who had entered Britain were most likely Jewish with ten percent being of other cultural denominations, i.e. political or catholic. Refugee nurses saw their numbers come from similar backgrounds; for instance, the Socialist Medical Association raised funds to bring fifteen nurses and doctors out of Spain to Britain, from where they went to China to work for the Red Cross.9 Particular pressure points of alien immigration occurred in specific time frames; Hitler’s coming to power in Germany – in 1933 –; the emergence of a quasi-Fascist regime in Austria – in 1934 –; the Austrian Anschluss occupation by Germany – in March 1938 –; the German annexation of the Sudetenland – in October 1938 –; and the Reichskristallnacht in November 1938.10 Britain’s policy for accepting refugees was limited to say the least, Immigration policy was shaped by the impact refugees would have on the labour market. The idea that the refugees would add to the already overstretched unemployed market was an anathema to the British government and they feared the backlash this would cause with the British public. This fact was a mainstay of the British immigration policy prior to World War II. The significance of Britain’s immigration policy is argued by the German historian Gerhard Hirschfeld at the University of Stuttgart,

7

Francis L. Carsten, “German Refugees in Great Britain 1933-45 [Notes],” in Gerhard Hirschfeld, ed., Exile in Great Britain: Refugees from Hitler’s Germany (Leamington Spa-Atlantic Highlands, N.J.: Berg Publishers,1984), 13 and 27. 8 Ari Joshua Sherman, Island Refuge. Britain and Refugees from the Third Reich 1933-1939, (London: Routledge, 1973), 245, 255-256 and 271. 9 Stewart, “Angels or Aliens?,” 151. 10 Ibid.

30

Medical Refugee Nurses in Britain: 1933–1945 that by the end of 1937, Great Britain harboured 5,500 of 154,000 refugees who had left Nazi Germany and yet by the beginning of World War II there was a total of 74,000 German and Austrians living in Britain.11

This number was significantly reduced when deportations and immigration was taken into account. However, it must be kept in mind when looking at these figures that many countries of origin did not keep records of all cases of emigration particularly when departing nationals were forced to sign an undertaking not to return. There was no single organizational, international, governmental or private recording of actual numbers of refugees. Receiving countries found it impossible to distinguish, in practice, between ordinary travelers and refugees. Many of the statistics that were maintained tended to be either understated to minimize anti-alien or anti-Semitic feelings. Or they would be overstated to show that one country was more willing to take refugees than others. Also to take into account is the re-migration of refugees from Britain as this was a regular occurrence before the outbreak of war and after. Accordingly, Hirschfeld states that of the 400,000 people who escaped from Germany by October 1941 only 10 to 15 percent found refuge in Great Britain.12 Britain’s policy in accepting refugees, therefore, was grudging – saying the least. Attitudes, both within the public arena, and governmentally, were guided by the labour market and the impact foreign labour would have on it. Before 1938, many refugees were received in European countries and the United States; the issue became even more difficult when war was announced in 1939. At this time all refugees in Britain who were re-immigrating to the United States were now not allowed to leave. Many groups of refugees who came to Britain or were trans-migrants awaiting their papers to travel on to other countries, were dependent on local Jewish agencies who had pledged to the government that the refugees they maintained would not be a burden on the British taxpayer. These agencies and the British Government had a great fear that antiSemitism would become a large aspect on the British home front and were continually alert to such aspects. Thus in 1939, tribunals were set up to

11 12

Hirschfeld, Exile in Great Britain, 2. Ibid.

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classify “enemy aliens” into groups of those who were victims of Nazi oppression and those who were not.13 Anti-foreign sentiment did occur and in spring 1940, large numbers of aliens were interned particularly after British defeat in Scandinavia and France. Though a few months later many interned refugees were gradually released. This had an impact on the labour force because by this time the demands of the British wartime economy meant that the arguments against refugees taking British jobs were muted. In fact as argued by the Glasgow health historian John Stewart, prior to the war the numbers of foreigners allowed to work in hospitals was 3 percent of the institutional staff, yet in the early years of war the total shortage of nursing staff was down by 10 percent because of a lack of student nurses being recruited by local schools.14 This allowed for an influx of refugee nurses, in mid-1940, the Nursing and Midwifery Department told the Home Office that 914 trained nurses, midwives and practitioner nurses were in employment of which many were German or Austrian. This was also confirmed by the Committee of Austrians in England who notified the Home office that 108 female and 6 male nurses were in the country.15 In 1941, it was noted that there were 111 male and female Polish nurses in Britain (out of a total of 2,486 refugees from Poland).16,17

The Medical Refugees Project Consequently, this gives a background history for the Refugee Nurses project and why it has developed. The Refugee Nurses project is an expansion of a current project on medical and scientific migrants started in 1997, by Professor Paul Weindling at Oxford Brookes University, England, in which it aims to create a database specifically related to the occupational history of a specific group of people, in this case medical refugees. This type of reconstruction has never been done before in British 13

Tony Kushner, “Clubland, Cricket Tests and Alien Internment, 1939-40,” in David Cesarani, and Tony Kushner, eds., The Internment of Aliens in Twentieth Century Britain, (London, England: Frank Cass and Company Ltd., 1993), 84. 14 Stewart, “Angels or Aliens?,”152. 15 A. Margaret Frey, TNA MH58/336, [Letter from A. Margaret Frey, Nursing and Midwifery Dept., Bloomsbury House to E N Cooper, Home office (August 10, 1940)]. 16 Stewart, “Angels or Aliens?,”156. 17 François Lafitte, The Internment of Aliens, (Harmondsworth: Penguin, 1940), 240.

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Medical Refugee Nurses in Britain: 1933–1945

history of medicine and health care. In fact historical research on refugees has tended to be based on exemplary life stories. The medical refugees project aims to serve as a model study and it is believed that a populationbased approach can be both illuminating on both an individual level and also allow collective structures to be analyzed. With medical refugees, it can be seen that they acted as a catalyst in developing research led medical provision. This is particularly noticeable if you look at specific wellknown characters, in their fields, such as the Vienna psychoanalyst Sigmund Freud and the immunologist and zoologist Leslie Baruch Brent from Cologne, which will be discussed in the next sections.

Sigmund Freud (1856-1939) Sigmund Freud was born in Freiberg, in Moravia, on 6th of May, 1856. His family moved to Vienna when Freud was 4 years old, where he progressed to medical school at the age of 17.18 In 1885, Freud went to Paris on a traveling fellowship to study with Europe’s most renowned neurologist, Jean Martin Charcot (1825-1893), a specialist in the study of hysteria and its susceptibility to hypnosis.19 In 1886, Freud opened his own medical practice, where he specialized in neurology, and also married Martha Bernays (1861-1951).20 In 1930 Freud received the [Johann Wolfgang von] Goethe Prize in appreciation of his contribution to psychology and to German literary culture. In 1933, when the Nazis took control of Germany, they destroyed and burned many of Freud’s books, since they had been indexed on the published list by the Nazi party on what they called “degenerate art and literature.”21 In March 1938, when the Nazis annexed Austria, this resulted also in violent anti-Semitic outbursts in Vienna, during which Freud and his family also began to receive visits from the Secret State Police (Gestapo).22 Freud then made the decision to leave Vienna, and was

18

David Hothersall, History of Psychology, 3rd ed., (Mcgraw-Hill: New York, 1995). 19 Joseph Aguayo, “Charcot and Freud: Some Implications of Late 19th Century French Psychiatry and Politics for the Origins of Psychoanalysis,” Psychoanalysis and Contemporary Thought, 9 (1986): 223-260. 20 Peter Gay, Freud: A Life for Our Time, (London: Papermac, 1988), 76. 21 Ibid. 22 Ibid., 624-625.

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assisted by a Nazi official in providing his family visas to go to Britain.23 The Freud family eventually left Vienna, in June 1938, via the Orient Express train to London. Yet as early as September 1939, he died of cancer of the mouth and jaw, from which he had suffered from for the last twenty years of his life.24

Leslie Baruch Brent (b. 1925) Leslie Baruch Brent was born on the fifth of July, 1925, as Lothar Baruch, in Koeslin, Germany (now, Poland), to German-Jewish parents. To escape growing German anti-Semitism, Brent was sent to England on the first of the Kindertransport (evacuation transport of children) in 1938.25 Baruch changed his name to Brent because his status as a German national would have made him liable for execution in the event of capture.26 After the war, he became a British citizen and enrolled at the University of Birmingham. He later became a faculty member in biology at the University of London, where he rose through the academic ranks and finally was awarded a prestigious Professor Emeritus status for his lifetime achievements. He co-discovered immunological tolerance with the British physiologists and immunologists Peter Medawar (1915-1987) and Rupert Billingham (1921-2002), when they injected cells from donor mice into fetal mice, and later neonatal mice, which would as adults receive donor skin grafts without rejection.27 The majority of medical refugees in the United Kingdom during the 1930’s and 1940’s were German-speaking (from Germany, Austria, Czechoslovakia, and other Eastern European territories that formerly belonged to Austro-Hungary); there were also small numbers of Poles, Italians and Spanish and a scattering of other countries. Most of the German-speaking refugees were physicians, but some were also dentists, surgeons, and non-medical psychoanalysts. An estimated one third migrated onwards to other countries, though most settled in the UK 23 Ibid.; David Cohen, The Escape of Sigmund Freud (London, England: JR Books, 2009), 152-153. 24 Cohen, The Escape of Sigmund Freud, 77-80. 25 Anthea Gerrie, “Revealed: the Wartime School That Saved Lives,” The Jewish Chronicle, (11 August, 2011). (Accessed September 29, 2011). 26 Howard Spier, “Leslie Baruch Brent: Ein Sonntagskind,” AJR Journal (November 2004), 11. (Accessed October 4, 2011). 27 Leslie Brent, “The Discovery of Immunological Tolerance,” Human Immunology 52, no. 2 (1997): 75-81.

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Medical Refugee Nurses in Britain: 1933–1945

permanently. In regards to admission, Britain’s record is controversial; there were those who supported the admission of medical refugees out of a sense that they could contribute to the modernization and supplementation of British medicine and science in general. However, in contrast, other professional groups argued against their continental contemporaries, seeing them as competitors and representing an alien style of scientized medicine.28 Continental medicine at this time was seen as more professional, specialized and largely based on experimental science; it was also more forward thinking in that woman had been admitted to higher institutions since the beginning of 20th century. The development of specialism on the continent meant that there was a difference in how medicine was perceived between Europe and Britain. Specialism in Britain only became significant after the launch of the National Health System (NHS) in 1947. Refugees coming to Britain were seen in this light by the medical associations and thus were prevented to practice. Paul Weindling argues that The prospect of scientifically-informed professionals modernizing health care provision was doggedly opposed. … the BMA [British Medical Association] and MPU [Medical Practitioners’ Union] regarded alien practitioners as a threat, because they represented a whole sale transformation in the structures of medical power and knowledge.29

However, though the British Medical Association (BMA) and the trade union of doctors and other health care professionals – the Medical Practitioners’ Union (MPU) – were against refugees, this did not stop them entering and practicing in Britain. To date, the Medical Refugees database has collated 5,219 refugee physicians, dental surgeons, psychotherapists and nurses that were able to work or gain qualification in Britain during the period 1930 to 1948. Opportunities for employment improved throughout the war period, this is particularly noticeable for refugee nurses.

28

Paul Weindling, “Medical Refugees and the Modernisation of British Medicine, 1930-60,” Social History of Medicine 22, no. 3 (2009): 11-24. 29 Ibid., 490.

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The Voice of a Previously Unrecognized Group: Refugee Nurses The Refugee Nurses project also seeks to give a voice to a group of people who have not been allowed, for one reason or another, to publicly come forward in the media and other social forums. Women, though making up a large proportion of those refugee professionals who came to Britain, due in part to the possibility of entering the UK on domestic service or nursing permits, which were both high demand areas, have had a weak historiography so far, and that of nurses is weaker still. Yet this should not suggest that it is because of insignificant numbers, since it is estimated in the scholarly literature that there were over 1,500 women who came to Britain as nurses or for nursing education.30 Constructing a picture of refugee nurses is difficult, since continental qualifications were not accepted in Britain and there were wide gradients in the practical and scientific qualifications that could be earned. Also it should be taken into account that many women, who came to Britain on a domestic servant’s visa, chose later to go into nursing after they had arrived (and thus would not have been identified up front in the immigration surveys as nurses). But these are not the only issues involved in constructing a picture of refugee nurses. Two main issues become apparent when looking at refugee nurses and their ability to work in Britain. These are: 1. The complexity of government regulations determining where, or if at all, refugee nurses might be employed. Though there was a desperate shortage of nurses at the outbreak of war, government agencies had to still deal with the fact of anti-alien sentiment and the ‘sensitive labour market issue’ where the Royal College of Nursing [RCN] sought to keep refugees out of nursing as they believed that this would take jobs from British nurses. 2. There were also employment constraints on the basis that foreign qualifications were not generally recognized. Fully qualified nurses therefore had to re-qualify under British training or work as assistant nurses. The contemporary issue of refugee nurse employment was not just fixed to the issues above however. In the Nursing Times, 1939, it is argued 30

Ibid., 451-459.

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Medical Refugee Nurses in Britain: 1933–1945

that the position of employing refugees as nurses had been quite difficult socially and economically. There was concern that language, custom and standards of skills would prove to be a barrier.31 That foreign nurses were needed was obvious to many in Britain at this time, but as the same as with home grown nurses as well, they could not be hired – since they needed to want to nurse first. The Nursing Times hence states: Women who nurse without loving the work will readily become so unnurse like that their attentions can be worse than scantier attention from those who are anxious to serve them. ... If the experiment is to be successful, the refugees admitted to our training schools must be admitted, firstly, because they wish to nurse, and not merely because nursing is one of the few professions in which the supply does not meet the demand... 32

As with the medical refugees, nurses require their own historian. As there are so few scholars who have studied this area (particularly the historical issue of refugee nurses) there is still a lot of original material to be researched and analyzed, however the material is fragmented. The papers of the refugee organizations are incomplete and those of nursing bodies, such as, the General Nursing Council and the Royal College of Nursing are largely silent on the subject of refugee nurses and their training. Very recently a small cache of files being held by the British Federation of Graduate Women was located, a reference to this material was presented in a recent publication by English social historian Susan Cohen,33 where she suggest that the federation helped 74 refugees gain English so that they could train as probationer nurses. There are materials in journals such as the Nursing Times and the Nursing Mirror, the files of government ministries such as the Home Office and the Ministry of Labour, local authority records; the administrative papers of individual hospitals, and of course personal recollections. But this does not argue the case that researching refugee nurses is an impossible task. My larger research project also intends to look at the impact of what refugee nurses did for the modernization of medicine in 31

No author, “The Refugee Problem,” The Nursing Times 35, no. 1764, (February 18, 1939), 191. 32 Ibid. 33 Susan A. Cohen, “‘Now You See Them, Now You Don’t.’ The Archives of The Refugee Committee of the British Federation of University Women.” Yearbook of the Research Centre for German and Austrian Exile Studies 9 (2007): 109-122.

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Britain. The records investigated so far have argued that refugee nurses were welcome where they managed to gain employment. In the records of the Royal Country Hospital in Winchester, Hampshire, the Matron estates of three nurses found that they were pleasant, willing to do the work required and had the ability to work unsupervised. This may sound a simple task to do but when looking at the other records of other trainee nurses it appears this was not a simple ability to find! The impact of what these women had on nursing can already be seen by the life stories of Annie Altschul, Lisbeth Hockey and Charlotte Kratz.

Professor Annie Altschul (1919-2001), Professor of Nursing Annie Altschul was born in Vienna in 1919; originally studying mathematics at the University of Vienna she left Vienna for London in 1938. In England, she worked as a nanny and a housemaid, before training as a nurse and midwife at Epsom County Hospital. In 1946, she became a staff nurse and a sister at the Maudsley Hospital and rapidly became a sister tutor. During the next decade, nursing developments at the Maudsley centered on the ideas and presence of Annie Altschul.34 She published two books, Psychiatric Nursing (1957), and Psychology for Nurses (1962), which ran to several editions. In 1964, Altschul left the Maudsley to be a lecturer in the Department of Nursing Studies at Edinburgh University. She became Professor of Nursing Studies in 1976, and remained at Edinburgh until she retired in 1983.35 She was member of the Mental Health Commission in Scotland and also of the Platt Committee set up by the Royal College of Nursing to study nursing education. She was appointed a Commander of the British Empire (CBE) in 1983. Appropriately she is commemorated for students by the Professor Annie Altschul Publication Prize, which she established. She died in Edinburgh December 2001.36

34

L. Dopson, “Obituaries: Annie Altschul,” The Independent, 2002, http://www. independent.co.uk/news/obituaries/professor-annie-altschul-729628.html. (Accessed February 10, 2009). 35 Ibid. 36 Ibid.

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Medical Refugee Nurses in Britain: 1933–1945

Charlotte Kratz (1922-2006), District Nurse Charlotte Kratz was born in Dortmund in 1922, and was the first nurse to graduate with a doctorate of philosophy. Kratz was a German-Jewish refugee, who worked as superintendent in the Dar es Salaam District Nursing Service, where she was able to secure a special training program for community nurses in the United Kingdom.37 In Britain, as well as internationally, Kratz’s name is associated with “community nursing.”38 She began training as a nurse at St. Thomas’ Hospital in 1944, where — because of the war— she spent time at the Royal Infirmary in Edinburgh in practicum. Later, she trained as a district nurse and was appointed nursing officer of the Queen’s Institute of District Nursing.39 In 1959, she was appointed for a district nurse position in Tanganyika.40 Kratz returns to England in 1963, and became a community nurse tutor, the first in Britain, at the Royal Free Hospital in London.41 In 1974, along with fellow nurse Dorothy Baker, Kratz developed the Department of Nursing at Manchester University.42 Alongside completing her PhD in long-term care of stroke patients, Kratz taught the sociology of nursing.43 She was offered an appointment with the Department of Nursing at Manchester University, as a Health and Social Service researcher upon completing her PhD in 1974.44 Until she retired in 1988, Kratz was a freelancing journalist for the Nursing Times, and actively took up campaigns, such as the District Nurses Action Campaign.45 At the age of 61 she was elected to the English National Board for Nursing and the United Kingdom Council for Nursing, Midwifery and Health Visiting.46 Before she died in Eastbourne, East Sussex in October of 2006, she was elected Fellow of the Royal College of

37

L. Dopson, “Obituaries: Charlotte Kratz,” The Independent, 2006, http://www.independent.co.uk/news/obituaries/charlotte-kratz-421371.html. (Accessed February 10, 2009). 38 Ibid. 39 Ibid. 40 Ibid. 41 Ibid. 42 Ibid. 43 Ibid. 44 Ibid. 45 Ibid. 46 Ibid.

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Nursing in 1983, and appointed Member of the British Empire (MBE) by the Queen in 1985.47

Lisbeth Hockey (1918-2004), Pioneer of Nursing Research Lisbeth Hockey was born on the 17th of October 1918 in Graz, Austria. Although her family were not practicing Jews, when Adolf Hitler (1889-1945) and his army moved into Austria, it was no longer safe for the Hockeys to remain.48 Lisbeth escaped to England with the Quakers, as a governess, to Seaton, Devon with the Wedgwood family.49 She was sent to Britain in 1938 as a medical student, where she studied general nursing at the London hospitals. Through her ambition to be a general practitioner, Hockey was made an honorary fellow by the Royal College of General Practicioners in 1977, and appointed the Order of the British Empire in 1979.50 She was awarded the Gold Medal of Honor in 2000 by the Queen’s Institute, in addition to publishing two: Feeling the Pulse (1966) and Care in the Balance (1968).51 From 1972 to 1982, Lisbeth Hockey was Director of the first Nursing Research Unit in Great Britain, at the University of Edinburgh in Scotland. She died in Edinburgh June 2004.52

Conclusion: A New Methodology In conclusion, Refugees from Europe were constantly looking for places to settle; displaced medical migrants and particularly nurses and women who contemplated entering nursing looked – with increasing desperation – throughout the world for locations where their skills might be valued, or at least for a place of safety from worsening Nazi persecution. Yet the same issue that was happening in Britain was happening elsewhere. Scientific and humane support for medical refugees clashed with professional restrictionism and animosity to alien practitioners. Because of these issues, refugees ended up in far reaching locations such as South Africa, Shanghai, Hong Kong and Burma, which later fell to 47

Ibid. L. Dopson, “Obituaries: Lisbeth Hockey,” The Independent, 2004, http://www.independent.co.uk/news/obituaries/lisbeth-hockey-730639.html. 49 Ibid. 50 Ibid. 51 Ibid. 52 Ibid. 48

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Medical Refugee Nurses in Britain: 1933–1945

Japanese occupation.53 A few even fell back into Nazi hands. A prime example of this is ship’s surgeon and Czech refugee, Karl Sperber (19101957), who was shipwrecked in the Far East and later sent to Auschwitz.54 It is estimated that about 400,000 refugees escaped mainland Europe during the 1930’s, yet only a small fraction, 10 percent to 15 percent, of them settled in Britain. Of these it can be said that 53 percent were women as they had the potential of gaining employment through domestic service and nursing. However, though it is estimated that 1,500 women aimed to make a career in nursing, they had many difficulties to deal with in becoming trained in Britain and a new methodology will need to be developed so as to understand these difficulties. In particular we shall have to keep in mind that: x Nurse training appears to have a far more decentralized structure, relatively high overall numbers, and a much more practical orientation. x Unlike medical qualifications from 1941, there was no system within nursing of the recognition of foreign qualifications. x The context was fundamentally different with nursing recognized by the Ministry of Labour as a demand area. x Nursing had a fundamentally different training structure with a series of graduated certificates (nursery nurse, state registered nurse, midwifery, psychiatric nursing). x The refugees had a fundamentally different approach to nursing: whereas the majority who entered medicine developed life long careers, the hypothesis is that nursing was a welcome temporary refuge for the majority of applicants, and a longterm career for a minority. x There is a fundamental gender difference, with a preponderance of women in nursing at this time. This again contrasts to medicine. It also poses a further set of problems such as marriage and name changes. x A hypothesis is that nursing was a demand area for younger women. An implication is that while virtually no medical refugees are alive to be interviewed, there are a good number 53

“FO 937/110: ‘Atrocities,’” February 11, 1946, The National Archives, War Office. 54 Paul Weindling, “Medical Refugees in Britain and the Wider World, 1930 – 1950,” 451-459.

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of former nurses still around. The Refugee Nurses project represents a last chance to discuss with and interview the surviving members of the cohort. x The countries of origin were fundamentally different – whereas medical refugees have an equal balance between German (mainly Jewish) and Polish physicians (mainly Catholic), the hypothesis is that far fewer Polish women entered nursing in the UK. To do this, the Refugee Nurses project shall in the near future research individual hospital records, refugee committees and societies and the records of the Home office and the Ministry of Labour. The Refugee Nurses project seeks to develop a “total population” approach to the medical refugees in the UK by focusing on refugee nurses from Europe coming to Britain 1933-1945. The project will consider: biographical aspects; sources including administrative, autobiographical memoirs, government papers, and interviews; the responses of the UK nursing profession, and the British government. The output of the project will be a relational database that can work as a biographical information pool of refugee nurses, which will supplement the existing database of medical refugees. The database’s “total population” approach will allow for linkages between different occupations, of which nursing and medicine are significant examples. It is hoped that this project will create wider awareness for a group of people that have to date not been able to be heard and that it shall be seen how these individuals impacted the modernization of medicine in Britain during this period and today.

HISTORY OF PUBLIC HEALTH

PLACATING THE BRITISH: THE CONTAGIOUS DISEASES ACT IN CANADA CAITLIN DYER

SUMMARY: The Contagious Diseases Acts were inaugurated throughout the British Empire amidst widespread opposition, except in Canada. Although Canada had its own version of the Act from 1865 to 1870 there was no public outcry. Why were Canadians less concerned about this controversial legislation than their British counterparts? When the Contagious Diseases Act was passed in Canada there were widespread concerns about the defense of the country against both the United States and Fenian raiders expressed by both Canadians and British administrators. The British went so far as to call Canadians unpatriotic because they did not put more money and resources into fortifying the country to spare the British the expense. Also at this time the Canadian government was attempting to secure funding to construct military fortifications. Hamilton, Ontario, one of the cities where the Act was supposed to be in effect, has no records of the Act ever having been carried out and actually put forward legislation contrary to the Act. Why would the Canadian government have taken the time to pass through the various stages of parliament and the senate a law that was never enacted? The Canadian government never intended to actually enforce the Contagious Diseases Act and the public were not aware it even existed. The government passed this legislation to show the British that they were serious about the defense of the country in order to get money for military fortifications. KEYWORDS: Public Health, History of; Medicine, History of; Canada; International Relations; Contagious Diseases; Health Policies, History; Military, History; Commonwealth; Social Revolutions; Politics of Disease PRECEPTOR: Dr. David Wright INSTITUTION: McMaster University

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Placating the British: The Contagious Diseases Act in Canada

Introduction The Contagious Diseases (CD) Acts were instituted amidst widespread opposition throughout the British Empire to protect the health of the army and navy. The Acts were designed to reduce the number of men who incurred sick days or were invalided by contracting venereal diseases. In effect, the Acts legalized prostitution in certain naval and military towns and required prostitutes to undergo fortnightly medical examinations where they would be checked for signs of venereal disease. If a prostitute was found to be ill of a venereal disease she could be confined in a lock hospital against her will for approximately three months depending on the particular Act (here, the Bill for Prevention of Contagious Diseases at Naval and Military Stations),1 or until she was deemed cured. Implicit in the Acts was the assumption that only women can transmit venereal diseases, as the soldiers and sailors were not required to undergo any such examination. Wherever these Acts were in place, widespread opposition and controversy was sparked. The opposition came to a height from 1869 to 1871 when the second amendment to the Acts in Britain emerged as public knowledge, which proposed to extend the time of detainment from three months to one year.2 The public was largely opposed to the Acts for several reasons: They appeared to condone poor morals in the country’s soldiers. Some doctors and health officials were not entirely convinced that the Acts were effective in preventing venereal disease (VD) and women stood up and rebelled against the gender bias inherent in the legislation. Opposition was by no means confined to Britain; the Acts were also in place in India, Malta and many other colonial countries where there was public opposition (see the works of the British historian Philippa Levine). Canada however, seems to be the exception to the rule. Although there was a Contagious Diseases Act passed in parliament, which was in effect from 1865 to 1870, there was a silence amongst the Canadian public with regards to the Act.

1

Government of Canada, Parliament, Statutes of the Province of Canada, Bill for Prevention of Contagious Diseases at Naval and Military Stations, session held in twenty-ninth year of the reign of Her Majesty Queen Victoria, 4th sess., 1865 (Canadian Act of Parliament: 8), 41. 2 British Parliament, Contagious Diseases (H.L.): A Bill Intituled an Act to Amend the Contagious Diseases Act,” British Parliamentary Bills, sess. 1868-69, no. 255, 1866, 3.

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This paper attempts to explain the silence of the Canadian public with regards to the Contagious Diseases legislation through a case study of the city of Hamilton, one of the ports where the Act was supposed to be in effect. Around the time the Act came into effect in Canada, the public was highly concerned about the defense of the nation. The American Civil War was coming to a close and a group of rebellious Irish supporters were seen to be a constant area of concern. The Contagious Diseases Acts were not in effect but merely on the record books to placate the British government in an attempt to secure funding and military personnel for Canada’s defense.

Context In 1865, Canada was not yet an independent nation. In fact, at the time “the province of Canada” referred to the united Upper and Lower Canada.3 Throughout this paper references to Canada are thus referring to the united provinces of Ontario and Quebec. By this point however, the unification of the entire country was being discussed, which would ultimately bring greater independence from Great Britain. Prostitution was an issue in Canada, as can be deduced from the annual report of the Police Commissioner of the City of Hamilton for the years 1865 to 1866.4 The report printed for the year 1864 states that 74 women were arrested for street walking, while 34 males and 46 females were arrested for “keeping disorderly houses and being found therein.”5 The frequency of these arrests can also be deduced from the Hamilton Spectator’s daily column, which summarized the events at the Police Court during a particular day. Accounts like this one were not uncommon for the time: DESCENT ON A HOUSE OF ILL FAME On Sunday night a descent was made by the Police on a house of ill fame, situated on King Street, near the Crystal Palace, and kept by a woman named Ellen Smith. The parties in the house were arrested, and brought this morning before the Police Magistrate. His Worship fined the keeper of 3 Cf. R. Douglas Francis and Donald B. Smith, Readings in Canadian History – Post-Federation, (Toronto: Holt, Rinehart and Winston of Canada, 1990), 1-35. 4 After this point, the annual reports are not available, as they were no longer printed in the Hamilton Spectator. 5 John Carruthers, “Annual Report of the Chief of Police,” The Hamilton Spectator, 21 January 1865, 2.

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Placating the British: The Contagious Diseases Act in Canada the house $80, or six months in jail. May Millar and Flora Jones, two of the inmates of the house, and William Kerr and Edwin Moffat, found on the premises, were each fined $50 or three months in jail. Two of the parties paid their fines yesterday afternoon.

The report for the year 1866 was structured differently and grouped street walking and vagrancy together, for a total of 365 people arrested for offences of this kind. 106 people were arrested for keeping or frequenting a house of ill fame or disorderly house in 1866.6 The City Hospital in Hamilton published figures on admissions for the year 1864, which became broken down by the kind of complaint for which a person was admitted to the hospital. For this year 8 people were treated for gonorrhea and 20 for syphilis, out of a total of 252 patients admitted during the year.7 This amounts to approximately 11 percent of the patients admitted to the hospital for the year. The only other disease listed, which admitted nearly as many as venereal diseases, was pregnancy, with 21 women admitted over the course of the year.8 Thus, venereal disease appears to have been an issue in Hamilton. However the legislators and law enforcers seem to have been more concerned with the moral implications of prostitution rather than the disease consequences. The total number of people arrested for prostitution-related offences for 1864 was 154, while the number of people treated for venereal disease was only 28. The state of the military in Canada at this time was in poor shape. In 1854 and 1855 there were militia reforms in the country, which modeled the volunteer force after the American volunteer corps already in existence and created volunteer battalions of cavalry, field battery, foot, artillery and infantry companies.9 Soldiers were divided into Class A (paid soldiers) and Class B (unpaid), but cuts to the budget continually reduced the number of Class A soldiers and caused worry among Canadians. Class A soldiers were generally better trained and had to attend one of the military schools set up around the province in order to receive this rank and receive pay for their duties.10 In terms of regular soldiers from the Imperial Army serving in Canada, the number of men who served is difficult to discern 6

William H. Nicolls, “Annual Report of the Chief of Police,” The Hamilton Spectator, 11 January 1865, 2. 7 Dr. Strange, “City Hospital Report,” The Hamilton Spectator, 13 January 1865, 2. 8 Ibid. 9 Hereward Senior, The Last Invasion of Canada: The Fenian Raids, 1866-1870 (Toronto: Dundurn Group, 1991), 27. 10 Ibid., 28.

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due to fluctuations, but it is estimated that there were approximately 2,263 regular soldiers of the British army serving in Canada in 1861.11 This was a very small number of soldiers to have stationed in such a large geographic area in the British colonies. According to the Army Medical Department Statistical and Sanitary Report for the year 1864, there were no recorded cases of venereal disease among the soldiers serving in Canada.12 The military structure of Canada at this time was not suited for the CD Act to function. The Act is meant to control venereal diseases among the regular army and navy who serve for years at a time and solicit prostitutes for sexual gratification. In Canada however, there were a very small number of regular army soldiers serving, around 2,200 at this time – as described above –, with the rest of the army composed of militia volunteers. The volunteers continued to live and work at home, perhaps training once weekly, but many would only attend roll call once a year. The large majority of volunteers would have been married and as the militia were only called up in the event of a local emergency or crisis they would have spent little if any time away from home, thus reducing the risks of clandestine sexual encounters. Moreover, even if the volunteer militia had contracted venereal diseases, it would have been inconsequential to the government, as the militia was not required to undergo medical examinations before admittance to their ranks. In the improbable case that the entire militia contracted venereal disease it would not have a huge effect as these men were rarely called up and most had never seen active combat.

Historiography The historiography of the Contagious Diseases Acts is represented by five historians with largely different perspectives. In her book Prostitution and Victorian Society: Women Class and the State, the modern European historian Judith Walkowitz at Johns Hopkins University focuses on the feminist reaction to the domestic CD Acts. There was an incredible amount of public involvement by the Acts supporters and critics. There were many groups founded to further both sides of the cause, including the 11

Ibid., 31. Army Medical Department Statistical, Sanitary and Medical Reports, On the Health of the Troops Serving in British North America. Volume VI: British Parliamentary Command Papers: Reports of Commissioners, 1864, No. 3730, 57.

12

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Ladies National Association for the Repeal of the Contagious Diseases Acts. These groups petitioned government, held demonstrations and wrote letters. The focus of her book is on Josephine Butler (1828-1906) who has been labeled as the first feminist through her work to get the CD Acts repealed. Walkowitz argues that Josephine Butler’s republican, feminist and religious sentiments were able to get the attention of the working class and united the population under this cause.13 However, Australian cultural historian Mary Spongberg directly challenges the way in which scholars like Walkowitz have analyzed the situation in her book Feminizing Venereal Disease. Spongberg argues that based on the fact that most laypeople were interested in furthering the laws used the words “prostitute” and “disease” interchangeably, whereas the medical professionals who were involved in the debate questioned the assumption that prostitutes were contaminated, as well as the way venereal disease was treated, that the role of medical practitioners is the most important when looking at the CD Acts.14 Bristol theologian and feminist scholar Lisa Severine Nolland also focuses on the domestic Acts and Josephine Butler and offers some explanation as to why legislators felt that the Acts were necessary. She frames her argument in terms of continental military competition, stating that the Acts were not solely for the prevention of venereal disease, but also a way to modernize the British Army. Nolland states that the army was the same in structure to the one that had defeated Napoleon nearly fifty years earlier, and one of the standard features of the continental armies was licensed brothels. As the British were unwilling to use conscription, they attempted to be better equipped, more efficient and more physically and mentally fit than their rivals.15 In terms of the colonial Acts, Elizabeth B. van Heyningen focuses on one of the only areas of Africa, which instituted the Acts. Van Heyningen argues that the reason for implementation was security and preservation of British rule. The only local requests for the Acts came from the Colonial Medical Committee, and the War Office threatened to withdraw Imperial authorities from the area if the Acts were not instituted. Thus she interprets the Acts in this case as relating not to local conditions but rather to 13

Judith R. Walkowitz, Prostitution and Victorian Society: Women, Class and the State (Cambridge: Cambridge University Press, 1980), 99. 14 Mary Spongberg, Feminizing Venereal Disease: The Body of the Prostitute in Nineteenth-Century Medical Discourse (New York: New York University Press, 1997), 73. 15 Lisa Severine Nolland, A Victorian Feminist Christian: Josephine Butler, the Prostitutes and God (Carlisle: Paternoster, 2004), 189-191.

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medical practitioners set on upholding the colony’s morals.16 Philippa Levine argued in her article “Public Health, Venereal Disease and Colonial Medicine in the Later Nineteenth Century” that morality was commonly associated with the Acts due to their relation with sexuality and was more frequently associated with them in the colonies, as the East was seen as a sensual place.17 Levine also argues in her book Prostitution, Race and Politics that the CD Acts, in addition to protecting the health and well being of soldiers in the Empire, also helped to protect the “whiteness” and purity of the race. By protecting the soldiers from venereal diseases, they could return to Britain upon completion of their terms of service and engage in heterosexual relations to propagate the race.18 In this way, Levine addresses the issue of race with regards to the Colonial Acts. Common to each historian’s interpretation of the Contagious Diseases Acts are the concerns surrounding morality in addition to the obvious health concerns. It appears that while Britain was concerned about the health of the army and the navy, they were equally concerned with morality. In some colonies like India, CD Acts prevented soldiers from interacting with prostitutes of a different race as they were seen to be dirtier than white women and morally questionable.19 As Levine explored, the Acts may also have been useful in keeping up the health of the race both in Britain and across the Empire. By keeping soldiers free from venereal disease they could return to Britain, take a wife, have some children and help strengthen the Empire. This paper hence attempts to build and expand on some of the arguments outlined above, especially those of Lisa Severine Nolland and Elizabeth B. Van Heyningen, specifically on the ideas that the CD Acts were interpreted as a way of keeping soldiers in better physical fitness and the notion that in some cases the Acts were instituted due to pressure from London, rather than local conditions.

16

South African historian Elizabeth B. Van Heyningen, “The Social Evil in the Cape Colony 1868-1902: Prostitution and the Contagious Diseases Acts,” Journal of Southern African Studies 10, no. 2 (1984): 173. 17 Philippa Levine, “Public Health, Venereal Disease and Colonial Medicine in the Later Nineteenth Century,” in Roger Davidson and Lesley A. Hall, eds., Sex, Sin and Suffering: Venereal Disease and European Society since 1870, (London: Routledge, 2001), 160-172; esp., 164. 18 Philippa Levine, Prostitution, Race and Politics: Policing Venereal Disease in the British Empire, (New York: Routledge, 2003), 44. 19 Levine, Prostitution, Race and Politics, 179.

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Concern for Defence of Canada More than a year before the CD Act was assented to in Canadian Parliament, there were concerns among both the population at large and the legislative bodies about the defense of the country. This development is important for understanding why exactly the Act was instituted when the conditions were not suited for it. The sentiments of both the general public and the legislative bodies can be deduced from reviewing issues of the Hamilton Spectator from 1864 and early 1865, as it carried columns discussing the proceedings of the British and Canadian Parliaments as well as news and general interest pieces. It appears that the general public during 1864 was very much interested in the defense of the country and the movements of the militia. In June of 1864, there was a review of the volunteer militia at Drummondville, Niagara Falls. Prior to the event, The Spectator published a number of articles relating to the coming spectacle. One article made implications about the location of the Review in the Niagara Region, where the militia had last engaged in hostilities during the War of 1812 and had been successful in this attempt. The article went on, What would be more appropriate, then, than the volunteers of to-day [who] should meet within sight of at least one spot consecrated to the memory of those brave men who rallied at their country’s call and rescued it from the possessions of a foreign foe?20

Following the Review, the Spectator printed this excerpt from the Buffalo Express: The Canadian Military Review – From all accounts the review of the Canadian Militia, at Drummondville, which it was announced would be a grand military display, proved a dead failure. Some ten thousand spectators were present, to witness the very bungling evolutions of from between two and three thousand troops and a section of a battery, under command of a titled commander who did not make his appearance on the field till near twilight. After the enthusiastic encomiums paid her Majesty’s loyal militiamen, by the press of Canada, we looked for better things than a laughable fizzle, bearing much resemblance of a sell.21

20 21

“The Volunteer Review,” The Hamilton Spectator, 15 June 1864, 2. “The Canadian Military Review,” The Buffalo Express, 23 June 1864, 2.

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The Spectator went on to disagree with everything printed in the excerpt, stating that “the review at the Falls, however, we repeat, was a grand affair,” and alluded that the past had influenced the reporter’s depiction of the event by concluding, “he may not have relished the thought of being in such close proximity with the spot where his ancestors were compelled to bite the dust, by the forefathers of every militiamen he has abused and misrepresented.”22 However, despite the very patriotic rebuttal printed by The Spectator, perhaps there was some truth in the story printed by the Buffalo Express as less than a month later, the British House of Commons entered into some serious discussions about the defense of Canada. On July 19, 1864 it was reported in The Spectator that “an important discussion” had taken place in the British House of Commons with regards to the British troops who were stationed in Canada.23 The intentions of the British government were to concentrate the regular forces in Quebec and Montreal in an attempt to force the provincial government to organize a large militia force in Upper Canada. The Spectator admitted that there had been little done for the defense of the country, saying “it is not to be denied that the Government of this country has been unmindful of its best interests in neglecting to provide means of defense against invasion from our American neighbors.”24 On August 6, 1864 a second report was published in The Spectator relating to the defense of Canada. In this article the British Parliament called into question the patriotism of Canadians because they did not take the defense of the country into their own hands and spare Britain the cost of maintaining a standing force. It was suggested that Upper Canada should be raising 100,000 volunteers. According to the article, Canada had approximately 25,000 volunteers at this time, while Britain had 60,110 from a population of 20 million and Ireland had 24,300 and a population nearly twice that of Canada.25 In addition, events, which transpired in October, made military conflict with the American Union government a possibility. In late October 1864, a group of Confederate soldiers who had been living in Canada raided the village of St. Albans, Vermont. These men robbed a bank, set fire to a

22

Ibid. “Canada in England,” The Hamilton Spectator, 19 July 1864, 2. 24 Ibid. 25 “Our Volunteer Forces,” The Hamilton Spectator, 6 August 1864, 2. 23

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number of homes and accidentally shot and killed one citizen.26 The Union reaction to this was incredibly harsh. The Canadian government, wanting to avoid military retribution, called out 2,000 volunteers to patrol the border and prevent similar occurrences from happening again.27 The British obsession with the defense of Canada continued into 1865 with debates, publications and laws. In the March 6th, 1865 issue of The Hamilton Spectator a letter to the Secretary of State for War from Lieutenant-Colonel William Jervois (1821-1894), the Deputy Director of Fortifications on the topic of Canadian defenses was published. The letter was dated January 1865, and its purpose was to convey Jervois’ ideas for the fortifications in Canada to the War Office after visiting the country in the autumn of 1863. It was by his suggestion that the British government endeavored to construct the fortifications at Montreal and Quebec, although he recommended that the Imperial forces not be withdrawn from Upper Canada completely, as the withdrawal would have a negative impact upon the moral in the area.28 This correspondence was also part of the official documents of the House of Commons in Britain and can be found in the Parliamentary Papers.29 Following the publication of Lieut.Col. Jervois’ report there was a debate in the Imperial Government about the defense of Canada. A correspondent to The Hamilton Spectator reported that the only firm decision that the government had taken was to spend £200,000 over four years to construct the fortifications recommended by Jervois at Montreal and Quebec.30 In early January, 1865 the balloting to appoint more members to the militia began eventfully. On January 2, 1865, The Spectator contained accounts of a riot in Chateau Richer where some citizens of the county declared that they would not let the government establish a militia in this region and attempted to stop the balloting with force.31 While no further reports of refusal to accept places in the militia were reported, there were 26 Wilfried S. Neidhardt, Fenianism in North America (University Park: Pennsylvania State University Press, 1975), 19. 27 Ibid. 28 Lt. Colonel Jervois, “The Defense of Canada,” The Hamilton Spectator, 6 March 1865, 2. 29 Lt. Colonel Jervois, Letter to the Secretary of State for War with Reference to the Defence of Canada, British Parliamentary Papers: Command Papers 1865, 37, no. 3434, 429. 30 “Our London Letter: Debate on Canadian Defences,” The Hamilton Spectator, 13 March 1865, 2. 31 “Militia Riot on Friday,” The Hamilton Spectator, 2 January 1865, 2.

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numerous reports of the inadequacy of the current Militia Laws. There were a number of Letters to the Editor of The Hamilton Spectator in January of 1865 opposing the law and offering suggestions for its improvement. This particular letter is signed “Tyro” and gives no other indication of who the author was or their position in society. Tyro’s letter points out that the current system of balloting men for the volunteers is entirely inadequate and states “… our Militia System is a downright farce, and any official who has the interest of the country at heart should notice it.”32 This is only one of many letters printed, which express many of the same sentiments. Thus, it was clearly not just the Imperial Government in Britain that was worried about the defense of Canada; it was a widespread concern throughout the country.

Canadian Delegation and Bid for Freedom Clearly the Contagious Disease Act was instituted during a time of concern over the defense of the country, but the real question of why the Act was instituted cannot simply be answered by this fact alone. In order to better understand the situation, an examination of a Canadian delegation sent to Britain to discuss the provisions of Confederation and the issue of defense in May, 1865 is necessary. The Hamilton Spectator printed reports from The Toronto Leader that the intentions of the delegates to Britain were to ask for a guarantee for the proposed fortifications as well as the entire debt of the country on the condition that the works of defense were undertaken and an efficient militia was maintained.33 Just over a month later, a correspondent was quoted in The Spectator stating that the defense negotiations were going quite well. The Question of the defenses is now before the Commission charged with that subject, who are preparing to state to the Government the measures necessary to be taken (emphasis added) with an approximate idea of what the cost would in all probability be, and as soon as this question has been fully considered, it will be discussed between the Imperial Government and the Canadian delegates.34

32

“The Militia Law,” Letter to the Editor, The Hamilton Spectator, 7 January, 1865, 2. 33 “An Imperial Guarantee,” The Hamilton Spectator, 1 May 1865, 2. 34 “The Mission to England,” The Hamilton Spectator, 3 June 1865, 2.

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This report indicated the Commission was establishing necessary steps to be taken by the Canadian government in order to secure funding for the defenses. There are no records of these discussions and we are left to speculate. Perhaps one of these steps was the establishment of a Contagious Diseases Act to further protect the valuable Imperial forces stationed in Canada. Even if the Imperial government did not suggest or require this legislation, promising to institute an Act would have made a favourable impression upon British politicians and demonstrated the willingness of Canadians to protect Imperial soldiers with fortifications and legislation.

Fenian Threat to Canada Amidst the concerns for the defense of Canada from the Union government another threat was just beginning to take shape.35 As the Fenian threat developed the need for Canada to defend it greatly increased. November of 1864 was when the first signs of violence from the Fenian Brotherhood were recorded. The Fenians were connected with the Irish Revolutionary Brotherhood (I.R.B.) in Ireland, and both groups were determined to secure Ireland’s freedom from British rule through armed insurrection.36 The Fenians hoped that tensions between Britain and the US would continue to grow in the early 1860’s embroiling the countries in a war and allowing the group to strike from Ireland at a weakened Britain.37 Many members of the Fenian Brotherhood had been in support of invading Canada to further the Irish cause and their plans finally began to solidify in the autumn of 1865.38 The Irish population of Toronto was largely in support of the Fenian goals but elsewhere in Canada there was little support for the Brotherhood, specifically due to their desire to invade Canada.39 On November 11 1864, the Spectator reprinted an article published in the Toronto Leader discussing police investigations into the group who “paraded the streets on Saturday night, armed with pikes and other murderous weapons.”40 By early January, it appeared that the whole 35

Hereward Senior, The Last Invasion of Canada: The Fenian Raids, 1866-1870 (Toronto: Dundurn Press, 1991), p. 7-10. 36 Neidhardt, Fenianism in North America, 5. 37 Ibid., 10. 38 Ibid., 29. 39 Senior, The Last Invasion of Canada, 33-34. 40 “The Fenians,” The Toronto Leader in The Hamilton Spectator, 11 November 1864, 2.

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province was alarmed with the Fenians and feared an attack. On January 4th, The Spectator published the account of an easterly county, stating quite an excitement here in regard to the Fenians. Pikes are said to be deposited at various points ready for use. … An attack is expected at any moment.41

Whether or not this was a dramatic exaggeration, there must have been at least some truth to these sentiments for the public to identify with. Ultimately the fears of the population were realized in 1866 when the Fenians launched an attack on Canada in the Niagara region.42

Instatement of the Contagious Diseases Acts in Canada Following the return of its delegates to Britain, Canadian Parliament began sessions again on August 8, 1865 and by the end of the month the House of Parliament began discussing the defense question. A parliamentarian suggested on August 23 that the militia should be organized on a permanent basis. Sir John A. Macdonald (1815-1891) replied “that the government were now anxiously considering the question of Militia in connection with the defense of the country, and were endeavoring vigorously to carry out the militia system…”43 On September 8, Macdonald gave a lengthy speech on the provisions for the militia which included the running of military schools, the number of volunteers estimated to be available and proposed changes to the balloting or conscription organization.44 On September 9, a bill was introduced to alter the Militia and Volunteer Forces Act with amendments for better instruction and a change in the balloting system.45 A few days later on September 13, Sir John A. Macdonald proposed a Bill for the Prevention of Contagious Diseases in Certain Naval and Military Stations. The bill was read for a third time on September 15 and passed through the Legislative Assembly after which it was presented to the Legislative Council and read for the first, second and third time on September 17, right before the end of the session.46 The Canadian CD Act was rushed 41

“Fenians,” The Hamilton Spectator, 2 January 1865, 2. Niedhardt, Fenianism in North America, 8. 43 “Legislative Assembly,” The Hamilton Spectator, 24 August 1865, 2. 44 “Legislative Assembly,” The Hamilton Spectator, 9 September 1865, 2. 45 “Legislative Assembly,” The Hamilton Spectator, 13 September 1865, 2. 46 “Legislative Council,” The Hamilton Spectator, 17 September 1865, 2. 42

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through legislation rather more quickly than what appears to be the norm as it was slipped in at the end of a session. Why would the Canadian parliament and Sir John A. Macdonald in particular, have seen the CD Act as a necessary or worthwhile piece of legislation to introduce? The detailed ledgers of all House business do not exist for this time period for us to see the exact transcripts of parliamentary sessions, and there was no debate published in The Hamilton Spectator. The Canada Gazette was published on a weekly basis to educate the public as to the proceedings of the government, but there is no mention of the Act in this medium either, thus the Act most likely aroused little opposition in parliament. In order to fully understand this predicament it is necessary to look back on the delegation sent to Britain earlier in 1865. One of the main objectives of the mission was to secure the defense of Canada. The Hamilton Spectator printed reports from The Toronto Leader that the intentions of the delegates to Britain were to ask for a guarantee for the proposed fortifications as well as the entire debt of the country on the condition that the works of defense were undertaken and an efficient militia was maintained.47 It is clear from the report of The Spectator’s correspondent that there were certain conditions, which the British government was going to impose upon the Canadian government concerning the management of the militia; these were clearly conditions that the Canadian government would have had to meet in order to be guaranteed the funding which they required. It will be recalled, from above, that the Canadian population lived mostly in sparsely populated rural areas and there were relatively few regular soldiers versus the number of militia volunteers. Therefore it did not make sense for the CD Act to be implemented in Canada. The legislation was better designed to function in a large urban area. Furthermore, a comparison of the Canadian Act of 1865 and the British Act of 1864 show the similarity of the two pieces of legislation. The Canadian Act is almost exactly the same as the British one. The only differences noted are the divergent phrasing in some clauses or different stipulations based on the particular hierarchy of officials in Canada versus Britain.48

47

“An Imperial Guarantee,” The Hamilton Spectator, 1 May 1865, 2. Government of Canada, Library and Archives Canada: Government Publications Collection, Bill for Prevention of Contagious Diseases at Naval and Military Stations: (as amended by Select Committee), 4th sess. of the Eighth Parliament of 48

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What Happened after the Act was Assented to? Following the instatement of the Contagious Diseases Act, it seems to fade from the public’s view. There are no further references to the Act in the Parliamentary Journals or minutes with the exception of the repeal Act in 1870. Although the minutes of the Hamilton City Council do not exist for this time period, the minutes were published in the Spectator and there are no references to instituting the Act or making budget allotments for Medical Officers of Health, despite the fact that Hamilton was one of the towns in which the Act was to be enforced.49 In fact, in 1869 the City of Hamilton enacted a by-law, which contradicted the Contagious Diseases Act. The by-law stated, That no person shall keep, inhabit or frequent, any house of ill fame in said city. That all common prostitutes or night-walkers wondering in the streets or highways of the said city, not giving a satisfactory account of themselves, shall be deemed vagrants, vagabonds, and disorderly persons.50

The terms of this bylaw would also seem to indicate that the Act was not enforced if one of the principle cities mentioned in the Act enacted a bylaw which outlawed prostitution where the Act semi-legalized it. It is also a possibility that the general public were not aware that the CD Act was in place. The Hamilton Spectator published the proceedings of the Canadian Parliament and when the Act came up in House business there was no protracted discussion of its implications. Also, the Canada Gazette, which continues to be published by the government, is a periodical, which outlines the debates and new bills brought up in the government. Although in somewhat of a different format from what we are familiar with now, the Canada Gazette was published on a weekly basis while Parliament was in session throughout the 1860’s. In the 1865 issues of the Canada Gazette there is no mention of the readings of the Contagious Diseases Acts in Parliament.51 Despite the fact it appears that the content Canada, Statutes of the Province of Canada Passed in the Session held in the 29th Year of the Reign of Her Majesty Queen Victoria, 1865. 1864: 212 (I.481), 38. 49 All issues of The Hamilton Spectator were checked from January 1st, 1865 to December 31st, 1870. 50 City of Hamilton, Bylaws Hamilton, Bylaw No. 8 (R352.071H179), CESH, Hamilton Public Library Archives, 1869, 23-25. 51 All issues of the Canada Gazette were checked from January 1st to December 31st, 1865.

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of other bills was published in the Gazette the content of the Contagious Diseases Act was not present. The only place where the Act is mentioned is in a list of bills, which were given the Royal Assent at the end of the session.52

Conclusions There were widespread concerns between both the people of Canada, as well as the British Parliament in London, England, that Canada was not well prepared to defend itself. There were few Imperial soldiers serving in Canada at this time and the majority of the country’s defenses relied on local militia volunteers. At this time the Fenian threat was rising, the chance of conflict seemed imminent and the military in Canada was in shambles. Canada’s population distribution was largely rural with serving militiamen remaining fairly close to their wives and homes. Instituting the CD Act in Canada at this time did not make sense given the population distribution, militia-style structure of the military and the small number of regular soldiers serving in the country. Meanwhile, the British government had recommended that fortifications be constructed at a few key military sites and the Canadian government was trying to impress Imperial Parliament with their plans for the future in an attempt to secure funding for the project. The only logical explanation for the institution of the Contagious Diseases Act in Canada is that the legislation was never in effect but merely placed on the record books in an attempt to placate British authorities concerned about the defense of the country. As Elizabeth Van Heyningen has argued that the CD Act was only instituted in the Cape Colony due to pressures from the British government not the local conditions, similar pressures were felt in Canada. Although the Act was not suited to local conditions the British put pressure on the Canadian government to which they succumbed in order to obtain Canada’s independence.

52 “Bills Receiving the Royal Assent,” in The Canada Gazette June-September 1865, 876.

A SCOURGE NO MORE: THE PORTRAYAL OF THE WHO SMALLPOX ERADICATION PROGRAM IN THE NORTH AMERICAN MEDIA (1967-1981) DAVID HARNETT

SUMMARY: Throughout recorded history, smallpox has been a constant scourge of mankind, ravaging millions and killing one in every three of the infected, leaving the survivors scarred and occasionally blinded. However, in 1980 the World Health Organization (WHO) officially declared smallpox the first disease ever to be globally eradicated, marking the end of an effort initiated in 1967 when there were 10-15 million cases of the disease. This WHO program has been widely hailed as the pinnacle of human achievement due to its use of science, medicine, and technology to effectively conquer a scourge of mankind. Through reviewing thirty-six articles on the eradication effort from the New York Times, Washington Post, and The Globe and Mail from 1969 to 1981, a profile of the mass media portrayal of the program has been reconstructed. Additionally, this contribution reviews academic journal articles focusing on the eradication program from a variety of sources to evaluate potential discrepancies between them in terms of degree of exaggeration and realism. Recurring themes from this investigation are that mass media accounts tended to be overly positive, optimistic, “Americanized”, and were not as different as one might expect from the portrayal in the academic media. Optimism was so wide spread that a 1972 article in the American Journal of Public Health outlined the possibility of achieving the total eradication of prostitution as a public health problem similar to that achieved with smallpox. This reconstruction can provide a unique window into the mindset of a previous generation, which tended to possess an unequivocal belief in the power of science and medicine to solve humanity’s pressing issues. This offers an intriguing contrast to the propensity to be skeptical of science and medicine, which tends to dominate the mass media in the 21st century. KEYWORDS: Smallpox; Public Health, History of; North America; Global Health; Historical Epidemiology; World Health Organization PRECEPTOR: Dr. Jim Connor INSTITUTION: Memorial University

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A Scourge No More

Introduction For the majority of recorded history, mankind has attempted to understand disease by associating it with the supernatural and divine displeasure. For centuries, humans took comfort in the notion that disease was beyond their influence, that religion and faith were the only media through which it could be comprehended. Advancements in science, specifically the development of germ theory and the assignment of biological causation to disease, have radically changed mankind’s view of and experience with disease. The notion that disease can be prevented and controlled has grown so profoundly that mankind now believes it can completely eradicate all sorts of human and animal pathologies from the face of the earth. The optimistic view that disease can be conquered through mankind’s ability to harness and use science and technology is not a universally agreed upon doctrine. However, those who believe in the supremacy of mankind to defeat disease certainly cite the success of the eradication of smallpox as primary evidence to support their cause. In 1798, British physician Edward Jenner (1749-1823) pioneered the practice of vaccination in the western world with the discovery that immunity to smallpox could be achieved via inoculation with the cowpox virus.1 This was certainly a significant scientific achievement, but the magnitude of its impact increases even dramatically when one considers the devastation the disease has wrought on mankind over the course of recorded history. Throughout the course of history, smallpox has consistently ravaged millions killing one in every three of the infected, leaving the survivors scarred and often blinded.2 Evidence indicates that the disease plagued ancient societies in Egypt, India, China and Greece beginning before 1000 B.C.3 In 1967, the World Health Organization (WHO) launched a campaign that aimed to globally eradicate smallpox based on a proposal made by representatives of the Union of Soviet Socialist Republics (USSR).4 This was an ambitious project given there were about ten to fifteen million annual cases of smallpox around this time. The project was officially completed in 1980 and the WHO could 1

Derrick Baxby, “The End of Smallpox,” History Today 49 (1999): 14-16; esp. 14. Mark K. Slifka and John M. Hanifan, “Smallpox: the Basics,” Dermatologic Clinics 22 (2004): 263-274; esp. 263. 3 Donald R. Hopkins, The Greatest Killer: Smallpox in History, (Chicago: The University of Chicago Press, 1983), 14. 4 Fred L. Soper, “Smallpox—World Changes and Implications for Eradication,” American Journal of Public Health 56 (1966): 1652-1656; esp. 1655. 2

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make the historic claim that mankind had completely eliminated an infectious disease from the face of the earth. The majority of the scholarly literature on the eradication of smallpox portrays the eradication of smallpox in very positive terms. The introduction of the recent book by the American international relations expert David Koplow, in Smallpox: The Fight to Eradicate a Global Scourge (2004), embodies this notion as he proclaims: “The medical history of smallpox is a saga of human suffering, unforeseen human inventiveness, and – ultimately – unprecedented human triumph.”5 Given that secondary accounts, with the advantage of twenty or more years of hindsight, tend to shower the eradication program with praise, it would be an interesting historical exercise to analyze the nature of the program’s portrayal in the available accounts of the media. Even newspaper publications within a year or two of the successful completion of the program tended to hail it as a pinnacle of human achievement. In a 1981 article from The New York Times, physicians mention the process of smallpox eradication as the gold standard of international cooperation, the principles of which could also be used by political leaders to end the nuclear arms race.6 A 1980 Globe and Mail article compares the international cooperation and compromises involved in a recent agreement on the Law of the Sea Treaty to the smallpox eradication program “on the [same] scale of human achievement.”7 The pre-investigation hypothesis is that the forms of media targeting the general public would exaggerate the story, by focusing on mankind’s ability to harness and control nature using the tools of science, technology, along with rational thinking. An insightful contrast to this form of media is offered through assessing the portrayal of the program in academic health journals during the same time period. These academic journals naturally target a significantly different audience, one much less inclined to embrace extravagant narratives and more likely to criticize the public health efforts and social costs of the program. The historian of medicine Howard Markel at the University of Michigan proposes in his seven leitmotivs, which appear in most disease epidemics or pandemics, that widespread media coverage was essential 5

David A. Koplow, Smallpox: The Fight to Eradicate a Global Scourge, (Los Angeles: University of California Press, 2004), 9. 6 “Physicians Urge Leaders to Stop Arms Race,” The New York Times (March 25, 1981), 28. 7 Geoffrey Stevens, “Canada May Gain Most From Milestone Sea Treaty,” The Globe and Mail (August 30, 1980), 3.

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and had both the ability to inform and misinform.8 This sentiment is clearly conveyed in a 1973 article, which is rather devoid of emotion until the author states that, “The Press, radio, and television can be a great help to the medical officer of health. They can also be a great hindrance.”9 Considering the historical context of the years in which the program took place, it seems more likely that the media may rather present a distorted representation of the program. First of all, the fact that the eradication program was suggested by the USSR during the Cold War emphasizes a high degree of international cooperation involved in the effort. Secondly, the program began in 1967, only two years before man landed on the moon for the first time. A definite optimistic sense of mankind’s ability to conquer the universe was fostered by the outer space explorations of the US National Aeronautics and Space Administration (NASA). The fact that this event coincided with the attempt to conquer a disease, which had plagued the globe for thousands of years, is of definite contextual significance.

Smallpox Eradication: An American Effort? A common theme which emerged from the analysis of articles from The New York Times between 1969 and 1981 was that there had been a definite attempt to publicly “Americanize” the smallpox eradication effort. The eradication of smallpox proved to be a significant accomplishment for the WHO and public health in general. Therefore, the natural desire to want to affiliate oneself and one’s country with the program is understandable. However, the portrayal in The New York Times was markedly biased. It appears very likely that the average member of the general public in the 1970’s would likely assign credit for the program to the US government after reading several of the articles in question. Another continuity between the articles is that they tended to emphasize the “otherness” of the disease. The effect of this was to reassure the American public that the disease had not been a direct threat to them, but also to create a sense of philanthropy with regards to the American public 8

Howard Markel, Alexandra M. Stern, J. Alexander Navarro, and Joseph R. Michalsen, “A Historical Assessment of Nonpharmaceutical Disease Containment Strategies Employed by Selected U.S Communities During the Second Wave of the 1918-1920 Influenza Pandemic,” Defense Threat Reduction Agency Report (January 2006), 19. 9 Wilfrid H. Parry, “Control of Smallpox,” Lancet 7812 (1973): 990.

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health aid overseas. The juxtaposition of the Americanized eradication program with the foreign nature of the disease itself helps to depict the program in an overtly positive manner from the American perspective. The primary mechanism by which the program became Americanized was through the central focus on Dr. Donald A. Henderson (b. 1928), an American public health physician who led the WHO effort from 1967 until the end of 1976.10 Many articles are constructed around and rely heavily upon quotes from Henderson with almost no other officials involved in the effort being discussed. Henderson’s name becomes almost synonymous with the eradication program itself. He is always the one to verbalize the profundity of the program evident from statements such as “… the first time that any disease has been wiped out deliberately by a campaign.”11 His American heritage is referenced repeatedly with statements like, “Dr. Donald A. Henderson, who is loan from the United States Public Health Service to direct the W.H.O. program … .”12 The efforts of the National Communicable Disease Centre (NCDC), currently known as the Centre for Disease Control and Prevention (CDC), are also emphasized in these articles. However, during times of political and economic setbacks and doubt as to the outcome of the program, New York Times journalists tended to avoid affiliating their home country with the program. Articles 10 The following biography is based on: The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions. Available online: http:// www.medicalarchives.jhmi.edu/sgml/henderson.html (Accessed January 28, 2010). Dr. Donald A. Henderson is a trained physician, having graduated from the University of Rochester School of Medicine in 1954, a public health expert and an epidemiologist, having received his M.P.H. from Johns Hopkins University in 1960. During his postgraduate training in medicine, he worked with the epidemiological intelligence unit of the NCDC. He gained most notoriety for leading the WHO smallpox eradication program and made significant contributions also to the poliomyelitis eradication efforts. Interestingly, Lawrence K. Altman, the author of many of The New York Times articles concerning the smallpox eradication program analyzed, worked under Dr. Henderson at the NCDC in 1963; a point which will be directly addressed in the later part of this contribution. Henderson was eventually appointed Dean of the School and Hygiene and Public Health at Johns Hopkins in Baltimore, MD, a position that he held from 19771990. He has still remained involved in public health research, and his name continues to be used synonymously for the wide success of the eradication effort. 11 “Asia is Reported Free of Smallpox for the First Time in History,” The New York Times, (November 14, 1975), 3. 12 Walter Sullivan, “Smallpox Declining Worldwide; End is Viewed as Likely by 1973,” The New York Times (September 20, 1971), 16.

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reporting surges in smallpox cases tended to make minimal reference to the American involvement in the program and instead focused more on the international nature of the program.13,14 Whether intentional or not, the portrayal of the eradication program in The New York Times was heavily Americanized through gradually making Henderson and the NCDC synonymous with the effort. The American nature of the eradication program was further developed by involving predominantly US citizens as scientific and public health personnel in the program efforts within overseas countries. The $15 million smallpox vaccination program in Africa, for example, is also the source of significant pride and frequent reference in these articles as portrayed in a 1969 article: “… the program would have been unsuccessful without both regional cooperation and American assistance.”15 The picture that accompanies this article shows a child being vaccinated by an African citizen who had been trained by American public health personnel. Clearly the US contributions to the program are the central focus of this article despite the fact that it was coordinated by an international organization, namely the WHO. The medical writer and political analyst Lawrence K. Altman (b. 1969), himself the author of many of the articles analyzed here, respectively proclaims … the WHO recognized the success of the American smallpox campaign in western Africa and developed a global program that Dr. Henderson headed in Geneva.16

This implies that the global program was fashioned after the American model, headed by an American, and by extension also of a fundamentally American effort. Similarly, a 1976 article focused almost entirely on the story of a public health worker from Grand Rapids, Michigan tirelessly searching for unreported cases of smallpox in Bangladesh.17 The portrayal

13

“W.H.O. Notes a Rise in Smallpox Cases,” The New York Times (April 9, 1972), 4. “Worldwide Drive on Smallpox Pressed in the Face of Statistical Rise,” The New York Times (July 23, 1972), 13. 15 Lawrence K. Altman, “100 Million are Vaccinated in Africa in 3-Year Campaign Against Smallpox,” The New York Times (November 30, 1969), 2. 16 Lawrence K. Altman, “The Doctor’s World: The Eradication of Smallpox,” The New York Times (October 16, 1979), sec. 3, 3. 17 William Borders, “Battle Goes on to Free World From Smallpox,” The New York Times (October 3, 1976), 17. 14

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of the efforts of regular American citizens contributing to the program significantly furthered the Americanization of the program. The aforementioned 1976 article contains a picture showing the American offering a reward to a group of poor Bangladeshi fisherman for reports of any cases of smallpox. The fact that the offered reward, thirtythree American dollars, is the equivalent of two months’ pay for the average Bangladeshi worker is also emphasized. A similar 1975 article shows a public health official in the Bangladeshi capital, Dacca, passing out pamphlets offering a $20 reward for reporting smallpox cases. Once again emphasis is laid on quantifying the significance of this amount is made evident: “The sum equals about one month’s salary of a well-paid Bengali.”18 Even making extravagant rewards available to the poorest of the poor could produce no new cases of the disease, a reiterated fact that highlighted the success of the program. This leitmotif also stresses the “otherness” of the disease. It reassures the public that its endemic nature is confined to the poorest corners of the planet with only the very disadvantaged being afflicted and that it offers no threat to the American people. The effect of this is to depict the philanthropic benevolence and altruistic motives of the American effort. Despite the fact that the American people were safe from smallpox, significant amounts of American resources were being allocated to combating it, a fact made abundantly clear to the general public through the frequent and public accounts of the media. The foreign nature of the disease is also further underlined through various references to the last known case of smallpox in the US, 25 years ago, while the article stresses that it was a case acquired outside of the country.19 After mentioning that the disease had remained only in Bangladesh, India and Ethiopia, a 1975 publication additionally emphasized that the last confirmed case in the United States occurred almost thirty years previous in 1949.20 In 1978, a medical photographer working in a laboratory storing one of the remaining stocks of smallpox in Birmingham became the first person in the world to die from smallpox in a year. Given that a death in the UK appears a lot closer to home than cases in Africa or Asia, it is not surprising that a Washington Post article attempted to distance the event by stressing that: “In the United States, the last reported 18 “Global War on Smallpox Expected to be Won in ‘76,” The New York Times (September 29, 1975), 1. 19 “End of Smallpox in 1975 Predicted,” The New York Times (May 1, 1974), 46. 20 “Smallpox is Nearly Ended,” The New York Times (March 30, 1975), sec. 4, 7.

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smallpox case was in the 1940’s … .”21 An official from the NCDC reassured the public, upon the cessation of routine vaccination, that “… the risk of smallpox importation to the United States is now essentially nil.”22 The ‘otherness’ of the disease is also illustrated through personalized accounts of the smallpox cases that commonly appear in newspaper articles.23,24 Providing intimate details about the lives of those unfortunate enough to contract the disease has the effect of evoking a sense of empathy as opposed to fear that the disease might once again be on the rise.

The General Media Coverage: Excessive Optimism and Positivity The depiction of the eradication program in the mainstream media was generally an overt celebration of its significance, success, and consequences. Its overtly positive description emerges simply from the diction used in the articles analyzed. The efforts of the WHO were described as resulting in a “striking decrease”25 in smallpox, a “remarkable change,”26 “dramatic progress”27 and as representing a “remarkable achievement.”28 The eradication of smallpox was hailed as a “public health miracle”29 and a “milestone in medicine.”30 The profoundness that these examples assign to 21

“Briton Becomes First to Die of Smallpox in Nearly a Year,” The Washington Post (September 12, 1978), sec. 4, 11. 22 Lawrence K. Altman, “All States Drop Smallpox Vaccinations,” The New York Times (January 29, 1976), 38. 23 Stuart Auerbach, “Smallpox: A Deadly Disease in its Death Throes,” The Washington Post (March 23, 1977), 20. 24 Victor Cohn, “Total Victory in Two-Century Effort is Proclaimed by Smallpox Warriors,” The Washington Post (October 26, 1979), 2. 25 “W.H.O. Says Smallpox has Decreased by 90%,” The New York Times (January 25, 1975), 29. 26 “Big Drop Reported in Smallpox in Asia,” The New York Times (August 10, 1975), 2. 27 “Last Smallpox Cases,” The New York Times (May 21, 1976), 16. 28 Lawrence K. Altman, “India Declared Free of Smallpox;” “2 Countries Left,” The New York Times (July 3, 1975), 29. 29 Lawrence K. Altman, “Smallpox Wiped Out in its Worst Form,” The New York Times (December 14, 1977), 26. 30 “Eradication of Smallpox to be Announced Today,” The New York Times (May 8, 1980), 21.

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this global health program also represents the general enthusiasm towards and praise of the program that can be consistently found throughout the period investigated. However, the use of such passionate phraseology may be explained by journalists attempting to win over a public largely apathetic and indifferent to the program. It is shocking that the May 9th, 1980, WHO announcement of the global eradication of smallpox was a seventh page story in The New York Times. This story would appear to be, at least to those familiar with the program, obvious front-page material. A primary mechanism through which the profundity of the WHO program had been conveyed was through emphasizing the deep running roots of the disease in history. The American journalist Harold M. Schmuck Jr. proclaims in a New York Times column that the disease has “… killed millions of humans and has spread panic and destruction for thousands of years.”31 One 1969 article contains a quote from US President Richard Nixon (1913-1994) hailing the program as “… dramatic proof that man can be free of age-old bonds.”32 Portraying the program as the culmination and completion of the work that British physician Edward Jenner (1749-1823) began about 180 years previously is also a recurring leitmotif.33 Upon the finding of no new cases of smallpox in six months in 1978, one columnist declares that this occasion represents the “… first time in recorded history, the world has gone six months without a reported case of smallpox.”34 The official announcement of the global eradication of the disease in 1980 allowed mankind to “… close a chapter in history.”35 The optimism regarding the eradication program is evident given the consistent pattern of predictions as to exactly when smallpox would be eradicated. The WHO tended to make overly optimistic predictions regarding the eradication schedule; however, setbacks that delayed this schedule did nothing to quell this sense of hope. Henderson predicted that eradication would be complete as early as 1973.36 An authority figure 31 Harold M. Schmuck Jr., Smallpox Virus is Stored in Laboratory for Insurance, The New York Times (May 13, 1978), 25. 32 “Nixon, Ending Holiday, Hails Fight on Disease in Africa,” The New York Times (December 1, 1969), 53. 33 Lawrence K. Altman, “A Big Step for Mankind: The End of Smallpox,” The New York Times (February 8, 1976), sec. 4, 9. 34 “No Cases for Six Months: A World Without Smallpox,” The Globe and Mail (April 22, 1978), 1. 35 “World Health Aides Mark Eradication of Smallpox,” The New York Times (May 9, 1980), 7. 36 Sullivan, “Smallpox Declining Worldwide,” 16.

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within the NCDC slightly adjusted this prediction to 1974,37 which was then subsequently changed to 1975,38 and then to 1976 39 as new outbreaks occurred. In a 1974 article, India’s Health Secretary asserts that the WHO deadline is unrealistic by stating, “I am Indian and I know my country and our problems … . I would give a deadline for total eradication five years from now.”40 Ironically, this official, whose prediction proved to be far more accurate than those of the WHO, was one member of India’s public health department, who the WHO blamed for the smallpox epidemics which ravaged the country: “Administrative failure by the state government, which is responsible for health control, was said to be the reason for the outbreaks.”41 Scapegoating particular groups of individuals is a common feature of many portrayals of the eradication effort such as the aforementioned example in India. When a major epidemic occurred in Bangladesh in 1972, reports indicated that the disease had been brought back from India by politically dissident Hindu refugees and had spread to the resident Moslem populations.42 The emphasis on the fact that the Hindus are refugees, the source of the outbreak, and that the Moslems are residents once again creates the notion of the “otherness” of the disease and reveals the longlasting political and religious conflict between the two groups. The quarantining of 450 people in West Germany in 1972 was determined to be the result of the spread of smallpox by a “Yugoslav migrant worker”.43 The WHO also assigned blame for a surge in smallpox cases in Ethiopia, India and Bangladesh to the spreading of the disease by “migrants and beggars.” The consistent designation of blame to migrants and the povertystricken represents clear examples of scapegoating. These explanations, which likely contain some element of truth, are convenient for both local officials and the WHO in that they absolve both groups of criticism. On the other hand, the poorest sectors of society have no media through which

37

“Smallpox Gains Noted,” The New York Times (May 15, 1971), 8. “End of Smallpox in 1975 Predicted,” The New York Times (May 1, 1974), 46. 39 “Asia is Reported Free of Smallpox for the First Time in History,” The New York Times (November 14, 1975), 3. 40 “Smallpox Epidemic Recedes in India,” The New York Times (June 23, 1974), 7. 41 Ibid., 7. 42 Robert Trumbull, “Major Smallpox Epidemic Reported in Bangladesh,” The New York Times (May 13, 1972), 3. 43 “West German City Widens Quarantine to Fight Smallpox,” The New York Times (March 31, 1972), 7. 38

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to defend them and are understandably more concerned with their inevitable struggle for survival. When these setbacks occurred in the form of new outbreaks of the disease, the media tended to not only abstain from criticizing the WHO, but used the opportunity to further praise the organization. In 1972, faced with a visible statistical rise in the number of smallpox cases, Henderson and officials from the NCDC claimed the statistics were exaggerated due to the WHO’s ever improving system of reporting new cases and increased diligence in searching for cases.44,45 In a 1974 article, Henderson claims that the surveillance methods employed at the beginning of the program were detecting only 2 percent of the total number of smallpox cases.46 Instead of the 130,000 cases reported in 1967, Henderson claims that 2.5-10 million cases of the disease actually occurred that year, thus emphasizing the progress which had been made. Henderson was admittedly “unhappy” when nine smallpox cases were found in Bangladesh forcing the revoking of the previous declaration that Asia had by now been smallpox-free. However, he attributed the discovery of the new cases to “intensive house-to-house searches”.47 Thus, even the setbacks the program experienced were portrayed as being the direct result of its unyielding diligence and perseverance. Quite remarkable is also the fact that there was a complete absence of questioning and critical evaluation, two central features of honest and thorough journalism, of these explanations in New York Times articles from this period. It is plausible, however, that even some minor investigative journalism would have been sufficient to reveal that the situation was not as desirable as the WHO had wished and claimed. Rather, journalists tended to continue their overtly positive portrayal of the program by putting positive twists on seemingly negative events. After the reappearance of smallpox in India in 1976, Lawrence K. Altman proclaimed that “WHO officials, far from being dismayed, pushed on with their effort … .”48 44

“Worldwide Drive on Smallpox Pressed in the Face of Statistical Rise,” The New York Times (July 23, 1972), 13. 45 “Reported Cases of Smallpox Rise 38% in World in 1972,” The New York Times (September 10, 1972), 58. 46 Lawrence K. Altman, “W.H.O. Confident Smallpox Can Be Erased in Year Despite India Epidemic,” The New York Times (June 7, 1974), 15. 47 Lawrence K. Altman, “Asia Not Smallpox Free Yet—9 Cases Found in Bangladesh,” The New York Times (November 22, 1975), 11. 48 Lawrence K. Altman, “A Big Step for Mankind: The End of Smallpox,” The New York Times (February 8, 1976), sec. 4, 9.

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A recurring narrative throughout the newspaper accounts reviewed is the tendency to employ war imagery and metaphors to describe the eradication program. One account describes the program as “the last battles of a global war that began in Berkeley, England, 179 years ago…”49 The WHO program is described by one reporter as a “search and vaccinate campaign.”50 These seek and destroy tactics employed by the WHO in their constant surveillance of smallpox cases are the source of repeated praise from journalists. The trend to associate the eradication program with war is embodied by the title of a 1979 Washington Post article announcing the official completion of the program entitled “Total victory in two century effort is proclaimed by smallpox warriors.”51 The effect of this is to portray the WHO officials as ruthless soldiers who did not cease fighting until the enemy was destroyed. The notion of “total victory” implies that smallpox has been eliminated as a threat, never again to return and harm mankind. The effect of equating the effort with a fullfledged war is to assign it profundity and characterize the officials involved as heroic. Wars are also inherently long, expensive and intense efforts. Affiliating the eradication program with war naturally justifies the program’s duration and cost while also emphasizing its significance. However, perhaps more importantly, wars involve an opponent that actively fights back. Thus, assigning smallpox “enemy status” naturally fits with its repeated reemergence after WHO officials had optimistically predicted its demise. The positive portrayal of the eradication effort in the public media is further revealed by the lack of attention paid to the substantial financial expenditures involved in the program. The few references to the economic component of the program consistently emphasize the savings that will be realized upon its completion, as opposed to the fact that significant sums of money were being allocated to the effort. One article asserts, “… eradication would save the US $150 million dollars a year.”52 Altman claimed that the world stood to save $2 billion per year upon the

49

“Global War on Smallpox Expected to be Won in ’76,” The New York Times (September 29, 1975), 1. 50 “Asia is Reported Free of Smallpox for the First Time in History,” The New York Times (November 14, 1975), 3. 51 Victor Cohn, “Total Victory in Two-Century Effort is Proclaimed by Smallpox Warriors,” The Washington Post (October 26, 1979), 2. 52 Lawrence K. Altman, “W.H.O. Confident Smallpox Can Be Erased in Year Despite India Epidemic,” The New York Times (June 7, 1974), 15.

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elimination of the disease.53 This fact was clearly reiterated in a 1978 article entitled, “$2 Billion Yearly Savings Expected From Eradication of Smallpox.”54 Evidence of criticism of the cost of the program was not found in The New York Times, however, a distinctly critical 1979 Globe and Mail article emphasized the exorbitant cost of the program and the fact that it took over a decade to complete. This article goes on to further question the notion of total eradication: “But how can the health agency [the WHO] be sure that the smallpox virus is not still lurking in an animal, in previously infected areas, or lie unidentified as yet in a similar kind of disease, ready to break out again?”55

It is this type of critical inquiry, a characteristic of all honest and thorough journalism that is almost completely absent in the articles from The New York Times and The Washington Post. The depiction of the eradication program in the mainstream media was thus generally an overt celebration of its success, and consequences. In this context, the eradication of smallpox was merely praised as a “public health miracle,”56 with journalists trying to win over a public largely apathetic and indifferent to the program and often with front-page coverage that diverged from the realities of the public health system in many developing countries.

Conclusions The newspaper coverage of the smallpox eradication program in the New York Times was markedly biased, presenting an Americanized, overtly optimism, uncritical accounts of its successes between 1967 and 1980. A potential explanation for this is the fact that a large portion of these articles, or at least the lengthy articles, were written by Lawrence K. Altman. Altman began working at the NCDC in Atlanta in 1963 where his boss was none other than Dr. Donald A. Henderson. This likely explains the constant featuring of quotes and opinions of Henderson in New York Times articles of the time. Thus, Henderson, the man responsible for 53

Lawrence K. Altman, “Smallpox Wiped Out in its Worst Form,” The New York Times (December 14, 1977), 26. 54 “$2 Billion Yearly Savings Expected From Eradication of Smallpox,” The New York Times (November 7, 1978), 28. 55 “Can Smallpox be Totally Eradicated?,” The Globe and Mail (May 1, 1978), 16. 56 Lawrence K. Altman, “Smallpox Wiped Out in its Worst Form,” The New York Times (December 14, 1977), 26.

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guiding the eradication program, appears to have had a significant influence over its portrayal in the public media. Altman was also a man who had clearly devoted his life to medicine and lamented that, “Although medicine is dramatic, the medical profession lacks the kind of theatrical flair demonstrated by athletes and entertainers.”57 He relished the opportunity to liken the final efforts of health workers overseas to when, “Babe Ruth once pointed to the bleachers and then whacked the ball for a home run.”58 This implied that the then current final efforts of health workers were a victory lap and that medicine was finally getting its opportunity to showcase its “theatrical flair.” The overt enthusiasm and passion towards the program, which dominated the depiction of the program by The New York Times, seemed to be a reflection of Altman’s personal fervor towards science, medicine, and public health. It would be an oversimplification, however, to conclude that the Americanization of the eradication program and its positive portrayal were merely a concoction of the writings of Altman. The trends to emphasize the American nature of the eradication program, the “otherness” of the disease, and the successes of the program were observed in the accounts of many other authors at The New York Times along with other newspapers. Additionally, even the academic accounts were not entirely absent of an occasionally juvenile excitement towards the eradication effort. Close analysis revealed that the newspaper and academic accounts also did not differ remarkably in their descriptions of the potential of the airplane as a worldwide vector for disease transmission and in their optimistic search for the next “disease” to be eradicated. The portrayal of mankind’s victory over smallpox was about as enthusiastic as expected, given the remarkable international cooperation that occurred during a time of constant paranoia over nuclear warfare, espionage, and other international conflicts, along with man’s recent conquering of outer space. All of these concurrent events, the significance of which may not have been fully realized at the time and which hindsight allows us to fully appreciate, perhaps justify the sensationalism assigned to the program in the media. They do not, however, excuse the complete lack of critical thinking and analysis present in the newspaper accounts of the time. This perhaps emphasized one of the primary roles of the mainstream media, which was to inspire the common man with stories of humanity’s 57

Lawrence K. Altman, “The Doctor’s World: The Eradication of Smallpox,” The New York Times (October 16, 1979), sec. 3, 3. 58 Ibid.

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greatest successes of the past and present as well as its potential for the future. The American Founding Father and Third President, Thomas Jefferson (1743-1826) famously wrote to Edward Jenner in 1806 commending him on developing the vaccination that was seen as a miracle cure for smallpox at the time: “Future nations will know by history only that the loathsome smallpox has existed.”59 Let us hope that this is the case and that the WHO proclamation of the official eradication of smallpox made on May 9, 1980, was the last announcement on the eradication status of smallpox that ever needed to be made. In a 1998 journal article, Dr. Donald A. Henderson proudly referred to the eradication program as “a cold war victory.”60 It appears that his fondness of the program’s accomplishments, which shone through in The New York Times articles analyzed, has not dwindled with time.

59

Hopkins, The Greatest Killer, 310. Donald Henderson, “Smallpox – a Cold War Victory,” World Health Forum 19 (1998): 113-119.

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ILLNESS AND DISEASE IN HISTORY

THE HISTORY OF THE TAINTED BLOOD SCANDAL IN CANADA: WHERE DOES THE RESPONSIBILITY LIE? HOLLY ANN GARNETT AND MEGHAN GARNETT

SUMMARY: The collection and distribution of blood contaminated with the human immunodeficiency virus (HIV) and hepatitis C in the 1980’s left over 1,000 patients with HIV and tens of thousands with hepatitis C throughout Canada. This paper examines the historical timeline of the related medical discoveries, such as the emergence of antibody testing for HIV and hepatitis C, as well as subsequent responses by the Government of Canada, provincial and territorial governments, along with stakeholder organizations, which paralleled the fate of those thousands of people that had iatrogenically acquired incurable blood-borne diseases. The sequels of the tainted blood scandal are numerous. As a result of losing public confidence, in 1998 the responsibility of collecting blood in Canada became administratively transferred from the Canadian Red Cross (CRC) to the Canadian Blood Services and Héma-Québec. In 2002, charges of criminal negligence were laid against the CRC, Red Cross director Dr. Roger Perrault, Health Canada officials Drs. John Furesz and Donald Boucher, the New Jersey-based Armour Pharmaceutical Company, and Armour executive Dr. Michael Rodell. Only minor penalties were however leveled: The CRC, for example, was fined $5,000 and asked to establish a $1.5 million dollar scholarship fund at the University of Ottawa for families affected by the blood transfusion tragedy. Furthermore, the four CRC-affiliated physicians as well as Armour Pharmaceutical Company were all acquitted of the criminal charges in 2007. From 1989 to 2006, the federal, provincial, and territorial governments paid over $2 billion dollars in compensation to the victims of the tainted blood scandal. An historical examination of this tragedy can thus serve as a reminder to physicians, health care professionals, administrators, politicians, and the Canadian public about the need for vigilance and humility in medicine. KEYWORDS: Blood Transfusion; HIV; Hepatitis C; Compensation and Redress; Canada PRECEPTOR: Dr. Kristin Burnett INSTITUTIONS: Nipissing University & Northern Ontario School of Medicine School of Medicine

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The History of the Tainted Blood Scandal in Canada

Background The human immunodeficiency virus (HIV) is a retrovirus (i.e. a ribonucleic acid [RNA]-based virus which can replicate in a given host cell due to a genetic process that is known as “reverse transcription”) that causes Acquired Immunodeficiency Syndrome (AIDS) by creating doublestranded deoxyribonucleic acid (DNA) from a single strand of ribonucleic acid (RNA) through the use of its characteristic reverse transcriptase enzyme. There are two virus strains: HIV-1 and HIV-2. The natural reservoirs of these HIV-1 and HIV-2 virus strains are the common chimpanzee (Pan troglodytes; an ape) and the sooty mangabey (Cercocebus atys; an old world monkey), respectively.1 The first cases of HIV-1 were identified in the United States, particularly in San Francisco, in 1981 in numerous homosexual males with unexplained Pneumocystis jiroveci pneumonia and the very rare skin lesion, which the Hungarian dermatologist Moritz Kaposi (1837-1902) had described in 1872 (henceforth known as Kaposi’s sarcoma). By 1984, HIV was confirmed as the causative microbiological agent of AIDS. A diagnostic test for HIV-1 became only available in clinical medicine by 1985 through a specific enzyme-linked immunosorbent assay (ELISA).2 Moreover, HIV-2 could only be isolated in 1986 in West Africa and in 1987 in the United States,3 while HIV-1 is the more prevalent strain in North America and worldwide. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, have provided the widely accepted and used definitions for HIV and AIDS, which are based on clinical manifestations and CD4+ (a glycoprotein that is part of immune cell surfaces; known as “cluster of differentiation four”) T lymphocyte counts (immunologically active cells found in the thymus organ in the upper mediastinum of the human and animal thorax). Today, the laboratory diagnosis of HIV is confirmed once viral antibodies, viral p24 (a capsid protein of the HIV) antigen, viral

1

Anthony S. Fauci and H. Clifford Lane, “Chapter 182: Human Immunodeficiency Virus Disease: AIDS and Related Disorders,” in Anthony S. Fauci et al., eds., Harrison’s Principles of Internal Medicine, 17ed., (New York: McGraw-Hill Medical Publishing Division, 2008). 2 Ibid. 3 Centers for Disease Control and Prevention, “Human Immunodeficiency Virus Type 2,” http://www.cdc.gov/hiv/resources/factsheets/hiv2.htm (Accessed February 28, 2010).

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nucleic acid, or cultured HIV have been detected.4 AIDS is defined as a CD4+ T lymphocyte count < 200/mm,3 CD4+ less than 14 percent of total lymphocytes, or pulmonary tuberculosis, recurrent pneumonia, or invasive cervical cancer in the setting of an HIV-positive adolescent or adult.5 HIV transmissions can occur through sexual intercourse, the use of injection drug use, transfusions of blood and blood products, incorporation of bodily fluids, and by vertical reproductive transmission from a mother to her infant. In the United States, approximately one-half of HIV infections are caused by homosexual male intercourse, whereas in resource-poor areas in less-developed and newly industrializing countries, heterosexual intercourse is the most common route of transmission.6 The disease of the human immune system progresses normally as follows: Two to four weeks after viral acquisition, patients may present with a variety of nonspecific symptoms including fever, lymphadenopathy, sore throat, rash, myalgia, arthralgia, headache, and mucocutaneous ulcers of the mouth, throat or intestines.7 Seroconversion – the detection of antibodies in the blood system as a result of infection – then occurs four to ten weeks after exposure to the virus. A clinical latency period later follows with or without persistent generalized lymphadenopathy (PGL). During this latent phase, the cell count and viral load typically maintain a steady state despite high cellular destruction and formation. Early symptomatic HIV infections follow, and are characterized by diseases that are commonly seen in immunodeficiency states but do not qualify as AIDS-indicator conditions, while also being related to the insufficient physiological activity of the immune system. Such disease examples include, for instance, candidiasis (a fungal infection), oral hairy leukoplakia (idiopathic white patches of the skin), cervical dysplasia, idiopathic thrombocytopenia purpura, and listeriosis (a rare bacterial infection). AIDS usually occurs when the CD4+ count decreases below 200/mm3. An advanced HIV infection has been described when the CD4+

4 Centers for Disease Control and Prevention, “Appendix: Revised Surveillance Case Definition for HIV Infection,” http://www.cdc.gov/mmwr/preview /mmwrhtml/rr4813a2.htm (Accessed February 28, 2010). 5 Centers for Disease Control and Prevention, “Acquired Immunodeficiency Syndrome (AIDS): 1993 Case Definition,” http://www.cdc.gov/ncphi/disss/ nndss/casedef/ aids1993.htm (Accessed February 28, 2010). 6 Fauci et al., Harrison’s Principles of Internal Medicine, chpt. 182. 7 Amy E. Colson and Paul E. Sax, “Primary HIV-1 infection: Pathogenesis; Epidemiology and Clinical Manifestations,” UpToDate.com (2009).

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count drops below 50/mm;3 this marks largely the condition when death begins to occur.8 The first antiretroviral drugs were available on the medical market in the year 1987. The more effective and pharmacologically “highly active antiretroviral therapy” (HAART) was first prescribed a decade later in 1996.9 Therapeutic AIDS “cocktails” consisting of at least two drugs from the nucleoside reverse transcriptase inhibitor (NRTI), non-nucleoside reverse transcriptase inhibitor (NNRTI), and protease inhibitor families are used as pharmacological remedies.10 Since the tainted blood scandal in Canada in the 1980’s, which led to tens of thousands of patients, was also due to the collection and distribution of blood contaminated with hepatitis liver viruses, it is necessary to introduce here also the transmission trajectories and pathological aetiology of this disease. The hepatitides viruses A, B, C, D, and E, are a heterogeneous group of viruses hailing from multiple families with varying structures, transmission paths, and physiological virulence. Hepatitis B became first identified in 1963 and hepatitis A one decade later in 1973. However, the blood tests for these two hepatitis viruses did not account for all transfusion-related illnesses, since a third non-A, non-B hepatitis (NANBH) was also described and became later named as a separate hepatitis type C.11 The hepatitis C virus (HCV) is a linear, single-stranded, positive sense RNA virus of the Flaviviridae family (i.e. yellow fever-like viruses that use anthropod vectors to intrude the human body). There are at least six genotypes of the virus, with genotype one being the most prevalent in the United States and worldwide.12 The HCV is transmitted through drug use by blood, injections, the incorporation of bodily fluids, as well as from mothers to their infants in the form of vertical viral infections.13 8

John G. Bartlett, “The Stages and Natural History of HIV Infection,” UpToDate.com (2009). 9 Ibid. 10 Fauci et al., Harrison’s Principles of Internal Medicine, chpt. 182. 11 Alan Franciscus, “A Brief History of Hepatitis C,” pp., 1-3, http://www.hcvadvocate.org/hepatitis/factsheets_pdf/Brief_History_HCV_2006. pdf (Accessed February 28, 2010). 12 Jules L. Dienstag, “Acute Viral Hepatitis,” in Anthony S. Fauci et al., eds., Harrison’s Principles of Internal Medicine, chpt. 298. 13 Public Health Agency of Canada (PHAC), “Transfusion Transmitted Injuries Section,” http://www.phac-aspc.gc.ca/hcai-iamss/tti-it/ttdi-eng.php#hiv (Accessed February 28, 2010).

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Hepatitis C most typically begins as an acute, asymptomatic infection. It progresses to chronic hepatitis in sixty to eighty percent of the patients; and twenty to thirty percent of those develop liver cirrhosis. Moreover, hepatitis C is a slowly progressing disease, such that those infected later in life may never develop clinical symptoms during their remaining lifetime. The virus can also spontaneously clear, although this is less likely after six months of infection. In terms of laboratory diagnostic approaches, HCV is most sensitively identified by polymerase chain reaction (PCR) detection of serum RNA, a biochemical technology that became available since the mid-1990’s. In the clinical settings, however, HCV is most commonly identified by anti-HCV through ELISA.14 Signs and symptoms of acute hepatitis C are rather mild if present, and include jaundice, malaise, nausea, and abdominal tender- and soreness (“right upper quadrant pain”) lasting two to twelve weeks. Patients with chronic infections may also complain of anorexia, myalgia, arthralgia (discomfort and pain in the joints), weakness, and weight loss. HCV infection can lead to cirrhosis, ascites (accumulation of fluid in the peritoneal cavity of the abdomen), esophageal varices, encephalopathy, liver failure, and hepatocellular carcinoma of the liver organ.15 Acute HCV infections are treated with PEGylated interferon (PEGylation is a biotechnological process by which polyethylene glycol polymer chains are attached to another molecule to manufacture a therapeutic protein or a complete drug structure) a minimum of three months after symptom onset. Chronic HCV genotype one infection is treated with PEGinterferon and ribavirin, optimally for forty-eight weeks.16

Viral Transmission in Blood and Blood Products Forms of viral transmission that became significant in the Canadian tainted blood scandal included infection with blood transfusions directly, or at least the therapeutic use of blood products. HIV, for instance, can be transmitted through whole blood, packed red blood cells, platelets, leukocytes, fresh frozen plasma, and clotting factors; however, it has not been linked to hyperimmune gamma globulin, hepatitis B immune globulin, plasma-derived hepatitis B vaccine, or Rho immune globulin (it 14

Sanjiv Chopra, “Clinical features and natural history of hepatitis C virus infection,” UpToDate.com (2009). 15 Ibid. 16 Ibid.

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is a medical treatment via intramuscular injections, used to prevent severe immunological conditions of haemolytic Rhesus disease of the newborn).17 It appears that HCV is transmitted through the same media.18 Transfusion-acquired HIV was first reported in a twenty-month old infant from the San Francisco Bay Area in the United States in 1982, and mandatory testing for HIV-1 in blood donations began only in 1985 in both Canada and the United States, while there has never been a reported case of HIV-2 transmission from blood products in North America. Nonetheless, both strains of HIV are now tested in blood transfusions and blood products; with the current prevalence of an HIV-positive unit is one per 1.5 million donations in the USA and Canada. The risk of infection after transfusion of a contaminated sample is thereby estimated to be 90100 percent.19 Conversely, the systematic screening of blood donations for the hepatitis B surface antigen (HBsAg) began already in 1972, which significantly reduced the number of transfusion-acquired hepatitis infections. However, approximately one percent of all units were still contaminated with NANBH, as it was known at the time. In fact, as many as ten percent of patients who received blood transfusions in the 1970’s were estimated to have acquired the virus, due to its widespread prevalence.20 The use of alanine aminotransferase (ALT), a blood transaminase enzyme that is elevated in hepatocellular injury, and the antibody to the hepatitis B core antigen (anti-HBc) screening tests in the United States in the 1980’s––along with HIV screening––reduced the risk of patients acquiring hepatitis C from blood transfusions.21 Serologic testing for hepatitis C virus (HCV) in Canadian blood donors began in 1990.22 In particular, a more sophisticated identification approach of the virus was made possible through the use of first-generation and second-generation 17

Fauci et al., Harrison’s Principles of Internal Medicine, chpt. 182. Justice Horace Krever, Commission of Inquiry on the Blood System in Canada: Final Report (Ottawa: Minister of Public Works and Government Services, 1997), 3. 19 Fauci et al., Harrison’s Principles of Internal Medicine, chpt. 182. 20 Dienstag, “Acute Viral Hepatitis.” 21 Valder Arruda and Katherine A. High, “chpt. 110: Coagulation Disorders,” in Anthony S. Fauci et al., eds., Harrison’s Principles of Internal Medicine, 17 ed., (New York: McGraw-Hill Medical Publishing Division, 2008). 22 Public Health Agency of Canada (PHAC), “Transfusion Transmitted Injuries Section,” http://www.phac-aspc.gc.ca/hcai-iamss/tti-it/ttdi-eng.php#hiv (Accessed February 25, 2010). 18

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anti-HCV assays in 1990 and 1992 respectively. The current prevalence of an HCV-positive unit is one per 2.3 million donations which can be especially attributed to the introduction of systematic PCR testing. Like HIV, the risk of HCV seroconversion (i.e. the emergence of detectable specific antibodies to microorganisms in blood serum) is about ninety percent post-transfusion.23 Today, Canadian Blood Services (CBS) screens all blood transfusions and blood products for HIV and HCV through both the application of an antibody test and a nucleic acid test (NAT). This has reduced the window period––meaning the time from viral exposure to positive test results––to sixteen days for HIV-1 and fourteen to twenty-eight days for HCV. Remarkably, between May 2001 and May 2003 Canadian Blood Services reported no cases of HIV and only one case of HCV, a result that could only be achieved through NAT screening, in combination with an expanded record of donation questionnaires.24

History of Blood Collection The International Committee of the Red Cross (ICRC) was founded in the nineteenth century, in 1863, by the Swiss businessman and social activist Jean Henry Dunant (1828-1910) after visiting the devastating battlefield of Solferino in 1859 during a business trip to Italy. Solferino was the last major battle in the Second Italian War of Independence, which lead to the Peace Treaty of Villafranca on July 12, 1859. Although, the battle had seen a tactic victory of the French and Allied troops over the Austrian and Northern Italian army, the casualties were so high that a commencement of the war was deemed too inauspicious to Napoléon III. of France (1808-1873). When Dunant had visited the battlefield of Solferino, after its nine hours duration, almost 3,000 Austrian soldiers had fallen and more than three times as many were severely wounded. Among the French alliance, 2,500 troops had been killed and approximately 12,500 had suffered battlefield injuries. The grossly horrifying conditions and suffering of the soldiers during and after the battle led Dunant to write his well-known book A Souvenir de Solferino (1862), which was only

23

Dienstag, “Acute Viral Hepatitis.” Canadian Blood Services, “Nucleic Acid Testing,” http://www.bloodservices.ca (Accessed February 25, 2010). 24

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translated into English in 1939,25 and to fervently advocate for the establishment of a political committee in Switzerland, which should develop medical and health care improvements for wounded soldiers and which on February 17, 1863 became the International Committee of the Red Cross. The Canadian Red Cross was established as a branch of the British Red Cross in 1896 by the Ontario physician Dr. George Sterling Ansel Ryerson (1855-1925), and became its own corporate body in 1909. The Canadian Red Cross Blood Transfusion Service began collecting blood in Canada in the year 1947, shortly after the Second World War. Furthermore, the CRC managed blood donations in Canada for fifty-one years, until September 28, 1998, when these services became transferred to the Canadian Blood Services and Héma-Québec, as shall be described in the following sections.26

Tainted Blood Scandal The collection and distribution of blood and blood products for transfusion and therapeutic purposes in the late 1970’s and 1980’s in Canada, before scientists even had a name for HIV and HCV, left a toll of over one thousand patients with HIV and tens of thousands with hepatitis C. Although AIDS had initially been clinically identified in homosexual males in 1981, officials became suspicious when three heterosexual hemophiliacs acquired a similar illness in 1982. It is necessary in this respect to recall that hemophilia A and B is X-linked recessive deficiencies of clotting factors VIII and IX (proteins and cellular factors that mitigate blood coagulation and thrombus formation following to injuries of the blood vessel system), respectively, which often necessitate transfusions to correct bleeding diatheses. Apart from hemophilia, transfusions of blood and its products are often required for other coagulopathies, during surgery, and in trauma resuscitation.27 The sequels of HIV and HCV infection are not immediately apparent in clinical settings, and as they surfaced with patients having acquired iatrogenic infections due to blood transfusions, so too did public reaction 25

J. Henry Dunant, A Memory of Solferino (French 1862), transl. by Norman H. Davis (Washington, DC: The American Red Cross, District of Columbia Chapter, 1939). 26 Canadian Red Cross, “Historical Timeline,” http://www.redcross.ca (Accessed February 25, 2010). 27 Krever, Commission of Inquiry on the Blood System in Canada, 3.

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to the tainted blood system. A subcommittee of the parliamentary “Standing Committee on Health and Welfare, Social Affairs, Seniors, and the Status of Women” convened between 1992 and 1993 and concluded that Canada’s current blood collection system did not respond quickly enough to the emergence of HIV. They identified two problems: (1) The timing of the introduction of an HIV screening test, and (2) the inefficacy of heat treatment in disabling HIV.28 The first case of HIV from a blood transfusion was reported to the Canadian Laboratory Centre for Disease Control in Ottawa, Ontario in September 1984, but blood donations were not uniformly tested for antiHIV until November 1985. This delay occurred despite evidence and the practice of testing nearly all blood transfusions and blood products in the USA and Australia for anti-HIV by May 1985. It is estimated that ninetyseven cases of HIV could have been prevented in Canada, had testing been implemented sooner.29 Secondly, the efficacy of heat-treatment depends on the temperature and length of thermal exposure. The first heat-treated factor VIII concentrates were commercially available in 1981 in Germany from a company called Behringwerke AG in Marburg, Hessia. In Canada, dry heat-treated factor VIII concentrates, manufactured by Hyland Laboratories in Ontario at a temperature of 60°C for seventy-two hours, were approved in November 1983. The version produced at 68°C for seventy-two hours by the Cutter Lab in Toronto, Ontario, was licensed in November 1984.30 By July 1985, all factor concentrates in Canada required the dry heat treatment. Unfortunately, a 1986 study in the British medical journal The Lancet demonstrated that preparing factor concentrates at 60°C may not be sufficient enough to disable HIV virulence and prevent blood-derived infections.31 A 1988 study in the Lancet showed that dry heat-treated factor VIII at 80°C for seventy-two hours was sufficient to inactivate non-A, non-B hepatitis. While it was not a study objective, incidentally, none of the participants developed HIV or hepatitis B either.32 28

Ibid. Krever, Commission of Inquiry on the Blood System in Canada, 329. 30 Ibid., 485. 31 Ibid., 3. 32 Study Group of the UK Haemophilia Centre Directors on Surveillance of Virus Transmission by Concentrates, “Effect of Dry-Heating of Coagulation Factor Concentrates at 80 Degrees C for 72 Hours on Transmission of Non-A, Non-B Hepatitis,” The Lancet 2 (1988): 814-816. 29

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The dry heat-treatment used in the 1980’s was hence not completely effective at deactivating HIV or NANBH. For the most part, during this time, laboratories did not dry heat their concentrates higher than 68°C, or longer than seventy-two hours due to the rising financial costs associated with such processing of blood concentrates.33 In an effort to produce a safer product, wet heat-treated factor VIII concentrates became later licensed in Canada in August 1986. Two months later, Armour Pharmaceutical Company’s dry heattreated products were even pulled from the pharmaceutical market in the United Kingdom, but against the advisement of the Canadian Red Cross, the Canadian Bureau of Biologics and Radiopharmaceuticals still allowed the distribution of dry heat-treated factor concentrates in Canada until July 1988. Unfortunately, at least eight hemophiliacs received dry heat-treated factor concentrates and subsequently developed HIV in 1987 before the products were eventually withdrawn from treatment use.34 Surrogate testing for disease, specifically NANBH, was severely underutilized in the 1980’s. Study results that were published in the New England Journal of Medicine as early as 1981, however, pointed to the use of alanine aminotransferase (ALT) testing to reduce transmission of NANBH. Surrogate testing with anti-HBc was also recommended in 1982 after a study by the Australian Red Cross was published in the Lancet. While the United States, Germany, and other developed countries began surrogate testing for NANBH in the mid-1980’s, these measures were never implemented in Canada. In fact, it was not until June 1990 that the Canadian Red Cross began testing for hepatitis C, through using the firstgeneration of anti-HCV assays.35 In order to protect their blood supply, the American authorities in blood collection recommended the widespread use of AIDS screening questionnaires for donors as early as January 1983; and these recommendations were put in place by March of the same year. The furthest the Canadian Red Cross got in screening for high-risk donors for AIDS was distributing pamphlets at clinics in 1984. In addition, the CRC never endeavored to find a surrogate test for HIV despite large promises to the contrary, a point, which became mute in 1985 with the discovery of anti-HIV drugs and therapies.36

33

Krever, Commission of Inquiry on the Blood System in Canada, 493. Ibid., 3. 35 Ibid. 36 Ibid., 282. 34

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The Fight for Compensation As the number of transfusion-acquired HIV infections grew, so too did rumblings of financial relief and compensation. Many hemophiliacs had received tainted blood as a result of their need for frequent blood transfusions.37 Most likely emboldened by the 1985 joint conference of the Canadian Hemophilia Society (CHS) and the American National Hemophilia Foundation (NHF) in Houston, Texas, activists in the CHS began investigating cases of transfusion-acquired HIV.38 Researchers scoured medical documents and personal testimonies, uncovering that failure by public health officials to test for HIV in blood donations had resulted in an estimated 1,500 cases.39 This early research into the scale of tainted blood scandal in Canada became known as the Archival Study.40 It would be another three years, however, before this evidence would also translate into formal calls for compensation.41 In his earlier review of the tainted blood scandal in Canada, public health reporter André Picard at the Toronto-based national newspaper The Globe and Mail has suggested a number of reasons why this amount of evidence was largely ignored by the public and media. He argues stigma surrounding HIV/AIDS and its prevalence in homosexual men as the most likely reasons.42 Many hemophiliacs, in particular, were wary of associating themselves with a seemingly embarrassing disease.43 Furthermore, Picard has pointed out that many hemophiliacs at the time were concerned about placing blame on the Red Cross and hospitals that had treated them for so many years.44 By 1987, it was apparent that the issues surrounding tainted blood were not going to disappear and the severity of illness among those who had

37

André Picard, The Gift of Death: Confronting Canada’s Tainted Blood Tragedy (Toronto: Harper Collins Publishers Ltd., 1995), 159. 38 Picard, The Gift of Death, 159. 39 Ibid., 160. 40 Norbert Gilmore and Margaret A. Somerville, “From Trust to Tragedy HIV/AIDS and the Canadian Blood System,” in Blood Feuds: AIDS, Blood and the Politics of Medical Disaster, Eric A. Feldman and Ronald Bayer, eds., (New York: Oxford University Press, 1999), 142. 41 Picard, The Gift of Death, 163. 42 Ibid., 160. 43 Vic Parsons, Bad Blood: The Tragedy of the Canadian Tainted Blood Scandal (Toronto: Lester Publishing Limited, 1995). 44 Picard, The Gift of Death, 160.

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contracted HIV was increasing.45 News of the situation moved into the mainstream media when seven Albertan hemophiliacs, all of whom had contracted HIV through heat-treated blood, came forward, thereby abolishing the myth that the crisis had passed.46 In November 1987, Chairman Robert O’Neill (b. 1936) of the newly formed CHS committee on HIV and AIDS called for financial compensation for those who had received tainted blood.47 The CHS continued fighting for compensation into the New Year, commissioning a study to determine exactly how much compensation was needed, and writing a formal request for compensation to the Canadian Blood Committee.48 Their appeals were bolstered in April 1988, when the Royal Society of Canada (RSC) also called for compensation. The Society was particularly concerned with the possibilities that people infected with HIV would encounter financial difficulties, periods of unemployment, inadequate sick leave benefits, and has insufficient life savings, leading to housing and other social challenges.49 In November 1988, the CHS sent a document to the Minister of Health and Welfare, Jake Epp (b. 1939), informing him that “one thousand Canadians with hemophilia have been infected with HIV from the use of government approved medical treatment.”50 The CHS argued that the lack of a national strategy or agency for the country’s blood supply, as well as dependence on American blood, contributed to the failure of the Canadian system.51 Moreover, by failing to prudently introduce measures to protect the blood supply and remove contaminated blood from the system in a timely manner, Canada’s blood services had infected many of their patients in the health care system. The CHS called for a package of financial support for the victims and their families, which would include reimbursement for loss of earnings and medical expenses, financial support when the victim passed away, and a payment to compensate for

45

Ibid., 161. Ibid. 47 Ibid., 163. 48 Picard, The Gift of Death, 163; Parsons, Bad Blood, 212. 49 Royal Society of Canada, AIDS: A Perspective for Canadians (Ottawa: The Royal Society of Canada, 1988). 50 Canadian Hemophilia Society, “Hemophilia Catastrophe Relief: An Urgent Request to the Government of Canada,” as cited by Picard, The Gift of Death, 163. 51 CHS, as cited by Picard, ibid. 46

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the “pain and suffering they have endured and the loss of the enjoyment of life.”52 The request was initially denied and lobbyists for the CHS, along with the victims, continued to advocate for a compensation package from the federal government. It took more than one year of lobbying before the new Health Minister, Perrin Beatty (b. 1950), agreed to a modest “disaster relief” package in order to maintain public confidence in the blood supply system.53 The package consisted of a one-time lump sum of $120,000 taxfree dollars for each victim, to be paid in four equal installments.54 In order to receive the payments, each victim had to sign a waiver agreeing not to sue the federal government. André Picard has suggested that Beatty agreed to a compensation package out of political fear of excessive lawsuits, which would ultimately cost more for the government than a modest relief package. In addition, the thought of fighting against the victims in court did not have any political appeal.55 Although Beatty attempted to include the provinces in a larger package that would have included an additional $260,000 per person, they refused to join.56 Consequently, the waivers did not include the Canadian Red Cross, which was funded by the provinces. As many victims of the tainted blood scandal began to sign the federal financial relief package, it appeared as though the provincial governments were not going to act on the issue, and would instead leave the costs of the tragedy with the federal government.57 However, the issue did not go away like many politicians had hoped and expected. By 1993, many victims had received their final payments of government relief.58 Contrary to governmental projections, many of the victims were still alive and needed continuing medical care and funds upon which to live.59 One victim of tainted blood, Randy Connors 52

Ibid., 165. Mary Gooderham, “Some AIDS Victims to be compensated,” The Globe and Mail (December 15, 1989): A1. 54 Gilmore and Somerville, “From Trust to Tragedy HIV/AIDS and the Canadian Blood System,” 142. 55 Picard, The Gift of Death, 168. 56 Picard, Ibid. 57 Ibid. 58 Orsini, Michael, “The Politics of Naming, Blaming and Claiming: HIV, Hepatitis C and the Emergence of Blood Activism in Canada,” Canadian Journal of Political Science 35 (2002): 475-498; esp. 478. 59 Picard, The Gift of Death, 173. 53

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(b. 1949), along with his wife Janet, made their story public and turned to their provincial government for assistance. Nova Scotian Minister of Health George Moody (b. 1942) responded with an offer of $30,000 taxfree dollars per year for life, prescription drug coverage, four years of post-secondary education for dependents, a death benefit, and funeral expenses for each of the sixteen tainted-blood victims in the province.60 Moody noted “it’s a tragedy for everybody, but these people were getting blood through a system to which the government contributed. Therefore, I think they have a legitimate claim to some assistance.”61 The rest of the provinces were now under the spotlight to find solutions for their residents in similar situations.62 Adding to the pressure was a report from the Commons Sub-Committee on Health Issues calling for the provinces to extend compensation,63 and extend the federal government’s relief program past its initial four years. It was around this time that Canadian Health Minister Benoit Bouchard (b. 1940) called for a public inquiry to investigate the situation.64 Throughout the summer of 1993 all provinces, except Québec, announced that they would compensate victims with the same financial plan in every province.65 After the CHS rejected their initial proposal, the provincial and territorial health ministers presented a more substantial offer in September 1993, which required the victims to once again sign a waiver agreeing not the sue the provinces and territories, nor the Canadian Red Cross.66 Although later bolstered by contributions by thirteen pharmaceutical companies who wished to join, the new plan was still less than Nova Scotia’s compensation agreement. Furthermore, the new MultiProvincial-Territorial Assistance Program (MPTAP) gave those who qualified a surprisingly short time frame in which to sign onto the deal, thereby limiting their window of opportunity for civil action and forcing a 60

Krever, Commission of Inquiry on the Blood System in Canada, 1031. Rod Mickleburgh, “N.S. to compensate victims of AIDS-tainted blood,” The Globe and Mail (April 15, 1993): A4. 62 Feldman and Bayer, Blood Feuds: AIDS, Blood and the Politics of Medical Disaster. 63 The Inquiry on the Blood System in Canada, which would become known as the Krever Commission after its commissioner Justice Horace Krever (b. 1929) from Toronto, Ontario, lasted two years and cost over $14 million. 64 Gilmore and Somerville, “From Trust to Tragedy HIV/AIDS and the Canadian Blood System,” 128. 65 Picard, The Gift of Death, 173. 66 Ibid., 175. 61

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decision before the recommendations of the public inquiry were announced.67

Hepatitis C Victims HIV was not the only virus that had been transmitted through blood and blood products in Canada; thousands of patients were also infected with HCV during the tainted blood scandal of the 1980’s and 1990’s. Although the virus was seen to have less dramatic adverse effects than HIV, many HCV-infected victims argued that the virus had catastrophic effects on their lives and that they merited compensation similar to that awarded to the population of HIV victims.68 However, the number of HCV victims was significantly greater and prospective compensation packages were calculated to be quite costly.69 HCV victims also accused the Canadian Red Cross of failing to protect them from the virus through unscreened donated blood. Many developed countries, including the United States, began using ALT and anti-HBc surrogate tests for HCV as early as 1986. However, Canada never adopted these measures, and only began testing for HCV in 1990 through firstgeneration anti-HCV assays.70 As a result of their flagrant inaction, approximately 26,800 individuals were infected with hepatitis C during the period when more sensitive testing was available, but not used.71 This issue was brought to the forefront in 1997 during the Inquiry on the Blood System in Canada, now known as the Krever Inquiry after its commissioner Justice Horace Krever. Krever concluded “compensating some needy sufferers and not others cannot, in my opinion, be justified,”72 arguing for financial assistance for both victims of HIV and hepatitis C. The government did not heed Krever’s advice immediately. HCV patients continued to lobby the government for compensation, calling themselves

67

Parsons, Bad Blood, 242; Gilmore, “From Trust to Tragedy HIV/AIDS and the Canadian Blood System,” 143. 68 Parsons, Bad Blood, 250. 69 Orsini, “The Politics of Naming, Blaming and Claiming,” 494. 70 Parsons, Bad Blood, 260; Krever, Commission of Inquiry on the Blood System in Canada, 1032. 71 According to the study by Dr. Paul Gully (b. 1947?) cited by Krever in the Commission of Inquiry on the Blood System in Canada. 72 Krever, Commission of Inquiry on the Blood System in Canada, 1045.

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the “forgotten victims” of the tainted blood scandal. They also launched class-action lawsuits against four provinces.73 In 1998, the federal and provincial governments came forward with a $1.1 billion dollar financial aid plan for the victims. The individual payments varied, to a maximum of $250,000.74 Only those who contracted hepatitis C from tainted blood between 1986 and 1990, when a screening test was available but not used, were eligible.75 The government argued that since no direct test was available before 1986, and they had implemented appropriate testing after 1990, they were not liable during any other period. This decision outraged many victims, as they felt the government had a moral responsibility to provide financial assistance, as they had for victims of HIV-tainted blood. Furthermore, the Ontario- and New Foundlandbased journalist and science writer Vic Parsons argues in his book Bad Blood: The Tragedy of the Canadian Tainted Blood Scandal (1995) that those who had contracted hepatitis C before 1986 would still have benefited from earlier serologic testing for the virus in their own blood. Had the virus been detected sooner, medical treatment could have been initiated earlier, dietary and lifestyle changes adopted, and secondary disease transmission prevented.76 Amidst intense pressure, Ontario extended their coverage in 1998 to those infected before 1986.77 Ontario premier Mike Harris (b. 1945) wrote to Prime Minister Jean Chrétien (b. 1934): “Your government’s commitment will ensure that this meeting can be about ‘how’ to compensate victims, not about ‘whether’ all victims are treated equally,”78 urging him to 73

Canadian Broadcasting Centre, “‘Forgotten Victims’ Hear Tainted Blood Settlement Details,” http://www.cbc.ca/health/story/2006/12/15/hepc-settlement. html (Accessed February 28, 2010). 74 Sonya Norris, “Hepatitis C,” Parliamentary Information and Research Service, http://dsp-psd.pwgsc.gc.ca/Collection-R/LoPBdP/PRB-e/PRB9915-e.pdf (Accessed February 28, 2010). 75 Canadian Broadcasting Centre (CBC), “Tainted Blood Scandal,” http://www.cbc.ca/news/background/taintedblood (Accessed February 28, 2010). 76 Parsons, Bad Blood, 265. 77 Orsini, “The Politics of Naming, Blaming and Claiming,” 484. 78 Mike Harris, Letter to Prime Minister Jean Chrétien (May 12, 1998), as cited by Hon. Consiglio Di Nino, “Commission of Inquiry on the Blood System in CanadaCompliance with Recommendations-Motion-Debate Continued,” Senate of Canada, http://sen.parl.gc.ca/senatorcon/PDFs/Vol137_issue61.pdf (Accessed February 28, 2010).

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compensate pre-1986 victims. Québec and Manitoba followed suit in 1999 and 2001, respectively. It was only in April of 2005 that compensation was extended to pre1986 HCV victims by the federal government, perhaps due to the fact that $1 billion dollars still remained in the original hepatitis C compensation fund. The House of Commons voted unanimously79 for a motion to accept a report by the Standing Committee on Health that called on the government to extend relief to another 5,000 Canadians.80 The package was further expanded in 2006, when the new Conservative government announced a final settlement package for those infected before 1986 and after 1990 that had yet to receive compensation. Health Minister Tony Clement (b. 1961) noted that, “While no amount of money can fully compensate these victims for their pain and suffering, Canada’s New Government has never wavered in its commitment to compensate all victims of tainted blood, no matter the date of infection.”81

Medical Error Drs. Ethan D. Grober and John M.A. Bohnen, surgeons at the Divisions of Urology and General Surgery at the University of Toronto in Ontario, have recently defined medical error as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result.”82 An adverse event, according to their clinical expertise and analysis is defined as an “unintended injury to patients caused by medical management (rather than the underlying condition of the patient) that results in measurable disability, prolonged hospitalization or both” by the Harvard, and Utah and Colorado Medical Practice Studies 79

Stephen Fletcher, Vote No. 66: Adoption of Seventh Report of the Standing Committee on Health (Tuesday, March 22, 2005), House of Commons of Canada, http://www2.parl.gc.ca/HouseChamberBusiness/ChamberVoteDetail.aspx?Langua ge=E&Mode=1&Parl=38&Ses=1&FltrParl=38&FltrSes=1&Vote=66 (Accessed February 28, 2010). 80 CBC, “Tainted Blood Scandal.” 81 Canada News Centre, “Courts Approve the Pre-1986/Post-1990 Hepatitis C Settlement Agreement,” http://news.gc.ca/web/article-eng.do?crtr.sj1D=&mthd =advSrch&crtr.mnthndVl=&nid=315379&crtr.dpt1D=&crtr.tp1D=&crtr.lc1D=&c rtr.yrStrtVl=&crtr.kw=tainted%2Bblood&crtr.dyStrtVl=&crtr.aud1D=&crtr.mnthS trtVl=&crtr.yrndVl=&crtr.dyndVl= (Accessed February 28, 2010). 82 Ethan D. Grober and John M. A. Bohnen, “Defining Medical Error,” Canadian Journal of Surgery 48 (2005): 39-44; esp. 42.

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conducted between 1991 and 1999.83 The authors maintain that not all adverse events are errors; rather, only those that are preventable. Finally, preventable adverse events are termed negligent adverse events when legal wrongdoing is at question.84

Issues in Government Responsibility This case certainly questions the Canadian government’s responsibility to provide financial assistance to patients who suffer as a result of an adverse medical event. Indeed, the federal government, along with provincial and territorial governments, played an important role in Canada’s blood collection system. The federal government regulated the processes of blood transfusions and therapeutic uses of blood products under the Food and Drugs Act,85 while the provincial and territorial governments provided the funding.86 In 2002, charges of criminal negligence were laid against the CRC, Red Cross national medical director Dr. Roger Perrault (b. 1936), Health Canada officials Drs. John Furesz (1927-2012) and Donald Boucher (1960-2012?), the New Jersey-based Armour Pharmaceutical Company, and Armour executive Dr. Michael Rodell (b. 1933).87 However, only minor penalties were levied: The CRC was fined $5,000 and established a $1.5 million dollar scholarship fund at the University of Ottawa in Ontario for families affected by the tragedy. The four physicians and Armour Pharmaceutical Company were acquitted of the criminal charges in 2007.88 If the government was not culpable for the problems with the blood system, then what role should they play in financial assistance for the victims?

83

Ibid., 40. Ibid., 41. 85 Kumanan Wilson, Jennifer McCrea-Logie, and Harvey Lazar, “Understanding the Impact of Intergovernmental Relations on Public Health: Lessons from Reform Initiatives in the Blood System and Health Surveillance,” Canadian Public Policy 30 (2004): 177-194; esp. 182. 86 Wilson, “Understanding the Impact of Intergovernmental Relations on Public Health,” 182. 87 Canadian Broadcasting Centre (CBC). “Judge acquits 4 doctors in Canada’s tainted blood trial,” http://www.cbc.ca/canada/story/2007/10/01/taintedbloodverdict.html (Accessed February 28, 2010). 88 CBC, “Tainted Blood Scandal.” 84

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The Krever Commission discussed a system in which financial assistance could be provided to victims of adverse medical effects without placing blame on a particular party. The Commission cited New Zealand’s Accident Compensation Act of 1972, which legislated that anyone could be compensated for accidental injury, regardless of whether or not culpability was established. This could include anything from motor vehicle accidents to adverse medical effects.89 However, the Canadian government was clear that no such extraordinary assistance fund would be considered. In 1993, Health Minister Perrin Beatty (b. 1950) stated that “the government could neither afford, nor is it proposing today to enter into a system where anyone who develops disease or suffers as a result of medical accident receives payment or vast amounts of assistance.”90 Another avenue for financial compensation for the victims was through civil action, which had the potential for significant financial return, but at the expense of drawn-out court battles and finding clear proof of fault.91 The Krever Report explained that “attempting to prove negligence or other fault in an adversarial system results in lengthy, complex and costly proceedings, with results that are unpredictable and often unsuccessful for the injured plaintiff.”92 In the absence of a no-fault compensation system93 and with the drawbacks of civil action, the government decided to offer monetary aid on the condition that all the recipients sign a waiver agreeing not to pursue legal action against the parties involved in the settlement, thereby absolving them of any wrongdoing. This is the essential difference between compensation, as was originally called for by the Canadian Hemophilia Society (CHS), and the catastrophic relief that was ultimately granted on compassionate grounds. Rhetoric around financial assistance during the tainted blood scandal largely focused on compassionate aid, rather than compensation. CHS President Elaine Woloschuk (1945-2012), for example, iterated: We drew a parallel between a natural disaster and a medical disaster, where nobody was truly at fault. We didn’t want to lay blame at anybody’s feet but we really wanted to highlight the issue, and look to the government 89

Krever, Commission of Inquiry on the Blood System in Canada, 1040. Warren Beatty, as cited by Gooderham, “Some AIDS Victims to be compensated.” 91 Krever, Commission of Inquiry on the Blood System in Canada, 1029. 92 Ibid., 1034. 93 Krever calls a system in which victims have the option to turn to an extraordinary assistance fund a “no-fault system.” 90

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Indeed, as packages of funding were announced, the language used by government officials suggested that the offers of assistance were made only out of benevolence. When speaking for the motion to extend compensation to all victims who contracted hepatitis C through the blood system, Member of Parliament Steven Fletcher (b. 1972) stated, “If the government votes against my motion, then it must explain why it is against compassion.”95

Conclusion In conclusion, the responsibility for the tainted blood scandal in Canada never fell on the shoulders of any one person or organization. In fact, in the context of accelerating scientific knowledge, an ever-changing political climate, the constraints of a publicly funded health care system, and the application of the ethical principle of primum non nocere, it is rather difficult to determine where the responsibilities for the tainted blood scandal lie. From 1989 to 2006, the federal, provincial, and territorial governments paid over $2 billion dollars in compensation to the victims of the tainted blood scandal. After managing blood donations for fifty-one years, the Canadian Red Cross transferred its responsibilities to the newly formed Canadian Blood Services and Héma-Québec on September 28, 1998.96 Better screening, more advanced testing, and heightened vigilance have nearly, albeit not entirely, eliminated the chance of HCV or HIV transmission through blood transfusions and other therapeutic blood products. While these improvements can never retract the irreversible damage of the tainted blood scandal on victims’ health and their families, they have demonstrated the government’s recognition of error and need for change, and restored public confidence in the vitally crucial blood collection system. 94

Elaine Woloschuk, National President of the CHS, as cited by Parsons, Bad Blood, 213. 95 Stephen Fletcher, “Hepatitis C,” House of Commons of Canada, http://www2.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode= 1&Parl=38&Ses=1&DocId=1787950#Int-1239577 (Accessed February 28, 2010). 96 Canadian Red Cross (CRC), “Historical Timeline,” http://www.redcross.ca/ article.asp?id=7824&tid=019 (Accessed February 28, 2010).

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APPENDIX: DEFINITIONS Cryoprecipitate: Concentrated precipitate from thawed fresh frozen plasma (FFP) that contains factor VIII, fibrinogen, fibronectin, factor XIII, and von Willebrand factor in FFP. Though it is more concentrated, it has the same infectious risk as FFP. Cryoprecipitate-poor plasma: The plasma remaining after cryoprecipitate has been removed from FFP. Factor VIII concentrates: Recombinant human factor VIII in a solution of polysorbate, sodium, mannitol, sucrose, and/or albumin. Fresh frozen plasma (FFP): Plasma prepared from whole blood or apheresis contains all protein and coagulation factors present in blood, and a citrate-containing anticoagulant from collection. Must be frozen within 8 hours of collection. Packed red blood cells: Concentrated red blood cells to a Hematocrit of 50-65% depending on the preparation. Most of the plasma and platelets have been removed. Serum: Blood plasma minus the fibrinogen and clotting factors Whole blood: Unaltered collected blood.

COMBATING SLEEPING SICKNESS: A GLANCE AT THE DEVELOPMENT OF TRYPANOSOMIASIS TREATMENT IN COLONIAL AFRICA ROSALIND ASHTON

SUMMARY: The early 20th century colonial period, during which European nations were exploring East Africa saw many medical advances in research in vector-borne diseases and their treatment. Trypanosomiasis devastated colonial parties not only through individual infection but also indirectly, by attacking domestic livestock. Before 1905, there was no effective treatment against the disease, in part because of its unknown etiology. Its treatment developed slowly during the 20th Century colonial period as understanding of the disease changed and various nuances of its infection were uncovered. From isolation camps to the first chemotherapeutic drugs, trypanosomiasis treatment has had a complicated history. Trypanosomes were not proven as the causative organism until 1903. Due to the fear of contagion, segregation camps were set up, and patients (mostly African) were often isolated from their families. Concerned that a high death count would undermine the legitimacy of African exploration, money from colonial governmental and research institutions poured into trypanosomiasis research in 1902. Much of the money was given to the Liverpool School of Tropical Medicine, where in 1905 the Canadian physician Harold Wolferstan Thomas discovered Atoxyl. Atoxyl’s popularity as the drug of choice for treatment is not entirely clear. Arsenical drugs, such as Atoxyl, were common during the beginning of the 20th century, treating a variety of ailments in Africa including syphilis and yaws, despite its unfortunate side effect of blindness. Its structure was manipulated by the German physician and pharmacologist Dr. Paul Ehrlich, until the 606th compound in a series of experiments resulted in Salvarsan in 1910. This treatment was the first major triumph in the synthesis of chemotherapeutic agents. KEYWORDS: Trypanosomiasis; Colonial Medicine; Africa; Sleeping Sickness, History of; Atoxyl; Historical Epidemiology; Public Health, History of PRECEPTORS: Dr. Gerri Frager INSTITUTION: Dalhousie University

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Introduction Although human sleeping sickness may not seem as prolific (and is certainly not given as much attention) as malaria and the acquired immunodeficiency syndrome (AIDS), it is still a rampant disease in subSaharan Africa and is responsible for a considerable degree of suffering and mortality in countries where it is endemic: “Some 55 million people in 36 countries are at risk, with an estimated 50,000 new cases reported annually.”1 The World Health Organization (WHO) currently estimates that in remote and war-torn areas of Angola, Central African Republic, and Sudan, infection rates are between twenty and fifty percent, making it a more efficient killer than the human immunodeficiency virus infection (HIV), HIV/AIDS.2 The 1997 epidemic in the southern Sudan, which infected 3,785 people,3 illustrates that current health care systems are still battling the disease and have made great progress in understanding its causation, but little in its treatment. At one point sleeping sickness was considered the biggest health problem in Africa, which experienced one remarkably terrible outbreak between 1900 and 1905 in the Belgian Congo killing half a million people.4 Because of its magnitude, the outbreak in the Congo has been labeled as one of the great epidemics in African history as well as one of the major turning points in the development of tropical medicine because it stimulated the rapid discovery of the causative organism as well as the vector transmission to humans.5 The disease was misunderstood for much of the early colonial period, and was a fatal mystery for which many different treatments were attempted. The treatment for trypanosomiasis developed slowly during the 20th century colonial period as understanding of the disease changed and various nuances of its infection were discovered. Sleeping sickness was the curse of humans during the colonial period for two reasons: it was able to hurt humans directly, through individual 1

Geoffrey Hide, “History of Sleeping Sickness in East Africa,” Clinical Microbiology Reviews 12, no. 1 (1999): 112-125; esp. 112. 2 World Health Organization, “African Trypanosomiasis or Sleeping Sickness,” Fact Sheet Number 259 (Geneva, 2006). 3 Anderson Wachira Kigotho “Southern Sudan hit by Sleeping Sickness Epidemic” Lancet 350 (1997): 455-528; esp. 502. 4 Steven Reithmiller, “From Atoxyl to Salvarsan: Searching for the Magic Bullet,” Chemotherapy 51 (2005): 234-242; esp. 237. 5 Jo N. Hays, Epidemics and Pandemics: Their Impacts on Human History, (Santa Barbara: ABC-CLIO Inc., 2005): 355.

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infection and also indirectly by infections of large animals. Harming domestic animals was a major hindrance when it came to the exploration of Africa, because when beasts of burden fell ill, exploration parties were forced to continue on foot, a much slower journey. Native Africans understood that nagana, cattle sleeping sickness, had been afflicting their livestock for some time, and they performed preventative measures against it. The zigua were much affected, as in the book “Famine and Social Change in Northeastern Tanzania” by the Iowa historian James L. Giblin illustrates, and they developed various preventative practices such as staggering settlements, moving their cattle at night, and creating areas of cultivation for their cattle as well as wooded areas where flies would infect wild animals and not their own.6 Though they may not have known the intricacies of the parasite causing them to be ill, they knew that flies were responsible for the sickness and recognized that they were not as active during the night. It took some time for anyone to realize what was causing the disease, though the missionary and discoverer David Livingstone (1813-1873) wrote about the significance of flies as early as 1849, and gradual entomological study was carried out, most prolifically by Sir David Bruce (1855-1931) in 1895 when he was studying the colonial disease nagana in South Africa.7

African Trypanosomiasis African trypanosomiasis is a blood-borne disease which is transmitted to humans by the bite of the tsetse fly, Glossina palpalis. The disease is described as progressing through two stages, early and late. Early-stage symptoms of the disease include swelling and inflammation around the bite site as well as hugely enlarged neck glands (known as “Winterbottom’s sign” observed in 1803),8 followed by fever, headaches, general body aching, vomiting, and “considerable emaciation in the more chronic cases.”9 Late-stage symptoms are the result of trypanosomes invading the 6

James Giblin, “Famine and Social Change in Northeastern Tanzania,” African Economic History 15 (1986): 85-105; esp. 88. 7 H. Harold Scott, A History of Tropical Medicine, (London: Edward Arnold & Co., 1939): 495. 8 Kirk Arden Hoppe, Lords of the Fly: Sleeping Sickness Control in British East Africa, 1900-1960, (United States of America: Prager Publishers, 2003), 29. 9 Harvey G. Soff, “Sleeping Sickness in the Lake Victoria Region of British East Africa, 1900-1915,” African Historical Studies 2 (1969): 255-268; esp. 256.

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lymph and central nervous system from the blood. Victims are often lethargic, suffer from psychiatric troubles, and fall into a coma, giving trypanosomiasis its common name, sleeping sickness.10 During the colonial period, death may have resulted after a few months or as late as several years depending on the strain. Before 1905, there was no effective treatment against the disease, in part because European medical officials could not figure out what was causing it. The earliest known account of sleeping sickness was written by John Atkins (1685-1757), an English naval surgeon who was on the Guinea Coast in 1721. He noted that “sleeping distemper” among the black population attacked the younger generations more often than the older ones and that fatality was high, and that if recovery ensued, the patients would “lose the little reason they have and turn idiots.”11 Physicians’ modern knowledge of sleeping sickness has relied heavily upon an increased understanding of parasitology and pharmacy, which has shown that the disease is caused by a type of protozoa, an organism at the bottom of the animal kingdom that may be divided into several subgroups. Trypanosomes fall under a subspecies of the group Mastigophora, and are characterized by being small and unicellular flagellates.12 They live in the bloodstream and digestive tracts of invertebrates, and are commonly incorporated in the life cycle of parasitic insect vectors such as the tsetse fly, responsible for African sleeping sickness.13 Trypanosomes were not discovered in mammals until 1879, when the Brazilian physician and public health administrator Carlos Justiniano Ribeiro Chagas (1879-1934) identified American trypanomiasis, and the first disease-causing trypanosome was described one year later: T. evansi causes surra, a disease famous for inflicting horses, camels, elephants, and dogs in Asia and North Africa, and which often shows symptoms similar to human sleeping sickness and nagana.14 It was not until fifteen years later, in 1895, that the second pathogenic species was discovered by Sir David Bruce, understandably named T.b. brucei, and ascertained to be the culprit responsible for “Tse-Tse Fly Disease” affecting cattle in South

10

Ibid. Scott, A History of Tropical Medicine, 456. 12 Geoffrey Douglas Hale Carpenter, A Naturalist on Lake Victoria with and Account of Sleeping Sickness and the Tse-Tse Fly (New York: E.P Dutton and Company, 1920), 11. 13 Ibid., 12. 14 Ibid., 14. 11

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Africa.15 No connection between fly disease in cattle and humans was made until 1903. T.b. brucei was determined to be the cause of nagana by Bruce, but T.b. gambiense was found by the English scientist Dr. Joseph Everett Dutton (1874-1905) in the blood of a patient in 1901 who was believed to have been suffering from malaria: an understandable hypothesis as the fever was the principal symptom of a disease ravaging populations at the time.16 The patient, an Englishman in charge of a steamer on the Gambia River, later died in Bathurst in 1903, after which his body was sent to Liverpool where Dutton made his discovery.17 Three subspecies of Trypanosoma brucei are currently recognized, and do not differ much from Bruce’s initial observations in 1895, though he was incorrect in assuming that all trypanosomes cause sleeping sickness: T.b. brucei infects animals but not humans, T.b. gambiense is defined as human-infective and is responsible for chronic sleeping sickness in West Africa, and T.b. rhodiense is described as human-infective and responsible for acute sleeping sickness in East Africa.18

The Early Discover of Sleeping Sickness The discovery of sleeping sickness in East Africa in 1901 may be attributed to the British-born medical missionary Dr. Albert Ruskin Cook (1870-1951) who, with his brother John H. Cook (b. 1841), was a staff member of the Church Missionary Society hospital at Mengo in Uganda. Dr. Cook wrote in his diary, “my brother Dr. J. H. Cook drew to my attention a couple of cases of what seemed to him to resemble the sleeping sickness. … I said we could settle the point in two minutes and taking a drop of blood from the patient, I examined it under the microscope.”19 An explosive epidemic was underway in this area, first noticed in Kampala and then centered in Busoga, resulting in the deaths of 200,000 Africans, roughly two thirds of the population.20

15

Ibid. Scott, A History of Tropical Medicine, 472. 17 Carpenter, A Naturalist on Lake Victoria with and Account of Sleeping Sickness and the Tse-Tse Fly, 23. 18 Hide, “History of Sleeping Sickness in East Africa,” 113. 19 Soff, “Sleeping Sickness in the Lake Victoria Region of British East Africa, 1900-1915,” 256. 20 Hays, Epidemics and Pandemics, 355. 16

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The Italian pathologist and bacteriologist Aldo Castellani (1877-1971) and his team were sent by the Royal Society to investigate the Ugandan epidemic in 1902. He began examining the cerebrospinal fluid of patients in the late stages of the disease and found trypanosomes without noting their significance. Bruce joined Castellani in 1903, and together they concluded that trypanosomes were present in the cerebrospinal fluid of the majority of patients suffering from sleeping sickness and that they were not found in healthy natives. Patients, who showed trypanosomes in the blood, but not the spinal fluid, were kept under observation, and it was discovered that over time they developed symptoms of the disease, and then showed parasites in their spinal fluid. Thus, it became routine to check both the blood and the spinal fluid of potential cases, and in 1904 the practice of gland puncture became regular practice to determine the presence of trypanosomes.21 While it is easy to describe the cause of sleeping sickness now with modern sophisticated medical equipment and a century of knowledge, it is interesting to note the abundant theories of what was causing the disease in the past. Some suggestions included labeling the disease as a type of nostalgia due to depression at separation from home, which explained why some slaves bound for the West Indies seemed lethargic. This theory was discounted by the fact that most of the slaves bound for the West Indies at this time were from the interior of the continent where sleeping sickness did not occur.22 There were also several toxin theories regarding the aetiology of sleeping sickness, including smoking Cannabis indica and drinking palm wine. However, these were decided to be untrue when it was realized that smoking Cannabis indica was observed all over the East where sleeping sickness did not occur, and that not all people who drank palm wine fell ill nor did sleeping sickness occur in many places where it was routinely drunk. It was also thought to be the result of other sicknesses rampant at the time such as beriberi or perhaps a side effect of heatstroke.23 Some felt that it was a different kind of malaria or hookworm infestation, others felt that cervical adenitis was the cause.24 Thomas Winterbottom (1766-1859) observed that “The natives would immediately call upon an indigenous healer if this was observed in a child, where in Gambia they would cut the 21

Scott, A History of Tropical Medicine, 466. Ibid., 469. 23 Ibid. 24 Ibid., 470. 22

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neck-stones of the boys to prevent the occurrence of sleeping sickness in later life.”25 The British colonial medical officers Dr. Frank Simpson Edward McCarthy (d. 1896) and Surgeon-Major Dr. Albert Augustus Gore (1840-1901) felt that extreme lethargy was due to these enlarged glands pressing on the vessels going to the brain, reducing cerebral blood supply, though admittedly this was not explored in depth and no recorded surgery was attempted by colonial officials to relieve this.26 In 1901, Commissioner Charles Eliot (1862-1931) of the East Africa Protectorate hypothesized that the disease was, “of African origin and attacks only the natives,”27 a belief that was shared by English officials until 1903 when a British woman returned from her trip to Africa and died of sleeping sickness. Trypanosomes, upon analysis, were found in her blood. Though it was thought at the time that Europeans might harbour the disease, it was generally accepted that only natives would actually die from it, and her death was a huge turning point in the disease’s etiology.28 It was also believed that the sickness was highly contagious because it seemed to spread rapidly in densely populated areas. The indigenous Ugandan people were said to “refuse to touch the effects of a man who had died of sleeping sickness or to eat with him when alive, and cases of the desertion of villages in which the disease had appeared are common.”29 Terrified tribes surrounding Busoga in Uganda relocated as soon as they noticed more and more cases of sleeping sickness in their village, inadvertently spreading the disease since one of the primary hosts of the tsetse is previously infected individuals who have dormant trypanosomes in their blood. Relocation also triggered bush re-growth, often creating ideal habitats for flies to settle and breed.30 Even though the disease was thought to be highly contagious, no drastic measures were taken by the colonial powers and their medical administration against the tsetse fly or sleeping sickness, because the numbers of European mortalities were not sufficient to warrant serious alarm. In 1902, only a year before the link between sleeping sickness and trypanosomes was established, doctors hypothesized that the disease might 25

Ibid., 456. Ibid., 470. 27 Soff, “Sleeping Sickness in the Lake Victoria Region of British East Africa, 1900-1915,” 256. 28 Scott, A History of Tropical Medicine, 459. 29 Soff, “Sleeping Sickness in the Lake Victoria Region of British East Africa, 1900-1915,” 258. 30 Ibid. 26

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possibly be attributed to a bacterial origin, namely a streptococcal infection. Microbiological germ theory had replaced the miasma theory of disease that linked it to the environment and climate, and staining as well as observations under the microscope was commonplace in colonial laboratories when presented with a new disease.31 Evidence for this was the existence of diplostreptococcus in the cerebrospinal fluid found in a number of autopsies of people who had died from trypanosomiasis. Castellani also felt that the disease may have had a bacterial origin, but later came to the conclusion that a streptococcal infection was a frequent finding in late stage cases, but was not responsible for its causation.32 The Scottish bacteriologist Patrick Manson (1844-1922), one of the pioneers of tropical medicine in the early twentieth century, came out with his Manual of Tropical Diseases in 1898, stating that the thread-like nematodes Filaria perstans, which could be found in the whole blood stream, were the cause of the “Negro Lethargy.”33 Before it was known what exactly was causing cases of sleeping sickness in the colonies, nothing very sophisticated could be done for patients. Because the fear of contagion was so strong, many segregation camps were set up,34 and victims were moved to special lazarets, and isolated from their families in order to keep the infection at bay.35 Total isolation of all suspected victims was the main course of action for colonial measures in the Congo before there was any drug therapy available and even after one came out on the pharmaceutical market. Victims were forbidden to travel by colonial officials who were terrified that they would spread the diseases to an uncontaminated region.36 These camps were also set up in British territory in Uganda, where sleeping sickness teams would venture into villages to check for the prevalence of the disease. Medical officials would feel the necks of a line-up of residents for enlarged cervical glands, take blood if they came across suspicious cases, and if the glands were swollen enough they would be punctured to check for trypanosomes under the microscope. If trypanosomes turned up 31

Hoppe, Lords of the Fly, 10. Scott, A History of Tropical Medicine, 470. 33 Ibid., 470. 34 Ibid., 523. 35 Maryinez Lyons, “Sleeping Sickness Epidemics and Public Health in Belgian Congo,” in David Arnold, ed., Imperial Medicine and Indigenous Societies (New York, St. Martins Press, 1988), 107. 36 Lyons, “Sleeping Sickness Epidemics and Public Health in Belgian Congo,” 108. 32

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in the analyzed blood samples, individuals would be further subjected to very painful lumbar punctures (spinal taps).37

Combating Sleeping Sickness in a Colonial Context The British were very interested in combating the disease as sleeping sickness had made many parts of their new overseas territories uninhabitable. An effective treatment for the disease would have been of great economic importance, especially once the colonial officials realized that it was not only a disease of natives!38 Officials were now concerned that a high death count would undermine the legitimacy of the British rule in Uganda, and additional money poured into research on trypanosomiasis, shifting the focus away from malaria, in 1902, due to the devastating epidemic that was taking place in Uganda.39 Much of it was given to one of the leading centres of bacteriology in the British homeland, the Liverpool School of Tropical Medicine (LSTM), where the Canadian physician Harold Wolferstan Thomas (1875-1931) was made director in 1904. The McGill graduate reported in 1905 that atoxyl, an arsenical compound may be useful in the treatment of T. brucei gambiense,40 and after many trials at the LSTM, the German bacteriologist Robert Koch (1843-1910) and Nobel Prize winner of 1905 reported that he had provided the first positive assault against the disease in 1906 in East Africa. The drug proved to be valuable to victims in the early stages of infection, while the parasite was still in the bloodstream and had yet to make its way to the cerebrospinal fluid. The only problem was that the treatment did not prove to be permanent, patients often had recurring bouts of sickness, and many died anyway.41 Atoxyl was believed to cure the disease within four to six weeks, so to monitor this, patients were subjected to routine screenings, including lumbar punctures to determine if the parasite had moved into the cerebrospinal fluid, and thus entered the second stage of the disease.42 37

Hoppe, Lords of the Fly, 135. Reithmiller, “From Atoxyl to Salvarsan: Searching for the Magic Bullet,” 237. 39 Hoppe, Lords of the Fly, 11. 40 Reithmiller, “From Atoxyl to Salvarsan: Searching for the Magic Bullet,” 237. 41 Soff, “Sleeping Sickness in the Lake Victoria Region of British East Africa, 1900-1915,” 261. 42 Lyons, “Sleeping Sickness Epidemics and Public Health in Belgian Congo,” 109. 38

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The reason for favouring Atoxyl as a treatment for sleeping sickness is not entirely clear. Arsenical drugs were popular during the very beginning of the twentieth century, treating a variety of ailments in Africa including syphilis (Baroness Karen Blixen, 1885-1962, for example, was treated with an arsenical therapy when she contracted syphilis), and yaws. Atoxyl came after a number of other arsenic-based pharmaceutics including Liquor arsenicalis and sodium arsenate, both which had some success, but more often than not resulted in terribly toxic side effects.43 It was felt by Patrick Manson and Robert Koch that “atoxyl could be for sleeping sickness what quinine was for malaria,”44 as it had proven effective in killing parasites in animal trials. Originally used for the treatment of certain cancers and dermatological problems, atoxyl delivered as a subcutaneous injection, was the first organic arsenical which proved to be much less toxic (hence its name) than inorganic arsenicals,45 though some of its side effects, too, were quite distressing. Belgian officials in their colony of nearby Congo debated whether the state had the right to impose atoxyl as a treatment as “up to thirty percent of those treated became blind as the drug atrophied the optic nerve”46 and many patients became violently ill. Nevertheless, Africans with enlarged glands were moved to isolation camps and given daily 5cc (cubic centimeter) injections of atoxyl in five percent solution between the shoulder blades for about three days. Often atoxyl was used in conjunction with other drugs such as scamin, émetique, orpiment, or diaxyl,47 and patients seldom had a choice when it came to being treated with a potentially lethal drug. While arsenic was never given as an isolated form of medication, raw mercury was often combined with strychnine as a therapy48 since it was a known poison to parasites in the blood, at least from in vitro experiments. Non-arsenicals began to surface around 1910 after experiments on rats infected with T. brucei were performed and found to be successful. The German bacteriologists Drs. Ludwig Brieger (1849-1919) and Max E. Krause (1879-1972) discovered a chemical dye that was non-toxic to man, even in large doses, and named it trypasafrol. This drug could be taken by 43

Scott, A History of Tropical Medicine, 525. Lyons, “Sleeping Sickness Epidemics and Public Health in Belgian Congo,” 109. 45 Reithmiller, “From Atoxyl to Salvarsan: Searching for the Magic Bullet,” 236. 46 Lyons, “Sleeping Sickness Epidemics and Public Health in Belgian Congo,” 111. 47 Ibid., 145. 48 Hoppe, Lords of the Fly, 74. 44

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mouth and was less likely than many arsenical drugs to deteriorate over time, especially if exposed to sunlight.49 Antimonials, equally as toxic as arsenicals, were also introduced in the first decade of the 20th century. Compounds such as antimosan, stibosan, stibenyl, styryl compounds, and styryl quinolines were experimental drugs which were eventually combined with and led to the wide usage of the arsenical drug tryparsamide and its Belgian equivalent, tryponarsyl. A popular drug between 1919 and 1925 in the Belgian Congo, tryparsamide was studied by Dr. Louise Pearce (1885-1959) of the Rockefeller Institute in clinical trials starting in 1920, who concluded that though the drugs may cause temporary, but not permanent, blindness in thirty percent of second stage cases, it represented an improvement upon previous statistics.50 Tryparsamide proved to be very effective in the Belgian Congo, especially in combating late-stage disease, and high numbers of cures were reported in Brazzaville, though it had certain drawbacks that atoxyl did not. Tryparsamide had to be taken carefully and diligently as the risk of arsenic resistance was high if an insufficient dosage was given and patients had to return at a set date, which was not always easily achieved in the colonies.51 The structure of atoxyl was manipulated by the German physician and bacteriologist Paul Ehrlich (1854-1915) and his chemist Alfred Bertheim (1879-1914) until the 606th compound in a series of experiments resulted in salvarsan in 1910. The treatment, originally used to combat syphilis, was the “first major triumph in the synthesis of chemotherapeutic agents.”52 The drug was later modified by Ehrlich to make neosalvarsan, a more water-soluble, and therefore injectable compound,53 which was used in conjunction with atoxyl, and found to free a patient of trypanosomes for two to four months.54 Determining whether the drug would result in lasting effects was the constant bane of researchers, and many drugs failed at providing long-lasting effects: (i) Although the administration of one dose of salvarsan, neosalvarsan, or atoxyl will sterilize the blood from trypanosomes, symptoms reappear in 49

Scott, A History of Tropical Medicine, 526. Lyons, “Sleeping Sickness Epidemics and Public Health in Belgian Congo,” 152. 51 Scott, A History of Tropical Medicine, 527. 52 Reithmiller, “From Atoxyl to Salvarsan: Searching for the Magic Bullet,” 240. 53 Ibid. 54 Lyons, “Sleeping Sickness Epidemics and Public Health in Belgian Congo,” 152. 50

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Combating Sleeping Sickness four months or so and the disease progresses to a fatal end. (ii) This is due to the trypanosomes finding a protection in the central nervous system where the drug cannot attack them and whence they can invade the blood again.55

Frustrated researchers also had to determine whether or not the drugs were effective in the early or late stages of the disease. Often it was possible to sterilize the blood of trypanosomes but not the cerebrospinal fluid. Combinations with atoxyl and its derivatives became commonplace when it was realized that suramin (Bayer 205) was very effective against the early stages, and tryparsamide against the late stages of trypanosomiasis; the suggestion of combining the treatments came in 1928. Treatment success for late-stage trypanosomiasis relies on a drug that can cross the blood-brain barrier to get to the parasite in the spinal fluid which was not possible with suramin because of its low diffusability into nerve tissue.56 A regimen of two injections of suramin, each one gram, and then after one or two months, twelve injections of tryparsamide, increasing the dose from two to four grams was followed in Tanganyika in 1928, with mixed results.57 The combination also promoted better patient outcomes as long term therapies involving suramin often caused potentially fatal cases of nephritis, so combining it with another drug helped to avoid this sideeffect.58

Conclusion While chemotherapy had greatly improved, the toxic symptoms and the discomfort for patients were significant even after arsenicals were no longer the sole kind of chemotherapy available. Melarsoprol was developed in 1949 and is still the primary drug used for late-stage infections, despite its risky side effect of reactive encephalopathy in ten percent of cases, which is fatal in half of those cases. Melarsoprol is still the last arsenic drug in existence and is very closely related to atoxyl. Currently there are few drugs that are fully effective against early-stage trypanosomiasis, and the development of drugs in the last fifty years has been paltry. Drugs developed before 1920 are still the most common treatments for early stage infections. The World Health Organization (WHO) lists pentamidine 55

Scott, A History of Tropical Medicine, 529. Ibid., 526. 57 Ibid., 528. 58 Ibid. 56

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as the most useful treatment for T.b. gambiense infections, and suramin is most commonly used for those associated with for T.b. rhodesiense.59 Today’s medicine has changed very little from medicine employed during the colonial period. Few new drugs have been developed since 1949 for the combat of sleeping sickness, and similar methods of detection remain in use, including haematological diagnostics and spinal fluid analyses. Eflornithine, registered by the WHO in 1990 is only effective against T.b. gambiense, and is an alternative to arsenical drugs, but requires a strict regimen and is difficult to administer.60 The “Resurrection Drug,” so named because it is sometimes able to bring late-stage patients out of their comas, requires one slow infusion of 400 mg/kg every twelve hours for a week, often a difficult schedule to adhere to during times of epidemic or in remote or war-torn areas.61 Because it is a flagellate, current research is focusing on drugs that render the trypanosome immobile, thus preventing it from moving from the bloodstream to the cerebrospinal fluid, halting the disease at its early stage, and rendering it more easily treatable with a significantly better outcome. Unfortunately, as with many topical diseases affecting the third world, funding for drug and therapy development is lacking, making sleeping sickness one of the most neglected afflictions in Africa, even though the continent is currently experiencing a resurgence of epidemics and significant forms of drug resistance. Although the existence of trypanosomiasis was documented as early as the 18th century, it took some time until medical officials knew what exactly was causing the disease. A variety of hypotheses were formulated to explain the cause of the disease, from toxin theories to side effects such as from beriberi and heatstroke. In combination with isolation camps, treatments were developed based at first on arsenic’s success at eliminating parasites from blood samples, and as understanding of how the disease progressed in two stages, on chemotherapies that halted the advances of the parasite from the bloodstream to the cerebrospinal fluid. Modern physicians are still faced with the problems that colonial officials 59

Hide, “History of Sleeping Sickness in East Africa,” 113. World Health Organization (WHO), “African Trypanosomiasis or Sleeping Sickness.” 61 Gerardo Priotto, Serena Kasparian, Daniel Ngouama, Sara Ghorashian, Unni Arnold, Salah Ghabri and, Unni Karunakara, “Nifurtimox-Elornithine Combination Therapy for Second-Stage Trypanosoma brucei gambiense Sleeping Sickness: A Randomized Clinical Trial in Congo” Clinical Infectious Diseases 45:11 (2007): 1435-1442; esp. 1435. 60

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dealt with when it comes to understanding how we might begin to tackle sleeping sickness during times of epidemic. Chemotherapies still develop slowly, and the process of exploring which drugs are effective against which stage of the disease, as well as if they will deliver a permanent cure are still major obstacles which clinicians face today. With current efforts aimed at preventative measures and sterilization of the vector, as well as some novel pharmaceutical developments, hopefully medicine will one day be able to also triumph over trypanosomiasis and prevent the unnecessary deaths of millions of people in Africa in the future.

THE ROLE OF PHARMACEUTICAL COMPANIES IN THE MEDICALIZATION OF MENTAL ILLNESSES BOLUWAJI OGUNYEMI

SUMMARY: Medicalization refers to when behavior once considered a valid deviation from the norm is subsequently deemed pathological and handled under the purview of medicine. The increasing availability and use of screening tests as well as identification and dissemination of risk and protective factors for disease lends itself to produce the “health-obsessed” societies that North America have become. Regarding the etiology of medicalization, critics have pointed their fingers at a number of sources: medical practitioners and the dominance of allopathic medicine have taken a lot of the blame in the past. The medicalization of mental disorders, for example the attention deficit hyperactivity disorder (ADHD), has a history fraught with controversy because diagnosis has often been a function of pharmacological treatment with a concomitant potential for profit. Scientists and clinicians employed specifically by pharmaceutical companies have a heavier hand than one might think in framing what constitutes mental disorders – many of which respond reasonably well to medication that the same companies manufacture. Advertising by multinational pharmaceutical corporations affect the way that society thinks of disease. Considerable portions of the revenue of support groups for particular mental disorders come from pharmaceutical companies that create medication to treat these same disorders. The dominance of biomedicine as a paradigm and changing societal norms has a part to play in the medicalization of mental disorders. This paper argues that medicalization is a socially-mediated phenomenon and medicalization of psychiatric disease especially so. Hence, the impact with which pharmaceutical companies have contributed to the medicalization of mental disorders will also be delineated. KEYWORDS: Psychiatry, History; Medicalization; Pharmaceutical Industry; Mental Illness; North America; Diagnostic and Statistical Manual of Mental Disorders (DSM); Biomedical Paradigm PRECEPTOR: Dr. Jim Connor INSTITUTION: Memorial University of Newfoundland

116 Role of Pharmaceutical Companies in the Medicalization of Mental Illnesses

Introduction The polymath, experimental scientist and founding father of the United States of America Benjamin Franklin (1706-1790) may have had it backwards, when claiming that “necessity is the mother of invention” (1784); rather than necessity being the mother of invention, it seems all too often that the opposite is true.1 The role of pharmaceutical companies in the medicalization of mental illnesses is largely an example of providerdriven demand in which the providers and creators of medication frame the nature of illness in their favour. Medicalization––in historical accounts of the development of modern psychiatry––is a term used to denote the process of otherwise normal behaviour being treated as a medical entity and thus requiring treatment or otherwise taken under the purview of medicine. Medicalization as a phenomenon has been growing rapidly in the First World. When treated under the scope of medicine, having a “disease” allows for doctors and other health professionals as well as scientists to redefine, re-evaluate and relay information about particular medical conditions. Since the term “medicalization” first appeared in the psychiatric and medical literature in the 1970’s, it emerged at the same time when fervent social criticisms of medical research and the health care system were put forward by popular authors such as Irving Zola (1935-1994), Peter Conrad (b. 1945) and Thomas Szasz (1920-2012).2 The Australian science writers and ethicists Ray Moynihan, Iona Heath, and David Henry (2002) have it right when they state that since the time of the first descriptions of medicalization, the social construction of illness has frequently become replaced by the corporate construction of disease.3 This is especially true in illnesses of psychiatric nature.

1 Cf. Stanley Finger, Doctor Franklin’s Medicine, (Pennsylvania, PA: University of Pennsylvania Press, 235-251. 2 Irving Kenneth Zola, Missing Pieces. A Chronicle of Living with a Disability (Philadelphia, Pa: Temple University Press, 1982); Peter Conrad, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders (Baltimore, Md: Johns Hopkins University Press, 2008); and Thomas Szasz, eds., The Medicalization of Everyday Life (Syracuse, NY: Syracuse University Press, 2007). 3 Ray Moynihan, Iona Heath, and David Henry, “Selling Sickness: The Pharmaceutical Industry and Disease Mongering,” British Medical Journal 324 (2002): 886-891.

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Medicalization of Mental Illness Medicalization has even been increasing over the past two decades with the greater availability of treatment options and pharmaceutical drugs. There are also considerable economic costs of medicalization, especially with a decline in socialized medical care and pharmacy care. Of course, pharmaceutical companies have been financially prosperous, which is precisely why they are interested in the medicalization of mental illnesses.4 Since the 1990’s, pharmaceutical companies have become more business-like in nature with mergers and takeovers, and an increased emphasis of marketing, as well as divulging considerable effort into research and development — including employing and working with a plethora of scientists and physicians.5 The latter two points will aid to delineate the ongoing role of pharmaceutical companies in the medicalization of mental illnesses. Table 1. Entries in the DSM by year of publication.

4

DSM Version

Year of Publication

Number of entries

DSM I

1952

106 (130 pages)

DSM II

1968

182

DSM III

1980

265

DSM IIIR

1987

292

DSM IV

1994

297

DSM IV TR

2000

365 (886 pages)

DSM V

May 2013

To be confirmed

Ibid. See, for example, the widely debated case of the president of the American Psychiatric Association (APA) being directly financially supported with funds and remunerated by payments from the pharmaceutical industry, in Marcia Angell, “Is Academic Medicine for Sale?,” New England Journal of Medicine 342 (2000): 1516-1518.

5

118 Role of Pharmaceutical Companies in the Medicalization of Mental Illnesses

The medicalization of mental disorders is one of the most widely understood and contentious instances of this phenomenon. The everincreasing cases in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) are a testament to this. Indeed, the DSM has grown from 106 entries in its first publication in 1952 (DSM I), to 364 entries in the current version; DSM IV.6 There are a variety of reasons for the increase between 1952’s DSM I with 106 conditions and the current DSM IV which enlists 365 conditions; including but not limited to increasingly valid criteria to test for disease, including those of psychiatric origin, increasing ability to recognize abnormal behaviour and/or a biopsychological basis for said behaviour or symptoms.

2-1 Volume of the DSM I (Frontispice). American Psychiatric Association, Diagnostic and Statistical Manual. Mental Disorders, (Arlington, Va: American Psychiatric Association, 1952).

6

Current, as of 2010.

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Introducing a New Concept: “Paramedicalization” Pharmaceutical companies are not innocent either; according to Moynihan, Heath and Henry (2002), close to half of the authors that contribute to the expanding DSM versions have had a relationship with a pharmaceutical company at some point.7 With regard to mental disorders, many critics of medicalization advocate paramedicalization, the replacing of medical or clinical emphasis in treatment of illness with a more holistic approach towards attaining health, as also a recent Finnish study has advocated for.8 The process of paramedicalization would include many elements of psychological medicine, such as intensive counseling, meditation practices and the support and insurance coverage of talking cures and psychiatric discourse. Paramedicalization further questions the assumption of normalcy of the traditional biomedical approach. A group of psychiatrists at the University of Washington in the United States, around Mark A. Stein, Christopher S. Sarampote, Irwin D. Waldman, Adelaide S. Robb, Charles Conlon,; Phillip L. Pearl, David O. Black, Karen E. Seymour and Jeffrey H. Newcorn (2003),9 has related that with reference to diagnosing cases of the attention deficit hyperactivity disorder (ADHD) and depression, there is a wealth of data to show that individuals are suffering from psychological problems and there are some cases that elicit “universal agreement” of interpretation of symptoms. The authors then go on to state that physicians are gaining more awareness of these conditions and that they can be “targeted by modern medical interventions.”10 It is possible that these “modern medical inventions” are not allowing clinicians to be more “aware” of disease but are actually creating the classification of disease itself. This speaks to the

7

Moynihan et al., “Selling Sickness,” 886-891. Raimo Tuomainen, Jyrko Elo and Markku Myllykangas, “Paramedikalisaatio: terveystyötä lääketieteen katveessa,” Sosiaalilääketieteellinen aikakauslehti 3 (1995): 217-223. 9 Mark A. Stein, Christopher S. Sarampote, Irwin D. Waldman, Adelaide S Robb,; Charles Conlon, Phillip L. Pearl, David O. Black, Karen E. Seymour and Jeffrey H. Newcorn, “A Dose Response Study of OROS Methyiphenidate in Children with Attention-Deficit/Hyperactivity Disorder,” Pediatrics 112, no. 5 (2003): e404e413; esp. 404. 10 Ibid. 8

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technological imperative; the tendency for physicians to employ new technologies when they become available.11 In his book The Medicalization of Society, the medical sociologist Peter Conrad speaks to the role of publications, particularly those by Dr. Paul H. Wender (b. 1934), a psychiatrist at the University of Utah, and Frank Wolkenberg (b. 1955), a free-lance science journalist, in particular, in the medicalization of adult ADHD. These two authors wrote of their unfortunate experiences with adult ADHD and reinterpreted their lives before the diagnosis. Later, Dr. Alan Joel Zametkin (b. 1950), a psychiatrist at the National Institute of Mental Health (NIMH) published an article describing how a positron emission tomography (PET) scan confirmed biological differences between victims of Adult ADHD and the rest of the “normal” population.12 After these publications gained mass readership, adult ADHD clinics became for example created at Wayne State University in Detroit, Michigan, and at the University of Massachusetts in Worcester. Here, society’s clamor about the “newly discovered” adult ADHD and the growing trend of becoming a risk-based society served in the increasing medicalization of mental illnesses. Many disconfirming studies of Dr. Zametkin’s original work were subsequently published, but did not gain mass attention by the public media, patients or health care workers; adult ADHD had already been well established.13 It is impossible to ignore the role of pharmaceutical companies in medicalization of mental illness: Most importantly, the Swiss pharmaceutical company Ciba-Geigy manufactures Ritalin®, which has become a widely prescribed drug treatment for child ADHD and adult ADHD alike. Ciba-Geigy furthermore provides considerable monetary subsidies and funding for organizations which support victims of ADHD, and this pharmaceutical company “has long been involved in framing hyperactivity and now ADHD as a medical disorder.”14 In 2005, twentytwo percent of the support group “Children and Adults with AttentionDeficit/Hyperactive Disorder’s” (CHADD) revenue for example came from Ciba-Geigy.15 Pharmaceutical companies have also likely played a role in the increases of stimulant use (methylphenidate, which is the 11

Juanne Nancarrow Clarke, Health, Illness and Medicine in Canada, 4th ed. (Toronto, On: Oxford University Press, 2002). 12 Cf. Paul Conrad, The Medicalization of Society (Baltimore: Johns Hopkins University Press, 2007). 13 Ibid. 14 Ibid. 15 Ibid.

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central pharmacological substance in Ritalin® is a neurostimulatory drug that is structurally similar to amphetamines) in America from 1995 to 2005, which has been estimated by Paul Conrad in his work to be between seven and nine-fold in just one decade.16 To be sure, the vast majorities of cases of psychiatric disease which have been validly diagnosed are genuinely biological or psychological in nature and would exist, whether or not pharmaceutical corporations exist; and therefore in these cases treatment is entirely warranted and appropriate. The phenomenon of medicalization, however, belongs to medical sociology, as it describes those cases and characteristics which cannot be nosologically classified easily in terms of “disease” or “non-disease,” which the medical community systematically uses for pathological taxonomic and diagnostic purposes. As is the case with Adult ADHD, the same medicalization is true for instance for “social phobia”.17 Although there are many instances of individuals who suffer from this biopsycholgical illness, if pharmaceutical companies had their way, almost anyone would suffer from and therefore be able to benefit from drug treatment options for social phobia.18 The Swiss pharmaceutical company Hoffmann-La Roche, for example, globally promoted an antidepressant named Aurorix® (moclobemide) as a treatment for social phobia. Moreover, the public relations department for this company concomitantly issued a press release, announcing that over a million Australians (out of a total population of 20 million people) would be suffering from social phobia and thus had to be medically treated by their physicians and psychiatrists.19 Around this time, Hoffmann-La Roche has also hired clinical psychologists to speak to how pharmacotherapy can ameliorate social phobia. Furthermore, Hoffmann-La Roche has funded a number of conferences on social phobia and in this way stabilized this condition as something that is prevalent and might affect any given person, while at the same time advocating for its pharmaceutical product, the psychotropic drug Aurorix®.20 16

Ibid. Moynihan et al., “Selling Sickness,” 128. 18 Peter Lurie and Sidney Wolfe, “FDA Medical Officers Report Lower Standards Permit Dangerous Drug Approvals,” Public Citizen (2 December, 1998). http://www.citizen.org/publications/release.cfm?ID=7104 (Accessed August 1, 2012). 19 Richard Horton, “The FDA and The Lancet: An Exchange (letter),” The Lancet 358 (2001): 417-418. 20 Moynihan et al., “Selling Sickness.” 17

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A Problematization of the Condition The increase of consumer-directed advertisements in the United States has helped to bolster medicalization of mental illnesses; pharmaceutical companies see individuals more so as consumers than patients. It has been well documented that advertisements create “desires.” Advertisements that purport that the prevalence of social phobia is high and that individuals will no longer be missing out on valuable relationships if they consider medication for the illness that they have are created by pharmaceutical companies in conjunction with consumer agencies and medical experts, so as to make a high number of people believe that they need medication to treat their social phobia. I would like to employ British sociologist Steven Yearley’s (b. 1956) “Actor-Network Theory” in order to give some tentative explanations how the process of pharmaceutical companies and medicalization of mental disorders works. According to Yearley’s theory, a group of actors or “truth-persuaders” undergo a series of social steps to medicalize a phenomenon. This begins primarily with a problematization of the condition, followed by the use of different social and medical techniques to construe that a condition is not a valid deviation but indeed a genuine illness. Then, frequently an enrolment of individuals in health care programs along with public roles in media events and advertisement campaigns occurs, which puts such individuals in the role of public representatives and proponents of medicalization, finally leading to a social mobilization of advocacy groups and stakeholders in the health care system.21 This enrolment stage is quite often flanked by company and medical publications, which have also played a large role in the historical example of the medicalization of adult ADHD. The public media likewise acts as a significant conduit to which pharmaceutical companies benefit from medicalization, since the tenets of the public media are often precisely in line with the functioning of many pharmaceutical corporations through economic interdependencies (payments for advertisement campaigns in newspapers and on homepages; the sponsoring of receptions and other social events; or cross-advertisement of media publications in company releases, etc.) and professional relationships (e.g. exchange of experts and other personnel between the two social systems).

21 Steven Yearley, Making Sense of Science: Understanding the Social Study of Science (London: Sage Publications, 2005).

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To give an example: Ciba Geigy has promoted childhood ADHD and adult ADHD and provided financial support to advocacy groups, in order to help furthering the problematization of the condition and ensuring that awareness of the disease remained present in societal discussions. The role of truth persuaders in social arenas is often taken on by medical experts. There are of course many medical experts, who are frequently hired by pharmaceutical companies or have advisor contracts and who will also advocate to the prevalence of mental illnesses and other diseases.22 To this end, it has been identified that between one quarter and one half of the psychiatrists involved in the publication of the DSM have received part of their income directly from pharmaceutical companies at some point. In both of these ways, medical experts are being deliberately recruited to problematize mental illnesses. As another example, Upjohn and Solvay shall be considered, a Belgian pharmaceutical company that manufactures the drug Luvox®, which is a psychotropic medication for the treatment of obsessive-compulsive disorder (OCD). This company has created brochures to appear in doctors’ offices, about the possibility of having obsessive-compulsive disorder, and with the intention that patients would ask their doctors about this medical condition and potential drug treatments for it. Upjohn and Solvay further funded specialized patient education programs and thus intensified the social and medical visibility of obsessive-compulsive disorder at large. Indeed, the more that people have come to think they might have such a disease, the more that disease was and is found and diagnosed.23 A spokesperson for Glaxo-Smith Kline, a British multinational pharmaceutical company that is one of the giants in research-based pharmaceutics, has stated that “PR [public relations] and media activities are crucial to a well-rounded campaign; particularly in the area of consumer awareness.”24 With the help of medical experts, the media, the psychiatrists – who have co-authored the Diagnostic Statistical Manual –, along with consumer groups and a wealth of financial resources, providerdriven demand has manifested itself as an important public force, while

22

Angell, “Is Academic Medicine for Sale?,” 1516-1518. Arline B. Curtiss, Depression is a Choice: Winning the Battle without Drugs, (New York: Hyperion, 2001). 24 Richard Deyo and Donald L. Patrick, Hope or Hype: the Obsession with Medical Advances and the High Cost of False Promises, (New York: AMACOM, 2005), 123. 23

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pharmaceutical companies have promoted the medicalization of mental illness. .

Conclusion Steven Yearley’s discussion on medical and social risk helps to delineate the fact that we have become a health-obsessed society pointing to the relationship of this with the problem of medicalization in western health care systems.25 Yearley has particularly stated that modern societies have become less focused with the production and allocation of goods and services and more concerned with ascertaining the decreasing risk of harm. These harms include pollution, the potential of radioactive contamination and, of course, medical diseases. In Making Sense of Science: Understanding the Social Study of Science (2005), he has analyzed that “A society’s risk anxieties relate as much to the cultural ‘insecurities’ of that society as to the actual extent of hazards.” When we apply this insight to the medicalization of psychiatric diseases, we can find for example––as has been argued in this paper––that the concerns for having conditions such as “ADHD” or “social phobia” often arise from media interventions or discourses on other social forums, which are frequently employed and dominated by the interests of globally active pharmaceutical companies. British sociologist of science Harry M. Collins’ (b. 1943) Empirical Programme of Relativism is thereby very useful in delineating the social driving forces and boundaries of medicalization. The main tenants in Collins’ theory are (1) understanding that scientific results are not absolute but flexible throughout history, and then (2) analyzing the social processes which are involved with the scientific, medical or technological interpretation of said results. (3) The final stage in his Empirical Program on Relativism is investigating the influence of society as a whole upon the scientists and physicians who both create classification of disease and develop the protocols for biomedical diagnoses.26 In the problematic case of medicalization of psychiatric illnesses, as I have argued above, we find that the technological imperative is at least one value in the medical community that promotes the medicalization of mental illness. The French philosopher and social theorist Emile Durkheim (1858-1917), one of the 25

Yearley, Making Sense of Science. Harry M. Collins, “Introduction: Stages in the Empirical Programme of Relativism,” Social Studies of Science 11 (1981): 3-10. 26

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founders of modern sociology, has stated that society is “external” and “coercive,” and indeed it would be remiss to neglect the role of society in defining illness in social and medical arenas, which are in turn coerced by the impact of pharmaceutical companies.27

27

Gianfranco Poggi, Durkheim (Oxford: Oxford University Press, 2000).

STIGMA AND GENDER

A LEPER BY NO OTHER NAME: PERPETUATING STIGMA IN MEDICAL DISCOURSE ANGELIQUE MYLES

SUMMARY: In 1995 a law had been signed in Brazil to outlaw the use of the term lepra, which was to be replaced with the word hanseníase.1 Hanseníase (referring to Hansen’s Disease and its bacteriological origins) was used in public health television campaigns to increase awareness of this new name. Now, why would a country undertake such an extreme measure to ban a word from being used by the public? The orchestrating of such an endeavor is not uncommon: swine flu was officially re-named H1N1; however, the re-labeling of leprosy was not as successful. For most people hanseníase simply became a synonym of lepra and the stigmatizing effects were also readily transferred. Treatment for leprosy became available in the 1940’s, and since 1981 multi-drug therapy has been the standard care. Nevertheless, despite the fact that the physical presence of the disease is no longer visible in developed countries, the use of “leper” in social discourse still allows the stigma to remain. Based on readings from a broad range of secondary sources I will explore the changing concepts of leprosy and illustrate how the rhetoric of the disease became more dangerous than the disease itself. The term ‘leper’ has become disassociated from the biomedical world and refers to a person avoided by others, a social pariah. The word ‘leprosy’ still conjures up images of rotting flesh and limbs falling off, both which are misinterpretations of the disease. The social construction of leprosy and its accompanying stigma have become part of our everyday language; thus words that were once used to describe the disease are now being used to refer to ‘otherness’ in society. Leprosy may be less of a medical threat today but, its rhetorical meanings and images persist. KEYWORDS: Leprosy; Hansen’s Disease; Medical Terminology; Stigmatization PRECEPTOR: Dr. Jim Connor INSTITUTION: Memorial University of Newfoundland 1

Cassandra White, An Uncertain Cure: Living with Leprosy in Brazil, (New Brunswick: Rutgers University Press, 2009).

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A Leper by No Other Name

Introduction In the Western countries2 leprosy may be under-appreciated and viewed solely as a medieval disease, recognized since the Book of Leviticus (6th century BCE) from the Hebrew Bible and the succeeding Christian tradition, but scarcely seen.3 The mythical status surrounding leprosy is partially due to the fact that it appears so remote from the current European experience. However, leprosy has no geographical boundary and still remains a serious health problem in over twenty countries, especially in India where there are an estimated 100,000 new cases per year.4 Fear of the disease still exists today, and it is people who are afflicted with leprosy and their families who must bear the burden of ostracism and forced seclusion.5 The term leper has lodged itself into common discourse and refers to a person avoided by others, a social pariah, and an untouchable. Mention the word “leprosy” and it will still conjure up images of rotting flesh and limbs falling off – both of which are misinterpretations of the disease.6 Popular views of leprosy have established it as a dark disease and the general population does not even have to possess real information about leprosy in order to envision horribly deforming images. The disease is also associated with tropical “jungle” life, despite the fact that it also has been endemic, although with minimal virulence, in countries such as England, Norway and Canada.7 The appearance of a leper segregated behind the walls of a leprosarium (“leprosorium” in the medieval European tradition) or banished with a bell or rattle still evokes a powerful reaction today.8 The negative and stigmatizing rhetoric that surrounds leprosy continues to infiltrate society and is imbedded in many cultures. For instance, in 2

Referring to cultures that are directly derived from European cultures, i.e. Europe, the Americas (North and South America), Australia, and New Zealand. 3 Jane Buckingham, Leprosy in Colonial South India, (New York: Palgrave, 2002). 4 Carole Rawcliffe, Leprosy in Medieval England, (Woodbridge: The Boydell Press, 2006). 5 “Lepers Still Feel Outcast, Discriminated Against,” Indian Express 2009. http://www.indianexpress.com/news/lepers-still-feel-outcast-discriminated-against/ 418652/ (Accessed April 20, 2010). 6 White, An Uncertain Cure. 7 Zachary Gussow, and George S. Tracy, “Status, Ideology, and Adaptation to Stigmatized Illness: a Study of Leprosy,” Human Organization 27 (1968): 316325. 8 Rawcliffe, Leprosy in Medieval England.

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Japan a law was established in 1953 that banished leprosy sufferers to sanatoriums. This law was abolished in 1996 and yet there are still occurrences where leprosy patients are exposed to extreme discrimination.9 These images have outlived the fact that leprosy is now curable with multi-drug therapy (MDT). The therapy combines antibacterial drugs and anti-inflammatory drugs, which are able to reduce nerve damage and prevent paralysis. My purpose in this paper is to discuss leprosy not as a disease but as a “term” that has become disassociated from the biomedical world. The rhetoric surrounding leprosy has been established since the Middle Ages and its mention in the Bible, thus its presence has been widely ingrained into cultural history in the Judeo-Christian Tradition. The social construction of leprosy and stigma in which it is embodied has become part of our everyday language. Thus words which once described the disease are now used to refer to “otherness” in society. Attempts to dissolve the terms leprosy and leper have been futile and this has been observed in various groups from medical and religious to the government and the general public. Leprosy may be less of a threat today in the developed world but its meanings and images remain culturally very active.

Background Leprosy, also known as Hansen’s Disease (HD)––named after the Norwegian physician Gerhard Henrik Armauer Hamsen (1841-1912), who described the pathogenic mycobacterium in 1873––is an infection of the skin and peripheral nerves by Mycobacterium leprae. In 2004, there were 407,791 new cases registered and thus leprosy continues to be a major public health problem.10 India, Brazil, Congo, Nepal, Tanzania, and Mozambique represent the countries with the highest number of new cases.11 Leprosy is also an illness burdened with meanings that range from stigmatization to moral defilement. Common belief held that it was by the

9

Justin McCurry, “Japanese Leprosy Patients Continue to Fight Social Stigma: 2 Years After Landmark Court Ruling, Incarcerated Patients Are Still Fearful of Returning Home,” The Lancet 363 (2004): 1396-1397. 10 World Health Organization, “Global Leprosy Situation, Weekly Epidemiological Record 80 (2005): 289-295. 11 Andrea K. Boggild, Jay S. Keystone and Kevin C. Kain, “Leprosy: A Primer for Canadian Physicians, Canadian Medical Association Journal 170 (2004): 71-78.

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will of God that people suffered from HD.12 A diagnosis of leprosy was essentially a death sentence. A person with HD became a social outcast and was required to be segregated from the rest of society.13 The ostracization of people with HD is pervasive throughout the history of the disease. The separation was implemented as a method used to deal with the fear and ignorance of the illness. The first International Leprosy Congress was held in Berlin in 1897 and resulted in the formal statement that isolation of leprosy sufferers must be practiced as far as possible to prevent transmission of disease.14 In 1873 Dr. Gerhard Hansen had discovered the leprosy bacillus, Mycobacterium leprae, in collaboration with the Breslau dermatologist Albert Ludwig Siegmund Neisser (1855-1916) to whom he had sent the specimens for further histopathological refinement and staining of the bacteria.15 This revelation provided evidence that people with HD were not victims of heredity or the wrath of God. There was a scientific explanation and proof that leprosy was not a disease cast down upon sinners–– it was in fact caused by a bacterium. Another misconception is that leprosy was believed to be highly contagious and that the infected had to be isolated, however, its transmissibility is quite low.16 Furthermore, ninety-five percent of people have a natural immunity to the disease.17 Despite this discovery the mode of transmission of HD is still uncertain and is thought to spread from human to human by droplets emitted during breathing or sneezing.18 Moreover, leprosy remains a “medical enigma”19 because modern physicians still do not know with certainty why the 12

Saul Nathaniel Brody, The Disease of the Soul: Leprosy in Medieval Literature, (Ithaca and London: Cornell University Press, 1974). 13 In 1737 (reprinted in 1974), the sequestering of lepers was carried out in the form of a burial ceremony: His face was covered by a black veil as he heard the mass. The officiating priest threw a spadeful of earth from the cemetery on the head of the leper three times, explaining that the ritual symbolizes the death of the leper to the world. The priest said: “Be dead to the world, be reborn to God.” (Ibid., 66). 14 Jane Buckingham, Leprosy in Colonial South India. 15 Gerhard Armauer Hansen, The Memories and Reflections of Dr. Gerhard Armauer Hansen, (Wuerzburg: German Leprosy Relief Association, 1976). 16 White, An Uncertain Cure. 17 Marcia Gaudet and James Carville, Remembering Leprosy in America, (Jackson: The University Press of Mississippi, 2004). 18 Nick Beeching, “Leprosy,” in Geoff Gill and Nick Beeching, eds., Lectures on Tropical Medicine, (Oxford: Blackwell Science Ltd., 2004). 19 Rawcliffe, Leprosy in Medieval England, 2.

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majority of people exposed to the Mycobacterium leprae have immunity, while others do not. Even though genetic susceptibility plays a valid role in the determination of who contracts the disease and who does not, the issue of poverty and structural inequalities also provides a major reason as to why we still see several hundred thousand new cases of leprosy each year worldwide.20 Leprosy is a disease of deformity and permanent physical impairment. If the disease is left untreated or undetected in the early stages it can lead to complications, such as the “claw hand,” in which the fingers become paralyzed in a claw-like position. Bones in fingers and toes may become reabsorbed, which gives a shrunken and swollen appearance in the hands and feet.21 These deformations represent the source of the myth that leprosy causes parts of the body to drop off. Treatment for leprosy became available in the 1940’s when Dr. Guy Faget (1841-1947) at Carville22 discovered that sulfone drugs were able to kill the bacteria.23 Since 1981, MDT has been used as the standard form of treatment and is highly effective, relatively free from side effects, and free of charge.24 MDT has prevented approximately two million people from developing disabilities associated with leprosy.25 Despite the fact that MDT is available and can treat leprosy within six to twelve months,26 it is the stigma of the disease that is a major factor leading to late diagnosis and it is the delaying of treatment that enables time for active transmission of the bacteria.27 Leprosy is a reportable disease and if there are suspected cases then the public health department should be notified.28

20

White, An Uncertain Cure. Ibid. 22 Carville, Louisiana, USA provided the only in-patient treatment hospital for leprosy patient from 1894 to 1999. 23 White, An Uncertain Cure. 24 MDT treatment has been made available by WHO free of charge to all patients worldwide since 1995. 25 MDT can clear viable bacilli but does not prevent nerve damage. 26 Beeching, “Leprosy.” 27 K. Abbrev Senior, “Stigma, Chemoprophylaxis, and Leprosy Control,” The Lancet 9 (2009): 10. 28 Boggild, Keystone and Kain, “Leprosy: A Primer for Canadian Physicians,” 7178. 21

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In 1991, the World Health Assembly set out to “eliminate”29 leprosy as a global health issue. Since the initiation of the program, fifteen million people have been cured of leprosy. Nevertheless, there are still numerous challenges to providing a timely diagnosis and treatment in order to avoid the development of permanent disabilities.

Leprosy Re-Branded The biggest disease today is not leprosy or tuberculosis, but rather the feeling of being unwanted.30 ––Mother Teresa (1910-1997)

Leprosy is unlike any other disease because it has had the unrivalled capacity to become more than a medical pathology. Leprosy is able to effortlessly become a focus for almost anything society finds troubling or fearful.31 For example, the New Zealand-born English professor Rod Edmond (b. 1944?) at Kent University compares communism with leprosy and states that “communism, like leprosy, is a contagion, and both are definitely un-American.”32 The term leprosy has become disassociated from the physical manifestations of the disease33 and redefined as an all-encompassing term used to label outcasts and social pariah.34 Leprosy has become entangled in the myriad of marginalized members of society: poverty, criminality, and insanity.35 It is understood less as a discrete term and more as an association with social outcasts. A leprosy sufferer in India not only embodied the stigma of the disease but also the label of poverty, vagrancy

29

Elimination is defined as prevalence of less than one case per 10,000 people. The Mother Teresa Center, Love: The Words and Inspiration of Mother Teresa, (Boulder, Co: Blue Mountain Press, 2007), 31. 31 Rod Edmond, Leprosy and Empire: A Medical and Cultural History, (Cambridge: University Press, 2007). 32 Ibid., 2. 33 Leprosy symptoms can take a decade or longer to develop. Skin and nerve cells are affected by Mycobacterium leprae, which creates discoloured lesions or patches of various sizes, shades and elevation. 34 Rawcliffe, Leprosy in Medieval England, 2. 35 As seen in the publication of Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (French 1961), transl. by Richard Howard (New York: Vintage Books, 1965). 30

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and criminality.36 Despite the fact that leprosy affected all races and socioeconomic classes in India, it was the poor and vagrant leprosy sufferers who were the focus of British attention and subjected to the British legal and medical authority. This was experienced through police intervention and hospitalization of the leprosy sufferer.37 Leprosy has been used as a metaphor for the human condition. For instance, the French cultural philosopher Michel Foucault (1926-1984)38 ascribes to the leper a status of social exclusion and subordination to external authority. The publication by the British cultural historian Timothy A. Hickman, The Secret Leprosy of Modern Days: Narcotic Addiction and Cultural Crisis in the United States, 1870-1920 also illustrates this point.39 The book is not about leprosy the disease but projects the image of social undesirables onto a new group of individuals––narcotic addicts, who are now branded as lepers. Leprosy has now become a catchall for any type of social outcast. This contrasts decisively with the situation of the Medieval Ages, since the accusation of leprosy changed its target; after 1170 CE vagabonds, beggars and heretics were burdened with leprosy, whereas the rich and powerful were all of a sudden immune. Leprosy sufferers were segregated into leprosariums to create order and allow for a highly structured society to evolve.40 The English historian Carole Rawcliffe uses the story of Alice Dymock (b. 1462) to illustrate the transference of leprosy as a sufferer of a disease to a term defining social undesirables branded as leprous: Alice Dymock was from Yarmouth and in the mid-1480’s she had charges of petty larceny, quarrelling with her neighbours and selling ale without a license. In 1496 she incurred fines for promoting immorality, scolding and receiving her lover. She was back in court in 1489 and again the following year. By 1499 a catalogue of charges now embraced keeping a suspicious house, bawdry and cursing her exasperated neighbours. In 1500 Alice was presented as a leper, who committed a grave nuisance by mixing among 36

Buckingham, Leprosy in Colonial South India. Ibid. 38 Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (French 1961), transl. by Richard Howard (New York: Vintage Books, 1965), 3. 39 Timothy A. Hickman, The Secret Leprosy of Modern Days: Narcotic Addiction and the Cultural Crisis in the United States, 1870-1920, (Amherst: University of Massachusetts Press, 2007). 40 Mary Douglas, “Witchcraft and Leprosy: Two Strategies of Exclusion,” Man 26 (1991): 723-736. 37

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A Leper by No Other Name adults and children. She was ordered to leave the borough within three months.41

It was Alice’s history of misbehaviour that branded her a spiritual if not a physical leper. This demonstrates the lengths taken by rulers of medieval British towns to protect the urban environment from corruption. A labeling of leprosy thus quickened Alice’s eviction from the general public and warranted a classification of social deviant. Another example was observed in 1905 when Penikese Island, Massachusetts was turned into the first “leper hospital” in the USA.42 Eight years after its inception Penikese was seen to have become less like a hospital and more like a dumping ground for people cast from society and shunned by the general public. Both of these situations exemplify the statement by the American public intellectual Susan Sontag (1933-2004) that “any disease that is treated as a mystery and acutely enough feared will be felt to be morally, if not literally, contagious.”43

Leprosy in Brazil: Hanseníase a Disease without Stigma? The term leper and leprosy are considered insulting and inappropriate except for in the Biblical context. Thus, there is a historical attempt to use Hansen’s Disease to distinguish between the present reality and the past symbol and myth:44 In 1932, Brazil described leprosy as “the most afflicting … and the most urgent of all national problems.”45 Leprosy was considered a sign of backwardness, and its presence was thought to discourage immigration of Europeans, who were considered desirable at the time. It was not until the 1970’s that forced isolation policies for leprosy were changed. In an attempt to reduce the stigma associated with leprosy, hanseníase was adopted by Brazilian leprologists to replace the term lepra. In 1976, the Brazilian Ministry of Health also favoured the term hanseníase. In 41

Rawcliffe, Leprosy in Medieval England, 252-253. Philip A. Kalisch, “Tracadie and Penikese Leprosaria: A Comparative Analysis of Societal Response to Leprosy in New Brunswick, 1844-1880, and Massachusetts, 1904-1921,” Bulletin of the History of Medicine 47 (1973): 480-512. 43 Susan Sontag, Illness as Metaphor, (New York: Farrar, Straus and Giroux., 1978), 6. 44 Gussow and Tracy, “Status, Ideology, and Adaptation to Stigmatized Illness,” 316-325. 45 White, An Uncertain Cure. 42

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1995 a law was signed to outlaw the use of the term lepra in Brazil.46 In contrast, the international community has been slow to adjust to the new terminology and has resisted the change because “‘Hansen’s Disease’ does not have the same power to attract charitable donors.”47 The World Health Organization (WHO) continues to use leprosy as well such organizations as the American Leprosy Missions. In Brazil the term hanseníase is used in public health campaigns on television, therefore its awareness is increasing. Nevertheless, the term lepra has not been entirely replaced and for some people the two terms have created a notion that hanseníase and lepra are separate diseases and that there is no connection between them.48 For most people hanseníase has simply become a synonym of lepra and the stigmatizing concepts are being transferred to the use of the term hanseníase. Even when language is stigmatizing, re-labeling does not always render the damaging term extinct. This is due to the fact that language has a deeper and lasting influence on social attitudes than any definition adopted by those in power.49 There is a cultural folk model in Brazil, which associates leprosy with dogs and that leprosy is carried by dogs.50 As with the difficulties in the translation of the Hebrew word tzaareth in the Bible to “lepra,” a similar situation occurred with the adoption of lepra in Portuguese. The word lepra is translated as both “leprosy” and “dog mange” in Portuguese, thus a misinterpretation can be made revealing that leprosy comes from dogs, and this is also visually reinforced because dogs are often seen with bad skin problems and open sores.51 This association is strengthened when examining the depiction of dogs licking the wounds of the catholic saints most closely linked with the disease, Saint Lazarus and Saint Roch. Other folk models in Brazil included the transmission of leprosy by eating certain foods, such as pork or fish.52 The association with leprosy and fish has been seen in other cultures as well. The British blamed leprosy on

46

Ibid. Ibid., 34. 48 Ibid. 49 Liora Navon, “Beyond Constructionism and Pessimism: Theoretical Implications of Leprosy Destigmatisation Campaigns in Thailand,” Sociology of Health & Illness 18 (1996): 258-276. 50 White, An Uncertain Cure. 51 Ibid. 52 Ibid. 47

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eating stale fish53 and the Chinese believed that leprosy was connected with consuming carp.54 Leprosy is a disease, can be called the epitome of stigmatization. There has been strong opposition by the biomedical community and leprosy sufferers to denounce the use of the terms leper and leprosy as it continues to perpetuate the stigmatizing views. A number of authors have had to validate the use of specific terms in their writing. Carole Rawcliffe, for example, acknowledges campaigns to eradicate terms, such as “leper” and “leprosy” from modern scientific and popular discourse.55 Nevertheless, the battle has only been partially successful. Today, the media and tabloid press still revert to offensive stereotypes of the “outcast leper.”56 However, with regards to Rawcliffe’s book to describe medieval lepers as “sufferers of Hansen’s disease” would be misleading. It would defeat the historical rationale of the book because Rawcliffe is examining lepra in all of its manifestations and diagnostic complexities through the experiences of medicine men and women. This view was also stated by the Canadian historian Philip Kalisch, when he acknowledged the fact that the terms “leper,” “leper home,” and “leper colony” are degrading to present victims of leprosy or HD patients, but in the interest of historical scholarship these words are employed to maintain accuracy.57 In addition, the New Zealand historian Jane Buckingham has stated that in the Hindu culture the people most affected by social and religious ostracism were the poor leprosy sufferers.58 By keeping the medical term leprosy it allows for the voices of those who have suffered to provide insight into the present experience of

53

Buckingham, Leprosy in Colonial South India. Loh Kah Seng, “‘Our Lives Are Bad but Our Luck is Good’: A Social History of Leprosy in Singapore, Social History of Medicine 21 (2008): 291-309. 55 Rawcliffe, Leprosy in Medieval England. 56 Headlines searched at random from online newspapers: ‘I feel like a leper admits Chambers’ (Guardian, 13 February 2008); ‘We’re beginning to feel like lepers, say Toronto residents’ (Guardian, 25 April 2003); ‘The day Conrad Black became a social leper’ (The Times, 12 November 2006); ‘Social lepers only in new `social exclusion unit’ (The Independent, 16 December 1997); ‘They treated me like a leper’ (Journal of General Internal Medicine 18, 2003, pp. 835-844). 57 Philip Kalisch, “Tracadie and Penikese Leprosaria: A Comparative Analysis of Societal Response to Leprosy in New Brunswick, 1844-1880, and Massachusetts, 1904-1921,” Bulletin of the History of Medicine 47 (1973): 480-512. 58 Buckingham, Leprosy in Colonial South India. 54

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leprosy and “it also recognizes the suffering of disease as a significant part of human history.”59

Leprosy: Ammunition to Support Campaigns Since biblical times, leprosy has become one of the most powerful medical and social tropes in human cultural history and literature. Manifesting itself as the ghoul costume, the rattle, and the chains, spurring feelings of revulsion and grotesque deformations.60 Contemporary leprosy has managed to acquire all of the characteristics of the medieval disease. The association regarding the identification of Old Testament leprosy with HD has been repeatedly criticized. In this context, the religious response to leprosy has been further profoundly influenced by the book of Leviticus61 and thus, Christian missionaries are seen to still invoke images of the unclean leper, expelled from society.62 HD sufferers63 have rallied against the church to remove the stigma that modern science has now been able to disprove. This social stigma was also deliberately used by protagonists of the Christian church during the Medieval Ages to create fear and horror but is now regarded as socially harmful and unjustified. Nevertheless, the missionary’s activity among leprosy sufferers depends upon the success of actively promoting the image of ostracism, suffering, and victimization for charitable purposes.64 Many charities that support leprosy sufferers have been criticized for pursuing the negative images through fundraising activities that depict leprosy sufferers as deformed and outcast.65 There are certain behavioural practices that contradict the stigma which surrounds leprosy. In separate communities in Ethiopia, affected and unaffected people were not segregated, nor were infected monks secluded from the community. This was possibly due to the widespread Ethiopian 59

Ibid., p. 6. Cf. Waren Dotz, “Leprosy: Reality and Metaphor in Literature,” The American Journal of Dermatopathology 4 (1983): 377-380. 61 Chpt. 13 of the Book of Leviticus: “He is a leprous man, he is unclean.” 62 Websites searched at random that display images of leprosy sufferers: “The Leprosy Mission Canada,” http://www.leprosy.ca/Page.aspx?pid=191 (Accessed April 15, 2010). 63 The Star (Carville’s patient magazine) campaigned to lift the stigma associated with leprosy that have been common since the Dark Ages but was unable to change the attitudes towards leprosy sufferers. 64 Rawcliffe, Leprosy in Medieval England. 65 Navon, “Beggars, Metaphors, and Stigma,” 89-105. 60

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belief that leprosy was a God-given, inherited disease that was not contagious.66 All monks refused treatment, “believing that the more maimed they were with leprous lesions, the purer their souls became.”67 The American anthropologist Cassandra White, states that: The reasons why a particular condition, character trait, or behaviour might be stigmatized does not necessarily have to do with any inherent feature of the attribute itself; it is more about how the features of an attribute are understood within a particular historical, cultural context.68

As noted above, leprosy became a haven for missionaries because it symbolized Christian charity. The history of leprosy treatment among the karo people of Sumatra exemplifies how missionaries used the situation as an evangelistic opportunity, which was thus dissolved in the twentieth century with the advent of new therapies. The leper in missionary work became the ultimate sufferer and thus leprosy work represented the essence of Charity as missionaries set out to redeem the leper.69 Caring for leprosy sufferers represented the self-sacrifice imbedded in Christian faith and thus the disease presented missionaries with a target population ready to receive a new religion and maintain a relative amount of control over people that was not possible elsewhere.70 Conversely, the negative imagery surrounding leprosy has also been used to the advantage of the sufferer. In the 1950’s a nationwide leprosy control program was initiated in Thailand. Up until the 1950’s beggars in Thailand were widely associated with having leprosy and thus there was a move to institutionalize the disease to solve the problem of beggary altogether.71 The haunting images of leprosy sufferers were observed to have been cultivated by those suffering from leprosy as they displayed their disfigurements and mutilations to arouse pity from the public.72 This has also been observed, for example, when the English anthropologist and 66 Richard Pankhurst, “The History of Leprosy in Ethiopia to 1935,” Medical History 28 (1984): 57-72. 67 Frank D. Schofield, “Some relations between social isolation and specific communicable diseases,” American Journal of Tropical Medicine and Hygiene 3 (1970): 167-169. 68 White, An Uncertain Cure, 133. 69 Rita Smith Kipp, “The Evangelical Uses of Leprosy,” Social Science & Medicine 39 (1994): 165-178. 70 Ibid. 71 Navon, “Beggars, Metaphors, and Stigma.” 72 Ibid.

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medical writer James Staples (b. 1850) saw leprosy sufferers in Mumbai,73 where in most other interactions leprosy deformities are disguised, however in order to beg; the disfigurations were accentuated or even invented.74 Furthermore, in Ethiopia, leprosy sufferers appeared to beg with almost total impunity.75 They would beg every morning from houseto-house and were scarcely refused because if they were they would return on the following night to curse any houses where they had been rejected and a popular threat would be to state, “I will lie on your bed.”76 Staples, also noted that begging was not seen to be a proper form of incomegeneration and that people would most likely conceal the fact that they earned money through begging, as they would conceal their leprosy deformities in non-begging situations.77

Leprosy in Translation Leprosy in Thailand was viewed as the most rejected medical phenomenon and was linked to ugliness, hopelessness, inferior status, and perceived as the “living dead” and associated with ghosts and stray dogs.78 Leprosy had further been seen as a disease that could only be religiously and socially accounted for through the accumulation of bad karma from numerous life cycles.79 There are some Thai words that became associated with leprosy and beggars; khitian means for example both a “leprous person” and a “leprous dog.” Dogs are perceived as worthless animals in Thai culture and thus this association with beggars illustrates the disgust felt by passers-by.80 When medical care of leprosy arrived in the 1950’s leper villages were changed into rehabilitation villages and social views gradually began to change towards leprosy patients, allowing them to become more accepted into Thai society and to lead normal lives. Thus, it 73

Staples stated that: “one man I knew, for example, improved his credibility as a beggar by wrapping his healthy hand––the one he held outstretched to passers-by for alms––in a length of bandage before setting out each morning. 74 James Staples, “Begging Questions: Leprosy and Alms Collection in Mumbai,” in James Staples, ed., Livelihoods at the Margins: Surviving the City, (Walnut Creek: Left Coast Press, Inc., 2007), 173. 75 Pankhurst, “The History of Leprosy in Ethiopia to 1935,” 57-72. 76 Ibid., 66. 77 Staples, “Begging Questions.” 78 Navon, “Beggars, Metaphors, and Stigma,” 89-105. 79 Ibid. 80 Ibid.

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seems contradictory that attitudes towards leprosy would revert to negative associations. Moreover, the Israel nursing scholar Liora Navon has revealed that in 1978 and 1983 leprosy was still associated with the figure of the beggar and that the disease was prevalent in dirty and primitive areas.81 Moreover, young leprosy patients who were interviewed separated themselves from real lepers, because they did not look like a leper, despite the fact that they had the disease. Opportunities to identify leprosy sufferers have diminished since the number of disabled patients has decreased due to the advent of MDT, with the newly diagnosed displaying no visual signs of the disease. Hence, there are terms, such as khirian, khitud, and khutang that used in everyday language (like “leper”) but which are detached from the disease leprosy itself.82 The words are used as metaphors for social inferiority to degrade other people if they are doing something that does not fit into the social surroundings, as opposed to actually describing a person with leprosy. Leprosy may no longer be associated with a physical beggar but the use of terms describing the person remains figuratively in the culture and embedded in their language. This disassociates the words from their stigmatizing origin and “normalizes” its use. As leprosy patients move away from the public eye the negative imagery associated with the disease will persist because there will be no one to refute these claims.83 This has occurred in other countries, such as the United States or Israel where leprosy rates are low but the public still view the disease as an extremely stigmatized health condition, despite the fact that it does not create a sense of personal threat.84 It is also important to note that the term for leprosy in Chinese even implies “moral corruption,” thus reaffirming that the word has acquired multiple meanings and associations and became embedded into the language of many different countries. Another example of the term leprosy being used under a different meaning appears in the journeys of the nineteenth-century British nurse Kate Marsden (1859-1931) to learn about the condition of several remote leper colonies in Central and Eastern Siberia.85 She witnessed the misery 81

Ibid. Ibid. 83 Ibid. 84 Ibid. 85 Kate Marsden, On Sledge and Horseback: To the Outcast Siberian Lepers, (New York: Cassell Publishing Company, 1892), 163. 82

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of the leprosy sufferers and their expressions of hopelessness. She also noted that Russians, who are sent for service into the Viluisk district of the northeastern Russian Sakha region use the name “leper” as a swear word:86 The swear word represents an illustration of the intense dread the natives have of leprosy and their conviction that “leprosy” originate[d] from the devil. ‘Smallpox, measles, scarlet fever,’ they say were appointed by God; but leprosy was sent by the devil. Hence the belief that lepers are possessed.87

These examples illustrate the strength of language and words even in modern societies. The transference of meaning from one association to another allows for discriminatory terms to persist in everyday society because the words take on a distinct meaning in absence of the disease in which they once represented. In contrast, there have been other diseases such as tuberculosis, which have been renamed without the same implications of negative social meanings.

Disease, Discourse, and Imagery of the Social Pariah: From Plague, to Leprosy, to Cancer, to AIDS, etc. Leprosy disappeared, the leper vanished, or almost, from memory; these structures remained. Often, in these same places, the formulas of exclusion would be repeated, strangely similar two or three centuries later. Poor vagabonds, criminals, and “deranged minds” would take the part played by the leper … .88 ––Michel Foucault (1961)

The misinterpretation of leprosy was due in effect to faulty translation. Lepers in the Old Testament suffered from a skin condition known in Hebrew as sãra’ath, which described physical symptoms, such as scaly, scabrous, and raw skin. This description came to embody many other skin diseases, such as eczema and favus.89 When the Hebrew word was translated to Greek in the second century BC, sãra’ath was renamed lepra and became associated with a range of benign skin conditions. Lepra 86

Ibid., 163. Ibid. 88 Foucault, Madness and Civilization, 7. 89 Rawcliffe, Leprosy in Medieval England. 87

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entered into the Latin vocabulary and was then used my medieval Christians. The vocabulary used to describe leprosy and its victims during this period became very complex and thus have affected our modern day understanding of the disease. The spots and stains of leprosy transformed into an effective metaphor for various manifestations of sin.90 It has been argued that medieval lepers were constantly misdiagnosed, however up until Hansen discovered the bacterium, Lepra represented a broad definition that encompassed many skin diseases and therefore the link between Hansen’s Disease as we know it today and lepra could not have existed.91 Furthermore, the Bible also discussed leprosy of house walls and of garments, which was definitely not caused by M. leprae.92 The socially laden terms associated with sickness and diseases have morphed into a parlance that allowed for the use of terms, such as cancer and leprosy in metaphors so that they add meaning to observations and statements. Leprosy is projected as a representation of the Medieval Ages when all-too-often prejudice and superstition guided people’s views and beliefs. Nevertheless, leprosy persists today and has become an emblem of decay, be it physical or moral. Susan Sontag has stated, for example, that “nothing is more punitive than to give a disease a meaning – that meaning being invariably a moralistic one. Any important disease whose causality is murky, and for which treatment is ineffectual, tends to be awash with significance.”93 In the West, the “leper’s” diseased body was the disgraceful metaphor of social disorder and was paired with dangerous affects that had to be controlled.94 Thus, “contagious leprosy” was used to solve social dilemmas by re-labeling (see former discussion on leprosy re-branded) difficult members of society (vagabonds, homeless wanderers, mentally ill) who needed to be put away and controlled.95 This form of labeling is observed in a wide variety of medical terms used as metaphors – from plague, heart attack to the use of general terms – disease, and disability.96 This was noted by Canadian health scholar Barbara Clow when examining the metaphors associated with tuberculosis and cancer: 90

Ibid. Ibid. 92 White, An Uncertain Cure. 93 Susan Sontag, Illness as Metaphor and AIDS and its Metaphors, (New York: Picador, 1990), 58. 94 Douglas, “Witchcraft and Leprosy,” 723-736. 95 Ibid. 96 Sontag, Illness as Metaphor and AIDS and its Metaphors. 91

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Tuberculosis enjoyed at least some measure of luster along with connotations of taint, while cancer was regarded with unmitigated horror, an illness with no redeeming virtue.97

The word cancer came to embody malevolence as well as malignance, thus adding unwarranted meaning to the disease.98 In her public writings and critiques of the established medical system in the United States, Susan Sontag sought to eliminate disease metaphors in order to allow sufferers to realize that cancer was a biological phenomenon rather than a social or moral one.99 She stated that a person living with a disease should not feel blame or guilt and there should be a movement to eliminate such discourse from being used.100 However, Pennsylvania-based medical historian Robert Allan Aronowitz argues that this debate illustrates a rather naïve and fantastical solution in which the biological core of disease can be separated from the attitudes, beliefs and social conditions in which it resides.101 Disease shapes and is shaped by human experience. As with leprosy, the negative imagery and metaphors associated with cancer have established the disease as loathsome and shameful. Every aspect of a person’s identity is constructed, as is pathological disease and the perception of illness. The social construction of disease constantly reminds us that medical thought and practice are never free from cultural constraint.102 When explaining sickness, terms and phrases will effortlessly develop because of the emotional and social experiences of the illness, and therefore the adoption of a disease in society is ultimately dependent upon social and biological factors.103 For instance, the word cancer is now synonymous with evil and is placed in sentences elucidating

97

Barbara Clow, “Who’s Afraid of Susan Sontag? Or, the Myths and Metaphors of Cancer Reconsidered,” The Society for the Social History of Medicine 14 (2001): 293-312. 98 Sontag, Illness as Metaphor and AIDS and its Metaphors. 99 Clow, “Who’s Afraid of Susan Sontag?,” 293-312. 100 Sontag, Illness as Metaphor. 101 Robert Allan Aronowitz, Making Sense of Illness: Science, Society, and Disease, (Cambridge: Cambridge University Press, 1998). 102 Charles E. Rosenberg, “Framing Disease: Illness, Society, and History,” in Charles E. Rosenberg, ed., Explaining Epidemics and Other Studies in the History of Medicine, (Cambridge: Cambridge University Press, 1991). 103 Aronowitz, Making Sense of Illness.

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images of darkness and shame––“Cancer that is gnawing away” represents its destructive association.104 Metaphorical images attributed to diseases are also transferable from one disease to another and it has been stated that acquired immunodeficiency syndrome (AIDS) has come to be known as the leprosy of the twenty-first century.105 Therefore, the images and meanings deposited on the disease leprosy are unceremoniously thrust upon people living with AIDS. The ignorance and fear of new diseases perpetuates stigma and studies have documented that people have the same views towards AIDS as they did with leprosy––that people with AIDS should not be allowed in society and any form of physical contact was to be avoided.106 In the early 1980’s, AIDS was a mysterious disease and it immediately evoked parallels with historic ones, such as bubonic plague, influenza and leprosy.107 The “AIDS hysteria” was created out of fear, not just of death but also of the unknown. The historic diseases left their mark equally in linguistic relics (“I’d avoid him like he had leprosy” or “I’d avoid it like the plague”).108 Thus, AIDS being relatively new is conceptualized in the context of our past experiences with diseases and the obscure. AIDS all of a sudden became the new leprosy and was quickly associated with death and punishment of sin, just as leprosy has been since the Middle Ages.109 The constant use of the terms leper and leprosy associated with human immunodeficiency virus (HIV) infection and people living with AIDS strengthens the sense of “otherness.” The leper is perhaps the most persistent widespread image of human exile and is viewed as someone who resides outside of the human community, both physically and spiritually.110 When diseases are viewed in this form they render a person as different and other than the rest of us – 104

Clow, “Who’s Afraid of Susan Sontag?,” 293-312. Sontag, Illness as Metaphor And AIDS and its Metaphors. 106 Gregory M. Herek, and John P. Capitanio “Symbolic Prejudice or Fear Of Infection? A Functional Analysis of AIDS-Related Stigma Among Heterosexual Adults,” Basic and Applied Psychology 20 (1998): 230-241. 107 William David Ross, “An Ethics of Compassion, a Language of Division: Working on the AIDS Metaphors,” in Carlos Cortess and John Pittman, eds., AIDS: Principles, Practices & Politics, (New York: Hemisphere Publishing Corporation, 1987). 108 Ross, “An Ethics of Compassion, a Language of Division: Working on the AIDS Metaphors.” 109 Ibid. 110 Ibid. 105

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leaving them to the slow death, deprived of relationships and human contact. By casting people living with AIDS and HIV into the story of leprosy they too become the “other” and thus it can be deemed justifiable to treat them less generously, less compassionately and less fairly.111 Consequently, it is the people living with diseases, such as cancer and leprosy (as well as their families) that must bear the burden of being associated with distasteful metaphors that reinforce the negative imagery associated with the diseases. The dissociation between the term leper and leprosy outside of its medical context has also occurred with another disease––typhoid.112 Mary Mallon (1869-1938) was an immigrant woman who made her living as a cook. She contracted typhoid around 1900 and became a healthy carrier of the disease.113 Most people have heard of “Typhoid Mary” and the phrase itself produces images of someone who carriers and gives disease to others. Mary is often portrayed in art as a cook stirring a pot of skulls. Nevertheless, the history behind the phrase has dissolved and the term has taken on a life of its own.114 The term “Typhoid Mary” has entered the English language as a phrase independent of Mary Mallon herself. As with the history of leprosy, Mary’s story has been misinterpreted and therefore accounts have been dramatized. “Typhoid Mary” is seen as a threat of contagion and pollution and continues to refer to a person to be feared and shunned, someone who carries a disease inside their body, which is intended to harm people around them.115 Mary Mallon was seen as part concept, part human. She had evolved into a catchall phrase and the media is still smitten with the term “Typhoid Mary.” 116 The current use of the phrase was used in an article in the Los Angeles Times in 2009, which stated: 111

Ibid. Typhoid fever is a life-threatening illness caused by the bacterium Salmonella Typhi. Department of Health and Human Services: Centres for Disease Control and Prevention, “Typhoid fever,” 2005, http://www.cdc.gov/ncidod/dbmd/ diseaseinfo (Accessed April 15, 2010). 113 Judith Walzer Leavitt, Typhoid Mary: Captive to the Public’s Health, (Boston: Beacon Press, 1996). 114 Leavitt, Typhoid Mary: Captive to the Public’s Health, 1. 115 Ibid., 203. 116 Quotations from articles searched at random: “Courtney Love may have been the late Kurt [Donald] Cobain’s [1967-1994; famous guitar musician with the rock group “Nirvana”] sweetheart, but much of America has long regarded her as rock’s Typhoid Mary” in ‘Love without emotion’ (guardian.co.uk , 8 February, 2004); 112

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A Leper by No Other Name The flu was over, but I was hacking like a computer geek. I spent much of the flight in the restroom, where I could convulse into coughing fits in private. Every time I opened the door, passengers glowered at me. By the time I arrived in Taipei, people were avoiding me as though I were Typhoid Mary.117

Another exemplary article appeared in an article in the New York Times earlier in 2005, which described: Odds are, if you’ve held a job, you’ve played hurt at least once. By this I mean you’ve been at your desk when you should have been in traction. Working sick comes in two categories: dragging yourself to work with something contagious, which makes you Typhoid Mary, and dragging yourself in when only you are suffering, which makes you Curt Schilling [b. 1966 – a well-known American baseball pitcher], bleeding through your sock for the sake of the team.118

Mary Mallon was among tens of thousands of Americans over the twentieth century who carried typhoid bacilli chronically within their bodies. She was among many who defied authorities by continuing to cook after being told of her carrier status. Nevertheless, we still see Mary Mallon as unique. Her name has now become a widespread negative description. Thus, like leprosy, the phrase “Typhoid Mary” has become a metaphor for contagion and the careless or purposeful spread of disease or infection and, more broadly evil.119 An interesting method of developing meaning can be seen when one “plague” is played against another to illustrate how dire a situation really is. In 1967, medical historian and physician Gordon W. Jones (1924-2012) wrote a survey article on “The Scourge of Typhoid.”120 He attributed Mary Mallon to the 1903 epidemic in Ithaca, New York in which 1,300 people

“The most I could get out of them was that you know, they did have an increase in cases around the time that the dog was tested, so we could kind of make that link. But I have no idea whether the dog was the Typhoid Mary or not” in ‘Poodle in pet therapy program found to have epidemic strain of C. difficile’ (The Canadian Press, 8 May, 2006). 117 “A Tutorial in Asian Healing Arts,” The Los Angeles Times (12 April, 2009). 118 “The Line Between Mettle and Martyrdom,” The New York Times (January 16, 2005). 119 Leavitt, Typhoid Mary. 120 Gordon Jones, “The Scourge of Typhoid,” American History Illustrated (1967): 22-28; esp. 25-26.

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contracted the disease.121 Although he blamed Mallon he also stated “no leper in the Middle Ages ever felt the hostile attention of the authorities more strongly.”122 Thus, a leper continues to remain the epitome of stigmatization when compared to other diseases and therefore adds meaning by allowing for typhoid to be measured against leprosy in order to demonstrate how dire the situation really was. PathologicalDisease discourse has also been seen in literature, which can act as another medium to perpetuate negative associations with disease. For instance, leprosy illustrated in the nineteenth and early twentieth- century fiction was meant to shock and imbue fear rather than inspire and moralize. In The Picture of Dorian Gray,123 the Irish writer and poet Oscar Wilde (1854-1900) describes the “leprosies of sin,” that are slowly eating away at the portrait hidden in the attic––it was “from within, apparently that the foulness and horror had come … .” Furthermore, in Graham Greene’s (1904-1991) novel, A Burnt-Out Case, the character named Querry, represents the burnt-out case of the title, exemplifying life in general as the disease from which he suffers.124 The multifaceted associations that have come to embody the burdensome term of leprosy are prevalent within multiple levels of modern societies.

Leprosy: The Invincible Term Leprosy is a term that will forever remain in our lives because it has become integrated into our language and culture through images and historical context and has taken on new meanings in various languages that are separate from the disease itself. Leprosy will always be known as the “fate worse than death.” In the 1800’s leper hospitals were described as “graveyards for the living.”125 Leprosy remained frightening not because it killed but because it left one alive with no hope.126 These associations may recede but unfortunately they will never disappear entirely because such affiliations will be transferred onto new diseases. 121

Jones, “The Scourge of Typhoid,” 22-28. Ibid. 123 Oscar Wilde, The Picture of Dorian Gray, ed. Donald L. Lawler (London: Vintage Books, 1988), 262. 124 Theodore Dalrymple, “Illness as Metaphor,” British Medical Journal 334 (2005): 1009. 125 Thomas M. Vogelsang, “Leprosy in Norway,” Medical History 9 (1965): 29-35. 126 William H. Jopling, “Leprosy Stigma,” Leprosy Review 62 (1991): 1-12. 122

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The physical disfiguring aspect of the disease is still the cause of societal stigmatization and the loss of social acceptance. Leprosy, like other stigmatized disease has become a “hook on which all failings could be hung.”127 Even in its sanitized name of Hansen’s Disease (HD) it still conveys meanings of a social outcast. Despite the fact that treatment is available, which can eliminate the disfigurement associated with the disease, patients at clinics loath to tell others about their diagnoses?128 Despite the fact that there have been aggressive campaigns by patients, government, and the community the story of leprosy and its shameful imagery and oppression will remain. Not too long ago, a physician in a New York Times article stated: “People used to be warehoused for this, we don’t recommend revealing it.”129 The disease, one of the oldest known to humankind will never disappear. Today leprosy sufferers experience more freedom than their predecessors because they do not have to fear confinement and institutionalization. Nevertheless, leprosy is still restrictive. The disease can impede an individual’s ability to make a living, to socialize and to enjoy life. Even when cases are no longer physically visible to the general public the use of leper in discourse will allow the scourge to persist forbidding it to be put to rest with other re-branded terms, such as “consumption,” “infantile paralysis”, and “phthisis.”

127

Staples, “Begging Questions,” 173. Susan Lerner, “A 61-Year Old Staten Island Man Who is Being Treated for a Recurrence of Leprosy, Says He Still Has Not Told His Wife of 40 Years,” The New York Times (February 18, 2003) – Leprosy, A Synonym for a Stigma, Returns. 129 Donald G. McNeil, “Where the Doctors Recognize Leprosy,” The New York Times (October 24, 2006). 128

HISTORY OF NEUROLOGY AND PSYCHIATRY

ORAL HISTORY OF DR. C. CHAN GUNN AND HIS NEUROPATHIC THEORY: IMS CHRIS NOSS

SUMMARY: Dr. C. Chan Gunn (b. 1931) was born in Malaysia and grew up during the Japanese occupation of his country. He was educated as a physician at Peterhouse College at the University of Cambridge. His upbringing in Malaysia familiarized Dr. Gunn with the practice of acupuncture; however his personal experiences and medical education left him sceptical of its use. He immigrated to Vancouver, Canada in 1966 where he became interested in chronic myofascial pain while employed with the Workers Compensation Board. A combination of meticulous physical examination of patients and the serendipitous discovery of a monograph written by Walter B. Cannon (1871-1945) — posthumously published in 1949 — would allow him to establish his neuropathic theory for chronic myofascial pain. Despite his scepticism of acupuncture, Dr. Gunn had been able to borrow an acupuncture technique termed dry needling and use it to treat these patients developing what is now known as Intramuscular Stimulation (IMS). Dr. Gunn has trained over 1,200 physicians and physiotherapists throughout the past thirty years in IMS and currently runs iSTOP, a non-profit clinic in Vancouver. This paper attempts to outline in brief detail, the modern history of myofascial pain and put Dr. Gunn’s contributions in context. The bulk of this paper is an annotated oral history transcript, based on a part-time one-year research project at the University of Calgary (Hotchkiss Brain Institute [HBI]) and at the University of British Columbia (UBC). A recurrent theme in this paper is the contrast between Dr. Gunn’s Asian heritage and his strictly allopathic theory. KEYWORDS: Dr. Chan Gunn; Neurophysiology, History of; Complementary and Alternative Medicine; Acupuncture; Physical Therapy; Peripheral Neuropathy; Traditional Chinese Medicine PRECEPTOR: Dr. Frank W. Stahnisch INSTITUTION: Queen’s University

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Oral H History Of Dr. C. C Chan Gunn And A His Neuroppathic Theory: IMS I

D Dr. C. Chan n Gunn – Biographic B cal Sketch Dr. Chitt Chan Gunnn was born April A 13, 19331 in Kuala Lumpur, Malaysia. D Dr. Gunn’s fatther, Lay Teik k Gunn (b. 19901) was a ch hemist by training andd worked as a British civill servant. In D December 194 41, when Japan attackked Malaysia,, his father’s status forcedd the family to t flee to Singapore fo for safety. Shoortly after arriving in Singgapore, C. Chu un Gunn, his brother Chit Tuan (bb. 1929) and his mother w were then forrced onto cattle truckss and sent bacck to Kuala Lumpur. L The family surviv ved many hardships duuring the war,, and when th he war ended C C. Chun Gunn n went to England to continue his studies. He studied meedicine at Peeterhouse College at thhe Universityy of Cambridg ge. Following his matriculattion from Peterhouse in 1950, Drr. Gunn com mpleted two yyears of posstgraduate training in tthe hospitals in London. During D this tiime he marrieed Peggy Loke, an arttist studying architecture a in n London andd they went on n to have two childrenn. In 1958, thhey left Lond don and returrned to Kualaa Lumpur where Dr. G Gunn started a busy geneeral medical practice. He used his background in pharmacoology to prod duce low cosst medication ns for his patients andd even perform med most of his h own laborratory work. However, H for political and personall reasons Dr. Gunn decidedd to leave Maalaysia in 1966 and im mmigrate to Vancouver V Can nada. At the ttime of their arrival in Canada, Drr. Gunn’s prim mary professiional interestt was to retu urn to his experimentaal research in pharmacolog gy and he resppectively took k a job in

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the department of pharmacology at the University of British Columbia (UBC) in Vancouver. Gradually Dr. Gunn began to miss clinical practice and primary care, so in 1967 he decided to accept a job with the Workers’ Compensation Board in the province. This career change sparked his longterm interest in chronic pain and would shape the next forty years of his professional life. During the 1960’s and 1970’s the pathophysiological study of myofascial pain was still in relative infancy. For example, at that time tenderness was not commonly thought of as a physical sign, but most often as a psychological problem. However, and seen in its longer course, the history of myofascial pain is fairly extended despite the late recognition of trigger points or tender points in muscle by the medical community at large. In the late 16th century, the French physician Guillaume de Baillou (1538-1616) introduced the term “muscular rheumatism” to describe a painful condition with decreased mobility of the limbs. Unfortunately, de Baillon used the term also to describe muscle pain as well as the sequels of acute rheumatic fever, which would mark the beginning of the confusing terminology in the area of myofascial pain that persists in medicine until today.1 Early in the 19th century, in 1816, a British physician William Balfour (1823-1903) described palpable nodules in the muscle of patients with muscular rheumatism and used massage to treat them; many would consider this the first documentation of fibromyalgia.2 Another French physician, François Valleix (1807-1855) became the first to extensively write about tight bands of tender muscle, in 1841, which he termed “Valleix points,” attempting to promote his own achievements and reputation.3 Interestingly, Valleix believed that his points would morphologically follow nerve pathways and were related to peripheral nerve compression.4 His résumé can be summated by the following: I conclude that pain, capital symptom of neuralgia expresses itself … in different ways. If it remains concentrated in the nerves one finds characteristic, isolated, painful spots; this is neuralgia in the proper sense. 1

Peter E. Baldry, “The Evolution of Current Concepts,” in Peter E. Baldry, ed., Myofascial Pain and Fibromyalgia Syndromes: A Clinical Guide to Diagnosis and Treatment, (London: Churchill Livingston, 2001), 3-13. 2 Ibid. 3 Ibid. 4 David G. Simons, Janet G. Travell and Lois S. Simons, Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. 2, (Baltimore, Md: Williams & Wilkins, 1997).

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Oral History Of Dr. C. Chan Gunn And His Neuropathic Theory: IMS If the pain spreads into the muscles … an obvious muscular rheumatism can transform itself into a true neuralgia.”5

He was essentially suggesting that the nervous system plays a central role in the evolution of muscular pain, a view that Dr. Gunn’s work would support 150 years later. In 1901, the famous Canadian physician and clinical pathologist William Osler (1849-1901) wrote: It is by no means certain that muscular tissues are the seat of the disease. Many writers claim, perhaps correctly, that it is a neuralgia of sensory nerves of the muscles.6

Generally, the literature moved away from this neuralgia hypothesis and in 1904 the British neurologist Sir William Gowers (1845-1915) introduced yet another term, “fibrositis,” to describe these tender points and reflect his belief that they were caused by inflammation in the fibrous connective tissue in muscle.7 Furthermore, in 1904, the Scottish physician Ralph Stockman (1861-1946) published a paper describing “inflammatory hyperplasia” on histological examination of these tender nodules, a finding that has not been observed since,8 while Richard Llewellyn (1906-1983) and A. Bassett Jones (1879-1958?) wrote a book entitled Fibrositis (1915) in which they broadened the term to include many other maladies such as gout, which rendered the term meaningless and created even more confusion.9 Relevant to the current theory was Michael Gutstein’s (b. 1901; also published under the name of Gutstein-Good, after his emigration from Germany to the United States) 1938 description of the “jump sign” (patients’ pain reaction to the application of external pressure) and his theory that “myalgic spots” were the result of local constriction of blood vessels caused by overactivity in the sympathetic fibres supplying them.10 In the early 1940’s an American physician Janet Travell (19011997) began to publish papers in this area and eventually popularized the 5

Baldry, “The Evolution of Current Concepts,” 3-13. William Osler, Principles and Practice of Medicine, 4th ed., (New York: D. Appleton and Co., 1901). 7 William Gowers, “Lumbago: Its Lessons and Analogues,” British Medical Journal, 1 (1904): 117-121. 8 Ralph Stockman, “The Causes, Pathology and Treatment of Chronic Rheumatism,” Edinburgh Medical Journal 15 (1904): 107-116. 9 Baldry, “The Evolution of Current Concepts,” 3-13. 10 Michael Gutstein, “Diagnosis and Treatment of Muscular Rheumatism,” British Journal of Physical Medicine 1 (1938): 302-321. 6

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term “myofascial trigger point.”11 She was able to clearly define the term and helped alleviate some of the confusion in this area. In 1983 she teamed up with another American physician David G. Simons (b. 1922) to publish Travell and Simons’ Myofascial Pain and Dysfunction: A Trigger Point Manual”.12 This book would become a crucial reference for physicians working in this area in the modern day. Together, their work and assumption that the trigger point was the source of pain and physiological dysfunction would form the main opposition to the investigations Dr. Gunn who has believed the trigger point was even a symptom of a greater problem of peripheral neuropathy. In practical terms, trigger points are the same as what Dr. Gunn has described as neuropathic points. Janet Travell had analyzed a trigger point as “hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is tender when pressed and can give rise to characteristic referred pain, motor dysfunction and autonomic phenomena.”13 Interestingly Dr. Gunn would argue that these features of trigger points are not clinical phenomena at all but are well documented features of neuropathy.14 While being employed with the Workers Compensation Board in the late 1960’s, Dr. Gunn was confronted with countless patients who complained of pain but had seemingly nothing wrong with them during a conventional physical examination. He was as perplexed as to how so many people could have pain and yet did not present any physical findings, that he used his background as a scientist to investigate this problem further. His investigation thus did not begin in a laboratory but rather in the clinic observing and treating these patients, involving methods of meticulous observation and rigorous physical examination. Early on he was able to establish that injured workers who had tender points in their muscles had a much worse prognosis than those without the tender points. His next observation was that these tender points also 11

Cf. Janet Travell, Seymour Rinzler and Myron Herman, “Pain and Disability of the Shoulder and Arm: Treatment by Intramuscular Infiltration with Procaine Hydrochloride,” Journal of the American Medical Association 120 (1942): 417422. 12 David G. Simons, Janet G. Travell and Lois S. Simons, Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. 2, (Baltimore, MD: Williams & Wilkins, 1999). 13 Ibid. 14 C. Chan Gunn and William Milbrandt, “Early and Subtle Signs in Low-Back Sprain,” Spine 3 (1978): 267-281.

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followed segmental nerve distributions. It is interesting in this context that as a child he had himself been treated with Traditional Chinese Medicine (TCM) but remained very sceptical about it, because a bout of diphtheria nearly killed him except for the intervention of his uncle, a western trained physician. The trip of the American President Richard Nixon (1913-1994) in 1972 to China however sparked a rising North American interest in Chinese medicine in particular because of the report filed by the US Times journalist James (“Scotty”) Reston (1909-1995). Mr. Reston was a reporter who had an emergency appendectomy while in China and was successfully treated with acupuncture for post-operative pain. Despite his scepticism of the practice, in 1974 Dr. Gunn travelled to China to investigate acupuncture. The Chinese government had severe travel restrictions at that time. Dr. Gunn hence used his position as the President of the Canadian Society for Asian Arts to travel under the guise that he was in the country primarily to study Asian art in order to get a visa to enter the Chinese People’s Republic. Upon his return home he gathered enough information to conclude that acupuncture may work for some problems and set out to find neurophysiological reasons for its proposed effects. In 1976, Dr. Gunn put forward that from his point of view most acupuncture points correspond to motor points, which in turn lead to other papers on the relationship between acupuncture and neural structures.15 His meticulous approach to examining patients led to several important discoveries which helped him to establish and document the physical findings to be expected in myofascial pain patients. In the late 1970’s, for example, Dr. Gunn began training in the use of electromyography (EMG) that helped him identify the early signs of neuropathy, which he then linked to myofascial pain syndromes and eventually lead him to develop his neuropathic theory. In a moment of unanticipated serendipity late one might in the library, he stumbled upon the monograph by the Harvard physiologists Walter B. 15 C. Chan Gunn, “Type Iv Acupuncture Points,” American Journal of Acupuncture 5 (1977): 51-52; “Motor Points and Motor Lines,” American Journal of Acupuncture 6 (1978): 55-58; “Acupuncture and the Peripheral Nervous System,” in Jacqueline Filshie and Adrian White, eds., Medcial Acupuncture: A Western Scientific Approach, vol. 1, (London: Churchill Livingstone, 1997), 137149; C. Chan Gunn, Frank G. Ditchburn, Martin H. King and Gerald J. Renwick, “Acupuncture Loci: A Proposal for Their Classification According to Their Relationship to Known Neural Structures,” American Journal of Chinese Medicine, 4 (1976): 183-195.

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Cannon (1871-1945) and Arturo Rosenbluth’s (1900-1970) titled The Supersensitivity of Denervated Structures (1949), which would thenceforth form the cornerstone of his neuropathic theory.16 Over the years Dr. Gunn combined his observations, physical examinations and Cannon’s Law to develop what is now known as Intramuscular Stimulation or IMS. Dr. Gunn furthermore borrowed an ancient acupuncture technique known as dry needling and applied it to his neuropathic theory. He began using EMG needles to stimulate neural structures (muscle spindles) and provide stimulation-induced analgesia for myofascial pain patients. Eventually, he then moved to acupuncture needles for greater patient comfort creating what is now known as intramuscular stimulation or IMS. The development of the neuropathic theory and IMS were the result of years of meticulous examination and treatment of patients. Dr. Gunn’s neuropathic theory borrows heavily from Cannon’s Law which roughly states that any disruption in a peripheral nerve (i.e. neuropathy) will cause super-sensitivity in the structures it innervates.17 In other words when the nerve supply is disrupted to a muscle that muscle and all the others supplied by that nerve will become supersensitive or tight and thus a potential source of pain. This is a well-known and welldocumented phenomenon in clinical neurophysiology nowadays.18 Dr. Gunn has promoted it as a fundamental process and principle cause of myofascial pain while his detractors argue that this is a relatively minor cause of myofascial pain. He has stated, for example, that the most common cause of neuropathy is spondylosis or spinal degeneration that affects us all because of gravity, injury and aging. IMS involves identifying neuropathic muscles by careful physical examination and treating them with stimulation induced analgesia using acupuncture needles. An acupuncture needle is inserted into the neuropathic muscle in order to stimulate the supersensitive muscle spindle (mechanoreceptor), which causes the muscle to contract (depolarize) grasping the needle and then relaxing. This process is repeated in all affected muscles with particular attention paid to the spinal muscles. A single treatment usually 16

Walter B. Cannon and Arturo Rosenbluth, The Supersensitivity of Denervated Structures, (New York: The Macmillan Company, 1949), 243. 17 C. Chan Gunn, The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, vol. 2, (New York: Churchill Livingstone, 1996). 18 Siegfried Mense and David G. Simons, “Neuropathic Muscle Pain,” in Muscle Pain: Understanding Its Nature, Diagnosis and Treatment, (Baltimore: Lippincott Williams and Wilkins, 2001), 62-83.

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involves multiple locations within each muscle and multiple muscles, often yielding more than forty points per treatment. The mechanism behind the pain relief created by IMS is a complicated although well documented neurophysiological process but involves reflex inhibition, the current of injury and platelet derived growth factor release.19 One interesting part of IMS theory is that normal muscles do not respond or contract when the needle is inserted because the muscle spindle is not supersensitive making IMS a diagnostic test as well as a treatment. Although Dr. Gunn’s IMS technique uses acupuncture needles, it has very little to do with traditional acupuncture itself, but strictly relies on simple human neurophysiology via the neuropathic theory. The true innovation of IMS is that because it is based on neurophysiology and requires no special equipment aside from acupuncture needles, it is easy to learn, simple to use and fits into “Western” models of pathophysiology requiring little change to a Western-style treatment approach. A lack of public funding in Canada for IMS, however, may have played a role in limiting its use by physicians who can bill for much more lucrative procedures. Nevertheless, in 1996 Dr. Gunn formed the Institute for the Study and Treatment of Pain (iSTOP), which operates as a non-profit organization in Vancouver, British Columbia.20 In addition to functioning as a well-known pain clinic, it also instructs physicians and physiotherapists in the theory and practice of IMS. iSTOP has a large group of staff which includes a team of physicians, physiotherapists and assistants. To date, iSTOP has officially trained over 1,270 Physiotherapists and Physicians from all over the world at locations in North America. There are also in excess of 2,000 practitioners in Korea, Norway, Brazil and Israel trained in IMS, altogether representing the 19

C. Chan Gunn, “Transcutaneous Neural Stimulation, Acupuncture and the Current of Injury,” American Journal of Acupuncture 6 (1978): 191-195; “Transcutaneous Neural Stimulation, Needle Acupuncture & ‘The’ch‘I’ Phenomenon,” American Journal Acupuncture 4 (1978): 317-322; The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, vol. 2, (New York: Churchill Livingstone, 1996); “Acupuncture and the Peripheral Nervous System,” in Jacqueline Filshie and Adrian White, eds., Medical Acupuncture: A Western Scientific Approach, vol. 1, (London: Churchill Livingstone, 1997), 137-149; C. Chan Gunn and William E. Milbrandt, “The Neurological Mechanism of Needle-Grasp in Acupuncture,” American Journal of Acupuncture 5 (1977): 115-120. 20 iSTOP, Istop the Institute for the Study and Treatment of Pain, 2009, http://www.istop.org (Accessed August 31, 2010).

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profound impact on how physiotherapists and physicians think about and treat myofascial pain disorders. Dr. Gunn has received great recognition for his work including the Order of British Columbia,21 the Order of Canada22 and was recently elected a Fellow of the Royal College of Physicians in Britain, while Dr. Gunn continues to actively practice and teach IMS at iSTOP in Vancouver, British Columbia.

Interview Notes This interview has been transcribed as accurately as possible. Names of organizations or people have been removed to protect their anonymity where applicable. There are also a number of words or phrases that were omitted because they were not audible during the transcription and are indicated by a break [ … ] in the transcript. CG indicates Dr. C. Chan Gunn speaking and CN indicates Chris Noss speaking.

21 The Order of Canada is awarded for lifetime achievement, service and dedication to the community and is awarded in all sectors of society. It is regarded as the centerpiece of the Canadian social and academic honor system. 22 No author, “Order of Canada,” Governer General of Canada, 2009, http://archive.gg.ca/honours/search-recherche/honoursdesc.asp?lang=e&TypeID= orc&id=6740 (Accessed November 12, 2009).

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APPENDIX A: INTERVIEW TRANSCRIPT Subject: Dr. C. Chan Gunn Date: June 10th 2009, 9:30 am Location: iSTOP,†,23 Vancouver BC

CN: What I would like to do at the start is to find out a little more about you personally. Maybe you could tell me a little about your personal background? CG: You have seen the one from Peterhouse have you?‡,24 CN: Yes. I have read that one. CG: Have you seen the one from Dr. Livingston’s book?25 CN: No. CG: I will get it for you. Dr. Livingston is about the same time as me, I think he is a year, he is from Cambridge too, a year ahead of me. But he has been in Canada, he is from Vancouver and he has been writing for BC [British Columbia] medical journal. And he started a book, his last book; he was going to start writing about all the important discoveries in medicine. And he shows that they come from people who are GP’s, right? Because the people that specialize, they get frozen. And nothing new comes from them. So the way we talk about the heart, the thing, was from the ... practitioner. A lot of the psychology was from one of the Russian writers. So he is almost finished his book and he had back ache and couldn’t get up. He was walking like that (demonstrating an antalgic gait, flexed at the hip). So eventually he came here, a couple [of] treatments, and he was standing up. He was so astonished that he wrote …,, I will get it. CG: (returns) go on. † iSTOP – Institute for the Study and Treatment of Pain. This is a non-profit organization Dr. Gunn founded in 1996 and is located in Vancouver, BC Canada. 23 http://www.istop.org. ‡ Peterhouse is the oldest college at the University of Cambridge founded in 1284. 24 Unknown, “Peterhouse Profile an Interview with Dr. Chan Gunn,” 2003 http://www.pet.cam.ac.uk/petreans/newsletter-2002/profile.html. (Accessed December 10, 2009). 25 Michael Livingston, in Cheri Bethune, ed., Listening in Medicine the Whiplash Mystery and Other Tales, (Victoria, BC: Trafford Publishing, 2005), 126-132.

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CN: Where were you born? CG: I was born in Malaysia CN: Where in Malaysia? CG: Kuala Lumpur. CN: Were you raised there? CG: I grew up there during the war. It was a tough time. The war came in 1939, 1940 the Japanese were in.§ So I was born in 1931, so I was a nine year old. So I grew up in the Japanese occupation.26 And it was a tough life because there was no food, you know, luckily I was just a bit younger. If you [are] a bit older they kidnap you and take you into work camps and all that.27 CN: And when did you leave Malaysia? CG: Knowing that when the war is over, we have to continue education. So during the war the schools kept opening, you see, so that you learned a little bit of this, and a little bit. But nothing much. A bit of Japanese, a bit of Mathematics. So when the war is over, at the age of 14, I was 14 then. So the war must come 10, 11, 12 (counting). Four years. Then I went to England, to school there. School, then university. CN: And you have one brother? CG: I have a brother. CN: ... I understand that he attended Cambridge as well? §

On December 8, 1941 Japan attacked British Malaya primarily because of its booming tin and rubber industry which helped provide essential raw materials that were frozen by the British, Dutch and American governments in the war effort. After the December 1941 attack on Malaya by Japan, Dr. Gunn, his brother Chit Tuan and their mother fled to Singapore fearing for their safety because of their status as a family of a British servant. However their stay was short and they were forced onto cattle trucks and driven back to Kuala Lumpur where they would stay for the remainder of the occupation. The occupation ended in August of 1945 after the bombing of Nagasaki and Hiroshima when the British returned and reclaimed the territory. Malaya gained independence from Britain only a decade later, on August 31 1957; and Malaysia was created on September 16, 1963. 26 Royal Australian Airforce, “A Brief History of Malaysia,” 2009 http://www.raafschoolpenang.com/ malaysia.htm. (Accessed November 12, 2009). 27 Ang Wen Juin, Cheong Shi Min and Loh Kok Kin, [Tan Sri Dato’ Gunn Chit Tuan], 2003, http://www.viweb.freehosting.net/GunnCT.htm (Accessed November 12, 2009).

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CG: Yes, he became the chief justice of Malaysia. He is a lawyer, right?†28 CN: And your father? CG: My father was, also went to the same college, in Cambridge. He was a scientist. So he went to Cambridge in 1919 or something like that. And the family ran out of money (laughing), so he was, then he got his bachelors [!], he worked as an academy scientist. CN: He eventually became an ambassador? CG: He became an ambassador so. He was a rubber planter in those days. [The] 1930’s was a depression time you know, the world was really depressed then. So he planted rubber, and from rubber he went into banking. He started some banks with some friends. CN: What are your interests outside of medicine? Outside of what you do here (at iSTOP) what are you interested in? CG: I’m …, unfortunately I’m good for nothing (laughing). It’s sad, isn’t it? You know I go out and try and play golf, I can’t whack the ball straight, I hit the ground. I play tennis and I’m always wrong side. So, I tried squash, I get dizzy. So I’ve got nothing to do and that’s why I spend time on, on doing this. But my wife is fed up with IMS you know? I don’t blame her. CN: What prompted your decision to go to Peterhouse? CG: My father went to Peterhouse. CN: Why did you decide to do medicine? †

Tan Sri Dato Chit Tuan Gunn, Dr. Chan Gunn’s brother was born in 1929. In 1977 he was appointed to the high court of Malay and in 1987 he was promoted as a judge in the Supreme Court of Malaysia. In 1992 he became the Chief Justice in the High Court of Malay, a post he held until his retirement in 1994. In the Malaysian honor system the title of Tan Sri is the second highest federal title and includes recipients of the P.M.N (Panglima Mangku Negara) which is the 7th highest federal award of which Chit Tuan Gunn was a winner. There are only 75 living recipients of the P.M.N at any one time. Lay Teik Gunn, Dr. Chan Gunn’s father was a British government civil servant in Malaysia and was appointed High Commissioner to Australia and New Zealand after Malaysia gained independence. He was also bestowed the honorific title of Tan Sri Dato in recognition of his service to the country. 28 Ang Wen Juin, Cheong Shi Min and Loh Kok Kin, [Tan Sri Dato’ Gunn Chit Tuan], 2003, http://www.viweb.freehosting.net/GunnCT.htm (Accessed November 12, 2009).

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CG: I wanted to be [an] aeronautical engineer because during the war kids played flying. But my father …, Chinese people do what their parents tell them (laughing). And so my brother should have done medicine but by the time the war ended, he [was] already older than me. So law was a short course, so he took the short course. So I had to do medicine. And since I was a top science student, I couldn’t avoid it (laughing). So I was a top student, so I took up science, it was quite interesting. CN: After you finished your time at Peterhouse, where did you go? CG: Peterhouse you see, Cambridge gives you …,, Cambridge gives you 3three years. So before you get into Cambridge you have done your 2 years pre-science, right? Then you do 3 years. Then after that you have to go to the hospitals for 3 years. So, after the hospitals for 3 years you go back to Cambridge and sit your …, your exams. And then after that you are let loose on the world (laughing). CN: Where did you go? CG: I did the hospitals in London.‡29 CN: After your exams? CG: I went back to do the hospitals in London. You know, you do a rotation. CN: When did you come to Canada? CG: I went back to Malaysia in 1958. And in 1966 we came here ... . So we looked around and thought of going to Australia or US or here. So when we came and looked around, Vancouver seems the best place. In those days it was very nice, very quiet. CN: It’s still very nice. ‡

Dr. Gunn trained at University College Hospital in London prior to his examinations. After sitting his examinations at Cambridge, he completed postgraduate training in orthopedics and general surgery at Epsom Hospital. He studied paediatrics under Dr. Thomas Stapleton (1921-2008) at Paddington Green Childrens’ Hospital. By working in under-staffed non-teaching hospitals he learned how to perform laboratory work and take x-rays, skills which were valuable to his later work. In 1958 he returned to Malaysia and started a general practice. The skills he acquired in London allowed him to take his own x-rays, do his own lab work and produce inexpensive medication for his patients. 29 Michael Livingston, in Cheri Bethune, ed., Listening in Medicine the Whiplash Mystery and Other Tales, (Victoria, BC: Trafford Publishing, 2005), 126-132.

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CG: It’s too crowded now. CN: So once you came here, where were you working? CG: I was working for compensation.† But the first year I worked at the University [of British Columbia]. And I was very keen on drugs then, everything was pharmaceuticals. So I worked in the Department of Pharmacology. So from there I decided I would go into clinical practice, I missed the clinical part. So I joined the compensation board because I didn’t want to wake up at night for night calls (laughing). So chronic pain is the simplest thing, there is no emergencies [sic!]. And that’s how I got into the pain picture. And my job after, in 1966, I joined … . My job was more or less although unsaid was to try and get people to go back to work. And they assumed everyone was, wouldn’t go back to work right? Because you can’t find anything wrong with them. So, I looked at all these people and couldn’t believe so many people with nothing to find. And that’s still the status today in medicine you know. Most people who look at patients cannot find what’s wrong with them. The first thing I did was, I took 50 patients who had been off work for long time.30 I gave you some reprints, did I? ...31 Looking at these people to see what’s wrong, and actually when you look at them very carefully there were certain spots that were painful right. In those days I didn’t know what those were, right. In fact [Corwin Samuel] West [1932-2004] called them ‘trigger points’ but I mean, at that time I hadn’t come across the word trigger point, so.‡,32 But why were they

†

Workers compensation board (WCB) of British Columbia. C. Chan Gunn and William E. Milbrandt, “Tenderness at Motor Points: A Diagnostic and Prognostic Aid for Low-Back Injury,” The Journal of Bone and Joint Surgery: American Volume, 58-A (1976): 815-825. 31 C. Chan Gunn, Gunn Ims: Reprints on Pain, Acupuncture & Intra-Muscular Stimulation, vol. 21, (Vancouver: Institute for the Study and Treatment of Pain, 2008). ‡ The term trigger zone was used by J. Edeikin and C.C. Wolferth in 1932. Janet et al. used the term trigger point in 1942. David G. Simons, Janet G. Travell and Lois S. Simons, Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. 2, (Baltimore, MD: Williams & Wilkins, 1999). Travell described a trigger point as a “hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is tender when pressed and can give rise to characteristic referred pain, motor dysfunction and autonomic phenomena.” 30

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tender, right? And then when we followed the history, those who were tender were off work for 19 weeks or 20 weeks, right?. And that’s the same as those who had straight leg raising or reflex loss. So, the tender point is equivalent to a neurological sign, right. And those without the tender points, they got back to work in 10 to 12 weeks, very quick. Something was hurt, it got repaired and they go back to work. But those tender points were neurological. And so then we found that these things were in a segment, L5 or S1. And curiously the segment is also in the posterior rami, right?. So they were therefore segmental …. So that’s interesting because no one had come up with it, no one had said let’s look at segmental things. The next thing was, this up here too (pointing to the neck), so we looked at this tennis elbow and they were also segmental.33 And then we did this with the physios, that’s why I work with physios. We did manipulation to free that (pointing to the neck) and they got better. Those where we put heat and other thing, didn’t get better. So it’s important to treat the nerve root, right? So from that we knew that. The next thing was to find out what was this tenderness was. And so when we use the word tenderness, in those days people didn’t believe tenderness was a sign. They say that it’s a psychological thing. But it isn’t, tenderness is now given a name, right? Allodynia or hyperalgesia, but in those days it wasn’t. CN: This would be in? (what era) CG: 60’s, early 1970’s. Because in 66, 67, 68 I was still doing the old fashioned thing, not getting anywhere, right? So now 70, gosh something is wrong. So it’s 70, 71 and in order to, so those days one of those things people were interested in was should it be operated on? And as a board doctor (WCB) I would have to give permission to operate. But the surgeons wouldn’t wait for that, they would operate anyway. So, how would you give permission? So I went to New York to learn how to do EMG’s.§ And the thing is, the EMG will tell you the early signs of radiculopathy, right? So hey, when you look at those, I did it on hundreds of patients, hardly ever any signs of denervation. Yet the doctors who 32

J. Edeiken and C.C. Wolferth, “Persistent Pain in the Shoulder Region Following Myocardial Infarction,” American Journal of Medical Science 191 (1936): 201-210; Simons, Travell and Simons, Travell & Simons’ Myofascial Pain and Dysfunction. 33 C. Chan Gunn and William E. Milbrandt, “Tennis Elbow and the Cervical Spine,” Canadian Medical Association Journal 114 (1976): 803-809. § EMG: Electromyography.

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operate said that it’s for denervation, right? But there was signs of irritability. So the irritability is known as neuropathy. Now, unfortunately I elected to use the proper medical word, neuropathy. But at that time doctors were already using the word neuropathy wrongly, as they still do. So they talk about neuropathic herpetic pain and all that. So they tended to use the word neuropathy to mean anything neurological is not well, right. But it isn’t. Neuropathy is defined as by [!] the proper EMG terms, irritability. And irritability can come for percussion or traction or anything. So I called it neuropathic pain right. And the astonishing thing is, now I have taught this and I have talked about this, in the iASP the international association for study of pain, right.34 Yet today, they have meetings all over the world for neuropathic pain. I have never been invited to one, you know that? And people knew that I was the originator (of the term neuropathic pain). CN: Why do you think that is? CG: Oh, doctors are very selfish people, I can say this ... . Some of those people, you see their names up on the board there. About 5 or 6 of them are all in the neuropathic game right. Some of them are just laboratory people, some of them are psychologists, but no true clinicians. And, they don’t like true clinicians because if I was at the meeting and you asked ‘why is this tender or why is [it] like that?’ I would be able to say this I find. Those people can’t say that, so they don’t like to have me around (laughing), it’s true that. Those people know who I am, why are they bluffing? CN: ... When I am reading the literature there seems to be a lot of confusion in general with the terminology used to describe these myofascial pain problems ... . What would you like to see changed in terms of terminology or do you wish you would have used a different word or what would you like to see changed in the future, to make things more clear? Is there anything? CG: Because, yes, I mean the word neuropathy is …, should be defined as, the true definition of neuropathy is, there is altered function in the peripheral nerve without necessarily having any altered structure. So you have this nerve and because it’s so early you don’t have any of the clinical

34 Edeiken and Wolferth, “Persistent Pain in the Shoulder Region Following Myocardial Infarction,” 201-210.

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signs, right? But in the EMG you see the signs.35 And the signs are, if you put the needle in, instead of going, the injury should just cause papapapa (indicating a big positive EMG deflection with quickly diminishing amplitudes using his finger) in the normal. But when it’s abnormal, Cannon’s Law†,36 and all that sort of thing, when you put that in, it will go (indicating lots of activity with big deflections) the whole screen fills up with waveforms right. Secondly, that waveform should die away very quickly if it’s normal. But when it’s irritable and neuropathic, it’s there for a long time, minutes, so when you touch it, it sparks up again. So it’s really hypersensitive. And the waveforms that come up are sharp waves and then you get giant waves and all the other things which are in the proper EMG terms right. But most doctors don’t do EMG’s, so most of those people ... in this neuropathic pain world are not qualified to be there. And I told them that you must, I told the University that these people should really, they should train a pain fellow, that pain fellow should know some EMG right. I don’t expect him to do thousands like I’ve done right, but at least they should have done 10 or 20 to hear that noise, to hear, so that they know what that irritability … [is]. Then of course nerves and 35

Michael J. Aminoff, “Electrophysiology,” in Christopher G. Goertz, ed., Textbook of Clinical Neurology, vol. 3, (Philadelphia, Pa.: Saunders Elsevier, 2007), 477-479. † Cannon’s Law: “when in a functional chain of neurons one of the elements is severed, the ensuing total or partial denervation of some of the subsequent elements in the chain causes supersensitivity of all the distal elements, including those not denervated, and effectors if present, to the excitatory or inhibitory action of chemical agents and nerve impulses; the supersensitivity is greater for the links which immediately follow the cut neurons and decreases progressively for more distant elements.” In other words when any peripheral nerve supply is disrupted (i.e. partially denervated) its end organs become supersensitive to their ligand. In the context of myofascial pain, when neuropathy is present at the nerve root, the muscle (at the motor end plate) becomes super sensitive (up to 10,000 times) to acetylcholine resulting in tightness, trigger points, pain etc. In this scenario the autonomic supply to the vasculature is also affected causing vasomotor (trophic edema and decreased temperature in that nerve’s distribution), sudomotor (increased sweating) and pilomotor (piloerection) disturbance. 36 Cannon and Rosenbluth, “The Supersensitivity of Denervated Structures,” 243; C. Chan Gunn, The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, vol. 2, (New York: Churchill Livingstone, 1996); C. Chan Gunn and William E. Milbrandt, “Early and Subtle Signs in Low-Back Sprain,” Spine, 3 (1978): 267281.

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muscles, once they become neuropathic they start to misbehave. They are not truly insulated, so they touch another one and they have cross …, cross – you know – growth, sprouting and all that sort of thing. So those sort of things are also important because they are part of the picture. So, but you see these people that’s their job right and they are well paid for it. You know the people, the man who wrote about some neuropathic swelling or something like that. They are full professors, and they, full professors are very well paid. Not only are they well paid but they get a lot of grants. So, I invited the head of McMaster’s [Department of Physiology] to come over and then, to discuss some of these things. And he immediately understood the basis of, of neuropathic pain. And he wrote a letter, that’s in the white book.37 Did you see that letter?38 A letter to say, Henry, James Henry, Jim Henry, to say that in his opinion of all the theories on back pain the Gunn theory is the right one, because it is based on ordinary physiology. And any physiologist can understand it right. But the other people with their conjectures and make mostly conjectures right, and to get a top physiologist backing me is a good thing ... I’ve been invited to give the inaugural lecture next week at University of Washington of the Cha Chi Ming chair. That’s a Chinese who has given money to University of Washington. And they are going to pay for a lecture every year and this is the first one. So my, I’m going to speak on acupuncture for pain, for chronic pain, a western model based on physical finding. And it will cover a lot of your thinking ... CN: ... IMS†,39 is based on neurophysiology and ...

37

C. Chan Gunn, Gunn IMS: Reprints on Pain, Acupuncture & Intra-Muscular Stimulation, vol. 21, (Vancouver: Institute for the Study and Treatment of Pain, 2008). 38 James L. Henry, “Letter to the Editor,” Pain Research & Management 13 (2008): 157. † IMS: Intramuscular stimulation. This technique involves inserting an acupuncture needle into neuropathic points in the muscle, which causes depolarization within the muscle (needle grasp) and subsequent reflex inhibition of the spinal segment (myotome). After needling these points, the electrical resistance measured at the skin is reduced creating a temporary artificial motor point. Dr. Gunn developed this treatment by borrowing an ancient Chinese acupuncture technique, dry needling and applying it to his neuropathic theory. Crucial to Dr. Gunn’s theory is that only neuropathic points respond to the needle stimulus by depolarizing while normal muscle shows no response which makes needling in this way an important assessment tool. This phenomenon is explained by Cannon’s Law.

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CG: It is known as stimulation induced analgesia.‡,40 Now that’s the oldest form of medicine. You know, you see a lioness licking its pup or someone shaking something. So, stimulation is the first thing. So, we have gone too far to drugs, right and drugs is [!] really too specific and narrow. Because in this stimulation thing, it explains myofascial pain, which is nothing to do with just muscles right. I mean it’s a neurological thing right, neuropathic thing. CN: What role do you think your Malaysian heritage played in the development of all of this (IMS), if any? CG: Well, Malaysia is, is really a part of China. You have been there, have you? CN: Yes. CG: Today it may not look so but all these big towns were Chinese right and the Malays lived in the villages. So, Philippines is the same too, right. So what happens is, I grew up there and it was a Chinese town. So when I was ill my mother would send for a Chinese physician and he would take my pulse, look at my tongue and give some herbs and it was fine, I got better again. But the most common diagnosis was one that could not be explained in the Western World, until recently. The most common diagnosis in Chinese medicine is heat sickness, hyper-oxidation. You 39

C. Chan Gunn, “Transcutaneous Neural Stimulation, Needle Acupuncture & ‘The’ch‘I’ Phenomenon,” American Journal Acupuncture 4 (1978): 317-322; The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, vol. 2, (New York: Churchill Livingstone, 1996); Walter B. Cannon and Arturo Rosenbluth, The Supersensitivity of Denervated Structures (New York: The Macmillan Company, 1949), 243. ‡ Stimulation induced analgesia is related to Ronald Melzack (b. 1929) and Patrick Wall’s (1925-2001) pain gate theory proposed in 1962 and again in 1965. As simplification, this well known theory proposes that pain signals can be modulated by stimulating the type 2 sensory fibres (A beta) which act to inhibit the C fibre pain signals. IMS stimulates the muscle spindle with a needle which then acts via type 2 sensory fibres to gate pain signals. This is only a single mechanism which helps explain the pain relief observed after IMS treatments, the complete mechanism is far more complicated. 40 Ronald Melzack and Patrick D. Wall, “On the Nature of Cutaneous Sensory Mechanisms,” Brain: A Journal of Neurology 85 (1962): 331-356; Ronald Melzack and Patrick D. Wall, “Pain Mechanisms: A New Theory,” Science 150 (1965): 971-979; C. Chan Gunn, “‘Prespondylosis’ and Some Pain Syndromes Following Denervation Supersensitivity,” Spine 5 (1980): 185-192.

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know now, we understand that we take antioxidants and all that, because the body gets hyper-metabolic right. We get red, the eyes get red and slight fever. So that’s the Chinese most common [disease], and indeed it’s [the] most common trouble that goes wrong because most people, we left our vegetable diet and all those things. So one day, I think I was seven, six or seven, I was very ill and my mother sent for the top physician, Chinese physician. And he came and did the usual thing and gave me some medicine. And the next day I was worse, I was vomiting, I was …, fever was higher. So she sent for the number two doctor ... His medicine was even bitterer. And the next day, that night I was really ill. So my mother got worried and sent for her own brother who was a western trained doctor (laughing). And luckily he came and looked in my throat, I was dying of diphtheria. So this was the beginning of the diphtheria anti-toxin,§,41 so I was one of the first to receive it ... . From my point of view I was very sceptical about Chinese medicine thereafter. And of course going to Cambridge for my education they brainwashed me right (laughing). CN: I recall ... around 1974 you were working for WCB and you became interested in acupuncture. CG: Well because Nixon went to China in 73.†,42 §

In 1884, the German physician Friedrich Loeffler (1853-1915) isolated the diphtheria exotoxin from the throats of humans. In 1890 the German-Japanese team of Emil von Behring (1854-1917) and Shibasaburo Kitasato (1853-1931) discovered the diphtheria antitoxin by injecting guinea pigs with a heat attenuated form of the toxin. Emil von Behring won the Nobel prize in medicine or physiology in 1901 for his work. The French veterinarian Gaston Ramon (18861963), of the Pasteur Institute discovered the diphtheria toxoid in 1924. 41 Anonymous, “Loeffler, Freidrich August Johannes (1852-1915),” World of Miscrobiology and Immunology, 2003, http://www.encyclopedia.com/doc/1G23409800352.html (Accessed November 3, 2009); Anonymous, “Emil Von Behring: The Nobel Prize in Physiology or Medicine 1901,” Nobel Lectures, 1967, http://nobelprize.org/ (Accessed November 4, 2009); Anonymous, “Kitsato Shibasaburo,” Encyclopedia Britannica Online, 2009, http://www.britannica.com/ EBchecked/topic/ 319619/Kitasato-Shibasaburo (Accessed November 3, 2009); Gaston Ramon, “Biographical Sketch Gaston Ramon (1886-1963),” http://www.pasteur.fr/infosci/archives/e_ram0.html (Accessed November 12, 2009); Christopher J. Rutty, [Connaught and the Defeat of Diphtheria], 2009, Web Page (Accessed November 12, 2009). † Scotty Reston was a reporter for the New York Times and went to China with his wife in early July of 1971. On July 9, 1971 the American Foreign Minister Henry Kissinger (b. 1923) secretly visited China on a trip to Pakistan to lay the ground

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CN: So Nixon goes to China in 1973. CG: And then came back. His, Reston, his reporter that went along with him had an appendix and they had to remove it. And after it was removed he developed gas and pain. And so instead of giving him drugs they sent for an acupuncturist. And the acupuncturist stuck needles here and there. And relieved his thing, so he astonished [everyone] that a needle could do it. So we decided, the workers compensation board then wanted to know about acupuncture. So I wrote a three page thing to say that it’s all bunkem [sic!] you know, it has to be bunkem [sic!] right (laughing). Because I didn’t know anything about stimulation induced analgesia then. But so happens in ‘74 we decided just go and look … see. And of course it was Red Guard period, so you, so you applied to the Chinese and the Chinese said “oh you want to look at acupuncture, no?” So we send it in again and this time we said, I was president of the Asian Arts, Canadian Society for Asian Arts,43 so we said we want to look at Asian arts. So they said for that we will let you in. So we flew all the way to Canton, Guangzhou. And then we got stuck there because we couldn’t move out, you know, so it was a bad thing. But fortunately one of the members of the society was a lawyer and he was the God son of Dr. ..., the Canadian doctor who went to China ... very famous doctor ... . He has been highly recognized by the

work for president Richard Nixon’s subsequent visit. Scotty Reston had his appendix removed on July 17th 1971 by Wu Wei-Jan at the Anti-imperialist hospital. Premier Chou En-Lai (1898-1970) asked 11 of the leading medical specialists to assist on the case. The surgery was uneventful but 2 nights after the surgery Mr. Reston experienced abdominal detention and pain secondary to gas. He was treated by Prof. Li Pand-Chi (b. 1927?) a traditional Chinese medicine practitioner. His treatment consisted of three acupuncture points (right elbow and below both knees) with moxibustion. Mr. Reston reported no discomfort during the treatment and relief of his symptoms within one hour with no reoccurrence. President Richard Nixon first visited China (Beijing, Hangzhou, Shanghai) from February 21-28 1972. Mr. Reston’s article “Now, about my operation in Peking” appeared in the New York Times and reportedly generated widespread North American interest in acupuncture. 42 Scotty Reston, “Now, About My Operation in Peking,” The New York Times, 1971. 43 Anonymous, “Canadian Society for Asian Arts: Building Bridges to the Arts and Cultures of Asia since 1969,” 2009, http://www.canadiansocietyforasianarts.org/. (Accessed December 15, 2009).

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Chinese.‡,44 But anyway, when he said that he was the God son, a big shot came to meet us at the hotel and arranged for us to fly to Beijing and take a train back... . So thanks for, for the doctor, I will think of the name later. So when, I talked to some doctors there about acupuncture and they were older doctors and they were western trained. And they said, you know, they couldn’t explain it but this darn thing works. So that’s the reason for it, so that’s why I came back and spent time on it. CN: ... So you started practicing acupuncture? CG: No the first thing was to find out what, what it’s all about right. But by a coincidence I am doing EMG’s right. So I stick needles everywhere. So the first thing is, we found out that they were motor points right and motor points charts, right? 45 And if you follow the muscles segmentally, most of the meridians follow the motor points. So that was important. So, from that we followed up. We found that most of the acupuncture points, ninety percent of them were over (motor points), so they were neurological right, so that’s the first thing. And then the next thing is, we did a study of low back pain at the compensation board.46 And this is an example of where the world I think, the medical world, is very wrong. They reviewed all the low back pain studies, with acupuncture. And some person who doesn’t know what it’s all about just read our paper and said “no good, ‡

Referring to Dr. Norman Bethune (1890-1939). Dr. Bethune was born in 1890 in Gravenhurst, Ontario and entered medical school at the University of Toronto in 1912. He quit after only two years of the program to join the army as a private soldier where he eventually received a medical discharge after being wounded in a WWI battle. He completed medical school and went on to enjoy a famously controversial career as a thoracic surgeon. In 1935 he joined the communist party of Canada. During the 1936 Spanish civil war he joined the Loyalist forces and established the first ever, mobile blood transfusion unit. In 1938 he went to China to help Mao Tse-Tung (1893-1976) and his guerillas set up field hospitals in their fight against the Japanese. He died in 1939 of septicemia stemming from operating in the field without gloves. Mao Tse-Tung was quoted as saying “We must all learn the spirit of absolute selflessness from him (Bethune).” 44 Robert Patterson, “Norman Bethune: His Contributions to Medicine and to CMAJ,” Canadian Medical Association Journal 141 (1989): 947-953. 45 C. Chan Gunn, “Transcutaneous Neural Stimulation, Needle Acupuncture & ‘The’ch’I’ Phenomenon,” American Journal Acupuncture 4 (1978): 317-322; Gunn, “‘Prespondylosis’ And Some Pain Syndromes Following Denervation Supersensitivity,” Spine 5 (1980): 185-192. 46 C. Chan Gunn and William E. Milbrandt, “Tennis Elbow and the Cervical Spine,” Canadian Medical Association Journal 114 (1976): 803-809.

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don’t bother.” And it was a …, it took over a year to do. And when we started working on it we had 19 doctors at compensation board across the country putting in input. And the most important thing is, you cannot stick needles in anywhere randomly as a control because you could hit another neural point right, so how do you do a control study? And this is one of the things that is holding, was holding acupuncture up. So we said, what we wanted to know, does it work or doesn’t it work? So if we say massage works or if we say hypnosis works, and lots of people said it worked. But when we get a back pain and try this and that, how do we know it works? Very simple, we send the man back to work, hard rock, climbing trees and see whether he lasts or not, right. And then he’s got to last for 3 months at least to make sure that the darn thing works. And of course this is what we did. We did a study and then those that said it got better we said it, … back to work and we followed them very carefully, we followed their pay checks and look at the books to make sure. And sure enough it worked. And that’s a proper study because to just say to the patient does it work or doesn’t [it] work, it’s all a verbal ... it doesn’t mean subjective ..., but it was voted down by Oxford University, you know, what you call them. I mean, that’s typical of medicine isn’t it? The people who know nothing say “oh it’s not worth it” but they didn’t look very carefully to see what we did and as you know we also looked at them very carefully (the patients in the study). But the next thing that we did was, by the time we were done [with] this study we learned a lot, we learned there were new physical signs, right. And that’s the beginning of neuropathic pain. We suddenly realized that these people who were tender, who had this, who had trophic edema, so the physical signs came right.†,47

†

Physical signs of neuropathy include but are not limited to muscle tenderness (“trigger points”), hair loss, decreased skin temperature, piloerection, trophic edema (peau d’orange sign, positive match stick test or positive skin roll) and increased sweating in the affected dermatome. Allodynia and increased muscle tone or banding within the muscle (i.e. trigger points) are prominent in the distribution of the affected nerves. See Appendix C. 47 C. Chan Gunn, Frank G. Ditchburn, Martin H. King & Gerald J. Renwick, “Acupuncture Loci: A Proposal for Their Classification According to Their Relationship to Known Neural Structures,” American Journal of Chinese Medicine, 4 (1976): 183-195; C. Chan Gunn, William E. Milbrandt, A. Steve Little and Keith E. Mason, “Dry Needling of Muscle Motor Points for Chronic LowBack Pain: A Randomized Clinical Trial with Long-Term Follow-Up,” Spine 5 (1980): 279-291.

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CN: ... So when were you able to sort of piece together that the same people with the tender points also had the trophic edema and dermatomal hair loss? CG: Gradually, it didn’t come right away. I mean it was, low back pain is not a simple thing. Today, to us, of course we know it becomes so simple right. But in those days we didn’t even know what a point was right. But the fascinating thing is, is that bit by bit we found that, as we were working, as we were touching, hey he’s cold you see. You touch a man and he’s normal, it’s get[ting] colder, it[s] get[thing] cold and sweaty and trophic edema is there. So all those things came gradually, it didn’t come straight away. CN: When did you start actually using acupuncture needles to treat these people? CG: We were using EMG needles at first.‡ But they were very painful. The western needle is very thick and fat. My nephew cursed me because it was so painful. So we got smaller, smaller needles. And so by the time we got into the acupuncture needles we realized what we were going [to] look for. Now we realized it has to contact the nervous system. And we realized it has to be neuropathy. And neuropathy must follow Cannon’s law right.48 So when you stick a needle just under the skin you don’t really know what’s happening. But the moment you go into muscle, now that’s interesting, you can stick it everywhere but it’s only in the affected myotome that you get the reflex. And that reflex is of course a myotactic reflex …, monosynaptic, right?49 So only a needle can tell you it’s neuropathic, because it does that (indicating a needle grasp). So there for all those people that talk all over the world, Hawaii, Bermuda and so on, they don’t know what they are talking about (laughing). And it’s astonishing, people get up and talk. And there was a doctor here in West Van, in Lion’s gate, she invited a doctor from the states who says he’s a ‡

Dr. Gunn was using EMG to examine these patients and during this work was able to discover the effect of inserting needles into these neuropathic muscles. The EMG needles were initially used because they were readily available but their size made the treatment quite painful. Gradually Dr. Gunn moved to using the much thinner acupuncture needles, which yielded the same effects with much less patient discomfort. 48 Walter B. Cannon and Arturo Rosenbluth, The Supersensitivity of Denervated Structures, (New York: The Macmillan Company, 1949), 243. 49 C. Chan Gunn, “Type Iv Acupuncture Points,” American Journal of Acupuncture 5 (1977): 51-52.

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professor of physical medicine, neurology, neurosurgery and whatever you know, I have never seen so many professorships. And he got up and talked wrong, right? But I didn’t get up and challenge him because these people are not only very egoistic, they are very ferocious you know. Can you imagine me getting up and saying ‘excuse me sir’? (laughing) CN: ... it is very clear that getting, I don’t know how to pronounce it, the Teh Ch’I is very important. CG: That was me who pushed it for years. CN: And when did you figure that out? CG: Soon after our own study.†,50 CN: Sometime in the 70’s? CG: Yes, right?. You must get that to prove Cannon’s Law, right? CN: Maybe we will get into that right now. So, can you tell me how you found the paper by Cannon and Rosenbluth?51 CG: It’s just one of those things, you know?. I just didn’t know, I was wondering why this thing happened. And it’s not in any of the books you can see. So I had all these old books and everything. So I was really getting, midnight, really getting tired, I going to sleep. And then I see an old book, just look at it, open the page and Cannon’s Law staring me in the face. It’s extraordinary, you know [how] these things are. You have to believe in those things right, I don’t know if you do? I wore this tie just to tell you. You know this tie, what it is? CN: No.

†

The neurological mechanism of needle-grasp in acupuncture was published in 1977 by C. Chan Gunn and William E. Milbrandt. This article proposes a neurological mechanism for the Chinese acupuncture phenomenon Teh Ch’i. Cannon’s Law states that only neuropathic muscles will be hypersensitive and thus respond to the needle by depolarization. In lay terms when a needle is placed into a neuropathic muscle, the muscle grabs onto the needle (physiological depolarization within the muscle resulting in a muscle contraction) giving a cramping sensation before relaxing thus reducing the tone in the muscle. 50 Walter B. Cannon and Aturo Rosenbluth, The Supersensitivity of Denervated Structures, (New York: The Macmillan Company, 1949), 243; C. Chan Gunn, “Type Iv Acupuncture Points,” American Journal of Acupuncture 5 (1977): 51-52. 51 Walter B. Cannon and Aturo Rosenbluth, The Supersensitivity of Denervated Structures, (New York: The Macmillan Company, 1949), 243.

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CG: This is a royal artillery tie. So my company, I got a company, I call it artillery‡ because it’s a collection of Gunn’s, right? The family is all Gunn’s (laughing). But anyway, there was a patient and this patient, his files were sent, about that thick (indicating a big pile) … I don’t know. And everything in this thing, every consultant who met this man, is this, a fake and all this sort of thing. So I told my girl, I said “I don’t think I want to see this guy because it’s a waste of time,””, everyone else had said it and he had been having pain in the groin for so long. So one day I wore this tie, I seldom wear this tie. So one day, when I wore this tie, in comes the man, right?. And my girl was telling him “Oh, Dr. Gunn won’t have time to.” And he comes in and saw me wearing this tie, which I hardly ever wear, right? And, and he said: “I say old boy, you’re one of us.” He was an officer in the Royal Artillery. So I said: “oh,” because of this coincidence, I said: “O.K. let’s have a look!” He was hit by a gun going backwards, big (gun), adductor, right?. Treat him, … release his adductor: One treatment, he had pain for years, it’s gone. And you know these things are really quite amazing. CN: Can you tell me ... this monograph (Cannon and Rosenbluth)7 seems to me, that when you read it, the conclusions that Dr. Cannon comes to seem to be supported by a lot of subsequent studies but nobody ever mentions it.’,52 I have not found virtually any mention of that paper with the exception of in his own biography.70 Why do you (think that is)? ‡

Dr. Gunn owns a private company which deals with real estate and property management outside of his career in medicine. ’ The monograph written by Walter Cannon is seemingly supported by many subsequent authors because it pertains to basic physiology. For example portions of the Hong’s motor endplate theory of the Chinese-American neurophysiologist Chang-Zern Hong (b. 1946) seem to be supported by Dr. Cannon’s monograph although Hong’s conclusions are very different. Hong states “The pathogenesis of an MTrP appears to be related to integrative mechanisms in the spinal cord in response to sensitized nerve fibres associated with abnormal endplates.” The conclusions made by Dr. Cannon presume that the cause of the end plate abnormality is neuropathy not that the end plate abnormality causes the neurological dysfunction. There is no obvious attempt by any of the authors in the modern myofascial pain literature that I reviewed to address the theory presented by Dr. Cannon aside from those working on Dr. Gunn’s neuropathic theory. My review included more than 80 peer reviewed articles and 5 pain textbooks ranging from 1942 to 2007. See appendix A for further discussion of this paper. 52 Walter B. Cannon and Arturo Rosenbluth, The Supersensitivity of Denervated Structures, (New York: The Macmillan Company, 1949), 243; Chang Zern Hong

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CG: (laughing) It’s in Gray’s Anatomy, in the small print, in the back of the chapter and when I want to look for it, I have never been able to find it, you know how big Gray’s is, because it’s not in the index. I just happened [to be] on it. You see. I sent those papers of mine, early papers, to a patient, ex-patient and this man was a very big shot diplomat in Kuala Lumpur in the Ford foundation, and he retired to Washington you know. So I send him all those papers, I said “I don’t know why Cannon is not known,” right? He called back and said he found out the reason. Because he happens to live right next door to Cannon’s daughter.53 Isn’t it a coincidence? So Cannon’s daughter explained to him that Cannon went to China in his last years, right?†,54 CN: China or Mexico? CG: China. As a visiting professor in physiology. And it was in China that he came back with these crazy ideas, autonomic balance, right?. Which you and I accept today, it has to be balanced. And also the Chi, everything must be in contact. This is one of the big points I am going to say in my lecture next week, [it] is that every cell must be in contact with another cell or with the nervous system. Otherwise they die, right? It’s the commonest cause of neuropathy and that’s what trophic edema is all the sign. And no one has noticed that before, including myself until now, I realized the darn cells if they are not in contact they go into neuropathy and there for get trophic edema. I told you about my wife? and David G. Simons, “Pathophysiologic and Electrophysiologic Mechanisms of Myofascial Trigger Points,” Archives of Physical Medicine & Rehabilitation 79 (1998): 863-872; John M. McPartland, “Travell Trigger Points – Molecular and Osteopathic Perspectives,” Journal of the American Medical Association 104 (2004): 244-249. 53 Elin L. Wolfe, A. Clifford Barger and Saul Benison, Walter B. Cannon Science and Society, (London: The Boston Medical Library in the Francis A. Countway Library of Medicine, 2000). † In early April 1935 Dr. Cannon and his wife arrived in Shanghai, China where he served as a visiting professor of physiology at the Peking Union Medical College (P.U.M.C). In August 1935, Dr. Cannon travelled to Russia to give an address at the 15th International Congress of Physiology at the request of the 1904 Nobel Prize winner in (medicine or physiology or medicine), the Russian physiologist Ivan P. Pavlov (1849-1936). In November 1944 Dr. Cannon and his wife travelled to Mexico City, where he worked with Arturo Rosenbluth on the The Supersensitivity of Denervated Structures prior to his death on October 1, 1945. 54 Unknown, “Ivan Pavlov: The Nobel Prize in Physiology or Medicine 1904,” Nobel Lectures Physiology or Medicine, 1967, http://nobelprize.org/nobel_prizes/ medicine/laureates/1904/pavlov-bio.html (Accessed November 10, 2009).

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CN: Yes, we are going to talk about her, hopefully. CG: Anyway when he came back, people wouldn’t listen to him. And that’s, I think, a lot of jealousy. Cannon was the smartest pupil from Oxford and became a professor at Harvard.‡,55 I mean that’s no mean job, that’s a big deal thing. From Harvard, … from Oxford to Harvard, and then when he came back with these things, [he] must have the Chi, must have the balance, they boycotted him right. Because in those days China was an ignorant, old [nation]. I mean today we are very different, people, the strength of a country determines your status, don’t you think so (laughing)? CN: ... He also died before the paper came out and Rosenbluth wrote it.56 CG: Rosenbluth wrote it back, he brought it back like that. “You must publish it, [it is] so important.” But when he went to the professors at Harvard, Harvard professors said “I have better things to do than publish dead people’s work”.’ That’s also medical jealousy, I think. There are not enough people in medicine who are generous at heart, right? You ask me why [the] doctor is that true? They only want one thing, money, right? ... No but it’s hard, for instance when I treat a patient you see I just ask for a few dollars, right? But if I was a footballer it would be a million dollars (laughing). CN: Who do you think besides Cannon and Rosenbluth, which authors have influenced you in your development of all of this? Is there anyone who you felt steered you in a certain direction when you read their papers or anything like that? CG: Early on, no, because no-one was in that field right. I mean now there is more and more people. You know, but, you know, I spoke [at] lots of

‡ After completing a preparatory course from 1892 to 1896, Walter B. Cannon entered Harvard Medical School where he graduated in 1900. He became an assistant professor in 1902, and in 1906 he went on to become The George Higginson Professor of Physiology and chairman of the department of physiology at Harvard Medical School, a job he held until his retirement in 1942. 55 Elin L. Wolfe, A. Clifford Barger and Saul Benison, Walter B. Cannon Science and Society, (London: The Boston Medical Library in the Francis A. Countway Library of Medicine, 2000). 56 Walter B. Cannon and Aturo Rosenbluth, The Supersensitivity of Denervated Structures, (New York: The Macmillan Company, 1949). ’ See Appendix A for further discussion of this topic.

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places, I have been all around the world but I’m never quoted. But you can see all sorts of things people…, and you can read that they know my work. CN: ... I spoke to Dr. (David) Simons recently. CG: David Simons? Oh David, David Simons. He was so nice to send me the book.§,57 But I wasn’t, he was angry with my letter.58 But I wasn’t meaning it too rude – in a sense, right? He was trying to look into molecular and I said that it is part of a bigger, bigger physiological problem. CN: What do you think about his theory?†,59

§

This is in reference to a pointed discussion between Dr. David G. Simons and Dr. Gunn in the Journal of Musculoskeletal Pain in 1998. Both parties were strongly expressing their competing points of view. After this exchange Dr. Simons sent Dr. Gunn a copy of the latest edition of his book with Travell, entitled Travell and Simons Myofascial Pain and Dysfunction: A Trigger Point Manual with an inscription recognizing Dr. Gunn’s contributions to the myofascial pain community as a sign of respect. 57 C. Chan Gunn, “Reply to Dr. Simons,” Journal of Musculoskeletal Pain 6 (1998): 129; David G. Simons, “Experimental Resolution of the Myofascial Pain Enigma [Comment on Gunn Research Ideas Article],” Journal of Musculoskeletal Pain 6 (1998): 123-127; David G. Simons, Janet G. Travell and Lois S. Simons, Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. 2, (Baltimore, MD: Williams & Wilkins, 1999). 58 C. Chan Gunn, “Reply to Dr. Simons,” Journal of Musculoskeletal Pain 6 (1998): 129; David G. Simons, “Experimental Resolution of the Myofascial Pain Enigma [Comment on Gunn Research Ideas Article],” Journal of Musculoskeletal Pain 6 (1998): 123-127. † The ATP (adenosine triphosphate) crisis theory proposes that abnormal depolarization at the end plate is responsible for the trigger points. Muscle contraction compresses sensory nerves reducing axoplasmic flow and reduces the release of molecules, which inhibit ACh release. This sustained contraction also causes compression of vessels, which supply oxygen, and leads to causing a depletion of ATP. These events lead to pre- and post-synaptic decompensations at a biochemical level. This theory leads to treatment recommendations, which include dry needling, spray and stretch, press and stretch etc. The integrated hypothesis is an attempt to tie together the end plate abnormalities, CNS effects and biomechanical factors. Note: I have incorrectly referred to the motor end plate hypothesis here and on the previous page as being primarily described by Hong, this hypothesis was the work of many researchers including Hong and Simons. One of the frustrations expressed by Dr. Gunn is that many theories are envisioned in the lab but do not hold up in clinical situations. For example the integrated

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CG: He believes that the trigger point is the answer, and [that] he is right but that is not the ultimate answer, right? I agree that there’s this point there and I agree you can feel it, we do right, all the time. But the point is, that follows a sequence which is segmental and you can, it’s part of this and that (referring to Cannon’s Law) and therefore when you get rid of it, and you can get rid of it by stimulation by any old, you can use laser or whatever. And then it disappears, right? So he’s right but he wrote a letter to say I am right, you know privately, you saw that letter? ...60 CN: ... I don’t want to paraphrase what they say but from what I can gather, between the trigger point people ... they have Hong’s motor end plate hypothesis and Simons has this ATP crisis …61 and they have come up with this integrated theory that explains all of this. They seem to agree that neuropathy is a cause of these points; there is a chapter in Dr. Simon’s book about that. I ran into one of his books the other day and he has a whole chapter on it. But I think their problem is that they say that it’s not the only cause.62 So in your mind do you think that there are other causes of these myofascial pain syndromes besides neuropathy?

hypothesis suggests that ischemic compression should make patients worse by further reducing the blood supply etc. However clinicians have been successfully using this technique since the mid 19th century. The treatment recommendations put forth by Simons et al. have been changed to reflect the integrated hypothesis, which theoretically discourages ischemic compression. These recommendations are largely based on laboratory findings rather than clinical observations, which create an incongruence between theory and practice, which frustrates many clinicians. 59 John M. McPartland, “Travell Trigger Points—Molecular and Osteopathic Perspectives,” Journal of the American Medical Association 104 (2004): 244-249; Ronald N. Culvert, The History of Massage: An Illustrated Survey from around the World, (Rochester: Healing Arms Press, 2002). 60 C. Chan Gunn, Gunn Ims: Reprints on Pain, Acupuncture & Intra-Muscular Stimulation, vol. 21, (Vancouver: Institute for the Study and Treatment of Pain, 2008). 61 Chang-Zern Hong and David G. Simons, “Pathophysiologic and Electrophysiologic Mechanisms of Myofascial Trigger Points,” Archives of Physical Medicine & Rehabilitation 79 (1998): 863-872; John M. McPartland, “Travell Trigger Points—Molecular and Osteopathic Perspectives,” Journal of the American Medical Association 104 (2004): 244-249. 62 Siegfried Mense and David G. Simons, “Neuropathic Muscle Pain” in Siegfried Mense, David G. Simons and I. Jon Russell, eds., Muscle Pain: Understanding Its

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CG: No you see. Let’s go back to basic physiology. In the aging process, as you get older and you can look in geriatric books and all that and that graph that I always show. That’s a WHO‡ graph, right? … and WHO. And it’s a known fact that the first things that age and are not reproduced or repaired is the nerves. Muscles can repair here and fibrose [sic!]. But nerves cannot. And when nerves go wrong, they found out that it goes wrong in the peripheral nervous system, this is a fact. The central nervous system is well protected and the only thing that happens to them is a stroke, embolus or thrombosis or something. But rare, right? For, one of those there will be a million of the peripheral. And then in the peripheral nervous system where does it happen? It happens at the nerve root and this is where the physiologists have found out that it’s there. And why is the Chinese system clever? It’s because they also found it by following the meridians, you follow it up, they have joined the posterior and anterior rami together to make it the nerve root.63 That’s the first thing that goes wrong. And then when you do an EMG study, the first thing that goes is that (referring to EMG changes) right and it’s very sensitive. And it’s very quickly reversible. That’s why when we reverse it, I think not only are we releasing the muscle spasm but a lot of it is the dissipation of trophic edema. Because it’s blocked right, because when you work on it you know within minutes, the thing is warm and then … So of course there is going to be …, of course the causes of neuropathy are hundreds. You know you look in the book, you know Bradley’s book? Have you read Bradley’s book? CN: Which book? CG: Bradley’s book,64 on the nervous system, that’s the only book, I mean. Bradley is still alive, I think. I can show you a copy of it. So basically there are many, many things that cause neuropathy but let’s not talk about hot water, this or that. That poor nerve is the thing that … And Nature, Diagnosis and Treatment, (Baltimore: Lippincott Williams and Wilkins, 2001), 62-83. ‡ WHO: World Health Organization. 63 C. Chan Gunn, “Type Iv Acupuncture Points,” American Journal of Acupuncture 5 (1977): 51-52; C. Chan Gunn, Frank G. Ditchburn, Martin H. King and Gerald J. Renwick, “Acupuncture Loci: A Proposal for Their Classification According to Their Relationship to Known Neural Structures,” American Journal of Chinese Medicine, 4 (1976): 183-195. 64 Walter G. Bradley, Disorders of Peripheral Nerves, (London: Blackwell Scientific Publications, 1974).

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now of course we also find, that what is happening is that the people who work on inflammation is [sic!] beginning to come to our thinking. And they are beginning to say this is what happens, and cancer follows that. So I wrote a letter to Nature magazine, I said: “This is wonderful because we have been looking at these physical signs to identify the neuropathic signs and which lead to subsequent, they call it parainflammation”.†,65 That’s [what] my talk is going to be about that next week ... . That’s very important. CN: ... Your belief is that spondylosis‡,66 is by far the most common cause of neuropathy? CG: I don’t say that, this is, WHO says that right. You look at the body. What they say is that gravity and stress on parts of the body of which the spine …, it doesn’t matter if gravity [is] hurting your shoulder or your knee or your ankle, right? But it hurts a hell of a lot when it affects the nerve root, right? CN: When this degenerative process is happening, it is happening regardless ... when we treat people (with IMS) they get better if we have appropriately diagnosed and treated them properly, but their spondylosis isn’t changing?

†

Ruslan M. Medzhitov (b. 1966) suggests that conceptually inflammation can be considered a spectrum from the basal, non-inflamed state to the full-fledged inflammatory response such as that caused by a fracture or infection. Parainflammation can be thought of as a mid point in this spectrum brought on by tissue dysfunction or stress rather than overt infection or damage. Dr. Gunn has previously (1978) described the same physical signs as para-inflammation and referred to them as signs of neuropathy. 65 Ruslan Medzhitov, “Origin and Physiological Roles of Inflammation,” Nature 454 (2008): 428-435; C. Chan Gunn and William E. Milbrandt, “Early and Subtle Signs in Low-Back Sprain,” Spine 3 (1978): 267-281. ‡ Spondylosis is also known as degenerative disc disease and is caused by age related degeneration of the intervertebral discs. Dr. Gunn has suggested that because aging, mechanical stress and gravity are unavoidable aspects of life, all humans are in a state of progressive spinal degeneration (to varying degrees) beginning after we reach spinal maturity as teen agers. 66 Sandeep S. Rana, “Cervical Spondylosis, Diagnosis and Management,” Emedicine (2009), http://emedicine.medscape.com/article/1144952-overview. (Accessed November 10, 2009); C. Chan Gunn, The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, vol. 2, (New York: Churchill Livingstone, 1996).

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CG: Oh but it does change if you, well you put them back to square one, right? I mean they are coming down, if you treat them they go back to there and they come down. Of course aging, but you can bring them back up. (Referring to slope of degeneration) CN: ... So you can change the slope of their decline? CG: You see what we do is we have to push them back until they turn a hundred and let them drop dead right, we don’t guarantee you beyond a hundred (laughing). CN: I read your paper on the adult respiratory distress [syndrome], the ARDS case ... perhaps you could tell me about how it happened?67 CG: My wife. I left her when I was going to Sri Lanka to lecture and she caught a cold or something. And then gradually, when I was in Sri Lanka, she got very weak and you know cough. It was during Christmas time and the doctor was not around. When the doctor came back, it was already gone for a week, before she went to see a doctor. Her doctor sent her straight to the hospital and she was admitted straight away. She was able to give her name and phone number and she passed out. She was unconscious for a month. And in that time I tried to get back as soon as I could, so by the time I got back she was already 9 days in coma and her lungs were filling up. And this, when you can find the virus it’s SARS, we call it SARS [Severe Acute Respiratory Syndrome] but when we can’t find the virus, and you can’t find it at all, then you call it acute respiratory distress syndrome. Apparently a hundred to two hundred thousand people die every year from that because people don’t understand it.§,68 And what it is, is very simple, this is parainflammation.69 Para- means equivalent to, so this is an inflammation. So in the normal way when we [are] looking at 67

C. Chan Gunn, “Acute Respiratory Distress Syndrome Successfully Treated with Low Level Laser Therapy,” Journal of Complementary and Integrative Medicine 2 (2005): 1-6. § It is estimated that 190,600 patients are diagnosed with acute lung injury in the US each year resulting in 74,500 deaths and 3.6 million hospital days. The inhospital mortality rate is estimated to be 38.5 percent. ARDS is a severe subtype of acute lung injury (based on the PaO2/FiO2 ratio). 68 Gordon D. Rubenfeld, Ellen Caldwell, Eve Peabody, Jim Weaver, Diane P. Martin, Margaret Neff, Eric J. Stern, and Leonard D. Hudson, “Incidence and Outcomes of Acute Lung Injury,” New England Journal of Medicine 353 (2005): 1685-1693. 69 Ruslan Medzhitov, “Origin and Physiological Roles of Inflammation,” Nature 454 (2008): 428-435.

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inflammation we [are] looking at red, hot, swollen …, right? So we say that’s inflamed. That’s the classic inflammation. That’s the way you and I would talk. And this has come from the Greeks, from the Romans, ancient Chinese and all sorts, it’s very old.’,70 Everything is red, hot, swollen, right? But the interesting thing is, when this type of things comes, this has come from very bad cells in real trouble. But cells also go inflamed, but instead of getting hot it remains cool, but the swelling is there you see, the swelling is trophic edema. So when you look at the back, that’s parainflammation.71 So that parainflammation means that this, the cells have, the environment have changed. The, it has to have the normal oxygen, osmolarity, everything, everything is in shape right. But if you take any one of those of course it goes wrong. But the most common cause of parainflammation is when it starts to lose contact.72 Every cell must be in contact with another cell and the contact comes through the neural system. So when you get neuropathy you start to lose contact. So we have been calling it neuropathic signs but the inflammation people have been calling it parainflammation.73 And that’s very important because they are talking about it now after we’ve talked about it for three decades right and yet they threw my letter away. I sent them photographs of the trophic edema and all that. The reason of course is [that] the people who wrote those papers, they are scientists right and not clinicians; they don’t realize the importance of that. Maybe they showed it to their doctor friends, they probably said it was junk right (laughing). CN: So your wife is in the ICU [Intensive Care Unit] and you go to see her.

’

The four components to classic inflammation were described by Celsius, a Roman doctor in the 1st century AD as rubor (redness), calor (temperature), dolor (pain) and tumor (swelling). 70 Mauricio Rocha e Silva, “A Brief Survey of the History of Inflammation,” Agents and Actions 8 (1978): 1-2. 71 Referring to the physical signs of trophic edema. These include but are not limited to positive matchstick test, skin roll or peau d’orange appearance. See appendix C for photos; C. Chan Gunn and William E. Milbrandt, “Early and Subtle Signs in Low-Back Sprain, Spine 3 (1978): 267-281. 72 John M. McPartland, “Travell Trigger Points—Molecular and Osteopathic Perspectives,” Journal of the American Medical Association 104 (2004): 244-249. 73 C. Chan Gunn and William E. Milbrandt, “ Early and Subtle Signs in Low-Back Sprain,” Spine 3 (1978): 267-281.

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CG: Everyday. And of course the doctors there never talk to you, you know, they are very rude, I don’t know why doctors are like that. You know, I outrank them, I am a full professor (laughing).†,74 Which is right. And this resident and all that, would sit there and write and wouldn’t talk to me. So I stood there, eight o’clock to nine thirty I had to come back to my own patients, this fellow wouldn’t put his head up to talk, so I left. But anyway, the doctor called up and said that …, bring the whole family. So the three generations were all there, right? Because he was going to pull the plug. So before he pulled the plug, I looked at her and I said: “Can I look at her?” And he said: “yes”. So o.k., I examined her and I said to him: “You know, nothing [is] wrong with the lungs.” And he thought I was nuts, because all [was] full of fluid up to there anyway. So he said: “What’s wrong?” And I said: “It’s the nerve to [the] lungs.” Because when you get neuropathy or when you get parainflammation the electrical charge to the endothelium is lost, right? And you have to restore that. Once you lose it, the cells shrink and there is a gap, so that’s called a gap formation and fluid leaks out. And this is a gap because unlike edema, which is just fluid, this one includes proteins, and cells and big molecules. So trophic edema needs a gap but fortunately gaps are close-able, right?75 So how to put energy back? If I brought needles to poke her and she died they would say “he poked her to death” (laughing). Isn’t that right? So anyway, I thought it over and I went back at eight o’clock and I brought my laser. So I was lasering [sic!] in between her ribs. And at that time there was an article to say that these are in fact …, inflammation is part of a neural thing. It’s a reflex from here, up to there and back down again. It goes up to the thalamus and medulla and back down through the vagus, you see? And, so better stimulate the vagus. So I did it here and all that (indicating points along the vagus distribution). I spent an hour doing it. That was the old days with just the small, little laser, right? So I finished at nine o’clock and he repeated the x-rays at five, because medical rounds at six, right? And he called me up and said “what have you done?” And I said “stimulated the vagus.” He said “by God whatever you stimulated is †

Dr. Gunn is a clinical professor at the Multidisciplinary Pain Center at the University of Washington in Seattle. 74 C. Chan Gunn, Gunn Ims: Reprints on Pain, Acupuncture & Intra-Muscular Stimulation, vol. 21, (Vancouver: Institute for the Study and Treatment of Pain, 2008). 75 C. Chan Gunn, “Neuropathic Myofascial Pain Syndromes,” in John D. Loeser and John Joseph Bonica, eds., Bonica’s Management of Pain, vol. 3, (Philadelphia: Lippincott Williams and Wilkins, 2001).

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drying up so fast.” In other words, if you close those gaps …, right? So, it took more days to clean everything up you know. CN: How long did it take? CG: Oh, another ten days of a …, because you could see it bit by bit, right? If I had my big one, nowadays you have these big lasers so you can do it faster, right? But one of our physios, his son was dying and he took the thing (laser), ok, and reversed it. One of my friends, my wife’s exdoctor, her husband had the same thing. And he was in the VG hospital‡ for about two weeks, and then they brought this there (laser) and did it, then he was able to breathe. But you wouldn’t believe it, so once he was able to breathe they pulled everything out, no more support. So he breathed on his own for a day [and] then died because he was too tired, you know. I mean you really should nurse the man back but medicine is peculiar. I must say it is peculiar. CN: For these ARDS people … for cases like this do you believe that your wife’s case was unique in that it was neuropathic or do you think that all of them are neuropathic? CG: Oh, I think they all are neuropathic. Basically the underlying thing is parainflammation, right? And the same thing is, the most common level is here (neck), isn’t it? And here (low back). And I have lost several friends to cancer of the pancreas and other things. Because when they get to this age, the spondylosis gets very bad.76 CN: ... Can you explain that to me? You mentioned it earlier, so when the spondylosis gets back how does that lead to (cancer)? CG: Spondylosis leads to neuropathy, neuropathy means that the cells are not … the connection between cells drops. When the cells drop the connection …, the voltage drops, right? And therefore when the voltage …, you can have a cell here and the voltage is 90, 90, 90, 89, this one [is] lower and it gets higher to the next. So the ones here (indicating the area of lower voltage) start to leak you see, they have lost connection. CN: So they become dysregulated?

‡

VG: Vancouver General Hospital, British Columbia, Canada. C. Chan Gunn, “‘Prespondylosis’ And Some Pain Syndromes Following Denervation Supersensitivity,” Spine 5 (1980): 185-192.

76

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CG: That’s …, apparently that is the most common cause of parainflammation, the loss of contact, right?77 That is why it’s so important to poke. When you poke you are making a nerve, temporary nerve (motor point) …†,78 It doesn’t make sense to anyone who hasn’t done it, you see, but there it is. CG: This is a good article … .‡,79,80 Now if you have an infection you get into the classic … But if you have a stress or injury right, injury belongs here but stress, the lack of contact, let’s see, basal … . See, the basic structure is there and this is all controlled by the white cell, the reticular endothelial system. So you have, when it’s not functioning they call it stress, right, of mitochondria and then it leads to parainflammation, right? You get infected or damaged, then you the get real inflammation. But we have been looking at this and no one has looked at that yet. And my lecture will be the first introduction to parainflammation. I think it’s terribly important but will it be wasted upon the audience? (laughing) So the pain department has invited me to give a talk on IMS, right? So, I can talk about IMS, low back pain, so it gives me a second chance to get at these people. But I talked to one of the doctors, SR, you know Dr. R? She says that the trouble is, if you aren’t paid for IMS, people aren’t interested.§,81 So I gave a talk to C.S. right, a practice and the same thing 77 Alberto Mantovani, Paloa Allavena, Antonio Sica and Frances Balkwill, “Cancer-Related Inflammation,” Nature 454 (2008): 436-444. † Referring to the current of injury or injury potential created by the needle. Poking a needle into a neuropathic point creates a temporary area of low resistance (measured at the skin surface), which is similar to what is observed over a motor point. This current of injury refers to the electrochemical changes, which occur within the muscle as a result of the needle insertion and result in resolution of the symptoms of neuropathy. 78 C. Chan Gunn, “Transcutaneous Neural Stimulation, Acupuncture and the Current of Injury,” Acupuncture & Electrotherpeutic Research International Journal 5 (1980): 83-91. ‡ Dr. Gunn is reviewing the Inflammation issue of Nature 454, no. 7203, at this point in the interview. 79 Alberto Mantovani, Paloa Allavena, Antonio Sica and Frances Balkwill, “Cancer-Related Inflammation,” Nature 454 (2008): 436-444. 80 Ruslin Medzhitov, “Origin and Physiological Roles of Inflammation,” Nature 454, (2008): 428-435. § In most provinces in Canada IMS is not a publicly funded procedure. Patients are required to pay for the treatment themselves. IMS is performed by physicians, physiotherapists and physician assistants. For example, in Alberta currently the cost of an IMS treatment by a physiotherapist ranges from roughly $75-90

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you know. The doctors sat there in the back and at the end of my talk [asked:] “is it paid for?” I said no, “o.k., good bye.” They didn’t even say thank you for the talk. CG: Here we are – … cancer-related.82 And this is what I think is very important. What I think is important and what you can follow up on is, no one examines patients who are dying of cancer. They see a biopsy, they see the slide. But what I want to know is, the breast is second, no one look[s] up there right (pointing to the neck)? Or cancer of the pancreas no one looks (pointing to back).†,83 And, my friends died and I didn’t know how to look at that, at that stage, right? So, like for instance, my wife has bad spondylosis and she had another attack. But this time causing terrific pain here right (indicating a region of the thorax). So her doctor didn’t know what to do, so eventually I treated her back. And by treating it, I could see all the trophic edema and all the spasm and when it got better, the pain just disappeared. So my daughter had irritable bowel [disease], frequency of urine, excess bleeding of the uterus and all that. And [her doctor] cannot fix in the medical [problem]. So I treated her back once a

according to the Alberta Physiotherapy Association fee guidelines at the time of the interview and takes approximately 30 minutes. A physician in Ontario using a nerve block to treat the same area could bill the government $164.45 for the injection alone (not including the consultation fees etc.) which would take much less time than IMS. Physicians using botox for these problems can bill patients well over $700 per treatment in Canada. 81 APA, “Alberta Physiotherapy Association,” 2009, http://www.albertaphysio.org/ admin/contentx/ default.cfm?PageId=9322 (Accessed November 5, 2009); OHIP, “Schedule of Benefits for Physician Services under the Health Insurance Act,” Ontario Health Insurance Plan, 2009, http://www.health.gov.on.ca (Accessed November 5, 2009); Unknown, “Kingston Cosmetic Instituite,” 2009, http://www. kingstoncosmetic institute.com/costframe.htm (Accessed November 5, 2009). 82 Alberto Mantovani, Paloa Allavena, Antonio Sica and Frances Balkwill, “Cancer-Related Inflammation,” Nature 454 (2008): 436-444. † Recent evidence has shown that parainflammation is related to cancer, because it causes cellular dysregulation and spondylosis has been shown to cause parainflammation previously. Dr. Gunn is alluding to his hypothesis that they may be a relationship between cancer and spondylosis because of their link to parainflammation. 83 C. Chan Gunn, “‘Prespondylosis’ And Some Pain Syndromes Following Denervation Supersensitivity,” Spine 5 (1980): 185-192; Alberto Mantovani, Paloa Allavena, Antonio Sica and Frances Balkwill, “Cancer-Related Inflammation,” Nature 454 (2008): 436-444.

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week and six treatments later everything cleared up.‡,84 In other words this neuropathy is terribly important. CN: ... you have trained people all over the world, people are doing IMS everywhere. CG: Well you know the interesting thing … like in Germany they do it and they give it, someone else puts his name on it too. CN: Really? CG: Well you know these things happen.§,85 And it happened in Switzerland, Italy. He [a physician] came here and did the course, he ‡

According to Cannon’s Law, dysfunction of a nerve root causes supersensitivity of its end-organs. Following to this concept, the cause of the organ dysfunction is neuropathy of its nerve supply. Dr. Gunn was using IMS to stimulate the dysfunctional nerves supplying these organs in order to normalize their function. For example the bladder detrusor is supplied by the spinal nerves S2-S4, these nerve roots also supply the sacral paraspinal muscles at that level. Needling the bladder is not practical but according to Cannon’s Law, by stimulating (needling) the paraspinal muscles there will be an effect (reduction of the supersensitivity) throughout the entire spinal segment, including the bladder detrusor in this case. This theory predicts a reduction in supersensitivity of all the end organs supplied by S2-S4 to varying degrees (based on their distance from the area of primary denervation) e.g. sacral paraspinal muscles, gastroc nemius, hamstrings, bladder etc. 84 Walter B. Cannon and Aturo Rosenbluth, The Supersensitivity of Denervated Structures, (New York: The Macmillan Company, 1949), 243; Henry Gray, Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 40th ed. (Churchill Livingstone, 2008). § Dr. Yun-tao, MA, PhD, developed systemic integrative dry needling (SIDN) which combines IMS and Travell trigger points and now offers courses around the world. Another of Dr. Gunn’s former students, Dr. Cynthia Gokavi (b. 1947?) offers courses in Gokavi Transverse Technique (GTT) and operates a pain clinic in Saskatoon, Saskatchewan. GTT involves the use of electricity (via acupuncture needles) prior to dry needling muscles in a transverse manner. GEMt is a company which now offers courses in what they call “TDN” or: trigger point dry needling (in the United States and Australia). On their website they state “The most common cause of nerve irritation and neuropathic pain is underlying spinal degeneration (i.e. spondylosis of the spine), which can be a result of trauma and/or normal wear and tear. Spondylosis irritates the nerve root and leads to neuropathy which can result in muscle shortening” which is essentially Dr. Gunn’s long standing opinion. Their course appears to be largely based on IMS, when compared with the material on their website. GEMt was formed in 2008 by Robert

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failed you know (laughing)? But, the moment he went back to Italy and Switzerland he started to teach and he is on the Internet now ... . The point is, it doesn’t say Gunn IMS it says his IMS. This thing is terrible, it’s so easy to copy, you see, but to get the whole picture is not easy. CN: Can you tell me about Dr. Ok (K Hwi Ok) from South Korea? CG: … Dr. Ok is a neurosurgeon. CN: How did you run into him? CG: I didn’t run into him, he just read the book86 and came here to be trained, you see. You know, he was so impressed by the thing. Last, we had one from Singapore in the last course. We’ve had one from Arabia. Because when you read this thing and you are a true doctor seeing doctors it makes sense, right? But it doesn’t make sense to the PhD’s, right? CN: How do you feel, because a lot of people in South Korea are practicing and you lecture … CG: Seoul alone is 2000 (practitioners). Now they had to stop. CN: Why? CG: Oh, big trouble there, the Chinese acupuncturists. In many countries the law allows Chinese medicine and Western medicine. And you are not allowed to infringe on the other right. So the Korean Chinese trained doctors have gone to the government to stop IMS because they say “it’s really acupuncture you know.” And they wrote me a letter to write … so I wrote a letter to the [Chief of] Justice to say that “I think either side could use it.” I said “either side, by anyone who knows his anatomy and physiology, full stop.” I haven’t heard from their office (laughing).

De Nardis and Edo Zylstra, who completed their training at iSTOP in May 2007 and April 2002 respectively, and are now teaching courses. 85 Yun-tao Ma, “Dry Needling Course,” 2009, http://www.dryneedlingcourse.com/ what_is_dry_needling.htm (Accessed November 10, 2009); Cynthia Gokavi, “Gokavi Acupuncture,” The Gokavi Transverse Techinque C, 2009, http://www. gokaviacupuncture.com (Accessed November 8, 2009); GEMt, “Global Education of Manual Therpists,” 2009, www.gemtinfo.com. (Accessed November 19, 2009); iSTOP, “Istop the Institute for the Study and Treatment of Pain,” 2009, http://www.istop.org (Accessed November 20, 2009). 86 C. Chan Gunn, The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, vol. 2, (New York: Churchill Livingstone, 1996).

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CN: So when you lecture ..., I assume you have found a lot of resistance in North America to these theories, based on what I have read in the literature? CG: The trouble is its just basic physiology, not many of them know their physiology. CN: (How) do you find that your ideas are accepted outside of North America? CG: Better, I think. Well you see like in Peru, right, they’ve had a couple [of] courses but you know there is five hundred people attending. So I think that’s good because they get the idea and they are doctors, they can poke, right? CN: ... In countries where there is a lot of Traditional Chinese Medicine being practiced with the exception of this legal problem now, do you find it is more readily accepted? CG: Well, we sent Dr. L and KL to China but the old boys couldn’t understand it [referring to western trained physicians], but the young ones did. So we took five hundred copies of my red book87 and it disappeared within …, you put it outside and [it is] gone. That shows that people are interested, right? So, one doctor wrote a letter to me, email. And keep [sic!] on saying, he talked to a friend who came, passed through Vancouver. He said why don’t you reply? I can’t read Chinese. My Chinese, you know, I mean it’s not possible, I mean how do you do a scientific discussion with someone who speaks only Chinese right? However, I mean there is recognition because you know I was given my fellowship just a few months ago by the British ... F.R.C.P., Fellowship of the Royal College of Physicians. You see in England, like here you get (F.R.C.P. [or] C.S. [College of Surgery], Canada [(C)], right? But in England it’s M, you only become a member right and then out of the membership, those who are distinguished eventually, as you get older I suppose (laughing), they are elected to fellowship. So I was elected to fellowship, last August or September. That’s a big deal; it’s the highest medical recognition in the British Empire, higher than the ones here because it’s the whole Empire right. So, there are quite a few in Canada I think. You know, all, they are usually teachers, people recognized for their 87

C. Chan Gunn, The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, vol. 2, (New York: Churchill Livingstone, 1996).

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[teaching]. So people recognize IMS and the neuropathy theory in England right, the people who read it. CN: What is your plan for the future for yourself? CG: I want to get out of this, my wife is very unhappy because she has had enough of iSTOP, you see. I don’t blame her. Our trouble is we can’t get doctors to come in, because it’s not a money-making thing, right? Maybe we should charge more ... you know the College of Chiropractic,† they want to teach it and Dr. HT, one of my old lecturers, she wants to be one of the teachers but the physios here don’t want it, so I’m in a difficult position. So I wrote back and said that they should learn it through McMaster’s [sic!] university, where they have medical acupuncture and then they can incorporate IMS theories. CN: One thing I have noticed and many of my colleagues have noticed, is that when we look at spines there are certain areas that are hypermobile, they move too much …;‡ if you examine them, they are always the neuropathic segments. Why do you think that is? CG: That is because the adjacent part is locked. It’s not because it’s too mobile here, it’s because the one above or below has become frozen. Because when you go through the gibbus,§,88 [it] is there and the tenderness is …, tenderness is a good physical sign for localizing it, you just [feel it]. And the amazing thing is that you can do this test right through clothes and everything. It’s quite straightforward, it’s just [that] people don’t think. After you read [Walter G.] Bradley [Disorders of Peripheral Nerves (1974)], you understand it a lot better. If you look in Bradley, there are hundreds of thousands of causes of neuropathy, right? But, we are talking [about] the most common. … (looking in Bradley) diseases of skeletal muscles, spinal nerve roots, right? Look at that syphilis … neoplastic everything. CN: What do you hope to see for the future, you plan to stop at some point, what do you hope happens for the future of these patients, these myofascial pain patients?

‡

Referring to findings during biomechanical spinal assessment. Gibbus refers to the step deformity found in forward flexion during the IMS assessment. This is one physical sign used to help localize neuropathy. 88 C. Chan Gunn, The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, vol. 2, (New York: Churchill Livingstone, 1996). §

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CG: I was thinking this thing should be handed over to the physios, [as] no doctors [are] interested. ... I think iSTOP is important for the physios because they need [it]; we were the people that said to the college of physiotherapy “let them poke” right. Now if I had not written the letter to, say let physios poke, they wouldn’t be poking today ... Apart...from the politics of IMS and the politics of iSTOP my wife is so fed up with the whole thing. So I am in the stage of wanting to drop the whole thing, and yet we are doing a lot of good, we are training a lot of people. CN: Thank you so much!

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APPENDIX B: TIMELINE 1931

C. Chan Gunn is born in Kuala Lumpur, Malaysia.

1946-1950

He attends the Leys School, Cambridge.

1949

Science prize. The Leys School, Cambridge.

1953

Bachelor of Arts. Peterhouse, University of Cambridge.

1956

Master of Arts, Natural Sciences. Peterhouse, University of Cambridge.

1957

Bachelor of Medicine and Surgery. Peterhouse, University of Cambridge.

1958

Dr. Gunn returns to Malaysia.

1958-1966

Principal. Group Family Practice and Industrial Medicine, Malaysia.

1964-1966

Chairman. International Red Cross Society, Kuala Lumpur, Malaysia.

1966-

Immigrates with his wife Peggy to Vancouver. Research associate, Department of University of British Columbia, Canada.

Pharmacology,

1967-1980

Clinic physician, Workers Compensation Board (WCB).

1970’s ca.

Travels to New York to get EMG training and begins using it extensively to investigate patients with myofascial pain.

1972

Founding member and president, Canadian Society for Asian Art.

1973

Interest in needling begins and development of IMS theory and practice begin.

1974

Trip to China, while looking for information about acupuncture.

1980

Finishes working at WCB. President, Gunn Pain Clinic, Vancouver BC, Canada.

1985

Clinical professor, Multidisciplinary Pain Center at the University of Washington School of Medicine in Seattle.

1986

International Dag Hammarskjold Award for Alternative Medicine.

1990-1992

President. American Society of Medical Acupuncture.

1992

Visiting Professor in Rehabilitation Medicine: University of Pennsylvania.

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1993

James Beaver Mennell Award in Physical Medicine.

1995

Founding President, Institute for the Study and Treatment of Pain (iSTOP), as a non-profit organization in Vancouver. Clifford G. Woolfe Award, Acupuncture Foundation of Canada.

1997

Honorary Fellow, Peterhouse, University of Cambridge.

1998

Honorary Fellow, Chinese Medical Association of Acupuncture, Taiwan.

2000

Doctor of Philosophy, [PhD] (honoris causa), The Open International University for Complementary Medicines, Columbo, Sri Lanka. Doctor of Science [DSc] (honoris causa), The Open International University for Complementary Medicines, Columbo, Sri Lanka.

2001 2002

Awarded the Order of British Columbia. Awarded the Order of Canada. Golden Jubilee Medal – part of the Canadian honours system recognizing outstanding achievement in community service. Clinical professor, Graduate School of Complementary and Altenative Medicine, Pochon CHA, South Korea.

2003

Janet Travell Clinical Pain Management Award, American Academy of Pain Management.

2007

Elected as a Companion of the Guild of Cambridge Benefactors.

2008

2010

Elected as a Fellow of the Royal College of Physicians in England. Gunn Gallery in Ward Library at Peterhouse opens. Dr. Gunn donates a large collection of ancient Chinese porcelain to the collection. President of iSTOP, Dr. Gunn continues his work in Vancouver B.C., Canada.

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APPENDIX C: MAJOR PUBLICATIONS BY DR. C. CHAN GUNN Note: Articles given in Italics, which Dr. Gunn cites as instrumental in the development of his neuropathic theory IMS. x Gunn, C. C. (1977). Type IV Acupuncture Points. Am J Acupuncture, 5(1), 51-52. x Gunn, C. C. (1978). Comments On “The Double Blind Study Comparing Disease to Placebo”. Spine, 3(3), 282. x Gunn, C. C. (1978). Motor Points and Motor Lines. Am J Acupuncture, 6(1), 55-58. x Gunn, C. C. (1978). Transcutaneous Neural Stimulation, Acupuncture and the Current of Injury. Am J Acupuncture, 6(3), 114. x Gunn, C. C. (1978). Transcutaneous Neural Stimulation, Needle Acupuncture & 'Teh'ch'i' Phenomenon. Am J Acupuncture, 4(4), 317322. x Gunn, C. C. (1979). Causalgia and Denervation Supersensitivity. Am J Acupuncture, 7(4), 7-14. x Gunn, C. C. (1979). Diagnosis of Low Back Injury. Spine, 4(3), 279. x Gunn, C. C. (1980). “Prespondylosis” And Some Pain Syndromes Following Denervation Supersensitivity. Spine, 5(2), 185-192. x Gunn, C. C. (1980). Tennis Elbow. The Surgical Treatment of Lateral Epicondylitis. Journal of Bone and Joint Surgery – American Volume, 62(2), 313-314. x Gunn, C. C. (1980). Tinel Sign in Brachial Plexus Lesions. Annals of the Royal College of Surgeons of England, 62(2), 154. x Gunn, C. C. (1980). Transcutaneous Neural Stimulation, Acupuncture and the Current of Injury. Acp and Electrotherpeut Res Int J, 5(1), 8391. x Gunn, C. C. (1989). Neuropathic Pain: A New Theory for Chronic Pain of Intrinsic Origin. Ann Royal College of Phys and Surg, 22(5), 327330. x Gunn, C. C. (1990). Mechanical Manifestations of Neuropathic Pain. Ann Sports Med, 5(3), 138-141. x Gunn, C. C. (1995). ‘Fibromyalgia’ – “What Have We Created?” (Wolfe 1993) [See Comment]. Pain, 60(3), 349-350. x Gunn, C. C. (1995). Musculoskeletal Pain. Journal of the Royal Society of Medicine, 88(5), 302. x Gunn, C. C. (1996). Chronic Pain: Time for Epidemiology. Journal of the Royal Society of Medicine, 89(8), 181-183. x Gunn, C. C. (1996). The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin (Vol. 2). New York: Churchill Livingstone. x Gunn, C. C. (1997). Acupuncture and the Peripheral Nervous System. In J. Filshie and A. White (Eds.), Medcial Acupuncture: A Western

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Scientific Approach (Vol. 1, pp. 137-149). London: Churchill Livingstone. Gunn, C. C. (1997). Radiculopathic Pain: Diagnosis and Treatment of Segmental Irritation or Sensitization. J Musculous Pain, 5(4), 119-134. Gunn, C. C. (1998). Reply to Dr. Simons. Journal of Musculoskeletal Pain, 6(4), 129. Gunn, C. C. (2001). Neuropathic Myofascial Pain Syndromes. In J. D. Loeser, S. H. Butler, C. R. Chapman and D. C. Turk (Eds.), Bonica’s Management of Pain (Vol. 3rd). Philadelphia: Lippincott Williams and Wilkins. Gunn, C. C. (2005). Acute Respiratory Distress Syndrome Successfully Treated with Low Level Laser Therapy. Journal of Complementary and Integrative Medicine, 2(1), 1-6. Gunn, C. C. (2006). Re: Electrical Twitch-Obtaining Intramuscular Stimulation in Lower Back Pain: A Pilot Study. American Journal of Physical Medicine and Rehabilitation / Association of Academic Physiatrists, 85(12), 1015-1016; author reply 1016. Gunn, C. C. (2008). Gunn Ims: Reprints on Pain, Acupuncture and Intra-Muscular Stimulation (Vol. 21st). Vancouver: Institute for the Study and Treatment of Pain. Gunn, C. C., Byrne, D., Chao, H., Chapman, L., Lam, A., Leung, M. K., et al. (2007). Upper Lumbar Radiculopathy – a Seldom Detected Cause of Back Pain. J Orthopedic Medicine, 29(3), 79-84. Gunn, C. C., Byrne, D., Goldberger, M., Lam, A., Leung, M. K., McBrinn, J., et al. (2001). Treating Whiplash-Associated Disorders with Intramuscular Stimulation: A Retrospective Review of 43 Patients with Long-Term Follow-Up. J Musculoske Pain, 9(2), 6989. Gunn, C. C., Ditchburn, F. G., King, M. H., and Renwick, G. J. (1976). Acupuncture Loci: A Proposal for Their Classification According to Their Relationship to Known Neural Structures. American Journal of Chinese Medicine, 4(2), 183-195. Gunn, C. C., Islip, M.C., Masters, P.L., Erskine-Murray, H., Rigg, C.A., Stapleton, T. (1960). Iron-Deficiency Anaemia between 3 Months and 2 Years of Age, and a Comparison of Treatment with Ferrous Sulphate and Ferrous Fumarate. Arch Dis Children, 35(181), 281-284. Gunn, C. C. and Lee, H.M.C. (1980). Male Pattern Hair Loss: A Supraorbital Nerve Entrapment Syndrome? Acupuncture Electrother Res Int J, 5(1), 83-91. Gunn, C. C., and Milbrandt, W. E. (1976). Tenderness at Motor Points. A Diagnostic and Prognostic Aid for Low-Back Injury. The Journal of Bone and Joint Surgery. American Volume, 58-A(6), 815-825. Gunn, C. C., and Milbrandt, W. E. (1976). Tennis Elbow and the Cervical Spine. Canadian Medical Association Journal, 114(9), 803809.

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Gunn, C. C., and Milbrandt, W. E. (1977). The Neurological Mechanism of Needle-Grasp in Acupuncture. Am J Acupuncture, 5(2), 115-120. Gunn, C. C., and Milbrandt, W. E. (1977). Peripheral Nerve Injuries Mimicking Lumbar Disc Herniations. BC Med J, 19(9), 350-352. Gunn, C. C., and Milbrandt, W. E. (1977). Shoulder Pain, Cervical Spondylosis and Acupuncture. Am J Acupuncture, 5(2), 326-332. Gunn, C. C., and Milbrandt, W. E. (1977). Tenderness at Motor Points: An Aid in the Diagnosis of Pain in the Shoulder Referred from the Cervical Spine. Journal of the American Osteopathic Association, 77(3), 196-112. Gunn, C. C., and Milbrandt, W. E. (1977). Utilizing Trigger Points. Osteopathic Phys, 44(3), 29-52. Gunn, C. C., and Milbrandt, W. E. (1978). Early and Subtle Signs in Low-Back Sprain. Spine, 3(3), 267-281. Gunn, C. C., Milbrandt, W. E., Little, A. S., and Mason, K. E. (1980). Dry Needling of Muscle Motor Points for Chronic Low-Back Pain: A Randomized Clinical Trial with Long-Term Follow-Up. Spine, 5(3), 279-291. Gunn, C. C., and Milbrandt, W.E. (1977). “Bursitis” Around the Hip. Am J Acupuncture, 5, 53-60. Gunn, C. C., and Sola, A. E. (1989). Chronic Intractable Benign Pain (Cibp) [Comment]. Pain, 39(3), 364-365. Gunn, C. C., Sola, A. E., Loeser, J. D., and Chapman, C. R. (1990). Dry-Needling for Chronic Musculoskeletal Pain Syndromes Clinical Observations. Acupuncture, 1(2), 9-15. Stapleton, T., Gunn, C. C., and Gelpke, P. (1960). Effect of Triiodothyroacetic Acid on the Electrocardiogram in Cretinism. Arch Dis Child 35(181), 276-280.

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APPENDIX D: DISCUSSION OF THE “THE SUPERSENSITIVITY OF DENERVATED STRUCTURES” There are many interesting issues related to the paper written in 1949 by Walter B. Cannon and Arturo Rosenbluth entitled The Supersensitivity of Denervated Structures––to which Dr. Gunn has drawn considerable attention to––, which I shall briefly map and discuss in this appendix. Arturo Rosenbluth (1900-1970), a Mexican physician, arrived at Harvard in September of 1930 as a holder of The John Simon Guggenheim fellowship. Although he had little expertise in the area of physiology, Dr. Cannon was impressed with him and took him into his own lab forming a partnership which would last until Cannon’s death in 1945.1 Rosenbluth grew up in Mexico and was the son of a Mexican-American mother and a Hungarian Jewish immigrant father. He had great interest in the scientific method, in particular the application of mathematics to research in physiology. Academically, he flourished at Harvard and published papers at a rapid pace including seven papers in 1932 and two more in 1932.2 Important to his role with Dr. Cannon was also their mutual work on a substance known as sympathin.3 Rosenbluth and Cannon were engaged in an academic dispute with the Cambridge pharmacologist Henry Dale (1875-1968), the Belgian radiobiologist Zénon Bacq (1903-1983) and others over the existence and role of sympathin chemical neurotransmission. In the end, Cannon and Rosenbluth’s hypothesis that there were two types of sympathin (E or excitatory and I or inhibitory) which were unique from adrenin (adrenaline) turned out to be wrong, while Henry Dale won the Nobel Prize in Physiology or Medicine in 1936 for his work on chemical nerve transmission. When Dr. Cannon retired in 1942 he strongly encouraged Harvard to make room for Rosenbluth and keep him on staff, when his tenure was up the following year. Yet despite Cannon’s strong support for Rosenbluth, there were many people at Harvard that wanted him to leave–– since Harvard University in 1942 was not a place devoid of anti-Semitism and racism. In 1934, for example, the German businessman and Nazi protagonist Ernst Hanfstaengl (1887-1975), a Harvard grad and close confidante of Hitler returned to his alma mater and gave the commencement speech. His presence did bring protests which eventually forced the chemist James B. Conant (1893-1879),

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Elin L. Wolfe, A. Clifford Barger and Saul Benison, Walter B. Cannon Science and Society, (London: The Boston Medical Library in the Francis A. Countway Library Of Medicine, 2000). 2 Ibid. 3 Walter B. Cannon and Arturo Rosenbluth, “Studies on Conditions of Activity in Endocrine Organs xxix. Sympathin E and Sympathin I,” American Journal of Physiology 104 (1993): 557-574.

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Harvard’s president, to refuse Hanfstaengl’s monetary gift to the school.4 His speech is just a single example of the mild anti-Semitism which is said to have existed at that time. Many of James B. Conant’s policies had in fact been discouraging to African Americans, Jews, women and immigrants.5 Rosenbluth’s Jewish heritage and close relationship with Dr. Cannon, one of the most influential researchers of the day may have been factors in the animosity many of his colleagues felt for him. Rosenbluth had filed the initial papers for his American citizenship but finally did not complete them.6 His status as a Mexican immigrant may have also influenced his worth in the eyes of his colleagues as well. Influential members of the Harvard elite blamed Rosenbluth for Dr. Cannon’s persistent belief in sympathin I and E, despite mounting evidence against it which turned out to be a major blemish on his otherwise impeccable academic record.7 Rosenbluth was also described as having a strong personality and at times being even arrogant. All of these factors led Rosenbluth to return to Mexico City in the summer of 1943 and to accept a job in the department of physiology at the Institute of Cardiology.8 Dr. Cannon retired from his official duties at Harvard as the George Higginson professor of physiology and department chair in 1942. However he did not retract from his work as a physiologist or figurehead. He still sat on the National Research Council’s (NRC) committee on the biological processes of aging and acted as the official head of foreign relations for the NRC.9 In 1944, he became a visiting professor at the New York College of Medicine and he also published an autobiographical memoir entitled The Way of an Investigator: A Scientist’s Experiences in Medical Research.10 Dr. Cannon and his wife traveled to Mexico, in February of 1945,11 with the intention of visiting Arturo Rosenbluth and performing the experiments he required to complete his monograph The Supersensitivity of Denervated Structures.12 Dr. Cannon had a long list of ailments 4

Morton Keller and Phylis Keller, Making Harvard Modern, (New York: Oxford University Press, 2001). 5 Ibid. 6 Elin L. Wolfe, A. Clifford Barger and Saul Benison, Walter B. Cannon Science and Society, (London: The Boston Medical Library in the Francis A. Countway Library of Medicine, 2000). 7 Ibid. 8 Ibid. 9 Ibid. 10 Walter B. Cannon, The Way of an Investigator: A Scientist's Experiences in Medical Research, (WW Norton & Co Inc., 1984). 11 Elin L. Wolfe, A. Clifford Barger and Saul Benison, Walter B. Cannon Science and Society, (London: The Boston Medical Library in the Francis A. Countway Library Of Medicine, 2000). 12 Walter B. Cannon and Arturo Rosenbluth, The Supersensitivity of Denervated Structures, (New York: The Macmillan Company, 1949).

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at the time of the trip including the persistent X-ray burns to his hands resulting from his early work on digestion, chronic unrelenting itching, a recent bout of Bell’s palsy and a basal cell carcinoma of the upper lip. During his time in Mexico, Dr. Cannon had a bout of itching which resulted in a serious skin infection, fever and malaise which ultimately forced him to return home early. His health recovered somewhat once he returned home, but on October 1, 1945 he died of acute febrile disease with pneumonia.13 During his 1945 trip to Mexico Dr. Cannon had asked his research partner Arturo Rosenbluth, if he would agree to finish his final monograph should he be unable to do so himself, and Rosenbluth agreed. Chapters 1 and 3-13 were authored entirely by Cannon prior to his death, chapters 10, 14, 15, 20 and 21 were partially written by Cannon and completed by Rosenbluth, chapters 2, 16, 17, 18, 19 and 22 were authored entirely by Rosenbluth.14 The 245-page monograph was eventually published in 1949 by The Macmillan Company in New York City. Part of my initial hypothesis was that The Supersensitivity of Denervated Structures had actually been an obscure paper that was ignored by the scientific community for unknown reasons. The circumstances mentioned above provide much plausible evidence for this assumption. I formed this hypothesis, because in reviewing the modern myofascial pain literature I was unable to find this paper cited, except by those researchers involved with Dr. Gunn’s neuropathic theory. Dr. Gunn also believed this paper to be obscure for unknown reasons and had attempted to investigate its obscurity periodically during his career. On August 9, 2009 after my interview with Dr. Gunn I personally spoke to the librarian and researcher Elin L. Wolfe at the Countway Library for the History of Medicine at Harvard, who has been the author of a biographical book outlining Walter B. Cannon’s life and works entitled Walter B. Cannon Science and Society.15 She was very familiar with the paper, as it was included in her book, and suggested that it may actually not be too obscure at all. I found it difficult to determine exactly how often it had been cited because of its nature as a monograph and the year of its publication. However after further research, I was able to find over 30 papers citing this monograph, which is most likely only a partial list (Appendix B). The years of publication of these citing Cannon and Rosenbluth (1949) ranged from 1950 up to 2007. The subject areas of these papers included any areas outside of experimental physiology, such as psychology, cardiology, neurology, plastic surgery and numerous others. I was still unable, however, to find widespread citation of this paper in the myofascial pain literature. Given the 57-year-span of citing publications, the wide variety of subject areas receiving it and the likelihood 13

Ibid. Walter B. Cannon and Arturo Rosenbluth, The Supersensitivity of Denervated Structures, (New York: The Macmillan Company, 1949). 15 Elin L. Wolfe, A. Clifford Barger and Saul Benison, Walter B. Cannon Science and Society, (London: The Boston Medical Library in the Francis A. Countway Library Of Medicine, 2000). 14

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that this is only a partial list, I found little evidence for the hypothesis that this paper is obscure or has been ignored by the scientific community as a whole. I reviewed more than 80 journal articles and 5 pain textbooks with publication years ranging from 1942 to 2007 in the myofascial pain area, while eventually finding no mention of Dr. Cannon’s monograph outside of those working on Dr. Gunn’s neuropathic theory. During the interview with Dr. Gunn, I asked him deliberately the question: “Can you tell me ... this monograph (Cannon and Rosenbluth, 1949) seems to me, that when you read it, the conclusions that Dr. Cannon comes to seem to be supported by a lot of subsequent studies but nobody ever mentions it. I have not found virtually any mention of that paper with the exception of his own biography. Why do you (think that is)?” He asked a similar question a number of years ago to one of his patients who happened to live next door to Dr. Cannon’s daughter in Washington DC. The explanation given to him was that Dr. Cannon traveled to China near the end of his career and upon his return, began working on autonomic balance and Chi which lead to the academic community boycotting him. In April of 1935, Dr. Cannon traveled with his wife to Shanghai, China, to serve as a visiting professor of physiology at Peking Union Medical College.16 The content of his lectures included homeostasis, chemical neurotransmission, emotions and numerous other topics. His work on homeostasis was ongoing prior to his trip to China and is likely what was being referred to as “autonomic balance” by Dr. Gunn’s former patient. I could find no evidence that his two-month trip lecturing in China led to any major deviation from his previous scientific work on homeostasis upon his return home. There was a suggestion by Dr. Gunn’s former patient that Dr. Cannon was boycotted in some way upon his return from China, a claim for which I was also not able to find any evidence for. Conversely, upon his return he continued to publish papers, held his positions on numerous committees and played an integral role in the functioning of Harvard Medical School.17 Dr. Cannon’s excellent standing among his peers at the end of his career is also pivotal from the biographical work titled Walter B Cannon Science and Society”.18 One of the editors, Elin L. Wolfe confirmed to me in a telephone conversation on August 9, 2009 that it was also her opinion that Dr. Cannon had an excellent academic standing at the end of his career. What are then the explanations for the lack of citation of The Supersensitivity of Denervated Structures in the myofascial pain literature? I think the most likely 16

Elin L. Wolfe, A. Clifford Barger and Saul Benison, Walter B. Cannon Science and Society, (London: The Boston Medical Library in the Francis A. Countway Library Of Medicine, 2000). 17 Edric Lescouflair, [Walter Bradford Cannon: Experimental Physiologist 18711945], 2009, Web Page (Accessed November 30, 2009). 18 Elin L. Wolfe, A. Clifford Barger and Saul Benison, Walter B. Cannon Science and Society, (London: The Boston Medical Library in the Francis A. Countway Library Of Medicine, 2000).

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hypothesis is that authors in myofascial pain have not cited this important paper, because they did not feel that it was relevant to their work. Conceptually, there are two major schools of thought surrounding myofascial pain, Dr. Gunn believes that this pain is a result of neuropathy and the trigger points or tender points found within the muscles are a symptom of this neuropathy. This theory is deeply rooted in clinical observation and relies heavily on Dr. Cannon’s work, The Supersensitivity of Denervated Structures for a theoretical explanation of these observations. The other major school of thought is that these trigger points or tender points are the cause and are not the result of neuropathy. Within this school there are several theories which attempt to explain the existence of these trigger points. Perhaps the two leading theories are the motor end plate theory and Dr. David G. Simons ATP crisis theory.19 The most recent theory is based on an integrated hypothesis, which attempts to tie together the end plate abnormalities, CNS effects and biomechanical factors. Both of these theories rely on biochemical and histological research findings rather than clinical observation to explain the existence of these trigger points. One of the interesting things about the academic disagreement is that Simons seems to accept that neuropathy causes trigger points but he disputes that it is the principle factor in the pathophysiology in most patients. David Simons wrote an entire chapter of his book “Muscle Pain” related to this issue, and interestingly he was himself born with the condition of severe congenital peripheral neuropathy which gave him firsthand knowledge of the relationship between neuropathy and myofascial pain.20 Dr. Chang-Zern Hong (b. 1946) at the University of California, Irvine, stated that “The pathogenesis of an MTrP appears to be related to integrative mechanisms in the spinal cord in response to sensitized nerve fibers associated with abnormal endplates,” but he has not attempted to explain the implications Cannon’s Law based on this theory.21 Dr. Gunn does not seem to disagree with Dr. Hong or Dr. Simons about their research findings, but he has nevertheless argued that it forms “part of a bigger physiological picture” (see above) further explained through Cannon’s Law. Dr. David Simons wrote in an 19 Chang-Zern Hong and David G. Simons, “Pathophysiologic and Electrophysiologic Mechanisms of Myofascial Trigger Points,” Archives of Physical Medicine & Rehabilitation 79 (1998): 863-872; John M. McPartland, “Travell Trigger Points—Molecular and Osteopathic Perspectives,” Journal of the American Medical Association 104 (2004): 244-249. 20 Siegfried Mense and David G. Simons, “Neuropathic Muscle Pain” in Siegfried Mense, David G. Simons and I. Jon Russell, eds., Muscle Pain: Understanding Its Nature, Diagnosis and Treatment, (Baltimore: Lippincott Williams and Wilkins, 2001), 62-83. 21 Chang-Zern Hong and David G. Simons, “Pathophysiologic and Electrophysiologic Mechanisms of Myofascial Trigger Points,” Archives of Physical Medicine & Rehabilitation 79 (1998): 863-872; John M. McPartland, “Travell Trigger Points—Molecular and Osteopathic Perspectives,” Journal of the American Medical Association 104 (2004): 244-249.

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email to the author on May 27, 2009 “Gunn shows that innervation of MTPs†,22 is compromised as also [Edward A. (“Andy”) Fisher] Andy Fisher [b. 1949?] at the New York University Medical Center] has shown eloquently clinically in many cases, but that compromise is NOT denervation primarily. That relatively minor feature of MTPs has been very poorly investigated. It has clinical significance but clearly is not part of the primary pathophysiology of MTPs which is well described in the Integrated Hypotheses and is increasingly being strongly substantiated with advanced research.” My interpretation of this statement is that he believes neuropathy is a minor feature of trigger points and the trend in the research is supporting his integrated hypothesis to which Cannon’s Law has no bearing. This may explain the lack of attention given to Cannon’s Law. Many of the researchers and clinicians on Dr. Gunn’s side are mystified at the lack of attention paid to Cannon’s Law because it seems to explain many of the clinical observations made by themselves along with researchers involved with the other myofascial pain theories. This often leads them to attribute this lack of attention to the litany of strange circumstances surrounding the publication of, The Supersensitivity of Denervated Structures. Dr. Gunn and his cohorts are frequently frustrated because many of the theories on myofascial pain are based on laboratory findings rather than clinical ones. For example, the integrated hypothesis predicts that ischemic compression‡ should make patients worse by further decreasing blood flow resulting in additional pre- and post-synaptic decompensations. This is a widely used technique and was even recommended by Janet Travell and David G. Simons originally in the first addition of their trigger point manual.23 The move away from this technique is due to laboratory findings, which led to a change in the theory behind the pathogenesis of trigger points. Many would argue that this change now makes the theory incongruent with clinical practice (i.e. ischemic compression reduces trigger points, and more importantly to the theory, it does not make them worse). In conclusion, I have found that there is significant evidence against the hypothesis that The Supersensitivity of Denervated Structures by Cannon and Rosenbluth would be an obscure publication, which has been largely ignored by †

MTrP or MTP: myofascial trigger point. These trigger points are essentially the same as what Dr. Gunn refers to as neuropathic points. 22 C. Chan Gunn, The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin, vol. 2, (New York: Churchill Livingstone, 1996). ‡ Ischemic compression is a massage technique where sustained firm pressure is placed on a trigger point until it subsides, usually 30 seconds to 1 min. As the name implies one theory for its efficacy is that it causes ischemia which stimulates release of the trigger point. 23 David G. Simons, Janet G. Travell and Lois S. Simons, Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. 2, (Baltimore, MD: Williams & Wilkins, 1999).

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the scientific community. Nevertheless, I did find little mention of this paper in the myofascial pain literature, outside of researchers working on Dr. Gunn’s Neuropathic theory or closely related topics. Also, the struggle between clinicians and laboratory scientists in research could be shown; and an attempt to discuss the arguments of Dr. Gunn’s main opponents is also made, including a discussion of Walter Bradford Cannon’s 1949 monograph. I was unable, however, to corroborate the explanation given to Dr. Gunn by his former patient, but could help to clarify some of the facts surrounding this article. In relation to this, I have also not found a definitive explanation of the lack of attention paid to Cannon’s Law, except to conclude that it is not viewed as relevant to the Integrated Theory by Dr. David G. Simons, which appears to be more central in academic neurophysiological circles today. Hopefully future research and clinical observations will lead to further developments and refinements regarding theories of myofascial pain.

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APPENDIX E: ARTICLES CITING CANNON & ROSENBLUTH (1949) Cannon, W. B., and Rosenbluth, A. (1949). The Supersensitivity of Denervated Structures – A Law structures a law of Denervation. New York: The Macmillan Company. Alder, M. W. (1966). The course of altered sensitivity to flurothyl following cortical ablations rats. The Journal of Pharmacology and Experimental Therapeutics, 153(3), 396-400. Almli, C. R., and Finger, S. (1992). Brain injury and recovery of function: Theories and mechanisms of functional reorganization. Journal of Head Trauma Rehabilitation, 7(2), 70-77. Axelsson, J., and Thesleff, S. (1959). A study of supersensitivity in denervated mammalian skeletal muscle. Journal of Physiology, 147(1), 178-193. Birder, L. A., and Perl, E. R. (1999). Expression of alpha-2 adrenergic receptors in rat primary afferent neurones after peripheral nerve injury or inflammation. Journal of Physiology, 515(2), 533-542. Birklein, F., Reidl, B., Claus, D., and Neundorfer, B. (1998). Pattern of autonomic dysfunction in time course of complex regional pain syndrome. Clinical Autonomic Research, 8(1), 79-85. Chu, J. (1999). Twitch-obtaining intramuscular stimulation: Observations in the management of radiculopathic chronic low back pain. Journal of Musculoskeletal Pain, 7(4), 131-146. Chung, C. H., and Kavalali, E. T. (2006). Seeking a function for spontaneous neurotransmission. Nature Neuroscience, 9(8), 989-990. Emmelin, N. (1962). Submaxillary and sublingual secretion in cats during degeneration of post-ganglionic parasympathetic fibres. Journal of Physiology, 162(2), 270-281. Emmelin, N., Malm, L., and Stromblad, B. C. R. (1960). Effect of denervation on the maximal secretory capacity of salivary glands. Experimental Physiology, 45(4), 349-351. Emmelin, N., and Muren, A. (1950). Supersensitivity of denervated organs to chemical stimuli. Nature, 166(4223), 610. Engelman, K., Mueller, P. S., Horwitz, D., and Sjoerdsma, A. (1964). Denervation hypersensitivity of adipose tissue idiopathic orthostatic hypertension. The Lancet, 284(7366), 927-930. Ennis, J. T., and Lewicki, A. M. (1973). Mecholyl esophagography. American Journal of Roentgenology, 119(2), 241-244. Fanciullacci, M., Franchi, G., and Sicuteri, F. (1974). Hypersensitivity to lysergic acid diethylamide (LSD-25) and psilocybin in essential headache. Specialia, 15(12), 1441-1443. Fujiwara, M., Hayashi, H., Muramatsu, I., and Ueda, N. (1984). Supersensitivity of the rabbit iris sphincter muscle induced by trigeminal denervation: The role of substance P. Journal of Physiology, 350(5), 583-597. Ga, H., Koh, H. J., Choi, J. H., and Kim, C. H. (2007). Intramuscular and nerve root stimulation vs lidocaine injection of trigger points in myofascial pain syndrome. Journal of Rehabilitation Medicine, 39(5), 374-378.

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Green, R. D. (1969). The effect of denervation on the sensitivity of the superior cervical ganglion of the pithed. The Journal of Pharmacology and Experimental Therapeutics, 167(1), 143-150. Harriman, D. G. F., and Garland, H. (1968). The pathology of Adie’s syndrome. Brain, 91(3), 401-418. Janowitz, H. D., and Grossman, M. I. (1951). An exception to Cannon’s law. Kurze Mitteilungen –Brief Reports (Experientia), 15(7), 275. Koltzenburg, M., Habler, H. J., and Janig, W. (1995). Functional reinnervation of the vasculature of the adult cat paw pad by axons originally innervating vessels in hairy skin. Neuroscience, 67(1), 245-252. Krone, A., Reuther, P., and Fuhrmeister, U. (1983). Autonomic dysfunction in polyneuropathies: A report on 106 cases. The Journal of Neurology, 230(1), 111-121. Larrabee, M. G., and Edwards, C. (1953). Excitation and conduction in the nervous system. Annual Review of Physiology, 15(1), 283-304. Miledi, R. (1960). The acetylcholine sensitivity of frog muscle fibres after complete or partial denervation. Journal of Physiology, 151(1), 1-23. Murray, J. G., and Thompson, J. W. (1957). Collateral sprouting in response to injury of the autonomic nervous system and its consequences. British Medical Bulletin, 13(3), 213-219. Parsons, K. F., and Turton, M. B. (1980). Urethral supersensitivity and occult urethral neuropathy. British Journal of Urology, 52(131), 137. Pazos, A. J., Orezzoli, S. L., McCabe, P. M., Dietrich, W. D., and Green, E. J. (1995). Recovery of vibrissae-dependent behavioral responses following barrelfield damage is not dependent upon the remaining somatosensory cortical tissue. Brain Research, 689(2), 224-232. Perl, E. R. (1999). Causalgia, pathological pain and adrenergic receptors. Proceedings of the National Academy of Science, 96(11), 7664-7667. Prosser, C. L. (1950). Supersensitivity of denervated structures: A law of denervation – book review. Science, 111(2882), 314. Reidl, B., Beckmann, T., Neundorfer, B., Handwerker, H. O., and Birklein, F. (2001). Autonomic failure after stroke – is it indicative for pathophysiology of complex regional pain syndrome? Acta Neurologica Scandinavica, 103(1), 2734. Santoni-Rugiu, P. (1966). An experimental study on the reinnervation of free skin grafts and pedicle flaps. Plastic and Reconstructive Surgery, 38(2), 98-104. Versteeg, P. G. A., Noble, M. I. M., Stubbs, J., and Elzinga, G. (1983). The effect of cardiac denervation and beta-blockade on control of cardiac output in exercising dogs. European Journal of Applied Physiology, 52(1), 62-68. Waddington, J. L., and Cross, A. J. (1978). Denervation supersensitivity in the striatonigral GABA pathway. Nature, 276(5688), 618-619.

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APPEND DIX F 3-2 Matchsticck test – the end e of a match hstick is used to compress th he skin, a positive show wn here is wheen the indentattion persists inndicating the prresence of trophic edemaa.

3-3 Peau d’oorange or orange peel appearance– the fingeers are run firm mly up the spine and the positive shownn indicates troph hic edema.

Chris Noss N

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3-4 Skin rolll – another tesst for trophic edema. e The skkin is rolled beetween the fingers as shoown and a posittive is the peau d’orange appeearance and thee feeling of increased resiistance.

3-5 Pilomotoor – the ‘goose bump’ appearrance is a classsic finding in neuropathy n because of aalteration in syympathetic affeerents causes ppiloerection. Th he buttock photo shown is of increasedd pilomotor actiivity in S3/S4 oon the left. It is important f cold tempeerature etc.) do o not cause to note that oother pilomotor triggers (e.g. fear, segmental acttivity but rather generalized actiivity in multiplee dermatomes.

RECALLING THE FORGOTTEN: DEMENTIA CARE FACILITIES AND PROGRAMS IN ALBERTA FROM 1900-1950 RIANA DOWNS SUMMARY: Before the turn of the century, very little was known about the origins and aetiopathology of mental disorders, including behaviours that have come to be categorized as “dementia.” Depending on the extent of their “madness,” individuals were either ignored, expelled, or imprisoned. For example, our current understanding of Alzheimer’s Disease, the most common form of dementia, as caused by neurological abnormalities, was only realized in 1906 when the Munich psychiatrist Alois Alzheimer (1864-1915) referred the clinical phenomenology in his famous patient Auguste Deter (1850-1905) at the Frankfurt Asylum for the Insane back to changes in the neurohistological structure of her brain. Such insights into biological psychiatry, highly impactful historical events like WWI, the Great Depression, and WWII, and other factors including social geographies created a unique mental health care environment in Canada in the early 20th century, and one that can also be intriguingly studied in the western province of Alberta. Before this revised pathological understanding of “dementia” at the beginning of the 20th century, in what ways were individuals who displayed symptoms of dementia or Alzheimer’s Disease treated in Albertan hospitals, asylums, and local communities? What types of institutions and/or social groups played a critical role in caring for Alberta patients with dementia during this time? Through this exploratory project, I aim to historically map out dementia care in Alberta from 1900 to 1950 using literature and archive materials in conjunction with relevant contemporary literature and materials. KEYWORDS: Dementia Care; Alzheimer’s Disease; Public Mental Health; History of Psychiatry; Alberta; Canada; 20th Century PRECEPTOR: Dr. Frank W. Stahnisch INSTITUTION: University of Calgary

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Introduction and Background This project falls under the umbrella of a larger project entitled: “Mapping Public Mental Health in the Provinces of Alberta and Saskatchewan in the first half of the 20th Century,” based at the University of Calgary (Professor Frank W. Stahnisch et al.), which examines some key players and institutions that influenced the historical development of public mental health in Western Canada. My own research investigation builds on this larger historiographical project in that it aims to determine what institutions or social groups performed the care for elderly people affected by historical equivalents of “dementia” (specifically Alzheimer’s Disease), in the province of Alberta between 1900 and 1950. The main benefit that we anticipate from this project is a greater understanding of the development of public mental health services in Alberta from the early to mid 20th century. Such an understanding can also be helpful for policy makers in this area as it will improve the transparency of decision-making processes and may also result in a greater appreciation for some of the central factors that originally influenced and shaped public mental health in this province. A secondary benefit to this research is that the research project further promotes the larger study of which it is part. This is achieved by advancing the historical objectives of the larger project, in particular by mapping out the influence of Alberta health care institutions and programs, as referents for further comparative investigations. The primary question to be answered by this project is: (1) Within Alberta, what types of institutions and programs played a key role in caring for patients with dementia, specifically Alzheimer’s Disease? Secondary questions to be investigated include: (2) How were institutions, and the care they provided, affected by federal and provincial politics?; (3) between 1900 and 1950, who diagnosed Alzheimer’s Disease in elderly patients?; and, (4) How did a medical diagnosis or lack thereof, affect patient care in the province? Since the time of the early Northwest Territories (NWT; or in French: Les Territoires du Nord-Ouest, TNO) during the mid-19th century, the mentally ill lived with their families, or in segregated isolation from society, or in judicial institutions,1 while a more complex relationship developed between society and demented individuals towards the end of 1

Cf. Bennett Simon, “Mind and Madness in Classical Antiquity,” in History of Psychiatry and Medical Psychology, eds. Edwin R. Wallace and John Gach (Columbia: Springer Science and Business Media, 2008), 181.

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the century before the last. Also in Western Canada, individuals were “ignored, expelled, or imprisoned ...,”2 depending on the extent of their “madness.”3 Only towards the end of the 19th century, more humanitarian methods of helping the mentally ill were beginning to take root. Such methods were a dramatic departure from the previous methods thought to cure insanity which included “advocating purging, bleeding, vomiting, and rotating on chairs.”4 Around this period, an understanding of mental illness as a complex entity, with causation potentially rooted in psychological, sociocultural and biomedical conditions, began to emerge.5 Biology and medicine were increasingly explored and accepted in society and soon preliminary drugs were being tested to help reduce and control mental illness, which later led to what would constitute neuropharmacology in the early to mid-20th century.6 Soon, the concept that brain abnormalities or damage could cause mental illness became a common social belief and medically held ideal.7

The Emergence of Alzheimer’s Disease In a leading psychiatric and medical textbook The Treatise on Insanity from the early 19th century, “dementia” was described as being a condition in which: “...there is no judgment either true or false. The ideas appear to be insulated and to rise [sic!] one after the other without connection, the faculty of association being destroyed.”8 The concept of mental illness caused by biological defect, and possibly other factors, has also led to some core assumptions in the current definition of dementia by the 2

Dora Weiner, “The Madman in the Light of Reason: An Enlightenment Psychiatry Part I Custody, Therapy and the Need for Reform,” in History of Psychiatry and Medical Psychology, eds. Edwin R. Wallace and John Gach, (Columbia: Springer Science and Business Media, 2008), 255. 3 Ibid. 4 Ibid., 281. 5 Cf. Dora Weiner, “Philippe Pinel in the Twenty-First Century,” in History of Psychiatry and Medical Psychology, eds. Edwin R. Wallace and John Gach, (Columbia: Springer Science and Business Media, 2008), 307. 6 John Gach, “Biological Psychiatry in the Nineteenth and Twentieth Centuries, in History of Psychiatry and Medical Psychology, eds. Edwin R. Wallace and John Gach, (Columbia: Springer Science and Business Media, 2008), 381. 7 Ibid. 8 Philip Pinel, A Treatise on Insanity, trans. D. D. Davis, 1801 [reprint], (Sheffield, England: W. Todd, 1806).

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American Psychological Association (APA). They define dementia as an umbrella term that encompasses several metal disorders that are … characterized by the development of multiple cognitive defects that are due to the direct physiological effects of a general medical condition, to the persisting effects of a substance or to multiple etiologies.9

The most common form of dementia today is Alzheimer’s Disease (AD).10 The first clinically noted case of Alzheimer’s occurred in 1906 and is credited to Dr. Alois Alzheimer (1864-1915), a German psychiatrist and experimental brain researcher.11 The exact cause(s) of this disease are yet unknown,12 but it is most often characterized by three features: an excessive and, toxic, level of “plaques––numerous tiny dense deposits scattered throughout the brain,” “tangles” within the neurons of the brain which prohibit essential functioning, and reduction of the brain mass as from brain cell death.13 Currently, there is no proven, complete cure for AD.14 Like other mental illnesses, this biological model of brain degeneration is a fairly recent neuropsychiatric understanding. Before this point, specifically before the year 1906, how were individuals who displayed symptoms of dementia or Alzheimer’s treated and understood? And how did the recognition of dementia and AD, as a specific illness, affect the diagnoses and treatment of patients with mental disorders and their resulting treatment? Looking at the diagnostic practices of practitioners of the time and the resulting effect on their patients, it is important to consider the contextual factors in which these diagnoses were developed. Thanks to the available scholarly literature and other publications, much is known about the general history of mental health in a broader sense, especially when considering a country of continental perspective. However, significantly 9

American Psychiatric Association, The Diagnosis and Statistical Manual of Mental Disorders, 4 ed., (Washington: American Psychiatric Association, 1994). 10 Ronald Hamdy, Joellyn Edwards, James Turnbull and Gillian Lancaster, Alzheimer’s Disease: A Handbook for Caregivers, 3 ed., (St. Louis: Mosby-Year Book, 1998). 11 Alzheimer Society of Canada, “What is Alzheimer’s Disease? Introduction,” (Accessed November 5, 2009) from http://www.alzheimer.ca/english/disease/ whatisit-intro.htm. 12 Hamdy et al., Alzheimer’s Disease. 13 Alzheimer’s Society of Canada, “What is Alzheimer’s Disease?” 14 Konrad Maurer and Ulrike Maurer, Alzheimer: The Life of a Physician and Career of a Disease, (New York: Columbia University, 1998).

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less is known about regional mental health histories in particular parts of Canada. This paper is hence specifically interested in the medical history of the province of Alberta within the timeframe of 1900-1950. Alberta became a Canadian province, from being a previous part of the NWT, only in September of 1905. Public health in Canada during the next 50 years was largely sporadic and its primary function was to assist the population during disease outbreaks.15 Key historical events during this time span, included the First World War (WWI) and the Second World War (WWII), the Spanish Influenza outbreak and the Great Depression, which all significantly altered the ways in which public health was thought of, delivered and used within Canada.16 Contextually, geography was, and to a large extent still is, also a significant factor influencing patient care. Treatment options available for rural and urban patients varied significantly from the Edmonton-Calgary Corridor to the rural towns and farmlands of Alberta.17 Another factor that impacted local public mental health approaches was the composition of the population, with different policies affecting specifically First Nations people18 and immigrants from Southern and Eastern Europe.19 In the early to mid-20th century all these factors – increasingly based on a new understanding of the biology of psychiatry and the medical identification of AD –, highly influential historical events, and local factors such as geography and politics combined together to create a unique mental health care environment in Alberta. During this time, it is acknowledged that mental institutions or asylums were traditionally used to house mental patients in Alberta20 as well as society in general.21

15 Public Health Agency of Canada, “Canada Public Health History,” retrieved November 17, 2009 from The Chief Public Health Officer’s Report on the State of Public Health in Canada 2008, http://www.phac-aspc.gc.ca/publicat/2008/ cphorsphc-. 16 Public Health Agency of Canada, “Canada Public Health History.” 17 Provincial Health Council of Alberta, Mental Health in Alberta Issues and Recommendations, (Edmonton: Provincial Health council of Alberta, 1998). 18 Ibid. 19 Wilfreda Thurston, Anne McCrath and Kamal Sehgal, Summary: “With Just Two Pennies in My Pocket, I Just Feel Not So Helpless:” A Report on the Mental and Occupational Health Promotion Needs of Immigrants in Calgary, (Calgary: Private Publisher, 1993). 20 Geertje Boschma, “A Family Point of View: Negotiating Asylum Care in Alberta, 1905-1930,” Canadian Bulletin of Medical History 25 (2008): 367-289.

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However this does not reflect the mosaic of events which would have affected mental health intuitions and the care they provided, particularly in terms of dementia patients. What is not explicitly specified within the available scholarly literature is what types of institutions (e.g. the Calgary General Hospital and Panoka Hospital) and programs (e.g. the health-care wing of the Farmers’ Women Union and the Farmers’ Union of Alberta) within Alberta played key roles in the health care for patients with dementia in the early to mid-20th century. Additionally, how were these institutions, and the care they provided, effected by factors such as federal and provincial politics of the time? Also, who diagnosed mental disease, specifically dementia and AD in elderly people in Alberta at this time, and did such diagnoses affect patient care in the province? This project aims to answer some of these questions by examining the mental health institutions and programs of the time against the backdrop of the many regional contextual factors which influenced them and the available public health services.

Historical Mapping of Dementia Care Facilities A traditional narrative review is beneficial, as it allows for the description of both clinical practice and scientific research,22 both aspects of which I wish to further expand upon in the area of dementia care in the early 1900’s. Secondly, narrative reviews allow for elaboration on the existing literature, which may lead to insights in the literature that have not yet been revealed.23 Finally, narrative reviews can be used to critically appraise the existing known literary works on a topic.24 In this project, I have chosen to use a modified version of a narrative literature review. This type of methodology has been selected as the goal of this project is to go beyond creating a summary of the peer-reviewed literature, as would occur in a standard narrative review. By applying a modified form of a narrative literature review, it is possible to consider many different sources and formats of information, besides peer-reviewed articles, that may be relevant to our topic of interest. This will allow us to map and create a 21 Marjorie Lowenthal, “Social Isolation and Mental Illness in Old Age,” American Sociological Review 29 (1964): 54-70. 22 Phillip Rumrill and Shawn Fitzgerald, “Using Narrative Literature Reviews to Build a Scientific Knowledge Base,” Work 16 (2001): 165-170. 23 Ibid. 24 Ibid.

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multi-dimensional understanding of what types of institutions and social groups played a critical role in caring for patients with dementia in Alberta in the early to mid-20th century that extends beyond the available peerreviewed literature. To begin, electronic databases (including Pubmed/IndexCat/NLM Library/Wellcome Trust Library/Alberta Medical History Collection©) were searched for publications related to the topic using key words related to the research question. Similar search strategies have also been followed with the Google® database so as to also include relevant physical and electronic grey literature. Historical archives, including the Calgary Glenbow Museum, the University of Calgary Archives, and the Provincial Archives of Alberta were also consulted. To be included, materials had to be related to the time period between 1900 and 1950, pertained to dementia as a mental illness, and specifically concerned AD. That these methods were actually able to give accurate accounts of dementia care facilities, as specialized forms of care in the mental health institutions particularly in Alberta, was however difficult to ascertain for several reasons. First, more than fifty years separate the research timeframe from the current date, which created problems of retrograde diagnoses and the transferability of psychiatric and mental health concepts (from modern understandings to contemporary methodologies). Also, narrative reviews often enough reflect researchers’ responsibilities to accept or decline materials and are likely based on the subjective opinions of the authors.25 Since many different types of materials from a wide variety of sources have been searched, overlapping details of events and situations could be further verified and sustained. In addressing researcher subjectivity in the context of this research project, personal accounts of physicians and administrators have also been of considerable informative value. In the context of this qualitative study, this helps to gain a dynamic working perception.26 In all, 18 electronic databases were searched, with two of the databases investigated being meta-databases (University of Calgary Library Summon and EBSCO Host) and results combined with many additional databases simultaneously. The findings of this research project are first outlined chronologically, demonstrating the progression of mental health care facilities and services that were offered within Alberta during the respective timeframe. This chronological approach helped to consider 25

Ibid. Catherine Marshall and Gretchen Rossman, Designing Qualitative Research, (Thousand Oaks: SAGE, 2006).

26

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how they contributed to and were affected by notable local, federal and international circumstances. A concise summary table of key events may be found in Table 1 in Appendix A.

1900-1909 Alberta became a province in 1905. This was a largely political move by the Liberal Party to prevent the Northwest Territories Conservative Party from creating a stronghold in the western side of Canada and to claim the valuable natural resources.27 That same year, also the Alberta’s Medical Professional Act was passed, while less than 325 physicians worked in the new province by this time.28 Only soon later, in 1907, the Public Health Act was passed, which divided Alberta into specific health districts with local governing boards overseen by the Provincial Board of Health.29 Even before joining the Canadian Confederation, several hospitals had been in existence in Alberta. These included, for example, the Calgary General Hospital which opened in 189030 and the Grey Nuns’ Hospital (later re-named the Holy Cross Hospital) in Calgary in 1891.31 Due to its fledgling provincial status at the time, Alberta had very few institutions that were specifically dedicated to mental health, and the existing hospitals often did not have specific psychiatric patient wards or beds. In fact, patients with severe mental illness were rather farmed out to more established mental institutions in neighbouring provinces, such as Saskatchewan (North Battleford) and Manitoba (Selkirk), leaving those with less severe conditions to be looked after by their families.32 Additionally, the Insanity Act was passed in 1907, in which individuals 27

Alberta Community Development, Cultural Facilities and Historical Resources Division, “Political Events—Alberta Becomes a Province,” last modified 2009, (Accessed March 27, 2010) from Alberta Encyclopedia Online http://www. abheritage.ca/ abpolitics/events/becoming_province.html. 28 Alberta Medical Association, Alberta Medical Association Position Paper on the Mental Health Needs of the Elderly, (Edmonton, Alberta: Alberta Medical Association, 2010). 29 Alberta Medical Association, AMA Position Paper, 2010. 30 David Scollard, Hospital: A Portrait of the Calgary General, (Winnipeg: Hignell Printing, 1981). 31 Evelyn Hardwick, Eileen Jameson and Eleanor Tregillus, The Science, the Art and the Spirit: Hospitals, Medicine and Nursing in Calgary, (Calgary: Century Calgary, 1975). 32 Boschma, “A Family Point of View.”

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had to be judged insane at a formal trial and be given a warrant of admission before they were allowed to be committed to mental institutes.33 Thus, family members had to go to court with the individuals in question and present a strong case before institutional care could be received. A significant contributor to the area of senior mental health during this decade – on a global psychiatric level – was a German physician, Dr. Alois Alzheimer. In 1906, Alzheimer was the first to clinically describe a disease form, which later became associated with his name as the medical eponym of Alzheimer’s Disease34 and was the first to notice the link between “neuron tangles” and dementia.35 This was a significant discovery for previously, as acknowledged by Alzheimer’s mentor and one of the founders of modern psychiatry Emil Kraepelin (1856-1926), physicians had difficulty in separating normal senility from senile dementia in their patients.36 Alzheimer’s discovery gave dementia a biomedical basis and allowed for the condition to be recognized as an abnormal structural condition of the brain. Despite this significance, however, it would be another forty years before such a diagnosis became widely used. This was largely due to the fact that the technology for diagnosis was lacking and controversy over the biological cause still lingered on.37

33 Government of Alberta. The Insanity Act, (Edmonton: PAA Statutes of Alberta, Canada, 1907). 34 Jesse Ballenger, Self, Senility and Alzheimer’s Disease in Modern America, (Baltimore: John Hopkins University Press, 2006). 35 Thomas Beach, “History of Alzheimer’s Disease: Three Debates,” Journal of the History of Medicine and Allied Sciences 42 (1987): 327-349. 36 Joseph Kwentus, “Alzheimer’s Disease,” Cambridge Histories Online (2008): 561-568. 37 Beach, “History of Alzheimer’s Disease,” 327-349.

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1910-1919 The end of World War One resulted in a relocation of Canada’s federal and Alberta’s provincial resources.38 Mental institutes converted to longterm hospitals and shifted the types of care that were provided, creating beds for the sudden excess of physically injured patients.39 This would have reduced the numbers of beds available for mentally ill patients, thus placing a larger burden of their care on their families or smaller community groups.40 Additionally, the war provided new types of mental trauma, which resulted in a diversification of the institutions’ services.41 By the second decade of the last century, the first provincial mental hospital, simply called “The Alberta Provincial Mental Hospital,” was opened in Ponoka (in 1911), almost half way between Edmonton and Calgary and close to the city of Red Deer.42 The Alberta Hospital was unique in that it was entirely self-sufficient––it had farms to produce its own food supply and provided the main employment for the small town of Ponoka located adjacent to it.43 Although Ponoka was a mental institute, there were no records found of patients with dementia or AD specifically.

38

Tony Cashman, Heritage of Service: The History of Nursing in Alberta, (Edmonton: Commercial Printers, 1966); Kate Colley, While Rivers Flow, (Saskatoon, Sk: Prairie Books, 1970). 39 Robert Lampard, Alberta’s Medical History: “Young, Lusty and Full of Life” (Red Deer: Robert Lampard, 2008). 40 Boschma, “A Family Point of View.” 41 George Agnew, Canadian Hospitals, 1920 to 1970: A Dramatic Half Century (Toronto: University of Toronto Press, 1974). 42 Ronald LaJeunesse, Political Asylums (Edmonton: The Muttart Foundation, 2002). 43 Alberta Mental Hospital of Ponoka Museum Collection, Museum Quarterly (1983): 35-6; Town of Ponoka, “History of Ponoka, Alberta,” last modified January 7, 2010. Accessed March 27, 2010 from Discover Ponoka http://www.ponoka.org/municipal/ponoka/ponoka-website.nsf/AllDocSearch/A6D 73912700A076B8725726F005F66A6/$File/Ponoka%20History.pdf?OpenElement.

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1920-1929 The end of WWI also brought with it an enlarged interest in biomedical research and an increase in the numbers of mental hospitals and facilities around the world.44 Alberta was not exempt from this revolution, where drugs began to be tested and used in mental institutions.45 This was in mental health, for such drugs – as lithium for dementia praecox (schizophrenia) and insuline use in insuline shock therapy (schizophrenia and intractable depression) –, allowed for some more control over mentally ill patients’ and the reduction of physical means of controls such as isolation and restraints.46 It also promoted thinking about mental illness as a physiological problem which could be treated by altering the body’s chemistry through drugs, a ground-breaking idea that previously had only had marginal support.47 Such discoveries may have had less impact on dementia during this time than they did on other mental illness as the causation of dementia was still under great debate in the medical community.48 Towards the end of this decade, the provincial government increased the funds it allocated towards mental health.49 Despite this, with the “roaring 20’s” in full swing and a rapidly increasing population, the provincial government’s main concern was to guarantee law enforcement services rather than to invest in new hospital and community care facilities for the “insane.”50 These political decision-making processes often left families with the burden of care for their mentally ill family members.

44

Jack Peach, In Sickness and In Health Holy Cross Hospital: Celebrating Our First Century of Care 1891-1991 (Calgary: Jasper Printing Group, 1991). 45 Agnew, Canadian Hospitals, 1920 to 1970. 46 Ewald Hecker, “On the Origin of the Clinical Standpoint on Psychiatry,” History of Psychiatry, 15, no. 3 (2004): 345-360. 47 Dimitrios Adamis, Adrian Treloar, Finbarr Martin and Alastair Macdonald, “A Brief Review of the History of Delirium as a Mental Disorder,” History of Psychiatry 18 (2007): 459-469. 48 Beach, “History of Alzheimer’s Disease,” 327-349; Jack Pressman, “Concepts of Mental Illness in the West,” Cambridge Histories Online (2008): 59-85. 49 Government of the Province of Alberta, Report and Accounts of the Administrator of Estates of the Mentally Incompetent Year Ended December 31, 1929, (Edmonton: Alberta Governemtn, 1929). 50 Donald McKerracher, Trends in Psychiatric Care, (Ottawa: Queen’s Printer, 1966).

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1930-1939 One of the biggest influencing social factors of this decade on health care as a whole was the economic crisis of the Great Depression. The stalled economy, combined with weather patterns that wrecked havoc on agricultural cycles across North America, pushed many families to the limit of their economic resources.51 In an effort to stimulate the economy, as well as to prevent and treat the Spanish Influenza virus that had broken out during the end of WWI and also became an increasing concern in Canada since 1919, the federal and provincial governments increased expenditures in many areas, including healthcare.52 This decade also saw the provincial government agreeing to subsidize a prepayment health care insurance program in 1935.53 Both these initiatives made healthcare more accessible to the general population. As a result, for the first time in the province’s history, patient numbers in mental institutions were almost equal to the number of occupied beds in regular hospitals.54 Many of the provincial mental institutes, such as The Alberta Hospital,55 the Lamont Public Hospital,56 and the Islay Municipal Hospital,57 were well established at this point. Additionally, increases in government funding had provided a greater range of services to patients and their families.58 At this time, the

51

Paul Collins, The Public Health Policies of the United Farmers of Alberta Government, 1921-1935, (London: University of Western Ontario, 1969). 52 John Gibbon and Mary Mathewson, Three Centuries of Canadian Nursing, (Toronto: The Macmillan Company of Canada, 1947); Public Health Agency of Canada, “Canada Public Health History.” 53 Alberta Medical Association, “Alberta Medical History Fact Sheet,” last modified March 10, 2010, (Accessed March 27, 2010) from Alberta Medical Association Topics of Interest http://webcache.googleusercontent.com/ search?q=cache:NUvBUGO3r3AJ:www.albertadoctors.org/bcm/ama/ama-website. nsf/alldoc/00707b190ee25fc487256f9d0072cb58/$file/fact_sheet.pdf%3Fopenele ment+hiatory+of+health+care+in+alberta&hl=en&gl=ca. 54 Scollard, Hospital. 55 Angus McGugan, The First Fifty Years: The University of Alberta Hospital, 1914-1964, (Edmonton: Private Publisher, 1964). 56 The Alumnae Association of the Archer Memorial Hospital of Lamont School of Nursing, The Lamp is Golden: Lamont and Its Nurses, 1912-1962, (Edmonton: Private Publisher, 1962). 57 Islay Hospital Board, The Hospital on the Hill, (Edmonton: The Douglas Printing Co., 1962). 58 Agnew, Canadian Hospitals.

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use of somatic methods to treat mental illness, such as electroshock therapy (electroconvulsive therapy; ECT), become much more widespread.59

1940-1949 As with WWI in the second decade of the 20th century, WWII made a lasting impression in this decade. Mental institutes across the province once again shifted their capacities to house war victims, reducing patient space available for those with mental illness.60 In 1944, one of the world’s first geriatric hospital unit was introduced in Canada at the Allen Memorial psychiatric institution in Montréal.61 There had been resistance to developing such a specialization in the past, for it was felt that seniors’ needs were not necessarily unique within the population.62 Hence, this was a significant step in healthcare for the elderly population, for it recognized the distinct needs of such patients and tailored their care to meet those specific physical and mental health needs.63 In addition, mental health was recognized as a significant health need at the level of provincial jurisdiction, when Saskatchewan announced its provincial coverage for mental health care on January 1, 1947, a first in Canada.64 In conjunction with the community recognition of geriatrics, the diagnosis of Alzheimer’s Disease become more readily diagnosed at this time, due in part to an increased understanding and agreement within the medical community about the causation of the disease as well as a population that had relatively longer lifespan than those previous.65

59

Edward Shorter, A Historical Dictionary of Psychiatry, (New York: Oxford University Press, 2005). 60 Dorothy M. McKerracher, Trends in Psychiatric Care; Public Health Agency of Canada, “Canadian Public Health History.” 61 David Hogan, “History of Geriatrics in Canada,” Canadian Bulletin of Medical History 24 (2007): 131-150. 62 Ibid. 63 Megan Davies, Into the House of the Old: A History of Residential Care in British Columbia, (Montreal: McGill-Queens University Press, 2003); Hogan, “History of Geriatrics in Canada,” 2007. 64 Agnew, Canadian Hospitals. 65 Beach, “History of Alzheimer’s Disease,” 327-349; Nicole Berchtold and Carl Cotman, “Evolution in the Conceptualization of Dementia and Alzheimer’s Disease: Greco-Roman Period to the 1960’s,” Neurobiology of Aging 19 (1998): 173-189.

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It was also during this decade that the medical and political focus began to shift away from large mental institutions to providing mental health care as an integrated aspect of hospitals. For instance, in the early 1940’s, the Calgary General Hospital had merely one to two beds dedicated solely for the use of psychiatric patients.66 Although it was a very small percentage of beds, this token gesture indicated that mental and physical health were becoming more integrated within the healthcare system. Additionally, these beds provided families with members living with dementia potentially easier access to mental health facilities for instead of being located in relatively remote locations like Ponoka; help was now available at their local hospital. This being said, such beds were not specifically earmarked for dementia patients but for all mental health patients. Thus, it is difficult to determine the extent to which such services were used specifically for the demented, but it may be assumed that they were utilized in some capacity for this population as well, since they were more accessible than ever before.

1950-Onwards In 1952, the first version of the Diagnostic and Statistics Manual of Mental Disorders (DSM-I) was published by the American Psychological Association and widely used by psychiatrists, clinical psychologists and epidemiologists.67 Alzheimer’s Disease had also been listed in the DSM-I under the umbrella category of “Chronic Brain Syndrome associated with other disturbance of metabolism, growth or nutrition.”68 Although still very general in its description, the prima facie recognition of Alzheimer’s in the DSM-I was important, as it officially acknowledged dementia as a mental illness and served as a testament to the almost fifty years of accumulated knowledge about AD. Finally, in this decade hospitals began to dedicate entire wards or floors to psychiatric patients instead of the previous one-to-two spare beds that were held open for mentally ill patients. In 1954 the Calgary General Hospital (CGH) received its first psychiatric ward, following recommendations for one as early as 1917.69 This marked another shift in metal healthcare provision. Large mental institutions were emptied of their 66

Scollard, Hospital. American Psychiatric Association, DSM-IV. 68 American Psychiatric Association, DSM-IV, 22. 69 Scollard, Hospital. 67

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patients, the most well individuals were sent back to their homes and families with medications to help manage their illness, the least well to the psychiatric floors or longer-term care in nursing homes, or much smaller, local mental health centres.70 Thus care for mentally ill patients shifted from larger institutions to families and local institutions, with support, if needed, from the larger, provincially supplemented institutions.

Discussion From this information, two large, overarching themes emerged. The first theme was the effect that medicalization had on the care provided to patients with dementia and AD. The exact definition of “medicalization” is debated within the medical and sociological communities (see also the article by Geertje Boschma in this volume, pp. 243-272). However, an understanding of the term particularly applicable to the themes found in this project is given by the American sociologist Conrad (1992) who describes medicalization as a “a process by which nonmedical problems become defined and treated as medical problems, usually in terms of illness or medical disorders.”71 Until 1906, no official, medically verified, diagnosis existed for the symptoms now attributed to AD. This resulted in a variety of diagnosis for the same condition and inconsistent treatment of patients with dementia and AD. Even after the diagnosis became clinically and pathologically described by Alois Alzheimer, it was not immediately taken up by the medical community.72 This was likely due to several factors. First, as noted by influential psychopathologist Emil Kraepelin, the broad range and ambiguity of the symptoms of Alzheimer’s Disease made it difficult to diagnose the condition.73 The only way in which physicians in the early part of the century could make a definite diagnosis was through a biopsy of the patient’s brain, which would be lethal to the patient, and therefore, thankfully, not performed.74 Today, Alzheimer’s Disease is diagnosed by a team of professionals, including physicians, social workers and physicists, who evaluate patients on an individual basis and come to a formal consensus agreement as to the diagnosis of their

70

Geertje Boschma, personal communication with the author, March 13, 2010. Conrad, “Medicalization and Social Control,” 209. 72 Beach, “History of Alzheimer’s Disease,” 327-349. 73 Kwentus, “Alzheimer’s Disease,” 561-568. 74 Shorter, Hospital. 71

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disease.75 However, in the early 19th century, such interdisciplinary teams were not possible due to lack of specialized training and limited manpower. This left the problem as to how diagnose AD, which in turn lead to its slow recognition by the medical community and underdiagnosis of individual’s with the disease. Another prohibiting factor to the uptake of the Alzheimer’s diagnosis was the lack of recognition given to the discipline of psychiatry. Until the 1920’s, psychiatry was often considered by professionals in other medical fields as a soft science or rather an experimental and ill-founded subdiscipline.76 It was viewed as dealing more with feelings and a qualitative expression of health and as such, it was often expressed as having no place in the realm of the biological sciences. Such attitudes were further enforced by the Insanity Act of 1907 in Alberta, in that in order for a patient to be admitted, they had to be committed in the juridical system by both the Crown and two medical physicians – not even trained in psychiatry. Such widespread anti-psychiatric leanings. This attitude would have hampered the medical diagnosis of AD, as those evaluating the patient’s symptoms correctly would likely have been well-trained psychiatrists. However, with the development of new psychiatric medications, treatments and psychosurgery beginning after WWI, psychiatry at the time now gained new ground within the medical community, for their use of “scientific” methods.77 The Canadian mental health scholar Ronald LaJeunesse (2002) cites an article printed in 1932 from the British Medical Journal which stated that the physical treatment of mental diseases “should have the effect on many people of bringing mental diseases within the same category of health as physical health”.78 This also helped to establish psychiatry’s reputation as a scientific discipline, which increased the power of psychiatrists and their access to patients. Thus, in the late 1930’s-1940’s, Alzheimer’s became much more readily diagnosed. Another major inhibiting factor towards Alzheimer’s diagnosis – at the beginning of the 20th century – was the lack of geriatric specialization within the medical community. Having a separate discipline for seniors was seen as redundant, as it was commonly believed that seniors could be 75

Kwentus, “Alzheimer’s Disease,” 561-568. Shorter, Hospital. 77 Berchtold and Cotman, “Evolution in the Conceptualization of Dementia and Alzheimer’s Disease,” 173-189. 78 LaJeunesse, Political Asylums, 81. 76

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treated in the same respect as other adult patients and that their needs were not unique enough to have to establish a specialization with them.79 It was not until 1914 that the term “geriatrics” was first coined and another three decades until the world’s first gerontological hospital unit became formed in Montreal.80 This attitude would also have hampered the diagnosis of AD. The result of the slow medicalization of the symptoms of what is now considered AD is that cases often went under-diagnosed and that it was likely difficult for families, especially before voluntary admissions under the Mental Health Act, to have family members experiencing symptoms of AD, admitted to mental institutions. The slow progression of psychiatry and gerontology to become disciplines within medicine has meant that the medicalization of AD, particularly in terms of medications for symptom management, largely occurred after 1950. The second main theme which emerged from this research project was the shifting responsibility of care for mentally ill patients. At the beginning if the 20th century, most care for such individuals in Alberta was the responsibility of their families. This was due in part to lack of provincial infrastructure as well as general lack of available psychiatric services at the time. Interestingly, the limited legislation around the treatment of the mentally ill, most notably again in the Alberta Insanity Act, had clauses for the admittance of patients, but no such directions for their discharge. This resulted in lengthy stays for those mentally ill who were admitted, sometimes for the remainder of their lives. In regards to AD, one wonders if this type of legislation would have encouraged or prevented families from seeking care. On the one hand, long-term care may have appealed to families, as dementia does not improve with time, but results in further deterioration of individuals’ mental states, making them increasingly difficult to care for as time progresses. Families, witnessing this decline over several years, may have realized its downward spiral and embraced institutions for providing care for their increasingly difficult to manage demented family members. On the other hand, knowing that a placement in an institution would likely last until the end of an elderly family member’s life may have deterred family members from placing them in institutional care settings. Families had limited visiting access due in combination to geographical restraints as well as institutional regulations, effectively removing patient in such institutions 79

Hogan, “History of Geriatrics in Canada,” 131-150. John Morley, “A Brief History of Geriatrics,” Journal of Gerontology. Series A, Biological Sciences and Medical Sciences 59 (2004): 1153-1172. 80

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from their family in an almost permanent fashion. This may have been viewed as traumatic by families, for those affected by Alzheimer’s Disease or dementia were elderly and the lifespan of such individuals was likely to be relatively short and families contact with their with their fathers, mothers and grandparents in this restricted time span after admittance would be severely limited. Additionally, it would have been challenging for families to meet the required legal necessities of getting family members with dementia admitted. A warrant of admission had to be administered by the Crown, which was only granted if the individual had been deemed a significant threat or menace to society, as well as the verification from at least two physicians of the patient’s mental instability before he or she was allowed to be admitted to a mental institution. Since most dementia patients would not have been a threat to society, it is likely that families had found it difficult to present a case to the Crown in which demented individuals were considered so socially dependent as to require institutionalization. Overall, however, it would seem that families did want greater institutional care for mentally-ill family members. Although the burden of care remained largely with families for the first two decades of the 20th century, families began to demand that the province and institutions accept a larger responsibility for care. This was due in part to the establishment of mental institutions, such as the Ponoka Hospital for the Insane, which made services more accessible. Also, the external threats and stress that had been born by the “home front” in WWI resulted in a societal mindset that was largely protectionist; ensuring the safety of its members from threat or harm was forefront in the public consciousness. Such new provisions for the specific needs of the mentally ill resulted in a push for a more efficient processes to admit the mentally defect and deficient to institutions, so as to protect society form their deviant behaviours. Following this, there was also interest in allowing physicians and psychiatrists, as compared to courts of law, power over admission as well as discharge. By 1924, changes to the Insanity Act, which renamed it as the Mental Diseases Act and allowed for voluntary admission or admission by a medical doctor to institutions, greatly opened up the institutional system. By the 1930’s, care of mentally ill patients was largely in the hands of institutions, such as the Ponoka Hospital. The Great Depression led to increased government spending to try and accommodate the economic downturn,81 and this also provided increased support for mental health 81

Collins, The Public Health Policies of the United Farmers of Alberta Government.

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institutes and programs. Many institutions dedicated exclusively to mental health existed across the province at this point, including the Ponoka Hospital for the Insane, the Oliver Institute, and the Red Deer Hospital and patient numbers in these and other mental health facilities were almost equal to those in medical hospitals.82 However, this burden of care was large, and many of the institutions were beginning to show strain.83 While several facilities underwent capital expansion projects to attempt to accommodate the increasing patient load,84 these institutes also began the shift away from institutional/provincially provided care and instead encouraged families to look after their own cases. For instance, the Mental Hygiene Clinic was opened at the beginning of the 1930’s at the University of Alberta Hospital. The clinic’s purpose was to inform the public about mental disorders and to “advise on the home treatment and management of disorders.”85 This clinic was highly successful and soon the number of staff working the clinics could not keep up with the numbers of the peoples from the surrounding communities who wanted to take them. This is an intriguing paradox. Although mental institutions were at their peak during this decade, this time also saw the start of instruction to families on how to deliver care to the mentally disabled, an initial formalization of family centered care. Such care methods were likely especially applicable to those families with demented individuals, for although difficult to manage at times, and increasingly dependent as the disease progresses, dementia patients would not have been a threat to society and generally within the realm of their families’ ability to look after. This shift was also likely due to the larger contextual factors at play ––the Mental Health Act, in allowing for easer admission, had resulted in greatly increased admission rates. The province, feeling the strain of the lack of resources yet increasing demand, responded by beginning to outsource care to families by providing education and care instruction. The aging trend extended into the 1940’s and 1950’s. General hospitals began offering beds dedicated exclusively to psychiatric patients and eventually, entire wards for psychiatric care.86 In extension, however, this 82

Scollard, Hospital. LaJeunesse, Political Asylums. 84 Gibbon and Mathewson, Three Centuries of Canadian Nursing; Scollard, Hospital; LaJeunesse, Political Asylums. 85 LaJeunesse, Political Asylums, 114. 86 Scollard, Hospital. 83

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resulted in a decrease in the use of institutions exclusive to mental health. It also promoted greater use of psychiatric care services, for they were more easily accessed, but were used by individual patients for much shorter periods. Instead of staying for months or years, as in many mental institutions, mentally ill patients would only stay a few days or weeks in hospital wards before being released back to their families or communities. Thus, while the institutions were likely involved in the care of more patients, the duration of that care was much shorter, and as such, families and communities had to provide care over a longer period of time in their local settings. Overall, the responsibility for the provision of care for the mentally ill between 1900-1950 followed various trends linked to larger contextual factors. At the beginning of the century, it was mostly provided by families of the mentally ill individuals. Twenty-five to thirty years later, it became heavily subsidized by institutions and by the end of the fifty year time period, the responsibility had shifted again back to families, although with more institutional support than would have been found at the beginning of the century. It would seem that responsibility for care of mentally ill patients, including those individuals with AD and dementia, is affected by many contextual factors. This responsibly was a dynamic entity subject to constant negotiation between the mentally ill individuals and their families and the mental institution system. Such shifting or juggling of the responsibly of care between individual families and larger public institutions has been considered by Arlie Hochschild, a prominent contemporary sociological theorist at the University of California at Berkeley. She termed the phrase “care deficit”87 to denote a situation in which an increased need for public care services exists, but the capacity of public care is reduced and the care burden is instead given to individual families. This care deficit has occurred has terms of care of the mentally ill in Alberta during the first half of the 20th century. At the beginning of the century, there was an increased demand for psychiatric services provided by the government. They responded, resulting in the “Golden Age” of institutional care in the late 1920’s to 1930’s. However, contextual factors (WWI and WWII) restricted the government’s ability to provide such care and it became difficult to match the amount of care available to the increasing demand for it. When the rate of care was unable to meet demand,

87 Arlie Hochschild, The Commercialization of Intimate Life, (Berkeley: University of California Press, 2003): 214.

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deinstitutionalization occurred, and the majority of the burden of care shifted back to families. Hochschild explores several potential solutions to such a care deficit, the resolution she most favourably refers to is the “warm modern ideal”.88 In this model, institutions and families both provide care to those who need it, and the level of care provided by each is negotiated based on the needs of the patient in question. The burden of care is shared between family and government, which is largely what seems to have occurred in the case of the mentally ill in the first half of the last century in Alberta. This flux of services is, at least according to Hochschild, a desirable state that results in the optimum care for those who require it.89 In summary, it would appear that key institutions, which played a role in caring for patients with dementia were primarily the families of individuals with the affliction, followed by care provided largely by provincial mental institutions, and later a combination of provincial services localized within existing health care institutions in conjunction with family care. The provision of care was never completely isolated to one group or another, but at times, certain groups assumed more responsibly than others, and the amount of care they assumed was largely due to the contextual factors during that time period. Also, the two groups influenced each other. When families required greater provincial support, their influence promoted the construction of new mental health institutes and the creation of greater capacity for mentally ill patients. In times when the government was no longer able to sustain this level of care, it shifted it back to families, but governmental institutions continued to offer support. In this way, the relationship between the two major institutions of government care and family care were in constant conversation and progressively adapted to one another. Although they did not always communicate well, overall the results of their care were positive and benefited families and the care that their demented family members received. Based on the historical source material for the research question of this project, it proved to be challenging to separate information specific to Alzheimer disease patients from those patients who had other forms of mental illnesses. The later, broad category was much easier to locate information on, however, the vast variety of illnesses encompassed by such an umbrella term is huge, and it was difficult to attempt to parcel out just dementia specific conditions. Going back to primary records would 88 89

Ibid., 222. Ibid.

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help to elevate this problem in future research endeavours. Through this review, I have endeavoured to generate further historical understanding of the mental health institutions and the care they provided to dementia and Alzheimer’s patients in Alberta from the beginning to mid-20th century. This exploration of the individual, family, provincial and public care provision for dementia patients in Alberta between 1900-1950 falls under the umbrella of a larger project, “Mapping Public Mental Health in the Provinces of Alberta and Saskatchewan it the First Half of the 20th Century.” Since this review looked at dementia care in Alberta specifically, it would be interesting to explore if similar trends existed in Saskatchewan as well and the extent to which local context in that province made care similar or different to that provided within Alberta.

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APPENDIX A Table 1. Summary Chart of Chronological Findings Decade

1900

1910

1920

1930

1940

1950

Relevant Context - 1905 Alberta (AB) becomes a province - 1906: Alzheimer’s Disease first described - 1907: Insanity Act passed - 1911: Alberta Hospital in Ponoka opens - 1914-1918: WWI - 1919: AB’s first public health department - Increasing provincial population - Heightened interest in biomedicine and health care - Provincial government prioritizes law enforcement over health care - Great Depression - Spanish Influenza - Patient numbers in mental hospitals almost equal those in medical hospitals - 1939-1945: WWII - 1944: One of the world’s first Gerontology Units established in Montréal - Psychiatric wards become common in General Hospitals - First edition of the DSM published

Dementia Care in Alberta - A warrant of arrest had to be issued to commit individuals to an asylum

- Rehabilitation focused on physical handicaps - Increased desire by families for facilities for their mentally ill family members - Reduction in government supported health care - Use of pharmaceuticals to treat mental disorders including dementia -Increased public health care expenditures = more treatment facilities - Experimentation with new somatic treatments - increased recognition of the “science” of psychiatry - Cases of Alzheimer’s become more recognized and readily diagnosed - 1954: first psychiatric ward built at CGH in Calgary – local treatment provided outside a mental institution

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APPENDIX B Table 2. Example of spreadsheet used in data collection. Material Title A Family Point of View: Negotiating Asylum Care in Alberta 1905-1930 A systematic Review of Cognitive Decline in the General Elderly Population Alzheimer’s Disease: A Handbook for Caregivers, 3rd ed.

AMA Position Paper on Mental Health Needs of the Elderly

Author

Boschma, G.

Park, HL O’Connell, JE Thomson, RG

Format

Location

Summary

Academic

CBMH.BCH M 25(2) 2008 pp.

Examines the meaning of mental illness and institutional care from a family’s point of view and the factors that shape the experience

Academic

Int. J Geriatric Psychiatry 18 2003 pp.11211134

Guide to explain Alzheimer disease and care of affected family members and relations to lay caregivers

Hamdy, Turnbull, Edwards,et al.

Book

WM 220.A 646 1998 c.1

AMA

Report

WI 145.A43 1990 c.1

Guide to explain Alzheimer disease and care of affected family members and relations to lay caregivers Examining the needs of elderly of the future; very brief report. Gives recommendations for promoting mental health, strategies to augment public support and volunteerism, assisted living longterm care, training of care providers, community mental health services.

Riana Downs

CHR Archives List

Dictionary of Mental Handicaps

CHR/AHS

Reference List

N/A

Lindsey, PL

Book

WM 13.L56 1989 c.1

237 List of archives and contact information for CHR Archives (electronic and hard copy) Concise definitions of mental conditions, meant to help lay people who cannot comprehend DSM III definitions understand mental disorders, Alzheimer’s def. Og. 12, dementia pg. 85

EUGENICS IN ALBERTA: THE LASTING EFFECTS ALLISON BARR

SUMMARY: “Eugenics in Alberta: The Lasting Effects” examines the Alberta Sexual Sterilization Act of 1928 and how this piece of legislation has affected the Western Canadian province of Alberta. This paper traces eugenics from the first supporters of its modern incarnation, to the ultimate repeal of the Sterilization Act in 1972, and through to the lasting consequences that the Province of Alberta is still struggling with today. During the 44 years that the Alberta Sexual Sterilization Act was in place, over 2,822 Albertans ultimately underwent sterilization operations. The men, women and children who were approved for sterilization were almost exclusively socially vulnerable; more women than men were sterilized, most were unemployed or held low-status jobs and most were from ethnic minority groups. The Act had a profound effect on victims of sterilization. Many of those victims were sterilized outside the law and this sparked some of the largest class-actions suits against the province of Alberta. It is clear that while the Sexual Sterilization Act of Alberta shaped the lives of many while in effect, it continued to play a large role in the lives of victims after the repeal. KEYWORDS: Eugenics; Alberta; Sexual Sterilization Act PRECEPTOR: Dr. Sasha Mullally INSTITUTION: University of Alberta

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Introduction While eugenics was a well-known and popular scientific theory during the first half of the twentieth century, Alberta was the only province of Canada in which it was so forcefully implemented. The passing of the Sexual Sterilization Act of Alberta in 1928 began a long chapter in Alberta’s medical history, as the Act was not repealed until 1972. During these 44 years, over 4,700 Albertans were approved for sterilization with 2,822 ultimately undergoing the operation.1 The men, women and children who were approved for sterilization were almost exclusively socially vulnerable. More women than men were sterilized, most were unemployed or held low-status jobs and most were from ethnic minority groups.2 The Sexual Sterilization Act and the associated Board of Eugenics created a lasting effect on Alberta. Most importantly, the Act had a profound effect on victims of sterilization. As this paper will examine, many of those victims were sterilized outside the law and this sparked some of the largest class-actions suits against the province of Alberta. Additionally, the men and women who served on the Board of Eugenics, such as the Edmonton psychologist John M. MacEachran (1877-1871), who acted as Chairman for four decades, were affected by the enduring stigma of the Act. It is clear that while the Sexual Sterilization Act of Alberta shaped the lives of many while in effect, it continued to play a large role in the lives of victims after the repeal. Before examining the long-term effects of the Sexual Sterilization Act and the Board of Eugenics, it is necessary to understand where this theory came from and how it was implemented in Alberta. The modern understanding of eugenics was put forth by the British natural historian Sir Francis Galton (1822-1911) during the late 19th century. The basic theory was that either encouraging the “right” families to produce more offspring or discouraging the “wrong” individuals from procreating would improve humans as a species. Galton’s theory garnered much praise and many prominent historical figures of the early 20th century, such as the British Prime Minister Sir Winston Churchill (18741

Since the number of Albertans who were sterilized varied from publication to publication, this essay will use the number given by Angus McLaren in Our Own Master Race: 2, 822. 2 Timothy J. Christian, The Mentally Ill and Human Rights in Alberta: A Study of the Alberta Sexual Sterilization Act, (PhD diss., Edmonton: Faculty of Law, University of Alberta, 1973), 123.

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1965) and the Canadian feminist Nellie McClung (1873-1951), were staunch supporters. During the 1920’s, the Canadian National Committee for Mental Hygiene (CNCMH), which was founded in 1918 at the end of WWI, carried out surveys in Alberta and British Columbia to examine the extent of what they referred to as “feeblemindedness”.3 The study done in Alberta was completed by the psychiatrist Dr. Clarence Meredith Hincks (1885-1965) in 1921 and found that much of the “feeblemindedness” in Alberta was caused by the new influx of Eastern European and Asian immigrants.4 So far, many historians have pointed to the higher levels of immigration on the Prairies as the reason for Alberta’s quick passing of the Sexual Sterilization Act and the high rate of sterilizations.5 The CNCMH believed that mental deficiencies directly caused the bad behaviour and sexual immorality in Canadian society.6 Forms of positive and negative eugenics therefore began to be considered as a plausible course of action to rid Canada of the ills of society. After the CNCMH had completed its survey, those who believed that mental deficiencies were tainting the quality of Alberta’s population felt there were only two options: sterilization (a form of negative eugenics) or segregation (a form of positive eugenics).7 Since segregation would have cost the province more funds and meant that generations of those deemed unfit to procreate would be institutionalized, many groups began campaigning in favour for the sexual sterilization. While the United Farmers of Alberta (UFA) were involved, it was the United Farm Women of Alberta (UFWA) and other influential women groups that began a strong movement for sterilization (see also the article by Riana Downs in this volume, pp. 205-228). Beginning in 1924, and comprised of extremely prominent women such as Nellie McClung and the first female magistrate in Canada, Emily Murphy (1868-1933), this movement of women was determined to weed out the undesirable traits of individuals.8 Emily

3 Ian Robert Dowbiggin, Keeping America Sane: Psychiatry and Eugenics in the United States and Canada, 1880–1940s, (Ithaca, New York: Cornell University Press, 1997), 179. 4 Christian, “The Mentally Ill”, 3. 5 Angus McLaren, Our Own Master Race: Eugenics in Canada, 1885-1945, (Toronto: Oxford University Press, 1990), 99. 6 Christian, “The Mentally Ill,” 5. 7 Ibid. 8 Ibid., 9.

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Murphy herself summed up the opinion of many Albertans: “Insane people are not entitled to progeny.”9

The Sexual Sterilization Act of Alberta The Sexual Sterilization Act of Alberta was not introduced until March 1927, by the Honorable George Hoadley (1867-1955).10 The Act was controversial as numerous Albertan government and civilian groups were not in favour of sexual sterilization. Both the Liberals as well as the Tory party were opposed to the Act. The People’s Protective League began fighting against the legislation as they believed it would infringe of human rights.11 Additionally, one member of the legislative assembly (M.L.A.) from the United Farmers of Alberta government was vocal in his opposition. Laudas Joly (1887-1960) stated that the legislation would create a board that would be open to abuse and infringed on people’s rights to liberty.12 However, since the United Farmers of Alberta government had the support of the UFA, UFWA and various other large groups, the Act was ultimately passed by the government on March 7, 1928 with 34 votes in favour and 11 against.13 After the Sexual Sterilization Act was passed, a Board of Eugenics was assembled and it met for the first time in January of 1929.14 At its inception, the Board of Eugenics was bound by certain provisions: [A]n appointed board would be granted authority to order sterilization of any person suffering from mental defect––defined as arrested or incomplete mental development before the age of eighteen––provided it obtained the individual’s consent.”15

A second board meeting was held in March 1929 to establish a regulated process in which to deal with future patients.16 Issues that would be under intense examination included the history of the patient and their family history, their nationality, the economic and social advantages of a 9

Ibid., 11. Christian, “The Mentally Ill,” 2. 11 Ibid., 17. 12 Ibid., 14. 13 McLaren, Master Race, 100. 14 Christian, “The Mentally Ill,” 22. 15 Heather Pringle, “Alberta Barren,” Saturday Night (June 1997), 4. 16 Christian, “The Mentally Ill, 23. 10

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future discharge from an institution, a physical examination as well as the patients consent. During the first year that the Board of Eugenics was active, four patients were reviewed and three were ultimately sterilized.17 When the Board of Eugenics was assembled in January of 1929, it consisted of four people: two members would be physicians nominated by the Senate of the University of Alberta and the remaining two would be non-physicians appointed by the Lieutenant Governor.18 While many men and women served on the Board in various roles, John M. MacEachran remained a consistent member as Chairman from 1929 to 1965.19 A psychologist and philosopher who trained at the University of Leipzig in Germany and the Sorbonne in Paris, France, MacEachran founded the joint Department of Psychology and Philosophy at the University of Alberta in 1909.20 Inspired by the ancient philosophy of Plato, MacEachran placed emphasis on the prevention of disease and the goal of human perfection.21 However, to achieve this goal, MacEachran routinely sterilized multiple dozens of men, women and children every year for 38 consecutive years. After MacEachran resigned from the Board of Eugenics in 1965, he destroyed his personal papers concerning the issue of sexual sterilization.22 While there is now little evidence to connect him to the Board of Eugenics, it is clear that he influenced the Board and their policies over the nearly four decades he served as Chairman. The Board of Eugenics traveled around Alberta, making visits to various health care facilities in order to examine patients. If the Board believed that procreation would result in the transmission of a mental disease or risk injury to the child, sexual sterilization would be recommended.23 However, there was a broad range of what could be considered dangerous to a fetus or infant. Sterilization was recommended for example for people with epilepsy, Huntingtion’s chorea and even neurosyphilis, a condition that was known to be non-transmissible to 17

Ibid., 24. Deborah C. Park and John P. Radford, “From the Case Files: Reconstruction of a History of Involuntary Sterilization,” Disability and Society, 13 (1998): 317-342. 19 Pringle, “Alberta Barren,” 5. 20 Ibid., 5. 21 Doug Whalsten. “Leilani Muir versus the Philosopher King: Eugenics on Trial in Alberta.” Genetica, (1997): 185-198. 22 Christian, “The Mentally Ill,” 22. 23 Kennedy G. McWhirter and J. Charles Weijer, “The Alberta Sterilization Act: A Genetic Critique,” The University of Toronto Law Journal 19, (Summer 1969): 424-431; esp. 424. 18

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Eugenics in Alberta: The Lasting Effects

progeny.24 Men and women with rare recessive diseases, such as TaySachs Disease, could also be included in sterilization measures even though genetic transmission is an incredibly unlikely event to occur since the combination of genes is so infrequent.25 As mentioned above, the most at risk to be surgically sterilized were those who were socially vulnerable. This included minorities, the young people and especially women. During the 44 years that the Act was in effect, more than half of those sterilized were women. Additionally, more than half were also under 25 years old.26 Certain minority groups were also more at risk than others. While Métis and Aboriginals comprise only 2.5 percent of Alberta’s population, they made up 25 percent of those sterilized.27 While MacEachran was acting Chairman, the Board of Eugenics kept their actions very private and low profile. By 1937, over 400 operations had already been carried out. However, the Social Credit Minister of Health, Dr. Wallace Warren Cross (1887-1973) , complained that only 400 out of 2000 people put forward were sterilized and therefore, the Sexual Sterilization Act needed to be amended.28 The government agreed, and in 1937, they removed the consent provision from the 1928 Act.29 If the patient, in the opinion of the Board, risked transmission of mental deficiency to their offspring, the need for consent was waived.30 The second and final amendment occurred in 1942 to include more mental deficiencies that would “benefit” from sterilization.31 These amendments posed numerous problems for those in opposition to the Act. While it was possible that the original board always had the best interests and intentions for their patients, by taking away the demand to receive active consent from individuals recommended for sterilization, future boards were given a great deal of power.32 It is also important to note that after the 1930’s, the Eugenic Society of Canada ceased to exist. As the rest of Canada was ending their involvement with eugenics, Alberta was giving their Board of Eugenics a carte blanche. The removal of 24

Ibid., 425. Ibid. 26 McLaren, Master Race, 159. 27 Ibid., 160. 28 Christian, “The Mentally Ill,” 25. 29 McLaren, Master Race, 100. 30 Christian, “The Mentally Ill”, 26. 31 Ibid., 29. 32 McWhirter, “A Genetic Critique,” 429. 25

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consent did produce changes in frequency of those who were sterilized. A disproportionate amount of Roman Catholics and Greek orthodox were recommended after 1937.33 Additionally, the time spent with the patients prior to determining their fate began dwindling during the 1930’s. Originally, a singular case would take the Board of Eugenics a half day, but after the second amendment they would examine dozens of patients in a morning or afternoon.34 As authors Kennedy G. McWhirter and J. Charles Weijer noted in their early 1969 paper, “The Alberta Sterilization Act: A Genetic Critique”, the medical advances between 1942 and 1969 made the original document and the subsequent amendments “scientifically illiterate.”35 After the amendment of 1942, the Sexual Sterilization Act remained unchanged. In 1969, the Progressive Conservative Opposition Leader, Joe Clark (b. 1939) charged David King (b. 1946) to examine the existing legislation to determine whether there were any documents that would go against their proposed provincial Bill of Rights.36 King researched until 1972, when he finally presented his findings. He believed that the Act was poorly constructed from a medical-genetic point of view and therefore the province of Alberta should not support a negative eugenics program. In medicine, a “mental deficient” would not exist. Since science had dismissed the theory that ‘like begets like’, it was much more complex to determine the transmission of mental illness. King noted that most people with mental disabilities have a lowered sex drive and many do not even reach the age of sexual reproduction. Finally, King observed that I.Q. tests, which played a large role in the Board of Eugenics’ decision to sterilize individuals, were notoriously unreliable.37 When the Progressive Conservatives took power over the Alberta government in 1972, King introduced a Bill to repeal the Sexual Sterilization Act which was passed almost immediately.38 By this point 2,822 people had been sterilized.

33

McLaren. Master Race, 160. Pringle, “Alberta Barren,” 7. 35 McWhirter, “A Genetic Critique,” 430. 36 Christian, “The Mentally Ill,” 31. 37 Ibid., 32. 38 Christian, “The Mentally Ill,” 30. 34

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Lasting Effects In 1955, 10-year-old Leilani Muir was dropped off at the Provincial Training School for Mental Defectives in Red Deer, Alberta.39 She lived there for one year before the medical superintendent, Dr. Leonard Jan Le Vann (1915-1987) began to test her to determine if she should be recommended for sterilization. While her school work was done well, she performed poorly on an I.Q. test administered in 1956 and was labeled a psychological “moron”.40 When Dr. Le Vann contacted the Provincial Guidance Clinic, where Muir had stayed previously, he was told that a former doctor believed “that there was an emotional involvement rather than a primary mental deficiency.”41 However, when Mrs. Muir met with the Board of Eugenics in 1957, she was not tested any further for mental disabilities or examined for extenuating factors. Her one-time score of 64 on an I.Q. test was enough for the Board of Eugenics to order her sterilized on November 22, 1957.42 Accordingly, in 1959, at the age of 14, Muir underwent a bilateral salpingectomy which destroyed her fallopian tubes as well as a routine appendectomy.43 She was only told about the appendectomy, which in itself was contrary to provincial law as appendectomies on healthy children were not authorized, and her parents were not contacted for consent.44 Muir was released from the Provincial Training School in 1965 and soon after married and attempted to have children. Doctors eventually discovered that unbeknownst to her, Muir had been sterilized in her youth. I.Q. tests taken later in life put her well within the limits of normal intellect.45 It seems clear that when living in a healthier environment, Leilani Muir had no distinguishable mental handicap. When examining Leilani Muir in the 1950’s, Dr. Le Vann tested her intelligence only once. According to Edmonton psychologist Dr. Roy Brown (b. 1945?) , the fact that she scored higher on her “performance” exam than her “verbal” should have signaled Le Vann to the possibility of

39

Joe Woodward, “No End to Doing Good,” Alberta Report 22, (July 3, 1995): 3841. 40 Ibid., 1. 41 Whalsten, “Leilani Muir,” 10. 42 Ibid. 43 Ibid. 44 Ibid. 45 Ibid., 11.

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abuse.46 A former nurse at the Provincial Training School also believed that the “small scars” found on Muir during her admission were another indication of domestic abuse.47 Since abused children often score much lower on I.Q. tests than healthy children, Muir believed this should have been taken into account by Le Vann. Muir was the first victim of wrongful sterilization to sue the Alberta government, beginning the process in 1989. Rather than apologizing and paying a settlement outside of court, the Alberta government insisted on a trial, which in 1995, brought forth many unpleasant details about the Board of Eugenics.48 Since the Board had acted outside the law of the day by sterilizing a person of normal intellect, the court decided in Muir’s favour and awarded her $740,780 and an additional $230,000 for her legal fees.49 Provincial lawyers have been quick to note that damages were high in the case of Muir because the Board of Eugenics acted outside the law of the day.50 Muir’s successful case however, spurred over 1,200 of the 2,800 sterilized to come forward and place large class-action suits against the government of Alberta.51 This legal process led to outrage from numerous groups: those who were sterilized within the law of the day, and Albertans who were not involved in any aspect of sexual sterilization.

Discussion How as a society do we compensate for behaviour that was accepted at the time? These types of questions are difficult, if not impossible to answer. Dr. Margaret Martin, an assistant professor of law at the University of Western Ontario, was believed that the Alberta government should not be liable for the actions of previous governments.52 “You can’t go back and litigate every historical outrage since the beginning of time. We’re creating a social schizophrenia, judging every historical act according to today’s moral standards.”53 The taxpayers of Alberta agreed 46

Woodward, “No End,” 2. Ibid., 2. 48 Whalsten, “Leilani Muir,” 8. 49 Ibid., 11. 50 Ibid. 51 Chris Champion, “Cashing in on Victimhood,” Alberta Report 24, (December 24, 1996): 32-33. 52 Ibid., 2. 53 Ibid. 47

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with her, believing that they should not be responsible for the mistakes of other administrations. However, the claimants of the class-action suits felt differently. By 1998, 500 of the 750 then claimants had received over $48 million in damages.54 At that point the government expected the remaining 250 cases to cost another $37.5 million. Other cases, similar to Muir’s, had become public knowledge. When Anna K. was approved for sterilization, the Board of Eugenics needed her consent since, in her case, consent could not be waived. Anna recalled the conversation with the Board: “They told me if I had any more children they would be born retarded, and that I couldn’t leave the hospital unless I had this operation.”55 Anna signed the consent form and her Fallopian tubes were removed on September 15, 1971.56 The “legacy” of the Sexual Sterilization Act did not only damage the victims of sterilization. Chairman of the Board for four decades, John M. MacEachran retired in 1965 and passed away in 1971, while the Act was still in effect. As MacEachran had founded the joint Department of Philosophy and Psychology, out of which later the two autonomous departments at the University of Alberta had evolved, numerous scholarships and awards, a lecture series and a conference room were all named for him posthumously.57 In any of the publicity that surrounded his retirement and subsequent death, his work with the Board of Eugenics was not mentioned.58 While some of his friends and colleagues would have left out these details due to personal embarrassment, many others simply did not know that MacEachran had been Chairman for 38 years.59 Beginning during the 1990’s, University of Alberta committees began to discuss the possibility of renaming the lecture series and scholarships given out in MacEachran’s name. Dr. Douglas Wahlsten (b. 1943), a professor of psychology at the University of Alberta began the motion to

54

Janelle Holden, “The Final Countdown,” Alberta Report 25, (November 16, 1998): 10-11. 55 Kevin Steel, “An Expensive Benefactor,” Alberta Report 26, (February 15, 1999): 21-23. 56 Ibid., 2. 57 David Kahane, William Sharp and Martin Tweedale, MacEachran Report: Report of the MacEachran Subcommittee (Department of Philosophy, University of Alberta, 1998), 1. 58 Whalsten, “Leilani Muir,” 5. 59 Ibid., 5.

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erase MacEachran’s name in September of 1997.60 However, not all University professors agreed with this drastic course of action. As noted above, many prominent Albertans had been staunch supporters of eugenics during its peak in the 1930’s. Professor William A.G. Graham (b. 1930), Associate Dean of Science in charge of research, in 1997, took issue with the psychology department erasing MacEachran’s name: “The most informed views of the day can be different in a generation or two. Do you rename Winston Churchill Square and Emily Murphy Park? Where does it all end?”61 Ultimately, the Department of Psychology decided to continue issuing awards and scholarships in MacEachran’s name, as it was his estate which funds two of the scholarships.62 The Department did however rename the MacEachran Conference room and MacEachran lecture series. Dr. Jeff Bisanz (b. 1950?) , a professor of psychology noted that it was not his beliefs that the University found reprehensible, but the decisions he made as Chairman of the Board of Eugenics.63 The Department of Philosophy implemented a subcommittee in 1998 to examine the issues of bestowing awards in MacEachran’s name. The subcommittee recommended ceasing awarding honours. “While the Department should remember MacEachran, however, it should not honor him, nor can it afford to be seen as minimizing or condoning his actions as head of the provincial Eugenics Board.”64 Both departments received criticism for their decisions. The Department of Philosophy was accused of having attempted to air-brush or re-write history, while the Psychology Department faced disapproval for continuing to accept money from the family which they openly passed judgment on. The Sexual Sterilization Act of Alberta and the Board of Eugenics drastically changed the lives of 2,822 Albertans during its 44 years in effect. However, the impact of the Act was so great that it continued to spark debate decades after its repeal. It seems clear that the Board of Eugenics routinely took advantage of the vulnerable position of its patients. These actions had lasting consequences for not only the victims of sexual sterilization but also for the men and women who served on the Board. As 60 Kelly Torrance. “The Sterilization of History”. Alberta Report, 24, (November 3, 1997), 1. 61 Torrence, “Sterilizing History,” 3. 62 Ibid., 1. 63 Ibid., 3. 64 Kahane et al., “MacEachran Report,” 6.

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noted with MacEachran, their participation with the Board of Eugenics tarnished their names and their previous, valuable work. However, the backlash that the members of the Board of Eugenics felt did not compare to harm and pain they caused to the men, women and children who were sterilized, whether “justly” or “unjustly” according to the laws of the day.

EDITORIAL NOTE

Professor Geertje Boschma, renowned nursing and public health historian at the University of British Columbia at Vancouver, and past President of the Canadian Association for the History of Nursing, gave the 2010 keynote address for the 19th History of Medicine Days conference in Calgary, Alberta, on Friday, March 12, 2010. Her topic, “From A Family Point of View: Negotiating Asylum Care in Alberta, 1905-1930” was based principally on a article she had published earlier for the Canadian Bulletin of Medical History. It is with great pleasure that this work appears in this volume, with permissions from the author and editors-in-chief of CBMH, Dr. Kristin Burnett, Lakehead University, and Jayne Elliott, University of Ottawa to represent the keynote address and discussion following. The invited keynote lecture was co-sponsored by the Calgary Institute for Population and Public Health (CIPPH) and the Calgary History of Medicine Society (CHOMS), for which the organizers of this event are very grateful.

A FAMILY POINT OF VIEW: NEGOTIATING ASYLUM CARE IN ALBERTA, 1905-1930 GEERTJE BOSCHMA

SUMMARY: This paper analyzes the meaning of mental illness and institutional care from a family point of view, using family correspondence and police reports about asylum admission of family members in Alberta at the beginning of the 20th century. Portraying the asylum as a place of negotiation, the analysis reveals that despite families’ lack of authority over asylum admission, they nevertheless were active participants in structuring this new form of public care once it became available in Alberta. Families negotiated and contested existing medical and legal norms that structured asylum care in order to meet their own needs and demands. Categories of age, class, gender, race, and region intersected in shaping the family experience of mental illness. The paper concludes that families expected a newly built institution to provide relief of their social problems, which was at odds with the legal and medical norms regarding asylum admission. KEYWORDS: Mental Illness; Family Correspondence; Alberta RÉSUMÉ: Cet article analyse, du point de vue des familles, ce qu’on entend par maladie mentale et soins en institution, ce à partir de correspondances familiales et de rapports de police sur l’admission en asile au début du vingtième siècle en Alberta. Décrivant l’asile comme un lieu de négociations, l’analyse révèle qu’en dépit du manque de pouvoir décisionnel des familles sur l’admission en asile, ces dernières ont été des participants actifs à la structuration de cette forme de soins publics, dès qu’ils sont devenus accessibles. Des familles ont négocié et contesté les normes médicales et juridiques existantes qui structuraient les soins de façon satisfaire à leurs propres besoins et demandes. L’expérience qu’avaient les familles de la maladie mentale était étroitement liée aux catégories d’âge, de classe, de sexe, de race et d’origine géographique. L’article conclut que les familles avaient, à l’égard de la nouvelle institution que constituait l’asile, des attentes quant à la résolution de leurs problèmes sociales qui différaient de façon marquée des normes médicales et juridiques concernant l’admission en asile. MOTS-CLÉS: maladie mentale, correspondance familiale, Alberta

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Seeking Help, Negotiating Admission Recent psychiatric historiography portrays the asylum as a place of negotiation.1 Families are depicted as active players in the construction of institutional care.2 These works dismiss older portrayals of the asylum as a monolithic institution, challenging the broad depictions of the asylum as a place of great confinement (Michel Foucault) or social control and expanding professionalism (Andrew Scull). The latter authors suggest that the asylum is reflective of expanding professionalism, merely seeking to socially control or confine the deviant and abnormal.3 The persistence with which Foucault and Scull’s work are used as a counter point is in some ways surprising. As early as the late 1980’s several Canadian psychiatric historians began to dispute the asylum as a monolithic institution. Notably, Patricia Prestwich, Mary Ellen Kelm, Cheryl Krasnick Warsh, and Wendy Mitchinson, examining the dynamics of asylum admission based on detailed analyses of patient records, while foregrounding questions regarding women and gender, argued that a focus on the meaning of the asylum from the families’ perspective challenged accepted views on medical and administrative power.4 Their studies demonstrated that 1

Susan Lanzoni, “The Asylum in Context: An Essay Review,” Journal of the History of Medicine and Allied Sciences 60, no. 4 (2005): 499-505. 2 James E. Moran, Committed to the State Asylum: Insanity and Society in Nineteenth-Century Quebec and Ontario (Montreal and Kingston: McGill-Queen’s University Press, 2000); James Moran, David Wright, and Mat Savelli, “The Lunatic Fringe: Families, Madness, and Institutional Confinement in Victorian Ontario,” in Nancy Christie and Michael Gauvreau, eds., Mapping the Margins: The Family and Social Discipline in Canada, 1700-1975 (Montreal and Kingston: McGill-Queen’s University Press, 2004), 277-304. 3 Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New York: Pantheon, 1965); Andrew Scull, Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England (London: Allen Lane, 1979); and Andrew Scull, The Most Solitary of Afflictions: Madness and Society in Britain 1700-1900 (New Haven: Yale University Press, 1993). 4 Mary-Ellen Kelm, “The Only Place Likely to Do Her Any Good: The Admission of Women to British Columbia’s Provincial Hospital for the Insane,” BC Studies 96 (1992-3): 66-89; Cheryl L. Krasnick Warsh, Moments of Unreason: The Practice of Canadian Psychiatry and the Homewood Retreat, 1833-1923, (Montreal and Kingston: McGill-Queen’s University Press, 1989); Wendy Mitchinson, “Reasons for Committalto a Mid-Nineteenth-Century Ontario Insane Asylum: The Case of Toronto,” in Wendy Mitchinson and Janice Dickin McGinnis, eds., Essays in the History of Canadian Medicine (Toronto: McClelland and Stewart, 1988), 88-109;

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families most often were not only the initiators of admission requests but also tended to use the asylum as but one option in a range of community and family resources. Within legal and medical constraints, families negotiated admission on their own terms. Other international asylum studies supported this view,5 and in subsequent critical scholarship this perspective has been consolidated.6 Families’ interaction with the asylum was shaped by their economic, social, and unique family circumstances. Asylum admission was not necessarily the endpoint. Many patients were discharged and went back to their families.7 Moreover, families often took care of their mentally ill members for some time before they sought admission.8

and Patricia Prestwich, “Family Strategies and Medical Power: ‘Voluntary’ Committal in a Parisian Asylum, 1876-1914,” Journal of Social History 27, no.4 (June 1994): 797-816. 5 See Nancy Tomes, The Art of Asylum-Keeping: Thomas Story Kirkbride and the Origins of American Psychiatry (Philadelphia: University of Pennsylvania Press, 1994); Anne Digby, Madness, Morality and Medicine: A Study of the York Retreat, 1796-1914 (Cambridge: Cambridge University Press, 1985); and Geoffrey Reaume, Remembrance of Patients Past: Patient Life at the Toronto Hospital for the Insane, 1870-1940 (Toronto: Oxford University Press, 2000). 6 Peter Bartlett and David Wright, eds., Outside the Walls of the Asylum: The History of Care in the Community, 1750-2000 (London: The Athlone Press, 1999); Joseph Melling and Bill Forsythe, eds., Insanity, Institutions and Society, 18001914: A Social History of Madness in Comparative Perspective (London: Routledge, 1999); and Roy Porter and David Wright, eds., The Confinement of the Insane: International Perspectives, 1800-1965 (Cambridge: Cambridge University Press, 2003). 7 David Wright, “The Discharge of Pauper Lunatics from County Asylums in Mid-Victorian England: The Case of Buckinghamshire, 1853-1872,” in Melling and Forsythe, Insanity, Institutions and Society, 93-112. 8 Mary-Ellen Kelm, “Women, Families and the Provincial Hospital for the Insane, British Columbia, 1905-1915,” Journal of Family History 19, no.2 (1994): 177-93, especially p. 179; David Wright, “Familial Care of ‘Idiot’ Children in Victorian England,” in Peregrine Horden and Richard Smith, eds., The Locus of Care: Families, Communities, Institutions and the Provision of Welfare Since Antiquity (London: Routledge, 1998), 176-197; and Geertje Boschma, The Rise of Mental Health Nursing: A History of Psychiatric Care in Dutch Asylums, 1890-1920 (Amsterdam: Amsterdam University Press, 2003), 125-130, and the table on p. 234.

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More research is needed to expand our historical knowledge of how families used asylums.9 In this paper, I analyze files containing correspondence between family members or their representatives and the Department of the Attorney General in Alberta about potential placement of mentally ill family members in a public institution in the first few decades following Alberta’s establishment as a province in 1905.10 These files include occasional police reports of cases, evaluated for admission to the asylum, but eventually dismissed and not admitted. The reports and letters give intimate insight into the social organization of the care of the mentally ill during the early 20th century in a particular context: western Canadian settler communities in a rapidly changing, newly constituted prairie province. Using more intimate sources such as personal letters and correspondence rather than administrative institutional records provides an opportunity to understand the meaning of asylum care from the families’ point of view. These sources might help to better understand how family agency was constructed, how family members’ ideas and motivations were shaped by multiple social, cultural, and economic influences as well as the perspectives of the many groups involved in negotiating admission. Letters are immediate, as Janice Dickin McGinnis notes, and — in this instance at least — not written with publication in mind, distinguishing from memoirs, diaries, or other biographical sources.11 Letters are explored as a material, embodied expression of the families’ work or agency to restructure difficult family situations, illustrating larger class and gender relationships.12 This paper explores the meaning of asylum care in the broader spectrum of community and public responses to mental illness, examining how multiple positions and understandings of institutional care were enacted. 9

Wright, Moran, and Gouglas, “The Confinement of the Insane in Victorian Canada,” 112. 10 The correspondence is held in the Provincial Archives of Alberta (PAA), Department of the Attorney General (DAG) files, Accession Number 66.166, Box 11 and 12, Files229a-k, dealing with insane persons, 1905-17 (Hereafter cited as PAA, DAG, file number). For privacy protection mentally ill persons and their family members are referred to by initials only. 11 Janice Dickin McGinnis, ed., Dr. Mary Percy Jackson, Suitable for the Wilds: Letters from Northern Alberta, 1929-1931 (Toronto: University of Toronto Press, 1995), 39. 12 For creative use of letters and editorials, see Jacqueline Bacon, The Humblest May Stand Forth: Rhetoric, Empowerment and Abolition (Columbia: University of North Carolina Press, 2002).

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Families were active participants in structuring this form of public care, despite their lack of authority over asylum admission. Recent historical scholarship, which explores processes of negotiation between the private and the public, between family life and larger political institutions and structures, furthers this insight.13 To map out the framework for analysis and to illustrate the multiple perspectives and interest groups involved in negotiating admission, I use one police report as a case example. Then, I explore family strategies in negotiating admission to the asylum in the letters, highlighting linkages between families and mental illness from three different angles. First, I will show the significance of socio-economic reasons in requests for placement, illuminating the local context of settlement and the realities of homesteading families dealing with mental illness. The cases illustrate how gender, class, and place interconnected in families’ strategies to create resources for themselves. Second, the negotiated nature of legal and medical norms will be highlighted, with a focus on the committal of children and young women. As such, asylum admission was part of a broader process of moral regulation of women. Finally, I discuss the central role of women in the caretaking of mentally ill family members, highlighting how families sought to use asylums as a continuation of care for chronically dependent members when women in the family could no longer do so, illustrating the gendered construction of asylum admission.

Seeking Help, Negotiating Admission In Innisfail, Alberta in 1911, a son laid information before Justice of the Peace (JP) J. D. Lauder that his father was insane.14 According to the law, in order to commit a mentally ill family member, information about the individual’s dangerous behaviour had to be laid before a JP, who after hearing evidence, could adjudge a person insane at a formal trial, including the reports of two legally qualified physicians, and forward the report to the Attorney General’s Department which could then issue a warrant for

13

Bettina Bradbury and Tamara Myers, eds., Negotiating Identities in 19th and 20thcentury Montreal by the Montreal History Group (Vancouver: UBC Press, 2005). 14 Crime report Royal North West Mounted Police (RNWMP), Calgary, 26 May 1911, regarding Mr. J. W., PAA, DAG, File 229c.

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admission.15 The term “insane” was commonly used at the time, as illustrated in Alberta’s Insanity Act, passed in 1907.16 Yet in the letters people used a wider range of terms to refer to mental illness, suggesting that a different, more medically based understanding of mental illness was already widespread culturally long before such change became transparent in legal terms.17 At the trial the son stated that his 69-year-old father “had been failing in mind for about one year.”18 The problem was that “his memory had gone and that he sometimes wandered off and did not know where he was going and got lost.”19 This description suggests that the son was seeking relief from a troublesome issue, for which an existing cultural response seemed the practical solution: admission to an asylum. The solution also appeared to be within reach. In 1911, the province of Alberta opened its public institution for the care of the insane in Ponoka, located between Edmonton and Calgary.20 The new Alberta government first continued familiar patterns established prior to the province’s formation, seeking to accommodate the insane in existing facilities, women in the Guard Room of the Royal Northwest Mounted Police (RNWMP) in Calgary and men in the Regina Jail, now in Saskatchewan, pending the issue of a warrant for committal to the Brandon Insane Asylum in Manitoba.21 Faced with the situation that the number of insane Albertans requiring placement persistently outnumbered beds, and with the asylums in Manitoba filled to capacity, Alberta was pressured to create its own facilities.22 The Northwest Mounted Police, 15

Responses from the Department of the Attorney General to inquiries about admission always included a careful outlining of this process. See for example, letter 27 August 1906, J. K. MacDonald to Rutherford and Jameson, PAA, DAG, File 229a. 16 Insanity Act, 1907. PAA, Statutes of Alberta, Canada, 1907. 17 In 1924 the “1907 Insanity Act” was renamed “The Mental Diseases Act.” See Statutes of the Province of Alberta, 1924, chpt. 25, p. 207-208. 18 Crime report RNWMP, Calgary, 26 May 1911; See also note 14. 19 Ibid. 20 Annual Report, Alberta Department of the Provincial Secretary (DPS), 1911, p. 9 and section “Hospital for the Insane,” p. 62-63. PAA, Alberta DPS, Report of the Provincial Secretary, 1911, box 1. 21 Annual Report, Alberta DPS, 1911, p. 62-63. 22 Letter 20 September 1905, Acting Deputy Attorney J. K. MacDonald to the Department of Justice in Ottawa. PAA, DAG, File 229a. Early correspondence from the Department of the Attorney General suggests that mental illness is dealt with as a legal matter, requiring government involvement only to meet the letter of

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dealing with overcrowded guardrooms and transportation forced the issue.23 Since the mid-19th century, asylum building was a forceful pattern in the state’s response to problems created by mental illness. There certainly seemed to be demand. As soon as the province opened a new institution, patient numbers soared from almost 200 in 1911 to about 750 a decade later.24 Despite the known disadvantages of large, overcrowded institutions by the early 20th century,25 Alberta followed existing patterns of asylum building. Shaped by a culture of boosterism and Anglo-cultural dominance, the government seemed committed to follow the leading approaches to psychiatric care in Britain and the US.26 A colonizing mentality, a frontier ethic valuing property and profit, and a general shift to scientifically based hospital care were important parameters structuring health care in the Prairie West.27 The frontier ethic the (insanity) law. See also Letter 5 October 1905, J. K. MacDonald to Officer Commanding, RNWMP, Calgary; Letter 30 September 1905, Deputy Minister of Justice E. K. Wanebe to J. K. MacDonald; and Letter 7 October 1905, Commanding Officer RNWMP to MacDonald. PAA, DAG, File 229a. 23 Letter 27 January 1909, Commissioner RNWMP, Saskatchewan to Acting Deputy Attorney General A. M. Blain, urging to open an asylum in Alberta. PAA, DAG, File 229b; Annual Report 1911, p. 62. PAA, Alberta DPS, Report of the Provincial Secretary, box 1. 24 Patients numbered 192 by the end of 1911 and 776 on 1 January 1922. Annual Report 1911, p. 62, see previous note; Annual Report of the Medical Superintendent of the Provincial Mental Hospital, 1922, p. 45, PAA, Annual Report of the Department of Public Health, 1922-1927. 25 For further discussion of the persistent overcrowding of asylums, see Boschma, The Rise of Mental Health Nursing; Harley D. Dickinson, The Two Psychiatries: The Transformation of Psychiatric Work in Saskatchewan, 1905-1984 (Regina: University of Regina Canadian Plains Research Center, 1989); Moran, Committed to the State Asylum; For Alberta: Mary F. McHugh Abt, “Adaptive Change and Leadership in a Psychiatric Hospital,” PhD thesis, University of Alberta, 1992; and Ronald A. LaJeunesse, Political Asylums (Edmonton: Muttart Foundation, 2002). 26 Julius Johnson, A History of Dedication and Caring: Alberta Hospital Ponoka 75 Years (Ponoka: Alberta Hospital Ponoka, 1986), p. 2. Mary-Ellen Kelm notes how a culture of boosterism amongst the provincial elites at that time enhanced the political willingness to invest in improvements and additions to the provincial hospital. Boosterism is here understood as boosting or otherwise promoting one’s town or area. See Kelm, “Women, Families and the Provincial Hospital,” p. 178. 27 Nanci Langford, “Childbirth on the Canadian Prairies, 1880-1930,” in Catherine A. Cavanaugh and Randi R. Warne, eds., Telling Tales: Essays in Western Women’s History (Vancouver: UBC Press, 2000), p. 147-173.

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and economic benefits may have sparked interest within the small community of Ponoka. Ponoka leaders, led by physician W. A. Campbell, “initiated a campaign and delegation to Edmonton based upon the economic benefits that would accrue to the town through building contracts and the economic presence of a hospital staff.”28 The economic gain was considerable. The asylum’s powerhouse, for example, generated electricity for Ponoka as well as the institution for almost 20 years. Likewise, the asylum was a source of local employment.29 Yet a culture of boosterism and economic gain provides only a limited explanation when endeavouring to capture family experiences. The Innisfail example illustrated a complex process of negotiation, drawing from familial, legal, medical, and social interpretations.30 The responses to the son’s request varied by player; the son, the police, the physician, the JP, and the father, who remained silent drew on different but overlapping cultural meanings of the asylum. Moreover, opinions differed as to how the relationship between this public institution and the private life of a family should be drawn.31 The physician, as medicojudicial expert on insanity, was a medical mediator in the translation of a private, familial concern into a publicly acknowledged, certified case of insanity. However, this role has sometimes been overestimated.32 Requests for admission reflect a complex social process with multiple groups and interpretations involved. The outcome of such negotiations was not determined from the outset.33 The Innisfail physician deemed the father neither violent nor dangerous to be at large, which constituted the legal 28

Johnson, A History of Dedication and Caring, 1-2, quote from p. 1. Ibid., 1-2. 30 Moran, Committed to the State Asylum, and Kelm, “Women, Families and the Provincial Hospital” also point out how admissions, most often initiated by families, involve social as much as medical reasons. 31 Bradbury and Myers, Negotiating Identities, 1-21, discuss the negotiated nature of relationships between the public and the private. 32 See Kelm, “Women, Families and the Provincial Hospital.” Elizabeth Malcolm, “‘Ireland’s Crowded Madhouses:’ The Institutional Confinement of the Insane in Nineteenth- and Twentieth-Century Ireland,” in Porter and Wright, The Confinement of the Insane, 315-333, argues that communities were well able to manipulate doctors and institutions for their own purposes. 33 Although the medical profession played an active role in reframing difficult behaviour or moral problems into medical problems, this evidence suggests that it is not a deliberate professionalizing strategy, as for example, Andrew Scull has argued. Scull, The Most Solitary of Afflictions, 175-231 and 344-352. 29

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definition of insanity in Alberta at the time.34 Employing a medicaldiagnostic framework, he did find the father to be suffering from “senile dementia or second childhood,” but not “in such a condition as to warrant him being sent to an asylum.”35 Having heard this report, JP Lauder sought no further evidence and dismissed the case. However, he (re)constructed the request quite differently from the physician, as social rather than legal or medical. He dismissed what he believed was a “case of a son not wanting to look after the father now that the old man was feeble and not able to work.”36 His statement reflected an older cultural image predating the 19th-century medicalization of insanity: the insane who, along with the infirm, old, and destitute could not provide for themselves and thus were entitled to poor relief.37 Lauder perceived the institution as a place of last resort, fit for the destitute unable to support themselves. He apparently felt that the son was able to do better. He may have imposed his own middle-class values upon the son, trying to direct him from a shameful place for the demented father.38 Lauder’s response suggested that the relationship between the private and the public was not straightforward, but (in)formed by a variety of meanings, cultural images, habits, and regulatory frames, as well as by age, gender, class, and race, in this case, white, Anglo-cultural dominance. Multiple cultural influences shape how the script is enacted, to use Judith Butler’s performative metaphor.39 The terminology used to refer to the mentally ill, and that term itself, is affected by a variety of meanings. Framing “mind problems” as illness is a historically situated and contested process. The current understanding of mental illness is influenced by its biomedical framing as a specific entity, with a specific cause, diagnosis, and treatment.40 But mental illness has not 34

Insanity Act, 1907. PAA, Statutes of Alberta, Canada, 1907. Crime report RNWMP, Calgary, 26 May 1911, note 14. 36 Ibid. 37 Megan J. Davies, Into the House of Old: A History of Residential Care in British Columbia (Montreal and Kingston: McGill-Queen’s University Press, 2003). 38 Davies uses the phrase “shameful place,” p. 6. 39 Judith Butler, “Performative Acts and Gender Constitution: An Essay in Phenomenology and Feminist Theory,” in Sue-Ellen Case, ed., Performing Feminisms: Feminist Critical Theory and Theatre (Baltimore: John Hopkins University Press, 1990), 270-82; Peter Burke, “Performing History: The Importance of Occasions,” Rethinking History 9, no. 1 (March 2005): 35-52. 40 Charles Rosenberg, “The Tyranny of Diagnosis: Specific Entities and Individual Experience,” The Millbank Quarterly 80, no.2 (2002): 237-260; Arthur Kleinman, 35

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always been understood this way. In the late 19th and early 20th centuries mental illness was seen as a process of inevitable mental degeneration.41 Some afflictions, notably epilepsy, were considered mental illnesses at the beginning of the 20th century, but are no longer perceived as such.42 Mental illness is neither a neutral nor fixed term, but rather a poorly understood, culturally negotiated event. A wide range of behaviours could fall within this category and might not always have implied mental illness in the contemporary sense. “Mental illness” or the older term “insanity,” as well as more specific diagnostic categories such as “idiocy” or “epilepsy,” must be understood in their historical context. “Feeblemindedness,” for example, a term frequently used in the letters, was unspecific. At the time it was applied to a wide range of socially unacceptable behaviours, reflecting a reproduction of cultural beliefs and inequalities as much as an application of a medical term in the literal sense. Moreover, “idiocy,” “mental deficiency,” or “feeble- mindedness” were most often understood as chronic mental illness in the early 20th century, whereas currently mental handicap or learning disability are more common and accepted terms.43 Therefore, I use the term mental illness or more specific categories as both a contemporary frame of reference and as historically and culturally defined notions. Linking social situations to medical terminology (and institutions) was already commonplace at the beginning of the 20th century. In 1914, for example, a woman wrote to Deputy Attorney General J. D. Hunt, to inquire whether her “blind and rather childish sister of 42 years old”44 could be placed. Her most pressing question was: “Could I make some arrangements with you to keep her at the insane hospital at Ponoka?” How being “blind and childish” would qualify as a case of mental illness or insanity is not obvious. Instead the reader must link the sister’s age, 42, and the descriptor “childish” to provoke an image of an adult woman still “What is a Psychiatric Diagnosis?” in Athur Kleinman, ed., Rethinking Psychiatry: From Cultural Category to Personal Experience (New York: Free Press and Macmillan, 1988), 5-17. 41 Boschma, The Rise of Mental Health Nursing, 59-78 and 129-131. 42 Ellen Dwyer, “Stories of Epilepsy 1880-1930,” in Charles E. Rosenberg and Janet Golden, eds., Framing Disease: Studies in Cultural History, 248-272, (New Brunswick, N.J.: Rutgers University Press, 1992). 43 See also David Wright and Anne Digby, eds., From Idiocy to Mental Deficiency: Historical Perspectives on People with Learning Disabilities (London: Routledge, 1996). 44 Letter 27 August 1914, Mrs. R. L. F. to Mr. J. D. Hunt, PAA, DAG, File 229g.

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in a state of childhood (and dependency), further compromised by being blind, unable to live on her own: “She has been with her parents all her life,” the woman wrote. She was seeking relief from a pressing social situation: “I took her off father’s hands as mother is dead [and] all the rest of us children have homes of our own.” She was less bothered with the terminology than with the need to find a place for her dependent sister: “I would like to find some place where she could get good care for the rest of her life.”45 She requested admission to an insane asylum, perhaps because she was unaware of alternatives or because it was a publicly funded institution. The meanings were negotiable. Even within its contemporary context, terms like insanity, destitution, and mental deficiency were popularly used as catchall terms referring to a range of socially unacceptable behaviours. How then are we to understand the role of the family in social processes of exclusion and marginalization? Interrogating the prevailing notion of the nuclear family as a normative structure, Nancy Christie and Michael Gauvreau seek to “map the margins,” questioning how families defined membership, dependency, and exclusion of “lesser members” as well as their agency in larger social and institutional constructions of marginality.46 How must family bonds, individual interests, and a family’s linkage to wider institutional structures, such as schools, social service agencies, and (mental) hospitals be evaluated? Perhaps the Innisfail son resisted Lauder’s reading, offended by the idea that he was not willing to provide for his father; he might not have perceived the asylum as a place of last resort, but as an opportunity for decent professional care or as a means of potential (state) assistance he and his father were entitled to. Or, perhaps the JP’s decision pushed him to rethink his civic responsibilities, forced to find alternate solutions within his family and community.47 Bettina Bradbury and the Montreal history group interrogate the relationship of family life to the larger world of formal politics, through what they conceptualize as “intermediate spaces,” within the “spatial organization of city life.”48 Rather than focusing on family homes or life per se, they focus on places, institutions, and processes, which “all fell between or spanned the worlds of formal politics and family life,” the “in45

Letter 27 August 1914, Mrs. R. L. F. to Mr. J. D. Hunt. Christie and Gauvreau, Mapping the Margins, 4. See note 2. 47 See also Moran, Wright, and Savelli, “The Lunatic Fringe,” (p. 297) for a similar argument. 48 Bradbury and Myers, “Introduction: Negotiating Identities,” 1, 3. 46

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between institutions.” Individual identities were formed and negotiated in intermediate spaces that were simultaneously “places of potential freedom, self-expression and assertion of citizenship claims and sites of unequal power relations and places of moral and social regulation.”49 Applying the concept of intermediate space to the asylum, the institution can be understood as a place of potential expression of freedom, a resource as well as a place of moral and social regulation, connecting the worlds of family and formal politics in negotiated enactment. The reports and letters also bring into focus the contingent, local context of a settler community in the midst of rapidly changing circumstances. Between 1901 and 1911 the population of Alberta increased more than five times, from 73,000 to 374,000, reaching over half a million (588,000) in 1921.50 In the midst of rapid population growth, the Alberta government aimed at restricting its involvement with health care to enforcement of the law, not intending to provide aid or service.51 Strategies to limit the government’s financial burden included inquiring about the possibility of deportation of mentally ill to their country or province of origin as well as exploring whether the family could be held fully or partially responsible for the costs of care.52 The letters from family and community members, however, exploring the possibility of admission or explicitly requesting committal for their mentally ill family member clearly indicated that families had an interest in aid, service, and admission.53 Families’ interests and expectations went beyond the letter of the law. Most requests for help were not in response to violent behaviour nor restricted to family members “dangerous to be at 49

Ibid. 3. Howard Palmer, Alberta, A New History (Edmonton: Hurtig, 1990), 78 and 198. 51 A similar focus on enforcement of the law as the primary governmental responsibility rather than on the provision of aid, is illustrated in the first annual report of the Department of Agriculture in Alberta in 1905, then responsible for public health: “the Department is called upon [by the public] to supply medical aid, whereas there is no appropriation for this purpose and the Department is only interested in seeing that the provisions of The Public Health Ordinance are enforced.” See Annual Report 1905, Section Public Health, p. 42. PAA, Alberta Department of Agriculture, Accession number 68.138, Annual Reports 1905-08. 52 Letter 21 November 1906, J. K. MacDonald to the Minister of the Interior, Ottawa. PAA, DAG, File 229a; Letter 7 August 1911, J. Dawson to L. F. Clarry, PAA, DAG, File 229c. 53 Of course, this comment is limited by the fact that I only rely on letters of families who did make requests for admission. 50

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large.” Families, particularly those that recently settled, felt the burden of caring for family members who could not take care of themselves, most often in cases of chronic mental illness. They asked the government for help, and their requests reflected some public awareness about the sort of cases and categories the government could provide help with. Mrs. T. from Strathcona, for example, knew about care for “incurables.” In August 1906, she applied to the provincial government “for the care of her son as an incurable,” who, a physician described in the accompanying letter, was “a case of congenital idiocy.”54 She likely just hoped that her son’s troubles could be acknowledged as a case of incurability, not because she had to deal with violent behaviour, but because his care might have been too demanding. The Medicine Hat General Hospital provided public care for “incurables.” However, the Deputy Minister explained to her that her son did not qualify for this category, as his was a case of insanity. He suggested applying to the Attorney General’s Department for admission to the insane asylum, which Mrs. T. subsequently pursued with help from a lawyer.55 The ability to write a letter and to solicit the support of a physician, a lawyer, or an MLA, for example, indicate that families had options and resources. Asylum care was sought by more than the poor and destitute. Some people also had moderate means, suggested by their willingness to pay for care.56

Isolation and Despair Still, socio-economic reasons figured importantly in requests for placement, illuminating the local context of settlement and the realities of homesteading families. By 1911, white people of British and Ontario origins dominated the area culturally.57 An American-type homestead policy — seeking to open the western Canadian prairies to Euro-Canadian agricultural settlement — came to fruition in the late 19th century. Agricultural settlement by immigrants from Europe and other Canadian 54 Letter 8 August 1906, G. W. Harcourt to Mrs. S. T., Strathcona, PAA, DAG, File 229a. 55 Letter 25 August 1906, Rutherford and Jameson, to J. K. MacDonald, PAA, DAG, File 229a. 56 Whereas Mrs. T. contacted a lawyer, other family members relied upon a physician or MLA for example. See for respective examples Letter 9 March 1912, Dr. F. R. Ross, MD, to Attorney General in Edmonton and Letter 4 January 1912, J. E. Stauffer, MLA, to the Provincial Secretary. PAA, DAG, File 229d. 57 Palmer, Alberta: A New History, 74.

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regions peaked in 1911.58 People sought state intervention to safeguard the economic interests of their homesteading affairs. In 1907, two sons retained a lawyer asking for help from the Department of the Attorney General to get their father back from the United States. They described him as a demented wandering old man, “who has proved up on a homestead here.”59 The sons were worried about losing the homestead property due to their father’s absence. Clearly, the circumstances of frontier life shaped families’ responses to mental illness, while gender, class, and place interconnected in families’ strategies to create resources for themselves. One widowed daughter, who had come to live on the homestead of her “maniac, occasionally violent, but also depressed father,” sought help from the Department of the Attorney General in finding him after he had suddenly left.60 The Deputy Attorney General assured her that if her father was adjudged insane, the property could be looked after.61 In another case, a husband and wife on a geographically isolated homestead desperately sought police protection “from what we believe to be an insane man,” they wrote, who was “continually after [the] wife,” trying to catch her alone, once successfully.62 Whether the intruder was insane in a literal sense, we do not know. The couple may have relied on popular representations of violent behaviour, but the threat seemed real: “The last time he came I drove him away at the point of the gun. This man has as many as four fire arms and carried one the last time he came here,” the husband stated. Yet the negotiation was not only about mental illness of the intruder. The letter did not indicate a request to have the intruder adjudged insane. What the couple likely sought to negotiate was protection for the wife in such a way that she would not end up in a state of mental incapacity. Both the perpetrator and 58

Sarah Carter, “Categories and Terrains of Exclusion” p. 62 and Nanci Langford, “Childbirth on the Canadian Prairies, 1880-1930,” 147, both in Cavanaugh and Warne, Telling Tales, 60-81, 147-173. 59 Letter 17 April 1907, C. W. Moore, Barrister, to the Department of the Attorney General, PAA, DAG, File 229a. 60 Letter 2 February 1914, Mrs. H. M. to the Deputy Attorney General, PAA, DAG, File 229g. 61 Letter 9 February 1914, Deputy Attorney General to Mrs. H. M. PAA, DAG, File 229g. 62 Letter 24 October, 1910, Mr. G. F. F. to A. M. Blain, Acting Deputy Attorney General; Letter 26 October 1910, A. M. Blain to Mr. G. F. F., and, same date, the Department of the Attorney General to the Officer Commanding of the RNWMP in Edmonton. PAA, DAG, File 229b.

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the victim are framed using mental illness terminology. Ever since the wife’s escape, the letter noted, “it has been impossible to leave her in the house alone” and she has “become almost a nervous wreck.”63 Women’s mental breakdown was commonly described in terms of nerves.64 Inability to leave a woman in the house alone had severe implications for the homesteading economy, which was based on a gendered division of labour. A mentally incapacitated wife, no longer able to perform her daily work, would threaten the family’s livelihood. Becoming insane or mentally ill as a result of isolation or loneliness on the prairies, in this case exacerbated by an intruder’s violent acts, is sometimes referred to as “prairie madness.”65 “Nervous breakdown” was also commonly used to describe situations of emotional distress and desperation, particularly in women. In the 1970’s, Elaine Silverman recorded some examples of despair among women on the Alberta prairies: one woman who remembered being severely ill at age six stated: “So mom had to nurse me. By the time she got me through she had a nervous breakdown. They worried so much about me [and] she had the hard work with the garden. It was just being absolutely tired and worried sick … . I don’t remember her ever quitting working, but she cried a lot for years after.”66 Another woman, who at age 17 had worked for a summer in the mental hospital at Ponoka, recalled how “there were several ‘prairie women’ there; they had nervous breakdowns because of the loneliness and the hardship.”67 Some described how they emotionally shut down in order to survive.68 Circumstances and emotional responses were clearly linked. The prairies also provoked experiences of exaltation. Some women felt the isolation to be profoundly encouraging and an opportunity to make the 63

See previous note. Wendy Mitchinson, “Women and Mental Health,” in The Nature of Their Bodies: Women and Their Doctors in Victorian Canada (Toronto: University of Toronto Press, 1991), 278-311; esp. p. 309. 65 The term was used to describe how loneliness and hardship among homesteaders on the prairies could drive them mad. How common the term was is unclear from the literature. See for examples, Dirk Hoerder, Creating Societies: Immigrant Lives in Canada (Montreal and Kingston: McGill-Queen’s Press), 151-6; Carol Fairbanks and Bergine Haakenson, Writings of Farm Women, 1840-1940: An Anthology (New York: Garland Publishing, 1990), 308 and 325-31. 66 Elaine L. Silverman, The Last Best West: Women on the Alberta Frontier, 18801930, revised and updated edition (Calgary: Fifth House Publishers, 1998), 165. 67 Silverman, The Last Best West, 166. 68 Letter 15 August 1912, L. F. Clarry to J. Reid, PAA, DAG, File 229h. 64

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best out of their lives. Physician Mary Percy Jackson (1904-2000), for example, who came to Canada in 1929 to take up a medical post in the Peace River area of Northern Alberta, described in letters home her life as adventurous and deeply fulfilling.69 She was single, well educated, resourceful, and with financial means. This suggests that it was often the combination of economic hardship and married life that put women in a particularly vulnerable position. Wives could lay no claim to property income and were dependent upon their husbands to financially sustain their families.70 Sometimes isolation and lack of resources on a homestead pushed an already destitute family over the edge. The situation of Mrs. H. is a case in point. Upon immigrating, Mrs. H. and her husband lived in Edmonton for eight years, where they had six children.71 Although the family struggled, and occasionally experienced profound marital conflict, they somehow managed until the husband took up a homestead in South Flat Creek, an isolated rural area north of Edmonton about 20 miles from Athabasca Landing. The family moved to the homestead when the oldest child was 12. Within months the family situation deteriorated to the point that they faced starvation according to a letter from Mrs. H. in December 1914.72 “I and my children are suffering from hunger on this farm, and we are about to die of starvation,” she wrote desperately to the City Police of Edmonton.73 Her letter was forwarded to the RNWMP in Athabasca, and upon investigation, officers confirmed an inadequate stock of food and noted that the children were not well taken care of. Although the husband was questioned about his financial situation, the situation grew more complex 69

McGinnis, Dr. Mary Percy Jackson. For vivid accounts of women’s homesteading experience and their isolation on the prairies see Linda Rasmussen, Lorna Rasmussen, Candace Savage, and Anne Wheeler, A Harvest Yet to Reap: A History of Prairie Women (Toronto: The Women’s Press, 1976), esp. 42-43, and Catherine Cavanaugh, “The Limitations of the Pioneering Partnership: The Alberta Campaign for Homestead Dower, 19091925,” Canadian Historical Review 74 (June 1993): 198-225. 71 Crime Report re Mrs. H., Destitute, December 1914, Constable E. H. Cornelius, RNWMP, with statement of Mrs. H. received 28 November 1914; Letter 28 December 1914, Jennie Robertson, Traveling Matron, to Mr. R. B. Chadwick, PAA, DAG, File 229h. 72 See previous note. 73 Copy of letter received from Mrs. H., attached to letter 28 November 1914 from R.B. Chadwick, Superintendent of Neglected Children, Edmonton, to Officer Commanding, RNWMP, Athabasca, AB, PAA, DAG, File 229h. 70

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when two weeks later he brought his wife to the police magistrate in Athabasca claiming she was insane, acting foolishly and dangerously, had threatened the oldest boy with a knife and did not let the children go to school.74 The physician called in to examine Mrs. H. did not find her insane. The commanding RNWMP officer subsequently noted: “[Mrs. H.] appeared before me this morning charged with being insane, but the doctor’s evidence is to the effect that at present she is not insane but should be under observation. Personally, I am of the opinion that all she requires is care and rest [and] she will come round alright.”75 The case was found to be one of destitution rather than insanity, highlighting the somewhat arbitrary nature of the negotiation process, where government officials — like the police officer in this case — sought to avoid framing the case as insanity, likely not wanting to complicate the family’s social situation. They relied on the older, more inclusive cultural notion of destitution and poverty, illustrating the fluidity of such notions in day-today use. While class and gender circumscribed their experiences, families were active participants in structuring the new form of public institutional care. In August 1912, for example, the Attorney General in Edmonton received a petition from 20 people in an Innisfail neighbourhood requesting “if anything [could] be done in the matter of Amy (pseudonym),” an alleged imbecile child, 10 years old, who was dangerous to the other children in the family, and whose parents lacked the necessary funds “to give her the attention required.”76 The Deputy Attorney General responded that children were not admitted at the hospital at Ponoka.77 In July 1913, there was another inquiry whether there would be a home for a 10-year old girl “that [had] been out of her mind” and whose family was very poor. With nine other children, the family was not able to take care of her.78 These examples pertaining to admission of children introduce the second perspective explored in this article. 74

Report re D. H., 10 December 1914 by police officer H. H. Cochrane; Deposition of D. H and of medical practitioner D. R. MacDonald in the hearing of Mrs. H., 25 December, 1914. PAA, DAG, File 229h. 75 Letter 25 December 1914, A. E. C. McDonnell, Supt. Comm. N Division, RNWMP to R. B. Chadwick, re Family of Mrs. H. PAA, DAG, File 229h. 76 Letter 10 August 1912, J. Reid to the Attorney General in Edmonton, PAA, DAG, File 229h. 77 Letter 15 August 1912, L. F. Clarry to J. Reid, PAA, DAG, File 229h. 78 Letter 3 July 1913, W. Niddrie to the Deputy Attorney General in Edmonton. PAA, DAG, File 229f.

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Admission of Children There were frequent requests in the family letters for admission of children described as “imbecile,” “epileptic,” or “feeble-minded,” contemporary terms people used to describe long-term dependence. These requests stretched the legal and medical norms for admission. According to the law, if family members did not display violent or destructive behavior there were no grounds for admission, particularly not for children. Still children were admitted, despite families’ lack of authority over the new therapeutic environment. A number of children between the ages of 10 and 15 were admitted to the asylum annually, and in some years even younger children appeared in the asylum’s records (Table 1).79 Table 1. Number of admissions to Alberta Hospital Ponoka by age (ages 5 to 20), 1912-1916. Annual report 1912 1913 1914 1915 1916

Ages 5-10 Male Female

Ages 10-15 Male Female 1

1 1

1

1 2

1 1 1

Ages 15-20 Male Female 8 3 1 6 5 3 7 4 6 3

Source: Annual Reports of the Hospital for the Insane, 1912 (p. 59), 1913 (p. 122), 1914 (p. 176), 1915 (p. 24) and 1916 (p. 52), in PAA, Alberta DPS, Annual Reports 1908-1970.

Another example of “pushing the boundaries” of admission criteria appeared in a letter written by a lawyer on behalf of a family in August 1911: “What steps are necessary to have an irresponsible girl placed in the asylum at Ponoka.”80 The letter seemed to suggest that this girl was pregnant with an illegitimate child, and perhaps the family thought of the asylum as a way to deal with socially controversial or unacceptable behaviour. The Deputy Attorney General mapped out the legal procedure, emphasizing that evidence “as to irrational acts and to the dangers of the 79 Annual Reports of the Hospital for the Insane, 1912-1916, PAA, Alberta DPS, Annual Reports 1908-70, box 1. 80 Letter 15 August 1911, Mr. E. Michener, Michener Carscall and Co to McLean, Provincial Secretary Department. PAA, DAG, File 229c.

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patient” had to be laid before a JP.81 Monthly returns, however, showed that occasionally babies were born in the asylum.82 Perhaps the asylum did serve as a solution for dealing with unwanted pregnancy, demonstrating that the public could shape the institution to their needs. In 1915, Thomas Dawson, Ponoka hospital’s first medical superintendent, sought admission for a woman, whom he described to be of limited mental capacity and pregnant with her second illegitimate child. She lived with her family.83 “This woman of 27 [...] is a moral imbecile and is five months pregnant. She shows defective mental power and control [and] her sister with whom she lives is no longer able to look after her.” The sister had young children of her own, and apparently the woman was sometimes violent, Dawson noted. She had not learned in school like other children, had fits until the age of 12, and had had another illegitimate child about four years earlier. Dawson concluded “I think the Hospital for the Insane seems to be the proper place for her. She may be able to contribute a little and [my colleague] will see that [the family] will pay what they can afford.”84 Both the cases of the “irresponsible girl” and the pregnant woman point to the complex and multiple ways families used the asylum. The family strategies taken in these examples may well have been either efforts to protect their kin, avoid stigma by framing the situation as illness, manage socially unacceptable behaviour, or remove a difficult family member from their midst. Framing Dawson’s request, initiated by the family and backed up by his alleged medical expertise, as a protective, preventive measure is in a sense controversial. As Joan Sangster pointed out, “protection, then, has a troubled history.”85 Even well-meant efforts to keep women safe or reform their alleged undesirable behaviours, were not ineffective but reproduced social inequality, racism, and sexual or gender 81

Letter 18 August 1911, Deputy Attorney General to E. Michener, PAA, DAG, File 229c. 82 Letter 6 May 1914, Acting Deputy Attorney General John D. Hunt to Superintendent Dawson, inquiring about infant Rose H., who had been released to the Matron of the Home for dependent and delinquent children in Edmonton. PAA, DAG, File 229g; The Monthly Return of March 1915 stated under general remarks: “Patient Mary Ann delivered of a living male child on 1 March 1915.” PAA, DAG, File 229h. 83 Letter 12 January 1915, Thomas Dawson to Deputy Attorney General J. D. Hunt. PAA, DAG, File 229h. 84 Ibid. 85 Joan Sangster, Regulating Girls and Women: Sexuality, Family and the Law in Ontario, 1920-1960 (Toronto: Oxford University Press, 2001), 1.

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control.86 “Sexual protection applied to girls under the previous Juvenile Delinquency Act (1908-1984) often slid into coercive surveillance, even stigmatizing incarceration,” Sangster noted.87 Dawson’s effort to bring this troubled case under the terms of Alberta’s Insanity Act could be seen as a comparably slippery slope — in the context of Alberta, it can be viewed as a prelude perhaps to the sexual sterilization of the mentally “deficient,” which became accepted practice in the province after the passage of the Sexual Sterilization Act in 1928.88 Asylum admission, then, is part of an “intermediate space” in which individual identity becomes negotiated, a space simultaneously a site of moral regulation, a place of potential freedom.89 How then did the sexual sterilization law meet the needs of families? Or did it? Anxiety over illegitimate pregnancy and procreation by people considered to be “feeble-minded,” “mentally deficient,” or “moral degenerates,” was reflective of rising social anxiety about the quality of the human race. Fear about degeneration arose in industrializing countries during the late 19th and early 20th centuries, particularly among the rising middle class. Eugenicists alleged the rapid growth of the lower classes through immigration and relatively higher birth rates threatened the stability and prosperity of the nation.90 A new preoccupation with mental hygiene emerged, interwoven with class-based concerns about the improvement of the race.91 In its wake, the prevention of mental illness and related social problems, ascribed in part to “feeble-mindedness” and “degeneration,” became an important goal in a broader social movement, often religiously motivated, to improve the race and create a strong new 86

Sangster, Regulating Girls and Women, especially chpt. 5, p. 131-167. Ibid., 1. 88 See Deborah C. Park and John P. Radford, “From the Case Files: Reconstructing a History of Involuntary Sterilization,” Disability and Society 13, no.3 (1998): 317342. 89 See Bradbury and Myers, “Introduction: Negotiating Identities,” (as discussed above). In this case, freedom likely means relief from a burdensome situation, and perhaps protection. 90 Angus McLaren, Our Own Master Race: Eugenics in Canada, 1885-1945 (Toronto: McClelland and Stewart, 1990). 91 David MacLennan, “Beyond the Asylum”: Professionalization and the Mental Hygiene Movement in Canada, 1914-1928,” Canadian Bulletin of Medical History 4 (1987): 7-23; Ian R. Dowbiggin, Keeping America Sane: Psychiatry and Eugenics in the United States and Canada, 1880-1940 (Ithaca: Cornell University Press, 1997). 87

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nation. Eugenic ideas of protecting the human race found fertile ground in Alberta’s conservative political climate. In 1928 the province established the Alberta Eugenics Board and passed the sterilization act, with the view that sexual sterilization of people considered to be mentally defective would contribute to racial improvement.92 The responses in the case examples of families trying to raise “irresponsible girls” and protect allegedly feeble-minded family members may also suggest that there was a certain demand or “bottom-up” backing for the passage of sterilization laws in Alberta. Eugenic ideas were supported by an organized mental hygiene movement, but likely they also may have made sense to a settler community struggling to raise vulnerable, developmentally challenged children in difficult circumstances. Pressured by difficult local circumstances on the prairies, and seeking to live up to middle-class expectations, homesteading and settling families may have welcomed such laws as they seemed to bring relief for families concerned about their chronic mentally ill or “feebleminded” members, especially women. This perspective is further supported by the view held by one of the province’s leading women’s activists at the time. Nellie McClung’s (18731951) work illustrates how such a measure could be seen as an advantage to, and could solicit widespread support from, women.93 McClung was an ardent advocate for women, women’s rights, and social reform, elected to the Alberta Legislative Assembly in 1921 as a Liberal opponent to the United Farmers of Alberta. In her biography, she proudly noted that “Alberta had the first Act authorizing the sterilization of the unfit in the British Empire.”94 Obviously, she perceived it as a major step forward in Canadian nation building, most importantly because of its implications for women. Vividly she pointed out how the value of the measure became clear to her “when a poor distracted mother from southern Alberta came to see me, bringing in her eighteen year old daughter, who was not quite 92

Park and Radford, “From the Case Files”; Diane Mansell, Forging the Future: A History of Nursing in Canada (Ann Arbor: Thomas Press, 2003), 129-135; and Diana Mansell and Judith Hibberd, “‘We Picked the Wrong One to Sterilise’: The Role of Nursing in the Eugenics Movement in Alberta, 1920-1940,” International History of Nursing Journal 3, no. 4 (Summer 1998): 4-11. The act was repealed in 1972. 93 Veronica Strong-Boag and Michelle Lynn Rosa, eds., Nellie McClung Clearing in the West and the Stream Runs Fast: The Complete Autobiography (Toronto: Broadview Press, 2003), 15. 94 Strong-Boag and Rosa, Nellie McClung, 443.

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normal,” but, was “unfortunately for herself rather an attractive girl and eager for life at all costs.”95 As in Dawson’s case, the observation clearly revealed the belief that an unsound mind and the lack of control over female senses were inherently linked, thus putting women at risk. Because their attractiveness was seen as their own misfortune, the onus was on women to keep their sexuality under control, which this young woman failed to do. In McClung’s view the mother was the way she ought to be, rather reflective of a biologically, and racially, based view that life itself was grounded in natural law.96 The thought that sterilization might be applied unjustly to people from particular gender, ethnic, or social backgrounds, and as a consequence construct them as vulnerable, would be a viewpoint foreign to McClung and her contemporaries. Confidently McClung used her political power to get the mother “in touch with one of the doctors in the Department of Health and a meeting was arranged the next day.” As much as Dawson might have sought to support a family seeking relief from a stressful situation, McClung immediately linked preventive sterilization to a happy family life. A year later, she noticed, “the mother looked younger” and the daughter was “well and neatly dressed, and involved in useful activities, […] the home was happy again.” Implicit in McClung’s view was that not intervening might drive the mother into madness. She pointed out how the mother confessed to her that “Things can’t go on this way. She’s on my mind night and day, and sometimes I’m afraid I’ll go crazy.”97 Whereas Dawson, McClung and some of their contemporaries advocated committal into the asylum or sterilization as solutions, the evidence suggests that they did not question that these were forced procedures. Others, however, challenged the forced nature of the committal process. A number of case files demonstrate how some citizens challenged the insanity law, as they grew uncomfortable with the forced nature of the admission procedure, not necessarily with admission itself. The correspondence included a number of requests for voluntary admission for female family members, pushing the boundaries of certified admission. Some people considered the formal admission procedure inappropriate or embarrassing. One man wrote to the Attorney General in 1913 asking whether his wife, suffering from “a complete nervous breakdown,” could 95

Ibid. Gisela Block, “Women’s History and Gender History: Aspects of an International Debate,” Gender and History, 1 (1989): 7-30. 97 Quotes from Strong-Boag and Rosa, Nellie McClung, 444-445. 96

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be placed directly, without first having to go through arrest, warrant, and placement in the guard room in Calgary.98 Another citizen, writing to medical superintendent Dawson, requested placement for his wife, on a “convalescent ward,” suitable for a feeble-minded, but not violently insane person.99 Some requests for help expressed a preference for avoiding the asylum altogether in favour of options such as a sanatorium or a private institution for treatment of alcoholism.100 Many psychiatrists supported voluntary admission, which they saw as closely aligned with a more prominent role of medical expertise in the care of the mentally ill.101 As their requests demonstrated, many families supported such a (state) interventionist approach to mental illness and to some degree helped shape the meaning and practice of asylum care. In Alberta, the Insanity Act of 1907 was amended and renamed in 1924, then providing a legal framework for voluntary admission and a more prominent role of physicians in authorizing admission.102

Women as Caretakers The third perspective presented here suggests that women were central to the caretaking of chronic mentally ill family members, paralleling larger social patterns of caring work.103 David Wright found that families of “idiot” children in Victorian England often looked for public service when 98

Letter 11 July 1913, Mr. A. A. F. to Attorney General C. W. Cross. PAA, DAG, File 229f. 99 Letter, no date, Mr. B. H. to Superintendent for the Insane Ponoka, forwarded by T. Dawson on 2 July 1913 to the Deputy Attorney General, L. F. Clarry. PAA, DAG, File 229f. 100 See, for example, Letter 30 December 1908, from Commanding Officer RNWMP Calgary to the Attorney General, Edmonton. PAA, DAG, File 229a, noting a request of a wife, asking to have her husband, who “took to drink,” treated at a private institution; another family requested permission to take their family member back to Ontario “to put him in a private sanatorium.” Same file, Letter 13 May 1909, Department of the Attorney General to the Officer in Charge, RNWMP Barracks Edmonton. This file also includes a Crime Report from RNWMP Constable B. Lea, 27 October 1910, reporting on a rancher’s suicide attempt. His relatives, requested “to take him to the coast and place him in a sanatorium.” 101 David MacLennan, “Beyond the Asylum.” 102 In 1924 the “1907 Insanity Act” was renamed “Mental Diseases Act,” and admission “by voluntary submission to treatment” or “by medical certificate” was added. Statutes of the Province of Alberta, 1924, chpt. 25, 207-208. 103 Rasmussen, Rasmussen, Savage, and Wheeler, A Harvest Yet to Reap.

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the mother (as the regular caretaker in the family) died and families could no longer deal with the needs of their relatives, an observation the letters confirmed.104 Children who allegedly suffered from chronic mental illness were not necessarily violent or dangerous, but their dependence depleted family resources and their care often fell upon the women in the family. The letters also confirm the observation from other studies of psychiatric care that families usually took care of their chronic mentally ill members for a long time before considering placement.105 In January 1912, for example, an MLA inquired on behalf of a family “whether they [could] get [a young man] placed in the asylum.” He “is feeble-minded and has been so since birth. Lately he is giving his guardians considerable trouble.” Apparently, his brother had taken up the responsibility of looking after him after their parents died, but it was unclear whether the brother had become the actual caretaker. He looked after the finances though. “His brother would also like to know what it would cost them,” the MLA pointed out. “His father left some provision in his will for his care.”106 We can only speculate whether the brother was married, whether he had a wife wanting or not wanting a role in daily care, or whether the young man’s behaviour had just grown too difficult. When the parents could no longer maintain the care of their mentally ill children, or they died, brothers and sisters were not necessarily prepared or able to take over. Sometimes difficult behaviour grew too complex, even for the women in the family. In 1915, a Deaconess of a Calgary church requested placement for a “12 year old girl who has epileptic fits and is mentally deficient” and whose mother was “anxious to have her placed.”107 Although we do not know the details of this family situation, the case suggests that since the mother was no longer able to provide care, the system of family care failed. The same seemed to be the case for a family from a town in Southern Alberta. The parents were desperate to find placement in an institution for their five-year old son, who was “hurt in the head with instruments at birth, [could not] talk, [took] fits averaging one a day, [was] not vicious, not difficult to manage, [had] no control over 104

Wright, “Familial Care of ‘Idiot’ Children,” 183. See note 8. 106 Letter 4 January 1912, J. E. Stauffer MLA to the Provincial Secretary. PAA, DAG, File 229d. 107 Letter 21 August 1915, Deaconess Janet M. Wood, Knox Church to the Superintendent of the Asylum in Ponoka, PAA, DAG, File 229i. 105

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excretions, and if put on the floor would lurch across the floor, [was] incapable of sitting on a chair without being held.”108 The parents were not without resources. They had traveled to Scotland for consultation to find a cure, but without results: “The child and mother have now returned from Scotland and all hope of relief or cure has been given up, and the child grows stronger and is difficult for the mother to handle.”109 It appeared that the family sought placement since the mother could no longer provide the care the boy needed. In other cases it was clear that the death of the mother was the main reason for seeking admission. In May 1915, a physician inquired on behalf of a father, “if there [was] any home or institution in Alberta,” for an incurable daughter.110 He described her as “an epileptic and cripple and also imbecile. She is 18 years old and has the development of a girl of ten. His wife is dead and he cannot look after his daughter.”111 Not being able to fill the gap left by the mother’s death could set off a family crisis. Such situations revealed the interconnectedness of gender and socio-economic circumstances. The loss of the core-caretaker threatened the family’s livelihood. In March 1912, for example, a family physician wrote on behalf of a father who wanted to know “if there is an institution where his daughter could be properly looked after.”112 The mother had died and the father, a coal miner, had to go away to work. The care of this daughter had become increasingly challenging. She was described in the letter as a 17-year-old girl, who for seven years had been subject to epileptic fits, described to be “usually quiet fits,” but during her latest attack “she was exceedingly violent and had to be overpowered — to keep her from doing bodily injury to her attendants. This situation likely tested the needs and commitment of all parties involved, creating a burdensome situation for the daughter in the first place but also for those around her. After the 108

Unsigned letter without date to the Superintendent, Home for Incurables, Portage la Prairie, Manitoba, attached to a letter 25 June 1917, Deputy Minister of the Education Department of Alberta to the Superintendent of the Provincial Asylum in Ponoka. PAA, DAG, File 229k. 109 Letter 18 June 1917, from H. S. Ireland to the Deputy Minister of Education of Alberta, forwarded by Superintendent E. H. Cook to the Deputy Attorney General of Alberta on 27 June 1915, PAA, DAG, File 229k. 110 Letter 17 May 1915, J. A. Little, MD, Coroner, to Mr. Fenwick, Deputy Attorney General. PAA, DAG, File 229h. 111 Ibid. 112 Letter 9 March 1912, Dr. F. R. Ross, MD, to the Attorney General. PAA, DAG, File 229d.

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mother’s death, the father left his daughter in the care of a younger sister of 12, but as her behaviour grew more difficult to manage, this situation could not be maintained: “the father is afraid to leave the girl alone with the younger sister. He would be willing to pay towards the girls’ keep at an institution,” the letter noted.113 All parties involved experience the crisis; the daughter was entitled to care that the family no longer could provide. The latter cases not only bear witness to the central role of women in the care of chronic mentally ill family members, but also point out how the asylum fit fluidly into a range of strategies families used to deal with the difficult behaviour and dependence created by mental illness.

Conclusion The letters and intimate detail of the police reports throw light upon the complex and multiple connections drawn between private family life and public institutions. In a tacit, but dynamic social process families negotiated meanings, practices, and options. They shaped the caretaking of their mentally ill family members, as they enacted and transmitted deeply felt, but also shifting values and beliefs about their entitlement as citizens. As much as the asylum embodied the views and practices of a dominant, white Anglo-Canadian culture, it was also a resource that adapted to some extent to the needs and expectations of a settler community. The requests for admission portray the asylums as an intermediate space that could be negotiated, and at points, resisted. In limited ways perhaps, families shaped existing facilities according to their own needs and interests. The occasional admission of children, for example, illustrates its negotiated nature. The asylum also operated as a space of moral regulation. Women were central to the care of dependent mentally ill family members outside of the asylum. Despite their lack of authority, families actively participated in structuring this form of public care, negotiating and contesting existing medical and legal norms of admission in order to meet their own needs.

113

Ibid.

APPENDIX

The following appendix contains the abstracts (in alphabetical order) of all other thirty-six oral or poster presentations that were given at the 2010 History of Medicine Days conference. The respective authors had either not submitted a formal manuscript for publication in the 2010 Proceedings Volume, or their submitted manuscripts were rejected following to the peer-review process in place.

WATERS AND SYRUPS: THE DECONSTRUCTION OF EIGHTEENTHCENTURY BRITISH MEDICINAL RECIPES FOR MODERN MEDICAL APPLICATIONS KATHERINE ALLEN

Apprehension and skepticism arise amongst scholars at the notion of trans-disciplinary methodology between science and history. To address these concerns I use the unique and useful lens, a woman’s domestic manuscript of medicinal remedies, written in 18th Century England. By deconstructing this manuscript, I attempt to introduce the potential of historical documents in medical research and try to persuade historians to consider looking at manuscripts in a more scientific light. Until recently, 18th Century manuscripts have been essentially overlooked for their merit in the history of medicine. Tracing the refinement of medicinal knowledge through the lens of “domestic chemistry” is a unique way of approaching the history of eighteenth-century British medicine. My manuscript contains a variety of recipes such as “The Palsy water [of] Dr. Nath” which calls for “flowers of Borage, Rosemary, Sage, Betony, Lilies of the [valley], Cowslips: of each one handful” among others. By deconstructing the recipes and looking at them as an historical collective, I will address how ingredients were combined, prepared and administered. My aim is to reveal how 18th century contemporaries understood early modern medicine and why these recipes were collected. Hence, there are areas within medicine already looking at plants, but they could be missing key information found via bioprospecting in historical sources. If ingredients and techniques used in these recipes can show potential effectiveness from a modern perspective, it can also allow historians to explore how contemporaries understood their recipes. Thus scientific methodology is necessary for deconstructing historical medicinal manuscripts. PRECEPTOR: Dr. Erika Dyck INSTITUTION: University of Saskatchewan

BORROWING AUTHORITY: FINDING NOVA SCOTIA’S PLACE IN THE EUGENIC DISCOURSE LESLIE BAKER

The concept of eugenics in early twentieth-century Canada was directly tied to discourses surrounding race, sex, population control, social hygiene, moral reform, and mental health. At a time when medicalization and modernization were closely linked in the public consciousness, eugenics became a catch-all phrase enabling reformers to address social problems in what appeared to be a ‘modern’ way. Traditionally defined by its ends rather than its means, eugenics was widely appropriated and supported by liberal and conservative, social and political groups alike and used to justify very different agendas by lending scientific authority to social fears, moral panics, racial doctrines, sterilization acts and immigration laws. In recent years much of the Canadian historiography has focused on the use of eugenics to support sterilization policies in the western provinces of Alberta and British Columbia. My research argues that eugenics was also a force in the lives of those who were the victims of segregation rather than sterilization policies. Strikingly, although Nova Scotia adopted segregation rather than sterilization policies, those involved in the debates were very much cognizant of the North American eugenics discourse as a whole. Individuals incorporated alleged scientific and legal findings from other localities, both Canadian and American, in their understanding of what eugenics meant to Nova Scotians. By interrogating these sources I suggest that not only is there a new perspective to be explored on Canadian eugenics but also that they can be used to demonstrate the connectivity to and awareness of North American medical debates and their significance for Nova Scotian legislators, reformers, physicians and public. PRECEPTOR: Dr. Erika Dyck INSTITUTION: University of Saskatchewan

GETTING THE BLOOD OUT OF YOUR BOOTS: THE MEDICAL ADVENTURE OF EXTERNAL COUNTER PRESSURE BRYDON BLACKLAWS

Basic to human physiology is that when a challenge is placed upon the ability of the cardiovascular system to effectively pump blood, blood will follow gravity and “pool” in lower areas of the body. For humans to survive such experiences as shock, early neurosurgery, flying fast warplanes, and eventually travel to space, the challenge of surviving through events that resulted in blood pooling in the lower limbs, and the person becoming hypoxic and unconscious, had to be overcome. An early pioneer to this challenge was a renowned 20th century surgeon, George Crile (1864-1943). Working in the field of neurosurgery, Crile found he could maintain the consciousness of his patients by using an external rubber ‘suit’ inflated with a bicycle pump. When a plane in which he was a passenger some years later crashed in the Everglades, Crile recounts thinking that his “rubber suit” might have prevented the blackouts he experienced while the plane was careening up and down just before it crashed. The same thing experienced by Dr. Crile during his plane crash threatened the survival of Allied pilots during high-speed aerial “dog fights” of World War II with increased “G-forces” in steep turns or dives. Aiming to solve this challenge, Canadian physicians in Toronto during 1939, particularly the physiologists Wilbur Franks (1901-1986) and Frederick Banting (1891-1941), developed external counter pressure using water-filled suits for fighter pilots. Their research produced the first human centrifuge in an Allied country and produced a water-filled suit (Frank’s Suit) that gave Allied pilots in WWII a distinct advantage at high speeds. The work on external counter pressure by Crile, Franks and Banting would continue to be evolved into life-saving medical treatments in military and emergency medicine. PRECEPTOR: Dr. Ronald D. Stewart INSTITUTION: Dalhousie University

PLASTIC SURGERY IN WORLD WAR I AND TODAY: THE PEDICLE FLAP CURTIS BUDDEN

Plastic surgery has its roots in ancient Hindu and Chinese medicine however many of the developments in reconstructive surgery were made in the World War I. One such area of development was the notion of utilizing pedicle skin flaps to remold areas of significant trauma. War leads to thousands wounded with significant facial trauma and World War I, through its technologic advances in weaponry, necessitated major breakthroughs in facial reconstruction. Through a survey of important historical texts and a review of surgical procedures, the impact of pedicle flap use by Sir Harold Gillies (1882-1960) will be explored. As an army medical officer in 1915, Sir Harold Gillies recognized a need for specialized maxillofacial handling of war wounds. At the time, surgeons were aware of the pedicle flap technique which involved grafting a partial flap to another location on the body however it was not readily used for facial trauma. After discovering that pedicle flaps would have a higher success rate if made into a tube, Gillies created the pedicle tube. These tubes were more resistant to infection and were able to reconstruct facial deformities of the ear, nose and maxilla. Used until the 1970’s, Gillies’ pedicle tube technique offered surgeons and patients numerous reconstruction marvels. The advent of free pedicle flaps using anastomoses altered the attachment of pedicle flaps although they are still used today. In a recent report of military plastic surgery performed in Iraq, pedicle flaps are being used for nasal and lower extremity reconstruction with a success rate of 92.9 percent. The lessons of World War I have built a foundation for today’s surgeons facing the enormous challenge of providing soldiers and civilians with a normalized appearance despite significant facial disruption. PRECEPTOR: Dr. Jim Connor INSTITUTION: Memorial University of Newfoundland

WITH YELLOW SIGNALS BURNING BRIGHT, ILL WINDS BRING FEVERS IN THE NIGHT: THE SECRETS OF PARTRIDGE ISLAND, CANADA’S FIRST QUARANTINE STATION ANNA DAVIES

Along the stretch of horizon seen from the heart of Saint John, New Brunswick, there is a tiny island that sits at the mouth of the harbour. Unbeknownst to most, Partridge Island is a national historic site, laden with over 200 years of history. The island was designated as Canada’s first quarantine station in 1785, and was the first point of contact for all immigrants en route to New Brunswick. Before its closure in 1941, it was estimated that over 3 million people were assessed, prior to reaching the mainland. Partridge Island is most often remembered for its gatekeeper role in 1846/47, when thousands of Irish immigrants fled to Canada to escape the Potato Famine. Many of these immigrants were infected with typhus, and over 600 people were buried on the island during the epidemic. Dr. James Collins (1824-1847) was one of the physicians involved in treating the rampant disease, and succumbed to it himself only a few short weeks into his service. He was one of twenty-three doctors who provided services to the quarantine station over the years, in thirteen small hospitals. Today, there are only remnants left of the old settlements, and a Celtic cross erected in 1927 that recognizes the lives of the Irish immigrants. Although the federal government has closed the site, there is strong local interest in reopening the island to the public, and reconnecting Canadians with a lost piece of their history. My paper provides an overview of the unique history of Canada’s first quarantine station. PRECEPTOR: Dr. Jim Connor INSTITUTION: Memorial University of Newfoundland

“IN GREAT MERCY DELIVERED:” MEDICAL AND THEOLOGICAL UNDERSTANDINGS OF PAIN IN EARLY MODERN ENGLAND ADAM FOWLER

Pain is an essential part of being human. Western philosophies and sciences of pain go back further than ancient Greece, and the discussion remains vibrant today. In early modern England, the waning pull of the church and the waxing influence of the sciences met and blended, allowing people in pain to draw on two important sources of explanation and solace. Even though medical and theological views of pain relied on one another and made many of the same assumptions, they varied in their focus. They both saw mind and body as inextricably linked, and therefore were also able to interpret pain in the context of punishment. Both medical and religious thinkers knew that the others’ expertise was necessary for dealing with bodily suffering, whether through identifying its source, actually relieving it, or offering consolation. Nonetheless, they differed in several key areas. Most importantly, they chose to emphasize different qualities of the pain they wrote on. This can be seen in discussions of the cause of pain, its benefits, its nature, and in practical suggestions about how to deal with it. In the real world, patients generally sought doctors first and clerics second, but both played an important role. Ultimately, sufferers found both secular and spiritual support in their distress —important in an era where medical relief from pain was often absent. PRECEPTOR: Dr. Lisa Smith INSTITUTION: University of Saskatchewan

KEEPING HEALTHCARE AFLOAT: THE LADY ANDERSON JOURNALS OF DR. ROBERT DOVE, 1936-1938 SHAINA GOUDIE

Newfoundland’s history has been shaped largely by its geography, and its medical history is no different. In the decade or so before Confederation with Canada in 1949, the Commission of Government in Newfoundland instituted a program in 1935 that delivered medical care by boat to the isolated communities of the southwest coast of the island, a much needed service in the years before road travel was possible. Dr. Robert Dove (1909-1970) was the second doctor on the Lady Anderson, the mobile marine clinic, and spent two years on service from 1936-1938. He kept a journal during his time on the ship, writing almost every day about the weather, the voyage, the communities and the patients he treated. These unique journals contained several black and white photographs, and detailed descriptions of the work of the Lady Anderson, Dr. Dove and the health of the communities. There is little research on this topic to date, so my discovery of these journals in 2008 while working as a historical research assistant provides a unique archival resource and perspective on the treatment of now diminished conditions such as tuberculosis, typhoid fever and dietary deficiencies. Studying the diaries has shown that Dr. Dove’s subsequent medical career was greatly influenced by his experience on Lady Anderson, as he went on to research malnutrition in Newfoundland. My close historical analysis of Dr. Dove’s diaries which I will discuss has uncovered accounts of challenges in delivery of healthcare to isolated communities seventy years ago that can be compared to those in the same areas today. PRECEPTOR: Dr. Jim Connor INSTITUTION: Memorial University of Newfoundland

“MARRIED TO ANGELS AND AMONG LOVELY PEOPLE:” THE HADAMAR MASS MURDERERS IN THE SHADOW OF DEATH CHRISTIANE GRIEB

The Hadamar Psychiatric Institution was a center of the T-4 Euthanasia program. Hadamar medical personnel was responsible for the murdering of more than 10,000 “patients” who had been classified as “undesirable” members of the German Aryan society or were found mentally disabled and not worthy to live. During the archival research for my master thesis, I found coincidentally the farewell letters of the convicted war criminals in the Hadamar war crimes trial. Tried before a U.S. Military Court, the Hadamar chief administrator Alfons Klein (d. 1946), and two male nurses, Heinrich Ruoff (d. 1946) and Karl Willig (d. 1946) were sentenced to death by hanging in 1945 (executed one year later), while the remaining convicts Adolf Wahlmann (1876-1956), Adolf Merkle (b. 1889?), Irmgard Huber (1901-1983) and Phillip Blum (d. 1976?) were sentenced to forced labour and incarceration for life. Found among the private estate papers of one of the interpreters for the American war crimes program, I analyze discuss the farewell letters of Heinrich Ruoff and Karl Willig under the theoretical framework of narrative psychology. Narrative psychology focuses on the construction and reconstruction of individual biographical narrative. Related to farewell letters, the imminent violent death might cause the writer to sustain social ties beyond death by using farewell letters as medium of confession, reconciliation with the family and community, and of re-constructing the life that is about to be taken as much as it addresses the breaking of these ties in the shadow of death. PRECEPTOR: Dr. Frank W. Stahnisch INSTITUTION: University of Calgary

FROM SINNER TO SAINT: DR. NORMAN BETHUNE DAVID ZHIFEI HAN

With the advent of World War One, trench warfare and hand grenades left new patterns of burns and fractures, opening doors for new developments in this growing field. The then-accepted treatment was really no treatment at all, but instead was tin masks to hide the soldiers’ deformities. It was Harold Delf Gillies (1882-1960), an army surgeon, who recognized the ineffectiveness of this patch-work solution to these soldiers’ physical and emotional health. With his induction of the first facial reconstruction unit, he propelled the training of budding plastic surgeons from around the world as well as a spirit of inter-professionalism. Of particular importance, he developed a revolutionary grafting technique allowing for a reduced infection rate and improved survival of both tissue and patient. The time between the two world wars was monumental in the implementation of academic training programs in plastic surgery. By the coming of the Second World War, several plastic surgeons were at the forefront, contributing to the advancement of this field. PRECEPTOR: Dr. Peter Warren INSTITUTION: University of Manitoba

A LICENSE TO KILL: THE MERCIFUL MURDERS OF DR. JOHN ADAMS CHARLES HO

Administering a drug to kill a patient is undoubtedly wrong. But what if the drug alleviates suffering? And what if the patient requests it? The questions that dominate the euthanasia debate today were thrown into sharp relief in 1956 upon the arrest of Dr. John Bodkin Adams (18991983) in the placid seaside resort-town of Eastbourne in South east England. For many years, Eastbourners whispered rumors of Dr. Adams killing his patients with morphine before making off with his victim’s possessions. However, none could deny that the patients in question were all frail and likely to die even without the injections. Indeed, most patients were in such great pain that they asked for the pain-killers themselves. Yet it was odd that Dr. Adams found himself in the wills of 132 of those patients. The legal battle that occurred in Dr. Adams’ trial pitted physician against physician. Did Dr. Adams kill his patients, or was it merely coincidental to pain management? Doctors lined up on both sides of the court to testify for or against their colleague. To the outrage of many, Dr. Adams was acquitted of murder in 1957. Hailed as a landmark case in the legalities of palliation, the case of Dr. Adams was first to establish the principle of double effect under English law. That is, a physician may administer drugs to alleviate pain and not be guilty of murder, even if the drugs inadvertently shorten a patient’s lifespan. Such a position appears to be tacitly approved in many other jurisdictions, such as Canada, Australia, and the United States. However, the case of Dr. Adams was marred with legal troubles and strong evidence of interference into the prosecution’s case. At the end of the day, the legality of palliative double effect may be as uncertain as the innocence of Dr. Adams. PRECEPTOR: Dr. Paul Potter INSTITUTION: University of Western Ontario

SOCIETAL RESPONSE TO CHOREOMANIA IN THE MIDDLE AGES SANJNA MIRIAM JOHN

For centuries, the choreomania of the Middle Ages has captured the imaginations of lay people and academicians alike. How could the frenzied, unstoppable and inexhaustible dancing of a single individual influence those who saw it to suddenly writhe and contort their own bodies, all the while begging for someone to stop them? And how could this plague go from town to town, inciting the same behaviour in each afflicted? Many intellectuals have set forth theories as to the etiology of these fantastical events. Over time, the favoured explanations have ranged from demonic possession to ergot poisoning to mass psychogenic illness. This paper analyzes the Zeitgeist that permitted and even encouraged these occurrences from the 14th to the 16th centuries. It also examines how contemporary society understood and responded to these individuals. Sources will include contemporary observations, historical writings, and images to elucidate the intricate interplay between cultural context and societal reaction that set the stage for the dancing manias of the Middle Ages. PRECEPTOR: Dr. Jacalyn Duffin INSTITUTION: Queen’s University

THE WILLOWBROOK HEPATITIS STUDIES: ETHICAL IMPROPRIETIES IN MEDICAL RESEARCH AND THE NEED FOR A UNIVERSAL PROFESSIONAL STANDARD YASIR KHAN

The Willowbrook Hepatitis Studies consisted of ongoing medical experiments conducted from the mid-1950’s to the early 1970’s, in which researchers knowingly inoculated developmentally disabled and institutionalized children with the hepatitis virus, in hopes of studying the disease process and developing a vaccine. Willowbrook on Staten Island, New York (USA) was initially intended to be a “school for the retarded” with an emphasis on the educational aspects of the institution. However, following the Second World War, conditions at Willowbrook rapidly deteriorated and by 1955 there were 3,600 children living in an institution which had a capacity for 2,500; by 1963 there were 6.000 residents. Due to the severe overcrowding issues at Willowbrook, it simply became a holding facility for the developmentally disabled, where infectious diseases became rampant due to the poor hygienic conditions. The Willowbrook experiments raised several ethical dilemmas, including the use of children, and developmentally delayed individuals in research. Researchers justified the experiments as being ethically sound (Krugman, 1986), while ethicists and historians have found numerous flaws in the study protocols, which seem to indicate a tendency towards morally irresponsible behavior (Rothman and Rothman, 1984). The establishment of a standard “code of professionalism” within the medical field would have allowed these researchers to be held accountable to a concrete set of principles, rather than laws and ethical guidelines which were in constant flux at that time. This would have ensured that researchers abided by the same principles of their profession, rather than excusing themselves from a moral obligation by concluding that their work had not violated any laws. PRECEPTOR: Dr. Jim Connor INSTITUTION: Memorial University

LESSONS LEARNED FROM MEDICAL EPONYMS: NEVER SWEAR FAITHFULNESS “WITH EVERY WAKING BREATH” ASHLEY KIM

Mythology, politics and art, while apparently distant from the world of anatomy and pathology, have made significant contributions to the language of medicine. Medical eponyms, which often recognize the contributions of influential physicians, also include references to iconic figures and historical events, thereby bringing culture and humanity back into the realm of science. The term “Ondine’s Curse” refers to a condition known as Congenital Central Hypoventilation Syndrome and was first reported in 1962 to describe patients who were unable to maintain control of breathing while asleep. The eponym is derived from early Romantic literature and the tale of Ondine – a water nymph who condemned her unfaithful husband to forget to breathe upon falling asleep. The “Mona Lisa Syndrome” came from attempts to solve the enigma behind Leonardo Da Vinci’s (1452-1519) painting. In 1989 it was proposed that the mysteriously elusive smile was due to a facial muscle contracture after abnormal nerve regeneration. Today the eponym is used in idiopathic cases of Bell’s Palsy in pregnant women and reiterates the complex genius of Da Vinci – a compulsive anatomist who routinely combined art and medicine. Reactive arthritis was described first by German doctor, Hans Conrad Reiter (1881-1969) in 1916, and the name “Reiter’s Syndrome” was adopted and published worldwide by Boston rheumatologists. Decades later, the revelation that Reiter was a proponent of the Third Reich’s eugenics movement and had sanctioned “medical experiments” that resulted in thousands of deaths, raised doubts about the use of an eponym. Retracing the stories behind such eponyms unveils legends rich with ancient culture, classical art, as well as significant political chapters in the history of humankind. It would be regrettable if by extinguishing these eponyms, we erased a link that situates contemporary medicine within our wider history and culture. PRECEPTOR: Dr. Paul Potter INSTITUTION: University of Calgary

ACUPUNCTURE: JOURNEY INTO THE WEST ERIN KNIGHT

Acupuncture, a treatment method that uses needles to pierce the skin, is thought to have developed along with the philosophies of Confucianism and Taoism in China. Artifacts have suggested that the method dates back to at least 1000 B.C. It had become a common method in China by the first century B.C. when it was described in the Yellow Emperor’s Classic of Internal Medicine. Acupuncture quickly became an essential part of eastAsian medicine. However, it has also been gradually adopted into western, allopathic medicine. While the treatment was popularized in North America following President Nixon’s (1913-1994) 1971 trip to China, acupuncture actually began its difficult journey into the west several centuries earlier. The journey began when the Dutch physician Willem ten Rhijne (1647-1700) brought knowledge of acupuncture to London in 1683. The method gained popularity over the following century, with many case studies being published in the early nineteenth century. Interestingly, while acupuncture was banned in China by the Royal Medical Academy in 1882, it was introduced to Canada by Sir William Osler (1849-1919), who had learned the technique in Europe in 1873. In fact, Osler comments on the usefulness of acupuncture in treating both lumbago and sciatica in The Principles and Practice of Medicine (1892). Although the technique was being used in the west, there was little reference to the traditional Chinese theories and methods. This void was filled by Dr. Edward Hume (1876-1957) who spent much of his career in China and relayed eastern knowledge to North America in the early twentieth century. Today, over 300 years since the journey into the West began, and there is ample literature on acupuncture, with evidence supporting its use in several afflictions. However, allopathic standardization has drastically changed this traditionally fluid, artistic and patient-centered method. Therefore, the question remains: has acupuncture lost its integrity along the way? PRECEPTOR: Dr. Peter Warren INSTITUTION: University of Manitoba

THE MANDATE TO HEAL: JEWISH MEDICAL ETHICS, AN HISTORICAL PERSPECTIVE JACINDA LARSON A popular modern-day view, held by many Jews and non-Jews alike, is that Medical Ethics within Judaism originated from biblical passages found in the Torah (the written Jewish law and scriptural tradition). However, as many 19th-century philological historians of medicine, including Julius Preuss (18611913) have pointed out, the structural establishment of Jewish Medical Ethics (JME) emerged from the Talmud (oral law). The Talmud centrally consists of two documents, the Mishneh (~200 CE) and the Gemara (~500 CE) and was developed as a written record of rabbinical discussion on Jewish law, ethics and customs originating from the Torah. Inferences from the oral tradition established the halachic (practical application of the oral law) basis of the modern medical practice of JME. This project aims at exploring the impact that the Talmudic roots of JME has on the history of medical ethics. By drawing on individual historical case studies, beginning with the Medieval Jewish physician Moses Maimonides (1135/38-1204), it will discuss how the “mandate to heal” (Tikkun Rafa) was interpreted from Torah, recorded in the Talmudic scriptures, and translated into thoughtful and distinct practices among Jewish doctors. Through the reception of Maimonides’ ten “Medical Works”, medical philosophies came to concentrate on an applied view of JME. This tendency is most evident when looking, for example, at such medical doctors and writers as Marcus Herz (1747-1803), Judah Leib Benjamin Katznelson (1846-1917) or Albert Moll (1862-1939). With the incorporation of the biblical “mandate to heal,” JME will be historically examined by discussing Torah and Talmudic medical regulations, theoretical medical texts and case reports that the aforementioned Doctors used or reflected upon. As it will be argued, Jewish Physicians of the early modern and modern period continuously relied on the conceptualization of Talmudic principles, which Maimonides developed, as a foundation for later Physicians working in this tradition. PRECEPTOR: Dr. Frank W. Stahnisch INSTITUTION: University of Calgary

A CLOAK OF SECRECY: TRANSPLANT TOURISM IN CHINA CAROLINE LEE

Boosting of a dramatic increase in quality of life and survival, organ transplantation has become the mainstay treatment for end-stage organ failure following the introduction of an effective immunosuppressant, cyclosporine, in 1983. However, medical institutions across the world quickly found that they did not have the capacity to meet the demands of patients due to a limited number of organ donations. These conditions of need and desperation catalyzed the establishment of transplant tourism. This phenomenon describes the purchase of organs from abroad in order to circumvent local laws while taking advantage of lax laws in developing nations. Since the mid-1990’s, China quickly became a popular destination for transplant tourism, especially with the government’s active endorsement of this industry. Wide-spread criticism became eminent as it was revealed that organs were often procured from executed prisoners, a practice that was carefully veiled by the Chinese government. Faced with an increasingly hostile international community, China introduced new legislation banning the sale of organs and new forms of punishment. However, while such moves were supported by bodies such as the United Nations and the international Transplant Society, experts continue to question whether these legislations are being enforced. In the face of such developments, this presentation will examine the issues surrounding organ trafficking in China with respect to kidney transplantation, focusing on the Chinese policies that founded transplant tourism; the means through which organs are procured; the ethical issues such procedures raise; and the subsequent response by the international community. Examining the issues surrounding organ trafficking and transplant tourism as a society facilitates the development of preventive measures to discourage such activity and new solutions for the problem of limited organ supply. PRECEPTOR: Dawna M. Gilchrist INSTITUTION: University of Alberta

RESPONDING TO PLAGUE: THE DEVELOPMENT OF SAINT ROCH AS A PLAGUE SAINT CLINTON LEWIS

This presentation examines the development of Saint Roch as a specialized plague saint following the plague’s arrival to Europe in 1347. Bubonic plague’s arrival to Europe in the mid-14th century with the Black Death and the continuing cycles of plague were events that forced individuals and societies to integrate the massive mortality associated with the pandemic into their day to day existence. The increasing number of artistic representations of Saint Roch as a specialized plague saints which could intervene on behalf of the citizens of Christendom demonstrates one method by which the epidemic infectious disease could be addressed. Secondary discussions of the various visual representations of these icons, as well as examinations of the works themselves, demonstrate the development of these saints, focusing primarily on works from the 14th and 15th centuries. However, Saint Roch is depicted in paintings, woodcuts, and manuscripts from the mid-14th century onward to the present day. Considering the rise of a specialized saint in response to epidemic disease provides a fascinating contrast in light of the recent development of pandemic influenza, AIDS, various cancers and our responses to them. PRECEPTOR: Dr. Frank W. Stahnisch INSTITUTION: University of Calgary

THE HISTORICAL DEVELOPMENT OF THE CUBAN HEALTH CARE SYSTEM JESSICA MOE

The purpose of this study is to examine how the Cuban medical system developed. Since 1959 when Fidel Castro (1965-2011) and his rebel forces marched into Havana, Cuba has been a symbol of revolution, for some admirable, for others deplorable. Health care in Cuba similarly embodies a revolutionary fervor because Cuba defies the purported correlation between national income and health. Despite a national income more akin to a developing country, Cuba boasts health indicators that parallel those of the developed world. Cuba boasts one doctor for every 170 population, the highest rates of treatment and control of hypertension in the world, and its infant mortality rate surpasses that of the United States.1 Over the years, challenges to the health system have been numerous. The US has held a trade embargo against Cuba since 1961. The Soviet Union, Cuba’s strongest ally, collapsed in 1991, ushering in a “Special Period” of necessary hardship. A mass exodus of thousands of physicians occurred in the 1960’s. Against all odds, the Cuban health system has thrived. This study synthesizes multiple sources of information on the Cuban medical system, including journal articles, books, documents and presentations produced by Canadian and Cuban government representatives, historical speeches, and interviews with Canadian doctors and researchers who have worked and/or studied in Cuba. This research demonstrates a unique context of social, political and historical forces that shaped the evolution of the Cuban health care system. It might also allow us to question the extent to which Canada can learn from the Cuban experience as we address continual issues of health care reform. PRECEPTOR: Dr. Jackie Duffin INSTITUTION: Queen’s University 1

Richard S. Cooper, Joan F. Kennelly and Pedro Ordunez-Garcia (2006), “Health in Cuba,” International Journal of Epidemiology, 35(8): 817-824.

FROM RADIOACTIVITY TO RADIATION THERAPY: HOW SASKATCHEWAN CANCER POLICY INFLUENCED THE CANADIAN HEALTH CARE SYSTEM MATHEW MOSSEY

The problem of cancer has long been an issue of vital importance to Canadians. As health care data was collected at a greater rate in the early 20th century, it became apparent that mortalities from cancer were a significant public health problem. In an attempt to reverse the impact of cancer, radiation therapy emerged as an effective tool in combating the disease and prompted a new hope that a cure for cancer would be realized in the not too distant future. However, due to the expense of obtaining naturally occurring radioactive elements, radiation therapy was limited to a select group of patients. During the Great Depression the inability of patients to pay for services prompted Saskatchewan to become the first province in Canada to provide cancer services that were funded by the state. The intrusion of the state into health care initially provoked anxiety among the medical profession. However, given the economic problems of the Great Depression, doctors found themselves re-thinking the role of government involvement in health care and endorsed the state’s plan. As the state provision of cancer services occurred more than thirty years before the implementation of universal health care, this presentation will consider how the practices and policies surrounding radiation therapy contributed to the establishment of Canada’s publicly-funded health care system. PRECEPTOR: Dr. Erika Dyck INSTITUTION: University of Saskatchewan

“MESSING WITH GENETICS:” PERSPECTIVES ON SYNTHETIC BIOLOGY FROM THE ORGANIC CONSUMERS’ ASSOCIATION DANIELA NAVIA, SIBAT KHWAJA AND NIKLAS BOBROVITZ

Synthetic biology, a rapidly advancing approach to creating new organisms through the manipulation and alteration of DNA, has the potential to literally alter life, as we know it. This technology follows the footsteps of genetic engineering, eugenics and experimental evolution, both in overall approach and surrounding controversy. The creation of consumer products, particularly foods, drugs and fuels, are particular areas individuals in this field are focusing on. These products have the potential to impact the health of individuals around the world for better or for worse. Attempts to introduce genetically modified products into consumer markets have been greatly compromised due to organizations opposing the creation of genetically modified organisms. This study seeks to describe the concerns regarding synthetic biology from the perspective of members of the Organic Consumers Association (OCA) who had some familiarity with synthetic biology. Members of the OCA answered a semi-structured questionnaire on various aspects of synthetic biology that was administered online (n=49). Participant responses were analyzed for general themes. There was a great deal of variation between the attitudes of members regarding synthetic biology, from those who oppose all genetic alteration of organisms for research purposes, to those with some weariness regarding the safety of particular consumer products. This study indicated that many individuals were concerned about the direction of the field. Public engagement by the science field is crucial in order to optimize the use of synthetic biology and to prevent it from becoming a blemish of our past. PRECEPTOR: Dr. Gregor Wolbring INSTITUTION: University of Calgary

MEASURING MIDWIFERY: MODELS AND (MISS) CONCEPTIONS VANESSA L. NELSON

On April 1, 2009 midwifery was approved for public funding by the Alberta government. The decision to publicly fund was long awaited and is regarded as one of the last achievements toward formally including midwifery within the provincial health care system. Since the “revival” of Albertan midwifery in the 1980’s, the movement has faced opposition from both the nursing and the medical professions. Despite this opposition midwifery has been able to make relative gains, largely owing to consumer mobilization and strong advocacy from within the midwifery community. Most notable milestones include the legalization and the establishment of professional regulation in the 1990’s. Surprisingly, the passing of provincial regulation did not promptly follow with public funding as it had in other provinces. This paper traces midwifery in Alberta since the 1970’s till the present. A gender approach is employed to understand “obstructions” to the delivery of midwifery services, such as the establishment of professional regulation, cooptation attempts by other professions, and the holdups to public funding. In conclusion, the identification of midwifery as a women’s policy aids in explaining the difficulties to this policy’s adoption. The following “obstructions” are addressed within this Alberta case study: the social and economic environment, the ideology of the dominant party, the strength of the stakeholders, and the controversial nature of the policy. The granting of public funding in 2009 has been widely celebrated within the midwifery community and by their consumer advocates. However, after a decade without funding many midwives have left the province, which has compromised their capacity to realize professional autonomy. Furthermore, its recent inclusion in the health care system presents a past challenge and co-optation, with a new face. PRECEPTOR: Dr. Frank W. Stahnisch INSTITUTION: University of Calgary

OUT FROM UNDER THE GAZE: FOUCAULT AND FALSE DICHOTOMIES TYLER PEIKES

Michel Foucault (1926-1984), French historian-philosopher, examined the development of clinical medicine in early 19th century Paris as a precursor for modern medicine. This period vastly changed the practice of medicine, anticipating the use of modern technologies such as Computerassisted Tomography (CAT) scan and Magnetic Resonance Imaging (MRI). The viewpoint of the profession towards the patient, or the gaze, a term coined by Foucault, was exemplified by Marie-Francois Xavier Bichat’s (1771-1802) “Open up a few corpses: you will dissipate at once the darkness that observation alone could not dissipate.” The gaze is the method of the clinician that approximates omniscience. It is informed through history taking and examination and carries with it the finality of pathology, wherein the end is just the beginning. Ultimately, the aim of the physician is to intervene for the good, but it remains to be seen how that is accomplished. In my paper, I explore the structure of the gaze by examining three dichotomies particular to medicine: history vs. examination, symptoms vs. signs and illness vs. disease, the latter of each favoured by the gaze. Ultimately, I attempt to show that the underlying dichotomy of subjectivity vs. objectivity, the latter also favoured by the gaze, is false, and therefore the three dichotomies cannot stand. What then is left? I argue that even concepts as fundamental as longitudinal diagnosis, imaging studies whether conventional or functional and underlying assumptions in sequencing neural activity all fall prey to the stricture of the gaze. In true patient-centered care, the physician takes the experience of the patient as primary and the interventions only as they impact on that experience. It is the experience that is often left out, but by focusing on it, I hope to demonstrate the immediacy of the missing dimension: time. PRECEPTOR: Dr. Peter Warren INSTITUTION: University of Manitoba

LIFE ON THE EDGE: THE SURGICAL RESIDENCY IAN PEREIRA

Surgery is commonly regarded as the most demanding specialty in medicine. Both physically and mentally taxing in workload and time commitment, it is known for attracting a surgical personality not feint of hand. Similarly, the surgical residency is renowned for its rigor, a trait instrumental in its extraordinary success. However, current trends threaten the foundation upon which the surgical residency was built, and both doctors and patients are now experiencing the dangerous results. Born out of medieval barbershops, surgical training was brought to North America as unstructured, unregulated, and often brief apprenticeships that were considered inadequate even after moving into hospitals in the 19th century. However, a century-old German model introduced to the Department of Surgery at Johns Hopkins University in 1897 would forever change surgical training in North America, bringing graded responsibility, a lengthy training period, and a restrictive lifestyle that made trainees unmarried residents of hospitals. Despite these hardships, the late 19th century promises of fame, fortune, and the ability to recognizably save lives made this model an overwhelming success. In the last century it has produced tens of thousands of skilled surgeons to care for society, attracted trainees from all over the world, and provided excellent care for surgical patients. However, perception of the surgical residency irreversibly changed in 1984 when a surgical tragedy took the life of an 18-year-old college student, setting in motion a series of events that would put surgical residents in between a public debate of the quality of a doctor’s life versus the quality of patient healthcare, and further compound emerging problems of changing demographics and technologies. As both the quality and quantity of surgical applicants is declining, is this debate threatening the future of the surgical residency or merely spurred a necessary evolution? PRECEPTOR: Dr. Paul Potter INSTITUTION: University of Western Ontario

APOLLO’S ARROWS: THE DECISIVE INFLUENCE OF DISEASE ON ALL ASPECTS OF WARFARE IN ANTIQUITY STEPHEN POW

This paper focuses on the almost understated influence of infectious disease on the numerous military conflicts of antiquity. By examining the primary sources of well-known poets and historians, we can see a trend whereby disease often times influenced the progress and outcome of such wars. In the poems of Homer (ca. 850), the lives of Plutarch (ca. AD 46120), and the histories of Arrian (ca. AD 86-160) and Thucydides (ca. BC 460-395), there are references to disease inflicting its damage on armies, civilian populations, and individual commanders themselves. Poorly understood by people of the time, the agency of disease often took a secondary role to the agency of great men, national character, and the fateful will of the gods. Nevertheless, an examination of the writings of the ancient authors themselves reveals how events of the times were shaped by disease. From the chaotic chariot warfare of the Mycenaean Age (ca. BC. 1600-1100) to the empire building of Alexander (ca. BC 400-300), the tremendous impact of disease can be seen. It was very much a variable shaping the political, economic and social conditions of the period. PRECEPTOR: Dr. Frank W. Stahnisch INSTITUTION: University of Calgary

THE BUS, THE PLANE AND THE BLIND BRITON: THE UNIQUE HISTORY OF THE EVOLUTION OF CHARITABLE EYE CARE JOHN DOAN ALI QAZALBASH

According the WHO there are 314 million visually impaired individuals in the world of which 87 percent live in developing countries. Recent advances in ophthalmological treatments have yielded tremendous dividends in affordability and accessibility. As a result over the past few decades a number of western charitable organizations have come to the fore in bringing vision care to impoverished individuals and communities. Utilizing journal articles, interviews, biographies and original advertising and appeals conducted by these organizations we argue that a combination of forces including technology, pharmacology, intelligent logistics and financial independence has brought about some extremely innovative and efficient solutions to targeted healthcare delivery. To illustrate our point we chronicle the history and define the widely disparate and evolving methodologies employed by three charities as they worked towards the common goal of improving vision throughout the developing world: The Seva Foundation was conceived in 1978 by the Brilliants, a husband and wife team out of Ann Arbor, Michigan. Their aim was to help marginalized individuals and populations wherever possible. Today, among other things, the foundation transports rural Tibetans in remote locations by bus to tertiary centres in Lhasa for cataract surgery. ORBIS was founded by Dr. David Patton (b. 1930) in the 1970’s who wanted to bring advances in vision care to the third world. The result is one of the most world’s most unique charities with its own Flying Eye hospital which disseminates knowledge and expertise to under serviced regions around the world. Sightsavers was founded by Sir John Wilson (1919-1999), a blind British humanitarian whose was instrumental in the fight against the eye disease, Onchocerciasis. His wife even coined the phrase “River Blindness” to make the disease more palatable to western donors. PRECEPTOR: Dr. Jacalyn Duffin INSTITUTION: Queen’s University

RADIOACTIVE QUEERS: DIAGNOSING AND PATHOLOGIZING HOMOSEXUALITY IN CANADA’S COLD WAR FRANCES REILLY

During the 1950’s, Canada witnessed a prolonged period of anxiety. While the threat of a nuclear bomb held a permanent place in the civilian’s consciousness, wide-spread fears of communist infiltration and social deviancy urged for increased protection of the nuclear family. In order to maintain a degree of normalcy and social order in a time of potential panic, the Canadian government worked hard not only to expose communist spies, but to ease the public’s fears of the impending nuclear war. Most surprising was the government’s efforts to identify, diagnose, and, eventually, cure the “disease” of homosexuality. This medicalization of homosexuality was influenced by Cold War fears of invasion and disease and was treated through the innovative psychological practices of the time and curious technologies like the Fruit Machine. This technological device was later discarded as bogus, but was initially used in Ottawa to objectively determine the sexuality of suspected individuals working for the government. My paper looks at the history of the Fruit Machine and the Cold War fear of homosexuality. While my research is based on the work of historian Gary Kinsman (b. 1955), my approach is different; rather than examining homosexuality as a Canadian security threat during the Cold War, I consider the fear of homosexuality to be more closely related to the fear of disease and radiation. Historians have commonly linked homosexuality to communist espionage, but it was also feared among Canadians as a contagious “sickness” that could potentially ruin the comfort of the nuclear family, the ultimate symbol of western freedom. PRECEPTOR: Drs. Erika Dyck & Valerie Korinek INSTITUTION: University of Saskatchewan

REAGAN, REGULATION, AND THE FDA: THE US FOOD AND DRUG ADMINISTRATION’S RESPONSE TO HIV/AIDS, 1980-1990 LUCAS RICHERT

The beginning of the AIDS epidemic in the 1980’s placed tremendous strain on the Food and Drug Administration, regulator of one quarter of the domestic US economy and protector of the nation’s drug supply. Much has already been written on the AIDS epidemic, and this body of literature continues to expand, but careful consideration of this subject matter is of crucial significance to understanding the interaction between regulatory agencies, the executive branch, industry, and the public. Periodically, the FDA has gone through phases in which various priorities dominated. At one point or another it has distinguished itself as a regulatory agency, law enforcement agency, and science agency, depending on the political party in power, the ideology of the FDA Commissioner, and the influence of external stakeholders. The AIDS epidemic, which gave rise to a new and robust coalition of AIDS activists, reformers, and libertarians, tested the agency’s institutional identity. To some commentators, the FDA’s management of the AIDS crisis was a serious blunder, akin to the Reagan administration’s failure. This paper contends, however, that despite the absence of presidential leadership, the FDA succeeded in rising to the challenge of the AIDS epidemic in the 1980’s by refashioning its existing regulatory rules, reaching out to the AIDS movement and the pharmaceutical industry, and maintaining its strong commitment to consumer protection. PRECEPTOR: Dr. Iwan Morgan INSTITUTION: University of London, England

IMMIGRANT FILIPINO NURSES IN WESTERN CANADA FROM 1950-2000: AN ORAL HISTORY STUDY CHARLENE RONQUILLO

Along with the growth in the number of immigrants settling in Canada as a whole, the Canadian health care system is incorporating increasing numbers of internationally educated nurses into the workforce. The Philippines is often identified as the largest producer of nurses for export globally and Filipino nurses are joining the Canadian health care workforce at a steady rate contributing to the growing diversity of nursing practitioners. To date, little historical analysis exists of their experiences despite the fact that Canada remains one of the major host countries of internationally educated nurses. This study explores Filipino nurses’ biographical oral histories in order to provide insight into their immigrant journey and integration into the Western Canadian health care workforce. It examines how their individual experiences are intertwined with larger migration patterns, educational trends, and foreign presence in the Philippines. The study further focuses in particular on Filipino nurse immigration to British Columbia and Alberta, using oral history interviews with immigrant Filipino nurses in these two provinces. Through exploration of life and work experiences, the study illustrates larger social trends reflected in individuals’ stories, as well as illustrating how larger social pressures were individually experienced. An intriguing historical understanding of the significant impact that Filipino nurse immigration has had on the Canadian health care system is pertinent in the broader context of colonization and nurse migration. Complementary to the impact on the Canadian system, how the educational, economic, and societal context of Filipino nurses in the Philippines shapes this phenomenon are highlighted. PRECEPTOR: Dr. Geertje Boschma INSTITUTION: University of British Columbia

EUGENICS AND CHANGING NOTIONS OF WOMEN’S BODIES IN TWENTIETH CENTURY ALBERTA AMY SAMSON

In 1928 Alberta introduced the Sexual Sterilization Act under the newly formed United Farmers of Alberta government. The Act, which allowed for the surgical sexual sterilization of ‘mental defectives’, served their larger political agenda that sought to promote a healthy citizenry while minimizing government expenses. This policy reflected the belief that the state had a key role to play in managing reproduction, particularly that of individuals whose judgment, appearance, behavior, and morality, or a combination of the above, deviated from Anglo-Saxon middle-class norms. Scholars have examined various aspects of this Act. Jana Grekul’s sociological studies of eugenics, for instance, provide an important statistical analysis of sterilization cases. Timothy Christian produced an honour’s thesis in 1976 examining the legislative debates surrounding the introduction and amendments to the bill, and Terry Chapman (1977) explored the early period in Albertan eugenics, giving particular consideration to racial categories. With regards to the broader Canadian eugenics movement, Angus McLaren’s pre-eminent study focuses particularly on the viewpoints of Canada’s leading eugenicists, and the ways in which they justified their beliefs in the pre-1945 period. The purpose of this paper is to trace the historiography of the North American eugenics movement, with particular focus on Alberta’s sterilization program, while drawing connections to various bodies of literature surrounding gender norms, and the female body. My larger study will contribute the historiography by merging these ideas in an examination of how constructions of the female body changed over time in Alberta, beginning with the suffrage movement in the early 20th Century until the beginning of second wave feminism in the 1960’s. PRECEPTOR: Dr. Erika Dyck INSTITUTION: University of Saskatchewan

HOW DESCARTES’ MIND-BODY DUALISM WILL AFFECT YOUR VISIT TO THE DOCTOR TODAY CARLY SCRAMSTAD

Based on the state of contemporary anatomical and philosophical research, Rene Descartes (1596-1650) provided us with the questionable notion that our soul was housed within the pineal gland of the human brain. He further suggested that a fire in our heart was responsible for the circulation of blood and spirits and his anatomical opinions do not stop there. Nevertheless, and despite his “misguided physiology,” on a visit to the doctor’s office today Rene Descartes’ legacy lives on. This essay examines the way in which Descartes’ views inform the contemporary mechanistic views that have brought us modern science and medicine. Descartes’ thought can be seen as a precursor to the school of iatromechanics and as an instigator of an entire science of medicine that sees the mind as distinct from the body, where this former, the mind, is thought to be of little significance for such notions as disease or health. Examination of Descartes’ principal notion of mind-body dualism, and it’s representation in his anatomical and physiological texts will provide a glimpse into medicine’s past but also, insight into its present and future. Ultimately, Descartes’ philosophical separation of mind and body led to a method of patient care and assessment that often failed to reconcile the patient’s disease with the patient’s illness. As more holistic approaches to health care develop, it remains pertinent to explore the history and origins of mechanistic views of the human body, to trace Cartesian ideas from their humble attempts to describe human anatomy and physiology to their widespread influence in the doctor’s office today. PRECEPTOR: Dr. Peter Warren INSTITUTION: University of Manitoba

THE SUMMERS OF FEAR: A HISTORY OF THE POLIO EPIDEMIC IN MANITOBA DAVINDER SINGH

On a Monday in 1956, Mr. P. D., aged 21, went to work, the next day he felt unwell and by Wednesday he developed paralysis and could not breathe. He was the only person to contract poliomyelitis in the Manitoba epidemic that year. In 2004, I interviewed him and he recalled being ventilated in an iron lung. Unfortunately he had not qualified to receive the Salk vaccine that had been developed the year before. During the summers of 1952 and 1953, Manitoba experienced the largest polio epidemic it had ever faced. In 1953 alone, 2,380 cases of polio were recorded, 1,200 of which were admitted to the King George Municipal Hospital and these admissions were limited to paralytic cases only. As a result, medical students, volunteers and anyone else the hospital was able to get were recruited to help with the growing epidemic. Many of the volunteers had to be trained on the spot to do tasks that a professionally trained nurse would normally do. So in the end, the staff at the King George ballooned out to 750 people, plus another 600 volunteers. The most severely affected victims of this virus could not breathe for themselves and had to rely on a large mechanical device known as the iron lung for survival. These cylindrical machines encapsulated the patient up to the neck and worked by having a cylinder at the foot of the device move in and out, creating alternating negative and positive pressure inside the cylinder. As many as 93 iron lungs were used at one time in 1953. Even though we have had a vaccine for over 50 years, the World Health Organization estimates in 2009 that 10 million children will become paralyzed by polio in the next 40 years. For some, the fear of polio still remains. PRECEPTOR: Dr. Peter Warren INSTITUTION: University of Manitoba

MEDICAL CERTAINTY: A HISTORY OF EVIDENCE AND AUTHORITY IN MEDICINE CHRISTOPHER ANTHONY SMITH

Increasingly, medical decision-making and policies are being shaped by empirical results from large clinical trials. “Evidence-based medicine” (EBM) is a recently and well-popularized term that denotes medical practice that is grounded in the results from experimental studies, often randomized controlled trials (RCT). Such trials now sit at the apex of medical evidentiary authority, and are widely conducted to verify the superiority of new therapies and techniques. In the past few decades Canadian researchers have played a pivotal role in the development of EBM by establishing the techniques of assessing, evaluating, and incorporating experimentally derived evidence into clinical decisionmaking. In this same period there has been a proliferation of medical “practice guidelines” in Canada, the USA, and the United Kingdom, which have likewise been shaped by the emerging EBM authoritative milieu. The clinical practice guideline (CPG) was initially intended to shape practice standards, and relied upon appeals to authority of prominent and respected practitioners within the medical community. More recently and in the wake of EBM, CPGs have come to be regarded as vehicles for “knowledge translation” (i.e. transference of research-derived knowledge into individual physicians’ practices), and its uptake in use in nearly all medical disciplines illustrates how it has shifted norms of knowledge authority, in addition to becoming a form of authority in its own right. The history of EBM and CPG provide a useful window on the “evidence revolution” currently happening in medicine, one that allows us to discern how statistics have “dethroned” personal reputation as the ultimate authority in medicine. PRECEPTOR: Dr. Jim Connor INSTITUTION: Memorial University of Newfoundland

“SHE EXHIBITED MASCULINE PROTEST:” THE CANADIAN MEDICAL ASSOCIATION JOURNAL AND THE EMBODIMENT OF FEMININITY DURING CANADA’S BABY BOOM, 1946-1966 HEATHER STANLEY

In the twenty years after World War II, Canada experienced a baby boom and with that influx of babies came concomitant shifts in the ideals of family, motherhood and femininity and masculinity. These prescriptive ideals were transmitted to the public through a variety of means and with varied levels of success. Analyzing the Canadian Medical Association (CMAJ), Canada’s foremost medical publication, during this time period provides insight into how the medical community engaged in creating and spreading these gender ideals to their colleagues and their patients. Amongst the groups that transmitted these ideals the medical community had a unique power; through their writings they created a world where femininity became embodied––that is, written in the flesh and soma of their patients via their case studies. Using psychoanalysis they argued that women were linked to their reproductive systems in ways that men were not linked to theirs. In particular, the medical community constructed pregnancy as the height of women’s emotional and psychological maturity. Contributors to the CMAJ, with a few exceptions, also made women’s mental and physical health dependent on her role as a wife and mother, a role that was firmly situated in the home. Thus, the CMAJ helped to recreate a separate sphere ideology remarkably reminiscent of the Victorian Era’s. Indeed, because gender and sex roles were folded in to one another, the medical community equated deviance from prescribed gender roles to illness and recovery of the gender role balance was both the cure for those supposed maladies and the evidence that the cure had worked. PRECEPTOR: Dr. Erika Dyck INSTITUTION: University of Saskatchewan

MEDICALIZING MACDUFF: CESAREAN SECTIONS, GENDER RELATIONS AND THE ROOTS OF OBSTETRICS IN LATE MEDIEVAL EUROPE HELEN VRADELIS

For much of the medieval period, cesarean sections were performed by European midwives as last-ditch attempts to save a dead mother's baby just long enough to baptize: a theologically- more than medically-motivated procedure. By the 16th century, however, the procedure was sometimes performed by medical men, covered by town laws respecting medicine, and discussed in physicians’ treatises. Can this evolution teach us anything about the context of midwifery in the late medieval period? Midwives’ performance of cesarean sections raises issues about gender roles and the standards of gendered behavior. The midwife, in performing the procedure and baptizing the resulting child, simultaneously entered the typically male arenas of surgery and sacrament. In the course of one of the most quintessential “woman’s jobs,” she performed ceremonies regarded as masculine territory. Does this imply a greater mutability of gendered behavior than typically considered? Is it simply the exception that proves the rule? These same “masculine” elements of the procedure, however, made cesarean sections one of the first elements of midwifery to be medicalized and gradually taken on by male practitioners. Cesareans served as a bellwether for male usurpation and medical redefinition of childbirth in general, intertwined but not identical processes that, together, put down roots for the coming field of obstetrics. What can we learn from those developments about the late medieval medicalization of childbirth, and even of other previously quotidian aspects of life? The medieval cesarean section is a useful crucible for the analysis of changing late medieval power relationships and cultural forces, especially shifting gender roles and the rise of academic medicine. PRECEPTOR: Dr. Faith Wallace INSTITUTION: McGill University

A WAR OF WORDS: THE CONTENTIOUS HISTORY OF CHIROPRACTIC IN NORTH AMERICA ANDREW WEISS

Chiropractic has had a turbulent relationship with the medical profession since its founding in Davenport, Iowa in 1885 by Daniel David Palmer (1845-1913). Its early expansion coming largely in areas with poor access to allopathic medicine services, it has now become an entrenched part of alternative medicine. Chiropractic bills itself, in the words of Professor Charles Picciotto, the chair of physics and astronomy at the Canadian University of Victoria, “as an alternate primary care methodology ... which private citizen’s use as first-contact providers for anything from cradle to the grave.” Chiropractic’s early antagonistic approach to allopathic medicine has been met by pronounced antipathy towards chiropractic from within medicine. Philosophically this is not surprising, the “anti-scientific” dogma of chiropractic has caused a split within the chiropractic community itself with a minority of chiropractors limiting their practice to spinal manipulations shown to have positive outcomes; while the majority of chiropractors continue to practice named techniques, such as the “hole-inone,” which they claim can cure any ailment afflicting the body. For better or for worse, chiropractic providers are in increased contact with allopathic medicine practitioners. Many clinics now include practitioners of both philosophies and this trend appears unlikely to reverse. Is this implicit endorsement of chiropractic in the best interest of patients? Time will tell, but on the whole the friction between these dogmas is sure to continue well into the future. PRECEPTOR: Dr. Frank W. Stahnisch INSTITUTION: University of Calgary

HISTORICAL INVESTIGATION OF CANADA’S CORD BLOOD BANKING SYSTEM JACQUELINE WILLINSKY

Umbilical cord blood extracted after delivery is a rich source of stem cells that can be used to treat many childhood diseases. The collection and transfusion of cord blood has proven benefits over other sources of stem cells. Canadian scientists have been at the forefront of cord blood research for decades, yet Canada differs from other developed nations in the lesser extent to public involvement in, and use of this technology. Reasons for this have yet to be expressed. Ten private blood banks dominate Canada’s cord blood storage, competing for the support of physicians and patients–– a dynamic that often makes Canadians uneasy when dealing with healthcare. This may affect communication and education about cord blood banking within the medical system. Articles and editorials dating back to the mid1990’s show that Canadians are comfortable with the idea of using cord blood, and that public discussion has centered around debating the country’s management of cord blood banks (public, private, or both). Why has Canada not opened a national cord blood service, and what shaped the current system? This research project addresses these questions from a historical perspective; sources include newspapers, medical journals and interviews. The study fleshes out social and political factors that have influenced Canada’s cord blood industry since the technology’s inception in the mid-1990’s. It explores the loss of public trust in Canadian Red Cross blood banks following the 1997 Krever Inquiry, as well as the effect of the United States’ stem cell policies on Canada’s cord blood system. Canadian Blood Services is currently moving forward in creating a national cord blood bank, making it an important time to examine the historical context of this topic. PRECEPTOR: Jacalyn Duffin INSTITUTION: Queen’s University

INDEX OF NAMES Adam biblical, 5 Adams, John Bodkin, 289 Alexander, the Great, 303 Allbutt, Sir Thomas Clifford, 4 Altman, Lawrence K., 66, 71, 72, 73, 74 Altschul, Annie, 37 Alzheimer, Alois, 213, 216, 221, 227 Arrian, 303 Atkins, John, 104 Bacq, Zenon, 200 Baker, Dorothy, 38 Balfour, William, 155 Banting, Frederick, 282 Beatrice Princess of England, 6 Beatty, Perrin (PM), 91, 97 Bennett, Abram Elting, 11, 12, 13, 16, 17 Bernard, Claude, 10 Bertheim, Alfred, 111 Bethune, Norman, 173 Bichat, 301 Billingham, Rupert, 33 Bisanz, Jeff, 249 Blixen, Baroness Karen, 110 Blum, Phillip, 287 Bohnen, John, 95 Bouchard, Benoit, 92 Boucher, David, 79, 96 Bovet, Daniel, 17 Bradley, W.G., 183, 195 Brent, Leslie Baruch, 32, 33 Brodie, Benjamin, 9 Brown, Roy, 246 Bruce, Sir David, 103, 104, 106

Butler, Josephine, 50 Cannon, Walter Bradford, 153, 159, 168, 170, 176, 177, 178, 179, 180, 181, 190, 203, 204, 205, 206, 207, 208, 209 Castellani, Aldo, 106, 108 Castro, Fidel, 297 Charcot, Jean Martin, 32 Chrétien, Jean (PM), 94 Churchill, Sir Winston, 241, 249 Clement, Tony, 95 Collins, Harry, 124 Collins, James, 284 Conrad, Peter, 116, 120 Cook, Albert, 105 Cook, J.H., 105 Crile, George, 282 Cross, Wallace Warren, 244 da Vinci, Leonardo, 292 Dale, Sir Henry, 10, 202 Dawson, Thomas, 271, 272, 274 de Baillou, Guillaume, 155 De Nardis, Robert, 192 Descartes, Rene, 309 Deter, Auguste, 213 Dove, Robert, 286 Dunant, Sir Henry, 85 Durkheim, Emile, 125 Dutton, J.E., 105 Dymock, Alice, 135, 136 Edeikin, J., 166 Eliot, Charles, 107 En-Lai, Premier Chou, 172 Epp, Jake, 90 Erlich, Paul, 101, 111 Faget, Guy, 133

318 Fletcher, Steven (MP), 98 Foucault, Michel, 135, 254, 301 Franklin, Benjamin, 116 Franks, Wilbur, 282 Freud, Sigmund, 32, 33 Bernays, Martha wife, 32 Furesz, John, 79, 96 Galton, Sir Francis, 240 Genesis book of, 5 Gill, Richard Cochran, 11, 12 Gillies, Sir Harold Delf, 283, 288 Gore, Albert Augustus, 107 Gowers, Sir William, 156 Graham, William A.G., 249 Greene, Graham, 149 Griffith, Harold Randall, 3, 7, 8, 13, 14, 15, 16, 17, 18, 19, 20 Alexander father, 14 Aylen, Linda wife, 15 Grober, Ethan, 95 Gunn, Chit Chan, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 165, 169, 170, 175, 177, 178, 180, 181, 183, 184, 186, 188, 190, 192, 196, 197, 198, 199, 200, 204, 205, 206, 207, 208 Chit Tuan brother, 162 Lay Teik father, 154 Gutstein, Michael, 156 Hanfstaengl, Ernst, 202 Hansen, Gerard Armauer, 129, 131, 132, 136, 137, 138, 144 Harris, Mike, 94

Index of Names Henderson, Donald A., 65, 66, 69, 71, 73, 75 Herz, Marcus, 294 Hincks, Clarence Meredith, 241 Hirschfeld, Gerhard, 29, 30 Hitler, Adolf, 29, 39, 202 Hoadley, George, 242 Hockey, Lisbeth, 37, 39 Holaday, Horace, 12 Homer, 301 Huber, Irmgard, 287 Hume, Edward, 293 Hunt, J.D., 264 Jackson, Charles Thomas, 4, 5 Jackson, Mary Percy, 268 Jenner, Edward, 62, 69, 75 Jervois, Sir William F., 54 Johnson, Enid, 3 Joly, Laudas, 242 Jones, Flora, 48 Jones, Gordon W., 148, 149 Katznelson, Judah Leib Benjamin, 294 Kelm, Mary Ellen, 254 Kerr, William, 48 King, David, 245 King, Harold, 10 Kinsman, Gary, 305 Kissinger, Henry, 172 Kitasato, Shibasaburo, 171 Klein, Alfons, 287 Koch, Robert, 109, 110 Kraepelin, Emil, 221, 227 Krause, Max E., 110 Kratz, Charlotte, 37, 38 Krever, Horace, 93, 97, 313 Lauder, J.D., 257, 261, 263 Lazarus, Saint, 137 Le Vann, Leonard Jan, 246, 247 Leopold Prince of England, 6 Leviticus book of, 130, 139 Lisa, Mona, 292

History of Medicine Days Livingston, Michael, 162 Livingstone, David, 103 Loeffler, Friedrich, 171 Long, Crawford Williamson, 4 Macdonald, Sir John A., 57, 58 MacEachran, John M., 240, 243, 248, 249 Maimonides, Moses, 294 Mallon, Mary Typhoid Mary, 147, 148, 149 Manson, Patrick, 108, 110 Marsden, Kate, 142 Martini, Margaret, 247 McCarthy, Frank Simpson Edward, 107 McClung, Nellie, 241, 273, 274 McIntyre, A.R., 12, 13, 17 McLeod, Enid Johnson, 17 Medawar, Peter, 33 Melzack, Ronald, 170 Merkle, Adolf, 287 Millar, May, 48 Mitchinson, Wendy, 254 Moffat, Edwin, 48 Moll, Albert, 294 Moody, George, 92 Morton, William Thomas Green, 4, 5 Muir, Leilani, 246, 247, 248 Murphy, Emile, 241, 242 Murphy, Emily, 249 Nath, Dr. 280 Nixon, Richard, 69, 158, 172, 293 O'Neill, Robert, 90 Ok, K. Hwi, 191 Ondine, 292 Osler, Sir William, 156, 293 Palmer, Daniel David, 314 Pand-Chi, Li, 172 Patton, David, 304 Pavlov, Ivan P., 179 Pearce, Louise, 111

319

Perrault, Roger, 79, 96 Plato, 243 Prestwich, Patricia, 254 Preuss, Julius, 294 Raleigh, Sir Walter, 8 Ramon, Gaston, 171 Reiter, Hans Conrad, 292 Reston, Scott, 158, 172 Rhyne, Ten, 293 Richardson, Sir Benjamin Ward, 4 Robinson, Victor, 7 Roch, Saint, 137, 296 Rodell, Michael, 79, 96 Rosenbluth, Arturo, 159, 177, 178, 179, 180, 203, 204, 205, 208, 209 Ruoff, Heinrich, 287 Ruth, Babe, 74 Ryerson, George Sterling, 86 Scull, Andrew, 254 Simons, David, 157, 180, 181, 182, 198, 206, 207, 208 Simpson, James Young, 5 Snow, John, 6, 7 Sperber, Karl, 40 Squibb, E.R., 12, 13 Staples, James, 141 Stapleton, Thomas, 165 Stockman, Ralph, 156 Szasz, Thomas, 116 Teresa, Mother, 134 Foucault, Michel, 143 Thucycides, 303 Travell, Janet, 156, 157, 166 Tse-Tung, Mao, 173 Valleix, Francois, 155 Victoria Queen of England, 5, 6 von Behring, Emil, 171 Wahlmann, Adolf, 287 Wahlsten, Douglas, 248 Wall, Patrick, 170 Warsh, Cheryl Krasnick, 254 Waterton, Charles, 9, 10 Wei-Jan, Wu, 172

320 Weindling, Paul, 31 Wells, Horace, 4, 5 Wender, Paul, 120 Wilde, Oscar, 149 Willig, Karl, 287 Wilson, Sir John, 304 Winterbottom, Thomas, 106 Wolferstan, Thomas, 101, 109

Index of Names Wolferth, C.C., 166 Wolkenberg, Frank, 120 Woloschuk, Elaine, 97 Wright, Lewis H., 13, 16 Wynands, J. Early, 8 Yearley, Steven, 122, 124 Zametkin, Alan, 120 Zola, Irving, 116

LIST OF PLACES Africa, 50, 66, 67, 101, 102, 103, 104, 107, 110, 113, 114 Central African Republic, 102 East Africa, 101, 105, 107, 109 Gambia River, 105 North Africa, 104 Sub-Saharan, 102 West Africa, 80, 105 Angola, 102 Arabia, 192 Asia, 67, 241 Australia, 87, 88, 121, 164, 165, 191, 289 Austria, 25, 26, 29, 30, 31, 32, 33, 39, 85 Vienna, 32, 33, 37 Bangladesh, 66, 67, 70, 71 Dacca, 67 Belgium, 102, 110, 111, 123 Brazil, 129, 131, 136, 137 Britain. See England Burma, 39 Canada, 3, 7, 8, 13, 14, 15, 18, 19, 20, 27, 45, 46, 47, 48, 49, 52, 53, 54, 55, 56, 57, 58, 59, 60, 79, 82, 84, 85, 86, 87, 88, 89, 90, 92, 93, 95, 96, 97, 99, 130, 154, 160, 161, 162, 165, 174, 189, 190, 193, 197, 213, 215, 217, 223, 225, 244, 254, 256, 268, 281, 282, 284, 286, 289, 293, 297, 298, 305, 307, 308, 311, 312, 315 Alberta, 90, 189, 190, 213, 214, 217, 218, 219, 220,

221, 222, 224, 230, 232, 233, 235, 239, 240, 241, 243, 247, 248, 249, 251, 253, 256, 258, 259, 261, 264, 267, 268, 272, 273, 275, 276, 277, 281, 300, 307, 308 Athabasca, 268, 269 Athabasca Landing, 268 Calgary, 153, 217, 218, 219, 220, 225, 226, 235, 258, 259, 275, 276 Edmonton, 217, 240, 258, 260, 268, 269 Innisfail, 257, 260, 263, 269 Islay, 224 Lamont, 224 Medicine Hat, 265 Peace River, 268 Ponoka, 222, 225, 230, 235, 240, 258, 260, 262, 267, 269, 270, 271 Red Deer, 222, 230, 246 South Flat Creek, 268 Strathcona, 265 British Columbia, 241, 281, 307 Vancouver, 153, 154, 160, 161, 162, 165, 188, 193, 197, 198 Lower Canada, 47 Manitoba, 95, 220, 258, 310 Brandon, 258 Winnipeg, 310 New Brunswick, 284 Partridge Island, 284

List of Places St. John, 284 Northwest Territories, 214, 217 Nova Scotia, 92, 281 Ontario, 47, 94, 174, 190, 247, 265 Gravenhurst, 174 Hamilton, 45, 47, 48, 52, 54, 55, 58, 59 Niagara Falls, 52, 53, 57 Ottawa, 79, 87, 96, 305 Toronto, 55, 56, 282 Quebec, 47, 53, 54, 79, 86, 92, 95, 99 Chateau Richer, 54 Montreal, 3, 7, 14, 15, 16, 18, 22, 53, 54, 225, 228, 235, 263 Saskatchewan, 214, 220, 225, 233, 258, 259, 298 Regina, 258 Saskatoon, 191 Upper Canada, 47, 53, 54 China, 29, 62, 138, 142, 158, 171, 172, 173, 174, 179, 180, 193, 197, 205, 283, 293, 295 Guangzhou Canton, 173 Shanghai, 39 Tibet, 304 Lhasa, 304 Congo, 102, 108, 131 Belgian Congo, 102, 110, 111 Brazzaville, 111 Cuba, 297 Havana, 297 Czechoslovakia, 29, 33, 40 Ecuador, 11 Egypt, 62 England, 4, 5, 6, 8, 9, 10, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 45, 46, 47, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58,

322 60, 72, 86, 88, 104, 107, 108, 109, 122, 130, 135, 136, 137, 147, 154, 161, 163, 193, 194, 198, 199, 259, 265, 275, 280, 285, 289, 304 Birmingham, 33, 67 Cambridge, 153, 154, 162, 163, 164, 165, 172, 197, 198 East Sussex Eastbourne, 38 Hamshire, 37 London, 27, 33, 37, 38, 39, 51, 154, 165, 293 Maudsley, 37 Manchester, 38 Oxford, 180 Surrey Epsom County, 37 Winchester, 37 Yarmouth, 135 Ethiopia, 67, 70, 139, 141 Europe, 3, 8, 26, 28, 30, 101, 104, 107, 130, 217, 241, 296, 313 France, 10, 31, 85 Paris, 32, 243, 301 Solferino, 85 Vimy Ridge, 15 Germany, 25, 26, 27, 29, 30, 31, 32, 33, 38, 41, 87, 88, 191, 292, 302 Berlin, 132 Dortmund, 38 Köslin, 33 Leipzig, 243 West Germany, 70 Greece, 62, 285 Guinea, 104 Hong Kong, 39 India, 46, 51, 62, 67, 70, 71, 130, 131, 134 Mumbai, 141 Indonesia Sumatra, 140

323

History of Medicine Days

Iraq, 283 Ireland, 14, 47, 53, 56, 284 Israel, 142 Italy, 26, 29, 33, 191 Japan, 40, 131, 153, 154, 163 Hiroshima, 163 Nagasaki, 163 Malaya, 163 Malaysia, 153, 154, 163, 164, 165, 171, 197 Kuala Lumpur, 154, 163, 197 Malta, 46 Mexico, 179, 202, 203 Moravia Freiberg, 32 Nepal, 131 New Zealand, 97, 164 North America, 17, 80, 115, 173, 223, 281, 293, 302, 308 Norway, 29, 130 Peru, 193 Philippines, the, 307 Poland, 29, 31, 33, 41 Auschwitz, 40 Koszalin, 33 Russia, 62, 64, 143, 179, 297 Scandinavia, 31 Scotland, 5, 14, 37, 277 Edinburgh, 37, 38, 39 Seoul, 192 Siberia. See Russia Singapore, 154, 163, 192 South Africa, 39, 103, 105 South America, 3, 8 Amazon, the, 8, 9, 11 South Korea, 192 Soviet Union, the. See Russia Spain, 15, 33 Sri Lanka, 185, 198 Sudan, 102 Switzerland, 86, 191 Geneva, 66 Tanganyika, 38, 112 Tanzania, 103, 131 Thailand, 140, 141

Uganda, 105, 106, 107, 108, 109 Busoga, 105, 107 Kampala, 105 United Kingdom, 25, 27, 28, 33, 35, 38, 41, 67, 88, 311 United States of America, 11, 12, 13, 15, 20, 27, 30, 45, 47, 48, 53, 56, 61, 64, 65, 66, 67, 68, 72, 74, 80, 81, 82, 84, 87, 88, 89, 90, 93, 118, 121, 122, 134, 135, 136, 137, 142, 147, 156, 157, 158, 160, 163, 165, 185, 191, 202, 203, 259, 265, 266, 281, 287, 289, 297, 306, 311, 315 California Berkeley, 232 Colorado, 95 Connecticut Hartford, 4 Florida Everglades, the, 282 Georgia, 4 Louisiana Carville, 133 Massachusetts Boston, 4, 292 Cambridge, 95 Penikese Island, 136 Worcester, 120 Massachussetts Penikese Island, 136 Michigan Ann Arbor, 304 Detroit, 120 Nebraska Omaha, 13 Nebraska, 12 New Jersey, 12, 96 New York, 65, 150, 172, 197, 203 Ithaca, 148

List of Places New York, 13, 61, 63, 64, 66, 69, 71, 73, 74, 75, 167 Staten Island, 291 Pennsylvania, 197 Texas Houston, 89 Utah, 95 Vermont

324 St. Albans, 53 Washington Seattle, 187 USSR. See Russia, See Russia Wales Bathurst, 105 West Indies, 106 Yugoslavia, 70