Kai Sammet
email: sammet@uke.uni-hamburg.de

Keywords: forced feeding, German psychiatry, sitophobia, stomach tube, techniques, 19th century Avoiding violence by technologies? Rectal feeding in German psychiatry, c

During the nineteenth century, the use of the stomach tube became the preferred method to treat the insane refusing to eat. But it was not unusual for this practice to result in violence and serious injuries. Especially around 1860, when the discussion of non-restraint in German psychiatry reached its climax, other methods of dealing with sitophobia became the focus of interest. In particular, two psychiatrists who ran a private asylum in Endenich near Bonn, Franz Richarz and Bernhard Oebeke, recommended rectal feeding as a means of avoiding violence and injury. This paper deals with this method and also outlines the different 'technologies' used to treat 'abstinent' insane patients.

Introduction

Refusal of food or sitophobia 1 is an intriguing issue in the daily practice of medicine. Nowadays it plays an increasingly common role in the field of geriatric nursing (see, for example, [START_REF] Borker | Nahrungsverweigerung in der Pflege: eine deskriptiv-analytische Studie[END_REF]. But refusal of food has been and is a topic particularly related to psychiatry, including, recently, anorexia nervosa and bulimia. Apart from the defining of eating disorders according to the concepts of modern nosology, much has been written on their history. 2 Sitophobia has often been a worrying part of everyday life in asylums. For example, in 1883Friedrich Siemens (1849-1935), head of the asylum Ueckermünde in the Prussian province of Pomerania, stated that:

in every asylum the consultations on the abstinent insane, the reports about food intake, the discussions on further measures and the implementation thereof absorb a great part of the daily routine. They demand a considerable amount of physical and mental effort on the part of the physicians and the attendants. 3 (Siemens, 1883: 568) Throughout the nineteenth century, refusal of food was the subject of lively debates in alienist circles, not least because it was closely linked to issues such as violence, behavioural ethics in asylums and the discourse on 'nonrestraint' in German psychiatry. 4 The discussion of these issues focused on the aetiology, pathogenesis and incidence of sitophobia in different mental disorders and on possible therapies. This paper outlines a special approach to treating sitophobia: 5 rectal feeding which was proposed as a possible substitute for forced feeding with the stomach tube, although the latter was widely recommended as a first choice, but also looked upon as being dangerous. To understand rectal feeding and other approaches to dealing with food refusal (Nahrungsverweigerung), it is necessary to set them against the backdrop of the institutionalization of German asylums in the first third of the nineteenth century. 6 At this period, abstinent patients came to the notice of the developing profession of psychiatry which was closely linked with the development of a specific institutional framework, the asylum. Psychiatrists were responsible for their charges, and the threat of death by starvation was a very disturbing factor.

How did they try to deal with this challenge? In short: by introducing and employing different 'technological methods'. 7 By 'technology/technique' I mean not only the use of instruments, 'machines' and so on (see Kurrer, 1990: 534); 'technique' also means 'plans', 'procedural instructions' and behavioural techniques. So, to treat sitophobia, different techniques or combinations of them were available. First, behavioural instructions: the attendant is given a standard set of rules by which to work, and this implies that he is not free to make use of his spontaneous judgement. These rules can be used as 'tools', as a certain modus operandi in similar situations. Second, 'technique' means skilled behaviour, routine H a n d g r i f f e or sequences of actions, like the 'technique' of piano playing or the 'technique' of introducing a tube into the nose. Third, apparatuses are instruments or means to standardize treatment. And finally, in the case of rectal feeding, we find a technique which can only be understood in the context of the development of chemistry and physiology, as will be shown below. All these 'techniques' were proposed, contested and described in a professional discourse related to the fact that asylums were complex institutions which could only be run with standardization and procedural instructions, and in which newly devised instruments and scientific developments (though in modified form) were utilized.

Forced feeding with the stomach tube: textbooks, 1860-1920

In examining German psychiatric textbooks published in this period, one sees that forced feeding with the stomach tube was prescribed as a standard method. In 1861 Wilhelm Griesinger (1861: 517) noted that forced feeding was recommended 'with considerable unanimity'. Nearly three decades later, Richard von Krafft-Ebing (1888: 307) mentioned that forced feeding with the stomach tube could nowadays be accomplished 'without inconvenience' thanks to tubes 'made of soft vulcanized rubber recently available on the market [START_REF] Westphal | Die Melancholie[END_REF]Alexander Westphal (1863-1941) held that forced feeding was unavoidable in cases of 'obstinate sitophobia' (Westphal, 1915: 113). Finally, shortly after World War I, Wilhelm Weygandt (1870-1939) saw feeding by gastric tube (Schlundsondenernährung) as the only means in cases of 'absolute refusal of food' (Weygandt, 1920: 116, 145). Most other psychiatrists agreed. 8 Specialized monographs and articles also proposed the gastric tube as a first choice. A critical survey by [START_REF] Pfister | Die Abstinenz der Geisteskranken und ihre Behandlung[END_REF] was praised because it recommended the use of the tube as 'self-evident' [START_REF] Anonymous | Rev. Pfister: Die Abstinenz der Geisteskranken und ihre Behandlung, Freiburg, Verlag von Enke[END_REF], and a decade later other authors were also advocating this technique (Krueger, 1912: 339;Mörchen, 1909/10).

But was forced feeding really so self-evident? Was a disquieting problem reduced to a simple technological procedure -if a patient refused to eat, was the stomach tube employed almost automatically? Were possible problems of sitophobia solved on the spot by applying a practice which made a network of actions 'durable' in simplifying it to a single technique? Was sitophobia 'black boxed'? Indeed, in the period around 1910-20, there seemed to be no alternatives to using the tube. In conceiving of the connection between social actions, procedures and apparatuses, Bruno [START_REF] Latour | Technology is society made durable[END_REF] holds that techniques are used to make social actions 'durable'. At the end of a process of attempts and negotiations, a single sequence of actions involving human and non-human elements (e.g., instruments, technical instructions) is 'selected'. One acts in the same way in every new instance of the phenomenon in question. As Nina Degele has put it: 'On the whole, technology invades human collectives, makes actions durable and therefore takes over regulations of social cooperation.' A complex chain of actions, involving different elements is made into an 'actant', a complex network of (human and non-human) actors. Problems seem to be solved, actions are made 'durable', the web of actions -deliberations, attempts, ethical assumptions, instruments and procedural instructions -are 'black boxed'. These elements have become invisible; former alternatives are not seen any more. The 'black box' prevents alternatives, problems and the complexity of the web from being seen. Black boxing is thus the 'process of closure and stabilizing into which those who believe in the soundness of the technique are drawn'; they make use of it, perhaps even propagandize it (Degele, 2002: 129, 130, 132, 134). 9 So treating sitophobia by forced feeding can be seen as an instance of 'durability' and 'black boxing': in textbooks, such as those cited in the previous paragraph, students and practitioners were instructed to make use of the gastric tube as the first choice. However, most of the texts were not so uniform and simple, and therefore the 'black boxing' was incomplete. Problems posed by sitophobia were often too awkward to be treated in a stereotyped manner, so other techniques were also described, but only recommended as a second or third choice or as auxiliary means. This reflected the discussions on refusal of food in mental illness. German psychiatrists in particular were sceptical about the stomach tube.

What should be done with a starving patient?

In 1847 Karl Hergt (1807-89), psychiatrist at the notorious asylum Illenau in the Grand Duchy of Baden, published a paper entitled Beitrag zu den Handgriffen der Fütterung widerstrebender Kranker in which he explained in minute detail how to deal with sitophobia:

The patient is laid down in horizontal position [. . .], pelvis, shoulders, hands and head are to be held by a sufficient number of attendants. The physician standing by the side of the patient presses the lower jaw with the hand which is positioned under it against the upper jaw meanwhile fixing the middle finger of the same hand between the opened lips at the line where both rows of teeth meet. The forefinger of the other hand, crooked like a hook, is introduced into the free corner of the mouth into the outer mouth cavity and with the help of the [. . .] thumb, by pulling [. . .], a pocket is made in which [. . .] liquid is gradually poured. (Hergt, 1847) This long-winded description was welcomed by his superior Carl Friedrich Wilhelm Roller (1802-78), then head of the Illenau. He stressed that this use of the hands (Handgriffe) helped to avoid two risks of the ordinary techniques of treating refusal of food: first, that of breaking the teeth and, second, the dangers of the gastric tube which the French alienist Jules Baillarger (1809-90) had recently described (Rr, 1847).

Hergt was not the only one to give specific instructions about getting food into the mouth. Specially designed spoons and mouth openers were a challenge to technical inventiveness, and German psychiatrists were very keen to find out about the most recent instruments or procedures. For instance, Theodor Schlemm (1846) brought interesting news from Paris: in the well-known journal Allgemeine Zeitschrift für Psychiatrie, he reported on a new gastric tube, invented by Francois Leuret (1797-1851) and made from sheep gut by an intricate process which produced a harmless instrument (Leuret, 1845). Heinrich Laehr (1820-1905) described a mouth opener resembling a face-mask:

It consists of an elliptic piece of wood or a metal plate into which a hole is drilled forming a sort of mouth. [. . .] The oval opening is equipped with a shutter which can be opened from outside to the inside when a spoon is introduced and which is shut immediately to stop the food being ejected. (Laehr, 1850) 10 German commentators looked carefully at reports on the stomach tube and were well informed about problems posed by this technique. Jules Baillarger, a dedicated advocate of the stomach tube (sonde oesophagienne), discussed forced feeding in several articles (e.g., [START_REF] Baillarger | De l'alimentation forcée des aliénés[END_REF][START_REF] Baillarger | De l'alimentation forcée des aliénés[END_REF]. Shortly afterwards sceptical comments were published in Germany. Willers Jessen (1823Jessen ( -1912)), in a critical review of the 1847 paper, stressed the 'disadvantages' of forced feeding (Jessen, 1848: 251) and a few years later Carl Friedrich Flemming (1799[START_REF] Anonymous | Besprechung des gegenwärtigen Standes der non restraint-Frage in Deutschland, Jahresversammlung des Vereins der deutschen Irrenärzte 1879[END_REF] agreed with his Italian colleague Andrea Verga (1811-1895) who was sceptical about forced feeding: 'He is especially wary, and rightly so, about the use' of instruments 'because of the danger of suffocation or serious injury caused by them' (Flemming, 1850: 659). 11 The danger of the introduction of the stomach tube played a crucial role in the reluctance of German psychiatrists to use it, and they were well aware of the possible fatal consequences of the feeding tube. Its introduction often damaged the larynx and pharynx. There was evidence that fatal aspiration pneumonia resulted if the tube was pushed into the trachea instead of the oesophagus -this was not unusual when stiff tubes were used, often equipped with a fish bone as a stylet. 12 Most papers, such as those by Baillarger, discussed limits, conditions and problems of forced feeding in detail. In cases of violent refusal of food intake, only certain manipulations were possible because of the anatomy of the lips, nose, larynx and pharynx and the tissues of the gastrointestinal tract. The intentions of the alienist, the anxiety of the patient, anatomy and technical standards interacted either with each other or against each other. But the dangers of the technique were not the only reason why some German alienists were sceptical about the tube.

Forced feeding was generally regarded as a last resort, and instructions were to avoid violence for as long as possible. Moreover, some alienists disliked using any instruments because this disrupted the relationship between alienist and patient. Heinrich Philipp August Damerow (1798Damerow ( -1866)), doyen of the German alienists in the middle of the century, commented on Hergt's and Roller's approach (Dw, 1847). To Damerow, using the tube was a pure technical procedure and therefore it must be wrong. He thought that treating sitophobia with forced feeding was an easy way out of solving an interpersonal problem. He had tried to use the gastric tube once, but only because he wanted to threaten the patient by demonstrating that he could overcome the patient's resistance if he wanted to.

Damerow's concern was not primarily the use of restraint and violence or possible injuries -he was sceptical about any 'technical procedures'. He proposed the observance of the old Hippocratic triangle: there was no fixed approach the physician should follow; there was the alienist, the illness and a patient. Damerow kept up the dogma of 'individualization', i.e., no instrument, no drug, no 'inanimate' element should be used to influence the patient, and nothing should be a 'go-between' between the patient and the godlike alienist. To 'individualize' in sitophobia meant not to use stereotyped and standardized procedures. In each case the ingenuity and the spirit of the alienist had to find the way to treat the patient. Damerow argued against 'techniques', be it manipulative techniques or instruments. Damerow's ideal was anachronistic at that time, and he himself was not consistent.

Around the middle of the century the asylum was often conceived of as some sort of 'organic machine'. 13 Roller, in his programmatic writing Die Irrenanstalt in allen ihren Beziehungen (1831), constructed the asylum as a complex organism/machine where inanimate and animate elements, bricks, rules and human beings were combined in such a manner as to put into effect the telos of the asylum: healing and curing. One main instrument was the 'house rules' (Hausordnung), which had to be extremely precise. It was more than a metaphor when Roller talked of the 'machine-like operation of the regulations of the house', for these were one of the most fundamental means of healing (Roller, 1831: 6, 7). According to Roller (p. xiii) the asylum should have the 'character of an organic [. . .] totality'. But it was a specially invented 'machine', constructed by man-made intentions. 14 To accomplish its telos, it must be a living organism -a machine in itself is dead and needed animating energy to be kept in action. A living organism had to be imbued with vitality. 'Only spirit can put life into things' (p. 71). The alienist was the absolute ruler, the order of the asylum originated from him, and it was his spirit which always renewed order -and thus his individual intervention was crucial in treating sitophobists.

But obviously relying only on the 'spontaneity' of the head was not practicable in asylums. Technical procedures or even instructions had to be employed, otherwise the running of a complex institution with its specialization of tasks would have been impossible. As mentioned above, with the establishment of asylums in the first third of the nineteenth century, alienists were for the first time confronted with the abstinent insane. Alienists were responsible for their charges and at that time they usually had to care for about 200-300 inmates, so they had to delegate powers and tasks to attendants and officials. To treat each case of sitophobia individually, as Damerow had thought, was a good, but unrealistic, dream which would only have ended in chaos. Standard practices had to be introduced.

Firstly, behavioural techniques had to be employed. The patient refusing food had to be watched carefully. Did he eat secretly in unobserved moments? Sometimes it would suffice for an attendant to go into the patient's room, put food on the table and to go out in silence. Some patients ate if a friendly attendant was close by. In any case, one should find out the patient's favourite dishes. Some psychiatrists thought that only slight pressure was needed. If the patient would sit with others in the dining room, the desire to imitate could make him to give up his unwillingness to eat. The alienists and attendants had to behave in a watchful, skilled and considered way: before forced feeding was carried out, rules and techniques of conduct had to be followed and these had to be learnt and practised. Treatment of sitophobia thus involved more than just the use of instruments. But what happened if behavioural techniques did not succeed?

Taking the middle way: rectal feeding Rectal feeding was discussed even more extensively than feeding with the gastric tube, but around 1860 this method played only a minor role. Heinrich Neumann (1814-84) held that experience had shown that rectal feeding was only a 'poor and insufficient substitute for natural feeding' (Neumann, 1859: 207). One searches in vain for any mention of this method in the first edition of Griesinger's well-known textbook ( 1845), but the second edition (1861) includes notes on rectal feeding. He stated that it could be used only 'in addition', which indicates that he did not take it very seriously (Griesinger, 1861: 517). However, rectal feeding had certainly been used and recommended by others -the application of Clysmata nutrientia or the application of clysters in general was a technique that had been used for centuries. It was utilized either to apply medicaments or, when humoralism was the major theory in medicine, to purify the body (see [START_REF] Zglinicki | Kallipygos und Äskulap. Das Klistier in der Geschichte der Medizin[END_REF]. But by the mid-nineteenth century clysters were mostly regarded as not sufficiently nutritional. Nevertheless almost all authors, at least during the 1860s, discussed rectal injections.

Rectal feeding was often included in a complex web of actions before the last resort of using the stomach tube. The opinions of the following authors are typical. Hergt (1877: 819) -by then an advocate of the gastric tube, and thus showing evidence of the new technology made durable -recommended 'nutritional clysters' as an 'imperfect substitute' only in cases where the stomach tube was a threat to the health of the patient. Similarly Krafft-Ebing (1888: 307) commented that if other means, for example clysters, were not successful in avoiding starvation the stomach tube had to be used. Hermann Krueger (1912: 339) said that 'one had to try to apply nutritional clysters before one used the gastric tube'. And Alexander [START_REF] Westphal | Die Melancholie[END_REF] held that, if persuasion was ineffective and the patient persisted in refusing food, rectal feeding should be used 'in the first place' but, if he still resisted, the gastric tube should be used without hesitation. Dealing with sitophobia involved stages of increasingly serious treatment. Rectal feeding would be a middle stage and could avoid violence altogether, so it is not surprising that it was recommended as a first choice at one point in the history of German psychiatry.

The discussion on non-restraint in Germany had reached its climax in the 1860s, having been rejected by most German alienists before then. First reports had been published in Britain around 1840, and the influential Damerow (1844: xxii-xxiii) described it as a 'hot-house plant', understandable only in the light of the abuses which had taken place in Britain. From 1860 there were some advocates of non-restraint, such as Griesinger andLudwig Meyer (1827-1900), and even those who still condemned non-restraint could not avoid hearing the arguments about it, so the idea became implanted in the minds of German alienists. 15 Forced feeding was becoming controversial because of shocking reports of harrowing scenes, for example, several attendants holding a patient who was shaking his head to prevent the introduction of the cruel tube, and also howling and crying, scratching and biting by the emaciated patient as he/she resisted and became exhausted.

Advocates of rectal feeding: the approaches of Richarz and Oebeke, 1861-85

It is not surprising that some alienists searched for alternatives to forced feeding, and at least two of them -Bernhard Oebeke (1837Oebeke ( -1913) ) and Franz Richarz (1812-87) -applied a method which they publicized enthusiastically. In 1869 Oebeke gave a lecture at a meeting of the Psychiatrische Verein of Rhine Province on the 'Behandlung der Nahrungsverweigerung bei Irren ohne gewaltsame Fütterung'; he noted that forced feeding with a tube was mostly used and approved of, whereas 'in every other respect, rejecting the use of violence and restraint in psychiatry is nowadays the done thing' [START_REF] Oebeke | Zur Behandlung der Nahrungsverweigerung bei Irren ohne gewaltsame Fütterung (Vortrag, 5. Sitzung des psychiatrischen Vereins der Rheinprovinz zu Bonn, 6[END_REF]. He praised a procedure developed by Richarz, saying that rectal feeding of abstinent patients ought to 'make the application of violence redundant'.

But ethical considerations were only one reason why Richarz and Oebeke recommended this method. Moreover, rectal feeding cannot be seen merely in the light of the dispute between restrainers and non-restrainers. Griesinger, for instance, recommended the feeding tube, although he was a 'nonrestrainer', whereas Damerow, never a 'non-restrainer', disliked the tube. So the relations between the ideal of 'non-restraint' and the introduction of a special technology were complex. Some, such as Richarz and Oebeke, advocated rectal feeding because they thought it helped to reduce violence, but others thought that using the tube was not at all violent. 16 Richarz and Oebeke were in a minority in their professional field, but they were neither heretics nor outsiders, and both were well accepted members of the profession. However, they had to act in a specific milieu -and this is a second reason why they were in search of alternatives to forced feeding. Richarz, after working at the Heilanstalt Siegburg in the Prussian province of the Rhineland, founded a private asylum in Endenich near Bonn in 1844 [START_REF] Richarz | Ankündigung[END_REF]. Oebeke, Richarz's nephew, began to work there in 1859 and was head of this asylum from 1872 to 1889 (Pelman, 1914). Richarz's attitude towards non-restraint and forced feeding was not only the result of 'humanitarian' ideals -he had to deal with a special clientele in his asylum for the better-off, with about 40 patients, and he had to earn his living from it. 17 So middle-class attitudes towards restraint and violence had to be taken into consideration. Such people were often the first to ban violence in general and they wanted their relatives to be treated without harshness [START_REF] Kaufmann | Schmerz zur Heilung des Selbst. Heroische Kuren in der Psychiatrie des frühen 19[END_REF], so it is understandable that Richarz searched for a milder treatment. Fortunately, 'biological' observations came to his aid. In 1869 he noticed that patients in public asylums, in contrast to his private patients, were 'more resistant and of a less nervous disposition' and therefore could bear forced feeding better than his patients whose feelings were not only more refined, but who were often fastidious and overprotected (Richarz, 1871: 213). Richarz and Oebeke had good reason to use a milder form of treatment.

Oebeke noted that, to date, 'injections into the rectum' were seen as only a curiosity, but now he had the 'progress of chemistry' on his side. Physiology and the establishment of modern theories of digestion, he believed, made feeding via the rectum a promising procedure. A method for converting albuminates into peptones had been discovered, therefore 'digestion by the stomach was not required for the assimilation of these substances' (Oebeke, 1871: 203, 209). Another argument was also involved: a specific physiological theory concerning the pathogenesis of sitophobia, developed by Richarz. In 1852 he had held that refusal of food was mostly due to the depressing effects of melancholia leading to the depression of the Nervus vagus which in turn resulted not only in a decreased desire for food but also in the inability of the intestines to 'assimilate' food. This explained why some patients fed with the stomach tube nevertheless lost weight and even died of starvation [START_REF] Sammet | Die Diskussion um die Nahrungsverweigerung in der deutschsprachigen Psychiatrie um 1850[END_REF]. Therefore one had to look for other passages; another method was required to bypass the paralysed small intestine so that survival could be ensured while the N. vagus was depressed.

But could peptones actually help to feed patients? Oebeke (1871) only mentioned a short communication by Hermann Eulenberg (1814Eulenberg ( -1902) ) who had reported on their use in feeding weak patients at a general hospital and who had recommended it for the treatment of sitophobia in madness, though without mentioning rectal feeding (Eulenberg, 1861: 4). Oebeke and Richarz, in searching for a suitable composition for the liquid to be injected, c o n f e r r e d with the chemist Hans Heinrich Landolt (1831-1910). He proposed cold Liebig's meat extract which was said to have a 'high nutritional value'. This peptonized substance should be administered alternately pure and mixed with port wine, added 'for vitalization and stimulation' and which could perhaps lead to a 'beneficial change in the activities of the nervous system'. Oebeke (1871: 204) believed his 'meat extract peptone' contained 'all the nutritious constituents' (except fat and fibre) 'of lean meat', including even the mineral nutriment. Therefore this extract seemed to him to be an 'inestimable means' which should be more widely used in psychiatry. Oebeke (1871: 205-9) then described ten cases in which he and Richarz had tried to use this method, from around 1861. 18 He reported convincing results. Death occurred in just one case: a 24-year-old woman died, but only because she had refused to be fed by clysters. For Oebeke, the refusal of rectal injections was the single important restriction of this method.

Oebeke (1871) only provided sparse information on the chemical and physiological fundamentals of rectal feeding, and Eulenberg, his 'warrantor' of the validity of the procedure, had not given any substantiated knowledge of the scientific background. This was not surprising because when Richarz first treated patients with rectal feeding at the beginning of the 1860s the understanding of all phenomena involved was rudimentary. But more information was not required then -the criterion of success was to preserve life. As only one person in ten had died, Oebeke inferred that saving the other patients was due to rectal feeding. For both of them the 'real' chemistry of peptones and the physiological principles of digestion in the rectum were only one element in their approach to dealing with sitophobia. Fifteen years later the 'progress of chemistry and physiology' had changed the picture.

In 1885 the question of the treatment of sitophobia appeared on the agenda of the annual meeting of the Verein deutscher Irrenärzte. The main speaker, Siemens, held that reduced food intake for the mentally ill as well as for the sane did not have 'as dangerous effects as generally' stated, and that 'an even longer period of complete nutritional abstinence can be tolerated within certain limits, usually without lasting effects' (Siemens, 1886: 459). 19 Oebeke (1886), the second speaker on the subject, reacted to Siemens' views, and he also reviewed progress in the understanding of nutrition, hunger and the nutritional value of rectal feeding. To understand his views, it is necessary to describe briefly the findings of research in the physiology of nutrition up to the mid-1880s.

Understanding peptones, digestion and the rectum

There were two closely connected problems in nutritional medicine, especially regarding peptones. 20 First, in order to treat patients unable to eat or drink, scientists tried to understand the digestive capabilities of the colon better. Was it possible to feed patients via the rectum? Was this anatomical structure able to absorb food and could rectal feeding therefore preserve life? Second, these deliberations were linked to the question of the physiological value of peptones -what role did they play in nutrition, if any?

An influential paper published in 1869 by Karl Voit (1831-1908) and Joseph Bauer dealt with the question of whether the 'secretions' of the colon could digest nutriments and, if so, could absorb these modified substances. Firstly, they found that the rectum was unable to absorb pure egg albumin, and it was only possible if common salt was added. Secondly, they saw that so-called 'acidalbuminats', i.e., proteins in acid solution (e.g., Liebig's 'meat infusion' or 'meat juice') were absorbed almost completely in the rectum, as were peptones which were produced from eggs, hydrochloric acid and pepsin. There was thus evidence that albuminous substances really could be used for rectal feeding. However, it seemed obvious that 'it was not possible to keep alive' a living being by means of clysters because, at best, only a quarter of the proteins required to sustain life could actually be substituted via the rectum (Voit and Bauer, 1869: 537, 538, 541, 543, 550, 553). Notwithstanding Voit's and Bauer's researches, it remained somewhat arguable whether the absorption of nutriments in the rectum was successful enough to preserve life. Although Hermann Schreyer (1870) endorsed the opinion held by Voit and Bauer, he nevertheless noted that those who had used rectal feeding held 'quite different views', and 'a definitive judgement' seemed to be impossible. It remained undecided whether nutritional clysters were 'useless' or helped to prolong life (Schreyer, 1870: 16, 21, 25). Twenty years later, Otto Deiters, after doing experiments with two female patients, claimed that his special peptone preparation could substitute sufficient protein (Deiters, 1892: 18, 29).

However, most scientists held the view of Wilhelm Leube (1842[START_REF] Pilcz | Lehrbuch der speziellen Psychiatrie für Studierende und Ärzte[END_REF], one of the best experts at artificial feeding. In summarizing the research up to the turn of the century, he asserted that it was obvious that, considering 'the restriction of intestinal villi on the small intestine, the capability of absorption of the colon is surely lower than that of the small intestine', and therefore it was clear that there were 'natural boundaries to the possibility of producing sufficient nourishment by artificial means' (Leube, 1898: 496-7, 512). 21 But there was another problem to be solved. Already Voit and Bauer had contributed to the closely linked question of the nutritional value of peptones. Today peptones are defined as hydrolytic fission products of proteins containing a mixture of peptides and aminoacids. The fission is effected either by chemical acids, e.g., hydrochloric acid, or by 'digestion' by enzymes such as pepsin (Reallexikon, 1973: P83). Around 1900 the definition read slightly differently: a peptone was a 'product which is formed from the protein of the food in the stomach under the influence of gastric juice and in the intestine under the influence of pancreatic juice' (Munk, 1898: 412). The term itself was defined in 1850 by the chemist Karl Gotthelf Lehmann (1812-63). In 1867Wilhelm Kühne (1837[START_REF] Anonymous | Rev. Pfister: Die Abstinenz der Geisteskranken und ihre Behandlung, Freiburg, Verlag von Enke[END_REF] established the fact that there were not only peptones of the stomach but of the pancreas as well, and he added that stomach peptones were not uniform substances. Kühne found a second fraction of the fission which he called 'albumose' or propeptone. Lehmann had held that proteins had to be 'peptonized' to be subsequently absorbed; they were rebuilt into proteins and then contributed to the rebuilding of biological structures (Munk, 1898: esp. 412-13). A dictionary in 1891 said that all proteins had to be 'peptonized' before they were absorbable (Villaret, 1891: 475), but nevertheless this question was hotly disputed.

In contrast, Ernst Brücke (1819-92) not only saw peptones as useless disintegration products which played no role in nutrition at all (Deiters, 1892: 3-5), but he also challenged the assertion that the 'utilization of albuminats for the organism must be foregone by peptonization' (Eichhorst, 1871: 570). At the end of the century the statement that albuminats had to be peptonized before they could be absorbed was refuted, and most scientists held that some proteins could be absorbed even in the rectum, 22 but the question was not settled fully. Leube in 1898 remained sceptical as to the therapeutic use of unmodified proteins. He asserted that the rectum was indeed able to absorb those substances, but it was 'a forced function', not a natural one of the rectum. But for the organism it was of great 'importance that nutriments introduced into the rectum for nutrition are capable of absorption as quickly as possible' (Leube, 1898: 503). So, around 1900, it was clear that, in principle, peptones were absorbable by the rectum, but it was also evident that they could not provide enough nutrients to preserve life. Moreover, there was another challenge endangering the method of Oebeke and Richarz. They had used clysters containing special ingredients, and to prepare their injections they used a quarter of a pound of beef, cut into little pieces, mixed with distilled water, some drops of hydrochloric acid and a little common salt; later, after a procedure of percolation, soluble pepsin was added, and, after a process of digestion, this solution was used for rectal feeding. 23 But were these clysters really useful? From about 1850 Justus von Liebig (1803-73) publicized meat extracts as food, particularly for the poor. After mass production of Liebig's meat extract started in Uruguay in the 1860s, a discussion began about the nutritional value of this product. 24 Voit and Bauer (1869) held that it had no nutritive value at all; for example, they found only 1.15% of protein in it. Hermann Eichhorst endorsed the findings of Voit and Bauer (1869: 544, 545) and said that he had found 'hardly' any 'traces of proteins' in the meat extract he had examined (Eichhorst, 1871: 655). The controversy continued for some decades, but around 1900 most scientists believed meat extract to have no nutritive value at all, although it should have stimulatory effects on the nervous system. Thus, Georg Klemperer (1865Klemperer ( -1946) ) remarked that its 'excitant effect on the entire nervous system can be guaranteed' which therefore 'contributes considerably to the refreshment and recovery of weakened individuals and subsequently to the achievement of a better alimentation' (Klemperer, 1898: 287).

So obviously 'rectal feeding' in general and Richarz' and Oebeke's peptone method in particular seemed to be a complete failure -at least when compared with their intentions. Trying to feed and keep alive patients in that way was impossible. But Oebeke (1885), having summarized the findings of the physiologists (and in doing so, showing that he was a bit more cautious as to the value of rectal feeding), noted that a human being was no 'arithmetical problem', and it was impossible to calculate exactly 'how long anyone can survive without food and drink in a given case' (Oebeke, 1885: 689). All the proposed normal values were not in accordance with his experience. For example, some asserted that nutritional abstinence could be tolerated for fifty days (if the patient took in water) or fourteen days (without water). It was also claimed that a human being could sustain the loss of 40% of his body weight. To Oebeke all these figures went against the dogma of individualization. The results available at this time were too ambiguous, and many questions were still unsolved. Oebeke was not an obstinate 'practitioner' who withdrew from scientific progress, and his greater caution and restraint about rectal feeding had much to do with the latest physiological findings which challenged the Endenich approach. But his experience and practical knowledge after a long career as an alienist made him sceptical about laboratory results.

In restating Voit's and Bauer's assertion that it was impossible to 'feed a human being adequately over a longer stretch of time', Oebeke (1886: 473-4) said that this was 'difficult to prove'. Laboratory results were not necessarily a yardstick for daily life. He added that other investigators had examined the absorption of other substances in the rectum, e.g. sugar, fat, which could help to maintain nutrition, so the Endenich approach could not be discarded outright, even if scientific findings were considered. Overall, he was very convinced in his judgement:

How long a human being can be kept alive if this procedure is followed exclusively cannot be said up to now, because the great advantage which could be achieved hitherto lies in the fact that the nutrition does not decline so rapidly and intensively and that perhaps the patients begin in the meantime to take food again. (Oebeke, 1886: 471) So the most obvious success of rectal feeding was a 'gain of time'. The advantages of this method had to be seen as a 'longer preservation of life, a prophylactic measure before the voluntary taking of food and the avoidance of any kind of restraint' (Oebeke, 1886: 469-70).

But even if scientific knowledge became accepted, solving the problem of sitophobia required more than implementing an isolated procedure more or less automatically. Alienists had to consider the ethical issues and the theoretical presumptions (such as Richarz' theory of the pathogenesis of sitophobia). Other factors to deal with were the resistance of the patient; the anatomy of the digestive tract; the problem of the stiff and dangerous tubes; and the procedural instructions for the attendants and alienists about stepping up intervention if necessary. All this made up a complex 'actant' or method which then in turn had to be tested in the reality of an asylum.

Conclusion

Rectal feeding was neither a failure nor a success. Many textbooks mentioned it as the middle step in a plan of escalation of treatment. This 'technology' was only an episode in the history of psychiatry, and it was not a common practice in all German asylums, but it should not be seen as having merely marginal importance. However, as more and more unsatisfactory results were obtained, its use decreased. What is more interesting is the fact that the simple action of putting a nutritional clyster into the rectum was part of a complex web of practices, deliberations, different medical theories, ethical considerations and experience; the physiology of nutrition, anatomy and the manufacture of peptones worked with and against socially/technically skilled attendants and alienists, who were instructed in the correct handling of sitophobists. Alienists hoped to avoid violence by employing different 'techniques' -although sometimes these failed. So, even when there was no alternative to the gastric tube, when the treatment of sitophobia was 'black boxed', when it was made 'durable', the complexity of the problem remained: the 'machines' could not work efficiently because of the 'duration' and obstinacy of sitophobia itself.

Notes

1. The term sitophobia originates from the Greek sitos meaning wheat, cereals or bread and, derived from that, food or aliment. So sitophobia means a morbid fear of food. 2. See, for example: [START_REF] Bemporad | Cultural and historical aspects of eating disorders[END_REF][START_REF] Blewett | L.-V. Marcé and the psychopathology of eating disorders[END_REF][START_REF] Brumberg | Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease[END_REF][START_REF] Habermas | Die Anorexia nervosa in der deutschsprachigen medizinischen Literatur des 19[END_REF][START_REF] Habermas | Historical continuities and discontinuities between religious and medical interpretations of extreme fasting: the background to Giovanni Brugnoli's description of two cases of anorexia nervosa in 1875[END_REF][START_REF] Habermas | Zur Geschichte der Magersucht: eine medizinpsychologische Rekonstruktion[END_REF][START_REF] Parry-Jones | Historical terminology of eating disorders[END_REF][START_REF] Parry-Jones | British contributions on the eating disorders: a historical perspective[END_REF]Vandereycken, van Deth and Meerman, 1990. 3. All translations have been made by the author. 4. This article is limited to German psychiatry, but when German authors mention foreign contributions to the field, I will cover them briefly. There were probably different national attitudes to dealing with food refusal by the mentally ill. It appears that in France the use of 'instruments' such as the sonde oesophagienne was quite widely accepted, but that German psychiatrists tended to a more sceptical position around 1850, as discussed below in the text. This question deserves further research which should address various issues: Were there different cultures of asylumdom and, if so, how did these influence the use of violence and specific technologies? Were there different positions on the ideal of 'non restraint'? Wider perspectives should also be considered, for example: did attitudes to day-to-day violence in general differ in France and Germany, and did these views, in turn, have effects on the discourse in psychiatry? 5. This paper focuses on the alienists' discourse on treating refusal of food. It will be outlined in the text below how the integration of rectal feeding in the everyday therapeutic regimen of 'sitophobists' was often a complex challenge. Further research, e.g., using case records from different asylums, is certainly needed to see whether there were differences between theory and practice. 6. On the origin and development of German mental asylums see, e.g. : Blasius, 1980: esp. 20-89;1994: esp. 15-61;Kaufmann, 1995: esp. 131-282. 7. This paper is only a part of a project on the history of sitophobia in German psychiatry during the nineteenth century. It is also a short contribution to the question of technologies in the history of psychiatry. Here I restrict myself essentially to the question of a specific therapy. In order to understand fully what sitophobia meant, further research is needed, e.g., on the discourse about its aetiology and pathogenesis. Why and how forced feeding with the gastric tube established itself as the most important technology also deserves examination. In the present context I can only report that it was widely accepted. Moreover, research on other techniques developed since the 1860s/70s must be done to understand better the role that 'technical solutions' played in psychiatry. In particular, the introduction of drug therapy and the use of syringes (e.g., for subcutaneous feeding) should be examined (on psychopharmacoloy as a 'representative of "technical" strategies of problem-solving', see Weber, 1999, especially 177-8; and on the history of the development of subcutaneous syringes, see [START_REF] Schramm | Zur Geschichte der subkutanen Injektion und Injektabilia in der zweiten Hälfte des 19[END_REF]. 8. A few are mentioned here: Arndt, 1883: 622-3;Gross, 1912: 164;Krafft-Ebing, 1879: 266-7;Leidesdorf, 1865: 171;Neumann, 1859: 207-8;Pilcz, 1904: 14, 39;1909: 16, 40-1;1919: 17, 42;1922: 15, 37-8;[START_REF] Schüle | Handbuch der speciellen Pathologie und Therapie[END_REF] 691-2; 1886: 340. 9. I cannot discuss actor network theory in detail, but see Law and Hassard, 1999. 10. Laehr was reporting on the instrument invented by J. F. B. Charrière (1803-76), who was assigned the task by L.-A.-E. Billod (1818-86), head of the French asylum in Blois. See the description and an illustration in Anonymous, 1850. 11. Verga's article had originally been published in an Italian periodical, but later it was translated into French and edited as part of a discussion in Annales medico-psychologiques. 12. On the complex history of 'gastric tubes' which were used for different purposes, see [START_REF] Korsch | Die Geschichte der Magensonde[END_REF], who reviews the literature particularly up to the first third of the nineteenth century. He makes clear that these apparatuses were often applied in desperate cases of, e . g . , obstructions of the oesophagus or dysphagia, and were then constructed 'spontaneously' without using them as instruments of daily routine. Around 1880 the scene changed. W. Leube, in one of the first monographs on the history of the stomach probe, mentioned that around 'three decades [ago], two main sorts of gastric tubes were established: those made of hard rubber and the English probes'; the former were 'very elastic', the latter were harder, but use of either could result in injuries of the oesophagus or even the stomach (Leube, 1879: 22-3). So, although there had been standardization, the technology of the instruments was not 'stabilized' up to that time. 13. The notions of 'organism' and 'machine' are not always opposed to one another. In fact the notion of 'machine' is more complex. On the history of this concept in philosophy, see Schmidt-Biggemann, 1980. 14. Healing is possible 'only in a new, purpose-built asylum' and only when all requirements are fulfilled; Roller, 1831: ix. 15. Even today, the remark made by Nancy Tomes (1988: 218, n.6) is still true: that '(t)here is surprisingly little written on the non-restraint movement'. This particularly applies to the history of German psychiatry (where there is only one study on the discussion of nonrestraint in German-speaking countries, and that is not really convincing: Geduldig, 1 9 7 5 . For the British case, see, for instance, Scull, 1983/4 (a brilliant study on the founder of nonrestraint), and Suzuki, 1995. Meyer should have been the first to implement non-restraint in a German asylum (in Hamburg): see Meyer, 1863: 575-9; 1897. There is also an instructive discussion of the (probable) fact that non-restraint was actually only implemented 'rhetorically' in Germany [START_REF] Anonymous | Besprechung des gegenwärtigen Standes der non restraint-Frage in Deutschland, Jahresversammlung des Vereins der deutschen Irrenärzte 1879[END_REF]. 16. Interestingly, the introduction of drugs in therapy was accompanied by discussions on its influence on violence or reduction of violence. Again, we find different attitudes to this: whereas some thought drugs should be seen as using a 'chemical straitjacket' and a means of disciplining the insane, others held that medicaments helped to calm violent inmates of asylums and were therefore an essential part of the introduction of 'non-restraint' (see Weber, 1999: 85). 17. At the start of 1865, the asylum had 36 patients living there; at the start of 1873 there were 41 [START_REF] Oebeke | Bericht über die Wirksamkeit der Heil-und Pflegeanstalt für Nervenkranken zu Endenich bei Bonn während des Jahres 1873[END_REF]. 18. Unfortunately patient records of the Endenich asylum could not be found. I am much indebted to Volker Roelcke, Giessen, and Lisa Orth, Bonn, who helped me to contact Wolfgang Schaffer, whose generous help I much appreciate. Dr Schaffer of the Rheinisches Archiv-und Museumsamt, where some primary sources of this asylum are deposited, told me that there are no case records extant. 19. Siemens had already expressed this opinion earlier [START_REF] Siemens | Zur Behandlung der Nahrungsverweigerung bei Irren (Erster Teil)[END_REF]; see also the reviews on his point of view by: Schüle, 1885; [START_REF] Stark | Rev. of Siemens, Ueber die Behandlung der Nahrungsverweigerung bei Irren[END_REF]. Siemens (1884: 416) added a case study about a patient affected by paranoia to emphasize his approach; although this patient was finally fed by the probe, Siemens used the case to illustrate that alimentary abstinence could be tolerated longer than previously thought. 20. My outline of the discussion about digestion and nutrition in nineteenth-century physiology is very simplified, and my account of the history of peptones is schematic; for the history of the physiology of nutrition and proteins in general, see [START_REF] Carpenter | Protein and Energy: A Study of Changing Ideas in Nutrition[END_REF]Mani, 1976. 21. Leube was one of the first to use so-called 'meat pancreas clysters' around 1870 -a method which was adopted by some alienists; see, for instance, the restrained optimism in the note of Arthur von Gellhorn, 1874: 341. 22. The detailed studies by Eichhorst (1871: 618, 646, 652) showed -as already stated by

Voit and Bauer -that egg albumin was absorbed only when common salt was added, and that undissolved fibrin of the blood as well as proteins of the blood serum could not be absorbed, whereas myosin and some sorts of alkali albuminats were reabsorbed. 23. The composition was never modified from that used early on; Oebeke, 1871: 205;1885: 695;1886: 470. 24. For a detailed account of this discussion about meat extract and meat broth, see Teuteberg, 1990: 9-37.


à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Introduction to Special Issue: Mind and body in the history of psychiatry

Sander L. Gilman

To cite this version:

Sander L. Gilman. Introduction to Special Issue: Mind and body in the history of psychiatry. History of Psychiatry, 2006, 17 (1), pp.5-7. 10.1177/0957154X06063065. hal-00570857

The contemporary assumption about the dissolution of the mind/body dichotomy has very specific roots in the debates about the normal and the pathological within psychiatry. The debates shape and are shaped by the assumptions about the pathological that underpin the professional fields of neurology and psychiatry. Today, as these fields seem again to be merging, many of the basic issues are again open for debate.

Keywords: body; education; Freud; mind; psychiatry

One of the odd legacies of Pauline Christianity and its attitude toward the body is dualism: the assumption that mind and body were in no way (or minimally) linked. The answer to this tenuous view -that the mind/soul sat in the body directing it like the driver of a coach or being carried by it as in a sedan chair -came with a vengeance in the nineteenth century with a wide range of views that assumed the primacy of mind over body or of body over mind, but in a manner that inexorably linked the two. It should be of little surprise that this re-establishment of the corporality of the mind and the psychological significance of the body took place within evolving nineteenthcentury medical specialties, especially those of neurology and psychiatry. The importance of a neurologist, Sigmund Freud, in linking mind and body (but making the body subservient to the mind) for our modern understanding of the nature of human experience is unquestioned. Yet his importance points to the centrality of the pathological in establishing this link as a commonplace. It was in those cases seen as deviant from some norm that the evident link between mind and body seemed to be seen. Freud was in no way unique; he was a product of the educational reforms of the nineteenth century, which made it possible to see science as the location for evidence in rethinking the relationship between the mind and the body. The reform of the Viennese Medical School had been accomplished by the time Sigmund Freud entered as a student in the 1870s. Wilhelm von Humboldt, academician and statesman, had created the model of the modern research institution in Berlin in 1810. He envisaged a 'universitas litterarum', uniting teaching and research under the same roof. This concept of a university devoted to creating and transmitting knowledge (Bildung) spread throughout the German-speaking world during the nineteenth century and served in the reform of many universities of the same type over the next century and a half. Wilhelm von Humboldt was influenced by the reform ideas of the philosopher Johann Gottlieb Fichte, the first vicechancellor of the university, and by the theologian and philosopher Friedrich Schleiermacher. Both wished to break with the institutions of the past that perpetuated older views rather than questioning them. From the outset, the university in Berlin had the traditional four classical faculties of Law, Medicine, Philosophy and Theology. But what went on in the faculties was very different from the traditional (originally medieval) universities where only teaching of received knowledge occurred.

Research was undertaken -if at all -in the academies. This was especially true in the new 'natural' sciences such as biology. When Johannes Müller came to the new university in Berlin in 1833 as full Professor for Anatomy, Physiology and Pathology, he created the idea of the modern laboratory. He created a research group, apportioned aspects of each of his projects, and encouraged his own students to undertake research. Müller strongly encouraged his students to branch off and do their own further work in collaboration with other, younger scientists. Müller's materialism meant that there was an underlying assumption that the experiences of consciousness (and later of the unconscious) were assumed to be linked to the material body. Somatic medicine became the place for the investigation of the mind. These students number among them the founders of modern neurology: Robert Remak (Remak's fibres) and Friedrich Henle (Henle's sheath). Another of Müller's students was Hermann von Helmholtz, well regarded as a physicist, physiologist, physician, biologist, mathematician, philosopher, engineer and inventor, who made important discoveries in physiology, optics, electrodynamics, mathematics and meteorology. He was also the scientist who linked qualities of perception, such as acoustics, to physical laws. These students and others, such as the father of modern cellular pathology Rudolf Virchow, were the cream of nineteenth-century science, and their students included scientists and physicians such as Sigmund Freud, a student of Ernst Brücke, who was a student of Müller, who moved the paradigm from mind being a reflex of the nerves to the mind creating somatic symptoms. The reform of the Viennese university and the creation of the so-called 'Second Viennese School', with its emphasis on laboratory research and its application to human medicine, took place in the latter half of the nineteenth century in the shadow of Humboldt's reforms.

These reforms meant that the new mind-body synthesis dominated all the medical science of the time. Yet it is clear that this view was not without its precursors. Our present volume spans the world before the nineteenth century and well after it. Dolly MacKinnon's discussion of the relationship between music, madness and the body is an indicator that a parallel tradition linking mind and body existed within the Western tradition. The British 'mad doctors' who dominated English medicine in the eighteenth century and who treated George III, as Dana Rovang shows, played with notions of the relationship between physical symptoms and the state of madness. Nineteenth-century thinkers such as Joseph Häussler (as discussed in the paper by Philipp Gutmann) and Hermann Joseph Löwenstein (see Classic Text No. 65) used sexual 'deviancy' to show the inherent relationship between the ill mind and the body in ways that set the stage for Richard von Krafft-Ebing and Freud's focus on the sexual. The legacy of psychoanalysis in the diagnosis and treatment of obesity by Hilde Bruch, as Sander Gilman shows, echoes Freud's views in very much his own cultural context. Psychotropic drugs such as Cardiazol treatment in British mental hospitals, as Niall McCrae illustrates, and psychosurgery, as Rakefet Zalashik and Nadav Davidovitch show, continued the assumptions about the close relation-ship between the treatment of mental illness and somatic interventions. Both illustrate what Dana Rovang claimed for England: that it is the cultural context which gives nuanced meanings to both the somatic and the psychological, to their perceived or real link and to the role that madness plays in the very definition of their relationship. Given that this set of assumptions also underlies contemporary models of treatment, it is clear that the debates about such somatic interventions and their implications for the very definition of the mind and the body are still very contested. Have we reached a point in the twenty-first century where there is no longer a line between mind and body, no demarcation, so that we think of the human being as simultaneously mind and body? But then we still turn to the 'pathological' experience of this mind-body to explore the impossibility of distinguishing the boundaries between them.

  , 17(1): 005-007 Copyright © 2006 SAGE Publications (London, Thousand Oaks, CA and New Delhi) www.sagepublications.com [200603] DOI: 10.1177/0957154X06063065


Eric J Engstrom
email: eric.engstrom@charite.de

Essay Review

Laurence A. Rickels. Nazi Psychoanalysis. 3 vols, with a foreword by Benjamin Bennett. Minneapolis: University of Minnesota Press, 2002. Pp. xx + 346, xxii + 332, xxiii + 346. ISBN 0-8166-3697-4, 0-8166-3699-0, 0-8166-3701-6.

Nazi Psychoanalysis poses a challenge to any book reviewer writing in an academic journal devoted to history. This is because book reviews have generally been understood to be critical tools that help us, if not 'discover' historical truths, then at least discern more plausible explanations or evoke greater understanding of historical phenomenon. Yet reviewers of Rickels' three-volume opus risk seeing their efforts fail to contribute much in the way of enhanced plausibility or expanded understandings, because Rickels' work subverts the very aims that book reviews are designed to achieve. One can perhaps turn the canons of literary criticism on his work with some effect, but to critique that work as history borders on the banal, because it assumes Rickels is something that he is not: an historian of psychoanalysis. Rickels presents the fruits of his literary labours in a trilogy, each volume being patched together around a general theme. Volume I is entitled 'Only Psychoanalysis Won the War' and returns to World War I theories of shellshock and war-neurosis in order to delve into concepts of psychological warfare. The second volume has the title 'Crypto-Fetishism' and explores the degree to which the 'Nazi moral system' parallels that of psychoanalysis, particularly in their common projection and protection of homosexuality. The final volume ('Psy Fi') explores ways in which Nazi Germany imagined and expressed itself through technology and science fiction or fantasy.

However, to summarize Rickels' work in this way is misleading, because it suggests thematic focus and narrative coherence. It would be more accurate to say that each volume is a collection of eclectic readings, subjective interpretations and performative takes on various psychoanalytic topics. Rickels' writing involves deploying a wealth of psychoanalytic themes and then -with the help of his considerable powers of language and imagination -associating, interweaving and juxtaposing them with twentieth-century Nazi and wartime culture. He roams widely and (care)freely, from shell-shock, propaganda, data encryption and the psy-op activities of military intelligence to homosexuality, the trauma of aerial bombardment, and the new psycho-cyborgian technologies that envelop plane pilots. No sooner has Rickels picked up one topic, than he abandons it again for another. In his 'excavation project' (I: 39), most chapters are only a few paragraphs long -just long enough to sustain his literary imagination, before he departs the scene for the next ad-libbed performance.

By the author's own account, Nazi Psychoanalysis is a:

long haul through tracts on war neurosis, military adjustment, and psychological warfare, all of which had been abandoned, now in the ditches of one world war, now inside the air-raid shelters of the other one, [that] leads to a reconstruction of what can be called to this day 'greater psychoanalysis'. By World War II, between the air-raid sheltering of the populace in a group-therapeutic mode and the intrapsychic wiring of the pilot to his machine, an axis of technologization was being followed, up through cybernetics (both in Gregory Bateson's sense of feedback and in Jacques Lacan's staging of the rearview mirror) all the way out to the fantasy horizon of science fiction, which is where this book begins again.

(I: xviii)

For anyone who has not already put the book down in frustration, the most succinct description of what interests Rickels comes later, after 60 pages of self-confessed false starts:

There are continuities and contexts missing from any history of modernism that subsumes, under the category of discontinuity, all tension between its most protected or progressive sources and the aberrations on a mass scale that, via symptomatic or dialectic connection, still belong to modernism, but modernism beside itself. But there are direct hits of continuity, too. What's missing or not seen is always the side-effect of what psychoanalysis calls identification, which originates in trauma. Not to see or to 'Nazi' is what fills in the missing-continuitiesand-contexts report. The histories of these missing entries, which are ultimately always into war, never really leave the corridor wars between different departments of psychological interventionism. (I: 61)

In other words, Rickels is interested in linking the history of psychoanalysis to Nazi Germany and in bridging the 1933/45 divide that, until recently, long dominated the historiographic literature. Rickels strives to associate and concatenate almost anything that has a psychoanalytic dimension to it with Nazi and German culture. He envisions his work as reconnecting 'all the outposts of frontline intrapsychic theorization and treatment inside the orbit of the central psychotherapy institute in Berlin' (I: xvii). To his mind, mass culture in Nazi Germany was saturated with psychoanalytic ideas and interconnections. In other words, he strives to demonstrate that Germany was no exception when it comes to the broad expansion of psychoanalytic understanding that characterized developments in other twentieth-century cultures.

Rickels delights in wordplay. His performance is an aesthetics of the word. He revels in expounding on his materials, mixing his metaphors and drawing liberally on the vernacular of late twentieth-century California, where he teaches German and comparative literature. His chapters consistently carry such evocative titles as 'Gotta read Goette', 'Hi Ya Heidegger' and 'Suckarama'. One chapter is called 'DSM3rd Reich', although neither DSM nor the Third Reich figure in the chapter. He is completely enamoured with his association of 'Nazi' with 'Not see'. A few -but only a few -of these literary gymnastics have a serious side to them. The affiliation of not-seeing with Nazis refers to the blindness within the historiography of psychoanalysis to any association with Nazism and the implicit suggestion that this blindness is somehow indicative of Fascist inclinations.

On occasion, Rickels strays from his own literary principles and actually tries to (ab-)use language as a medium to communicate some information. Such is the case in the chapter 'Simulations', where he sketches the ideas of Binswanger, Gaupp, Nonne and others on war neurosis. Although at times the text is literally nothing more than a string of quotations, this and a few other chapters provide -horribile dictu -a summary of historical attitudes.

Rickels takes no prisoners when it comes to scholarly conventions. His performance makes no discernible distinction between method, narrative and subject matter. Given his associative, even flippant, narrative technique, why he even bothers occasionally to provide references to secondary literature is anyone's guess. The relationship between text and image in the book is tenuous at best. Although he has nothing to say about gas masks, the first volume is peppered with pictures of gas masks. For the most part, Rickels appropriates his protagonists and does as he pleases with them. In his deliberations on Rado -and others for that matter -there is far more Rickels than Rado. Indeed, this is not a book in which readers will learn much about the historical figures that one could expect to be included in a study of Nazi psychoanalysis. It is worth noting, for example, that key members of the psychoanalytic community in Nazi Germany are barely mentioned at all. According to the index, in the 1000 pages of Rickels' trilogy, Felix Boehm is mentioned on only 7 pages, Werner Kemper on 4 pages and Karl Müller-Braunschweig on 5 pages. That is about the same amount of attention that Rickels devotes to Walt Disney, Bram Stoker, Beate Uhse and H. G. Wells. Not surprisingly, therefore, an enormous gap opens up between these volumes and the expectations that many readers will bring to them. If readers are to take anything historically meaningful away from Rickels, they will have to come to him either saturated with knowledge about twentieth-century psychoanalysis (and contemporary debates in literary criticism) or equipped with an especially ebullient imagination.

Rickels has no truck with other scholars in the field. In the introduction, he attacks Geoffrey Cocks and the second edition of his book on psychoanalysis in Nazi Germany (1997) for taking 'another look at the materials by the stolen fire of my work (admittedly reduced to a night-light by the shame of it)' and chastises academic historians and the 'small-change' (I: xix-xx) of their careerism. He shows essentially no interest in the work of Alexander and Margaret Mitscherlich, Regine Lockot or Peter Riedesser and Axel Verderber, preferring instead simply to 'zap the historians of the Nazi era of German psychotherapy out of the running commentary' (I: 37). If Rickels cannot be bothered to engage the work of these and other authors, he will hardly be in a position to object if others either take issue with the selfindulgence that pervades his writings or simply ignore them altogether. For readers who may be interested in Rickels' idea of 'greater psychoanalysis', but who cannot stomach the twists and turns of his postmodern roller coaster, Eli Zaretsky's recent study Secrets of the Soul (2004) will prove far more rewarding.

All of this is not to say that Rickels will leave readers wholly devoid of insight. He won't. But the problem for historians is that many of his insights might just as easily have been drawn from an imaginative reading of, say, Erwin Jaensch or Willy Hellpach (whom Rickels appears never to have heard of) -or, for that matter, the writings of any number of other twentiethcentury German psychologists and psychotherapists. For much of what he describes as being part of 'greater psychoanalysis' in Nazi Germany might just as plausibly be subsumed under the rubric of 'greater psychology' or 'greater psychotherapy'. But, of course, this fails to bother Rickels much, because such historical contexts just do not show up on the horizon of his postmodern perch. Indeed, history matters little to him and he admits as much: he sees himself 'preparing neither a legal brief nor a history', but instead speaking before a 'court of mourning' (I: 99), whatever that might be. Whether he is speaking to a court that is mourning the losses attributable to Nazism or to psychoanalysis is not evident.

Nazi Psychoanalysis comes with high praise from two icons of postmodernism. On the cover blurb, Judith Butler describes it as 'marvelously witty, ironic, erudite, and original'. Fredric R. Jameson believes that Rickels has 'unearthed a mass of fascinating information' and that the book will 'constitute a provocative contribution to both psychoanalysis and to studies of Nazi Germany'. And Sander Gilman recommends the book as 'idiosyncratic and illuminating'. The book is certainly idiosyncratic. Whether it is illuminating is altogether another matter. Rickels will perhaps be illuminating to those who have chiefly an aesthetic appreciation of language. Or to readers for whom psychoanalysis is the alpha and omega of their lives. And perhaps Rickels is illuminating in the sense that -to borrow some psychiatric jargona 'Wortsalat' is illuminating, i.e., in the sense that it teases with and provokes 'modern' or rational sensibilities. In any case, if illumination comes at all, it will come only to readers who have no pretensions to 'understand' what Rickels writes. Those in search of a coherent argument will be shunned by him at every turn. Perhaps, like a work of art, his book can be experienced, but it cannot be 'understood' in any conventional sense. Rickels' volumes can be counted among those pervasive but invisible aesthetic shockwaves given off by the implosion of that aging red-giant-of-a-star called psychoanalysis. They may disturb the space and time through which they pass, but they will no longer illuminate very much.


Keywords: Cole, Culpeper, erotomania, female sexuality, history, hysteria, nymphomania, Rivière, satyriasis, womb, 17th century

The word 'nymphomania', the concept of 'madness from the womb' and the belief in the existence of a behaviour consisting in an abnormally high female sexual drive converged during the second half of the seventeenth century to give rise to a new clinical category which, with minor changes, has survived until the present (e.g.,.

This Classic Text, an excerpt from the work of Lazare Rivière, provides a glimpse into the process whereby medical categories are constructed. According to Rivière (and many others) 'madness from the womb' was a disease which resulted from overheating and putrefaction of accumulated seed (female sperm) in the womb. Like all medical constructs, 'madness from the womb' (and soon nymphomania) included a symptomatology, natural history, aetiology, prognosis and cure. It is also clear that it was rehash of the earlier moral notion of 'satyriasis' (a male category applied to women) and the expression of seventeenth-century changing male attitudes towards, and fears of, female sexuality.

Introduction

The Classic Text that follows -'Madness from the womb' 1 -illustrates an early stage in the construction of 'nymphomania'. 2 Still present in the 'International Classification of Diseases' (I C D -1 0; WHO, 1992), 3 n y m p h omania shows a symptom-profile similar to the current notion of 'sexual addiction' [START_REF] Goodman | Sexual Addiction[END_REF] Sometime during the second half of the seventeenth century, 'madness from the womb' started to be called 'nymphomania'. The new name reflected a change of view from the old claim that it was exclusively 'caused' by overheating of the seed in the womb to the view that pathological changes in other parts of the female anatomy (like the labia minora or nymphae) were also implicated. This broadening of the concept led to the reclassification of nymphomania as a form of 'erotomania' [START_REF] Berrios | Erotomania: a conceptual history[END_REF].

The author

Classic Text No. 66 is an excerpt from the English translation of the 1653 edition of Praxis medica, a book by Lazari Riverii, Lazarus Riverius or Lazare Rivière. 5 Rivière (1589-1655) was born in Montpellier where he also trained as a physician. Having failed his medical examination in 1610, he managed to graduate only after Easter 1611. This inauspicious start seems to have stimulated Rivière into working harder, and in 1622 he succeeded Laurent Coudin as a Professor of Medicine at Montpellier. At the time of his death, Rivière was described as being 'Counsellor and Physician to the Present King of France' (the young Louis XIV).

Considered by Jean Astruc 6 as more clever than scholarly ('Habile plutòt que réellement savant'), Rivière was viewed by many, and particularly by the members of the Paris Medical School, as a medical popularizer or worse. For example, Guy Patin 7 (1846) regularly referred to him as a 'charlatan'. This notwithstanding, Rivière is credited with having introduced chemistry in the medical syllabus at Montpellier [START_REF] Chéreau | Rivière, Lazare[END_REF] and with having tried to reconcile the ideas of Galen and Paracelsus.

The translators of Praxis medica (as The Practice of Physick) were Nicholas Culpeper, 8 Abdiah Cole and William Rowland. In his introduction to the text, Peter Cole 9 (the publisher) intimated that a fourth translator had asked to remain anonymous. Cole also explained that the book was for the use of people without Latin or recourse to physicians. In addition to Rivière, Culpeper translated Platter, Sennert and others, and it is often not clear whether similarities in clinical description and treatment shown by the English renditions of these various books reflect, in fact, Culpeper's 10 own ideas.

In 17 sections, the book covers most known diseases and their treatments. The translation carries as an appendix a medical dictionary 'explaining hard words used'. Section 15 is on the 'Diseases of Women' and includes 24 chapters, of which the Classic Text is Chapter 5. Chapter 6 deals, in turn, with 'Of the Mother-Fits, or Womb Sickness' (also called 'hysteria'). It is of some interest that these two chapters, although dealing with what (anachronistically) would be called 'psychiatric disorders', are included by Rivière in the gynaecological section of his book rather than in the section of 'Diseases of the Head' together with phrenitis, melancholia and mania.

The text

Written in the same format as the rest of chapters, 'Madness from the Womb' comprises an introduction and then subsections on causes, signs, p r o g n o s i s and cures. When dealing with the latter, the author occasionally refers to treatments included in the chapters on madness as also being of use for the problem in hand. Rivière does not cite any other works except one by William Harvey. 11 Since the eighteenth century, it has been suggested that Rivière actually copied from Sennert's work 12 [START_REF] Bayle | In Daniel Leclerc's biographie medicale[END_REF][START_REF] Dezeimeris | Rivière, Lazare[END_REF]. A comparison of Chapter 5 with the corresponding text by [START_REF] Sennert | Practical Physick; The Fourth Book in Three Parts[END_REF] indeed shows some similarities. For example, both writers believed that the 'disease' (Sennert calls it 'frenzie of the womb') resulted from accumulation, heat and putrefaction of the seed in the womb, and that it affected virgins and widows. They believed that the condition could only be treated during its early stages. Sennert differentiates it from 'salacity', where there is 'delirium' (i.e., signs of infection, confusion and fever), and from 'the melancholy of virgins and widows'. Both authors recommend similar treatments: emulsions, electuaries and baths based on the same herbs and substances.

But Sennert was not the only one writing along those lines. For example, Platter (1664) also included a chapter (XVIII) 'Of lust and lechery' which he defined as an 'immoderate inclination to venery . . . this is sometimes in males and females but different, in that men are sooner hot; women are long cooling . . . ' (p. 172). The cause of immoderate lust were plenty of seed and heat. He also recommended electuaries and purges.

It is of some interest that a number of books on diseases of women published during the first half of the seventeenth century do not actually include a condition of increased desire for venery. For example, in his G u n a i k e i o n T o m Haywood (1624) dedicated a chapter to 'De Laenis, or of Bawdes' but does not conceptualize bawd behaviour as a disease: 'From the honour of women I now come to the disgrace and shame of their sex, in which I will strive to be as brief as I know the very name to be to all chaste minds odious. Sotades Marionites C i n e d u s, that is, one abused against nature or addicted to preposterous venerie . . .' (p. 343). In fact, most of the historical personages commented upon by Haywood are men, 13 with only a few women being mentioned towards the end of the chapter.

The same is the case with The Sicke Woman's Private Looking Glass where, in 15 chapters, Sadler (1636) describes a variety of gynaecological disorders to 'enable women to inform the physician about the cause of their grief'. Chapter 6, on the 'Suffocation of the mother', is a standard account of Hippocratic and Galenic views on hysteria and includes no mention of an inordinate interest in venery.

In his interesting Diseases of the Soule, Adams (1616) discusses increased desire for venery but as a medical problem for men. In the chapter entitled 'Inflammation of the reines, or lustfulness', Adams states:

The signs are many. There is a beating paine about the first joint of the back, a little above the bastard ribs, and with others, which modesty bids cover with the clock of silence. The lustful man is a monster . . . he affect Popery for nothing else, but the patronage of fornication, and frankness of indulgence . . . (p. 45).

The construct

By the second half of the seventeenth century, 'madness from the womb' was renamed nymphomania (e.g., [START_REF] Lochner | [END_REF]. Indeed, the term had already appeared in Blancard (1684: 208): 'nymphomania, the same as furor uterinus'. The French Encyclopédie dutifully defined the term (Diderot and D'Alembert, 1753-1765):

FUREUR UTERINE, nymphomania, furor uterinus; c'est une maladie qui est une espece [sic] de délire attribué par cette dénomination aux seules personnes du sexe, qu'un appétit vénérien démesuré porte violemment à se satisfaire, à chercher sans pudeur les moyens de parvenir à ce but; à tenir les propos les plus obscènes, à faire les choses les plus indécentes pour exciter les hommes qui les approchent à éteindre l'ardeur dont elles sont dévorées . . . References to nymphomania are abundant throughout the eighteenth century, and the great nosologists of this period included it in their classifications. For example, Boissier de Sauvages (1771: 691) provides a detailed account of nymphomania: 'violent desire shown by certain women for the pleasures of love-making'. Boissier offers a four-fold classification: salacitas (Sennert) which starts in adolescence and affects virgins; furiosa, an advanced form of the condition which leads to madness and dementia; ardor uteri, which results from pathology of the womb, leading the sufferer to desire coitus in spite of the pain that it may cause her; and pruritus uteri, when it is a vulvar itch which starts the condition. Boissier agreed with Sennert (and others) that the latter may not, in fact, be a genuine form of nymphomania.

A book by M. D. T. Bienville 14 entitled Nymphomanie also appeared in 1771, published in Amsterdam and later in Paris [START_REF] Bienville | La Nymphomanie ou Traité de la fureur utérine[END_REF]. It is often quoted by historians as the starting point in the process of construction of nymphomania. In its six chapters this short work covers well-known ground: female anatomy, definition of nymphomania, aetiology, symptoms and levels of severity, diagnosis and prognosis and treatment. The author includes at the end of his book an interesting chapter on the role of the imagination in the production of nymphomania. Given the organic and moralistic approach taken by earlier writers, Bienville's effort to understand the condition in psychological terms was original and useful.

After listing about 20 different names for the 'disease', Louyer-Villermay (1819) refers to two important dissertations published between 1650 and 1700 in which the term 'nymphomania' appears in their title. 15 Refusing to pass moral judgement, Louyer-Villermay agreed with Rivière that nymphom a n i a was a veritable 'mental disorder' and suggested that it went through three stages. In the third stage the patient becomes violent, attacks men and even dogs in her search for sexual satisfaction, and prognosis is sombre. Believing that nymphomania had existed since antiquity, Louyer-Villermay wondered why the great classical authors had not mentioned it (except Soranus). 16 Nothing new was said about nymphomania during the rest of the nineteenth century. Views continued oscillating between it resulting from a local pathology of the uterus or of the brain. Although all authors seemed to suggest that it was very frequent, they borrowed cases from each other with worrying regularity [START_REF] Ball | La Folie érotique[END_REF][START_REF] Bouchereau | Nymphomania[END_REF][START_REF] Moreau | Les aberrations du sens génésique[END_REF]. [START_REF] Riverius | The Practice of Physick[END_REF]; see also Note 5. 2. The literature on the history of nymphomania is extensive, e.g., Groneman, 2000. 3. It corresponds to category F52.7: 'Excessive sexual drive: Both men and women may occasionally complain of excessive drive as a problem in its own right, usually during late teenage or early adulthood (includes: nymphomania and satyriasis)'. 4. The following are commonly listed as defining criteria:

Notes 1. Chapter 5 in
'1) Frequently engaging in more sex and with more partners than intended; 2) Being preoccupied with or persistently craving sex; wanting to cut down and unsuccessfully attempting to limit sexual activity; 3) Thinking of sex to the detriment of other activities or continually engaging in excessive sexual practices despite a desire to stop; 4) Spending considerable time in activities related to sex, such as cruising for partners or spending hours online visiting pornographic Web sites; 5) Neglecting obligations such as work, school or family in pursuit of sex; 6) Continually engaging in the sexual behaviour despite negative consequences, such as broken relationships or potential health risks; 7) Escalating scope or frequency of sexual activity to achieve the desired effect, such as more frequent visits to prostitutes or more sex partners; and 8) Feeling irritable when unable to engage in the desired behaviour.' 5. The first Latin edition of this book was published in Paris in 1640 [START_REF] Riverii | [END_REF]. 6. Montpellier trained, Jean Astruc (1684Astruc ( -1766) ) was the first provincial physician to be incorporated without taking a series of examinations into the 'Noble Medical School of Paris' [START_REF] Chéreau | Astruc (Jean)[END_REF]. He wrote widely on matters medical, surgical, historical, psychol o g i c a l and gynaecological. His book on the diseases of women was translated into English (Astruc, 1740/1743). 7. Guy Patin (1601Patin ( -1672)), a famous physician, historian and essayist, and for a time Dean of the Paris School of Medicine. Conservative in medical theory and in politics, he opposed Harvey's ideas on the circulation of the blood and also [START_REF] Renaudot | Les Consultations charitables pour les malades[END_REF] efforts to develop health services for the poor (Chéreau, 1885;[START_REF] Jestaz | Édition critique de lettres de Guy Patin (Bibl. nat. de France, Baluze 148)[END_REF]Reveille-Parise, 1846).

8. Nicholas Culpeper (1616Culpeper ( -1654)), English botanist, astrologer, apothecary and medical translator. Destined for the church, he attended Cambridge University for a time but left without graduating after his girlfriend was killed by lightning. In 1643, fighting on the side of Parliament, he received a serious chest wound. An antinomian, a republican and a severe critic of the monopoly on health exercised by the Royal College of Physicians, he translated their Pharmacopoeia into the vernacular, adding to it new definitions, remedies and methods of making medicines. He formed a useful partnership with Peter Cole [START_REF] Furdell | Oxford Dictionary of National Biography[END_REF], who continued publishing works by Culpeper after his premature death aged 38 [START_REF] Curry | Oxford Dictionary of National Biography[END_REF]. 9. A well-known London printer and bookseller, Peter Cole (?-1665) was often in trouble with the governments of the day for his outspoken views and publications. In addition to the many medical works he did with Culpeper, he also printed theological and political tracts [START_REF] Furdell | Oxford Dictionary of National Biography[END_REF]). 10. For example, in Directory for Midwives, a posthumous publication attributed to [START_REF] Culpeper | Culpeper's Directory for Midwives or a Guide for Women[END_REF], there is a chapter on the 'Frenzie of the womb' which is a direct copy of one in Sennert (1664). 11. Rivière quotes a case from Harvey's (1653) Anatomical Exercitations concerning the Generation of Living Creatures: 'A knew a noble lady, which was wild by reason of a uterine melancholy and distemper, for above 10 years together: and when all remedies had been in vain employed, she fell at last into the bearing down of the uterus; which accident, contrary to others judgment, I did prognosticated would conduce to her health; and persuaded her not to return her womb, until its distemper was assuaged by the outwards cold air: the success was answerable to my persuasion, and in a short time she was perfectly cured; and her womb being at last restored to its seat, did remain there, and she lives a healthy life, even to this day …' (p. 502; original italics). 12. Daniel Sennert was born in Breslau on 25 November 1572. Trained in philosophy at Wittenberg and then in medicine at Leipzig, Jena and Berlin. In 1602 Jean Jessen, his teacher, resigned his chair in favour of Sennert. In addition to his great medical erudition, Sennert actively participated in the theoretical debate of the period trying to harmonize Galenic medicine with the new iatro-chemistry of Paracelsus (e.g., [START_REF] Sennert | Chymistry made Easie and Useful or the Agreement and Disagreement of the Chymists and Galenists[END_REF]. He was six times vice-chancellor of Wittenberg. Sennert died in 1637 (Dezeimeris, 1839). 13. Before the 17th century, writers tended to discuss excessive sexual drive under the general category of satyriasis. For example, Bernardus Gordonii (1574: 602) wrote: 'Satyriasis est continua virgae erectio cum desiderio de appetitu ad coitu. Priapismus es immoderata & continua virgae erectio sine appetite & desiderio …'. This differentiation Gordon borrowed from Caelius [START_REF] Aurelianus | On Acute Disease and on Chronic Diseases[END_REF]. 14. It is claimed that although M. D. T. Bienville was born in France, he trained as a physician in Holland and practised in the Hague and Amsterdam. In addition to his book on nymphomania, he wrote on smallpox and issues pertaining to health and therapy. He died sometime after 1780 [START_REF] Michaud | In Biographie universal[END_REF]. 15. One was by [START_REF] Lochner | [END_REF] and the other by Crausius (1691), the latter having been submitted to the University of Jena. 16. In his G y n a e c o l o g y, [START_REF] Soranus | Gynaecology. Translated with an introduction by Owsei Temkin[END_REF], discussed excessive sexual need in women but in the section on 'satyriasis'. Caelius [START_REF] Aurelianus | On Acute Disease and on Chronic Diseases[END_REF] expands upon these comments: 'All these symptoms [of satyriasis] occur also in women who are affected by the disease, but the itching is stronger in their case because of their nature. This itching of the genitalia makes them put their hands to these parts in shameless fashion; they accost all who come to see them, and on their knees beg their visitors to relieve their lust …' (Acute Diseases, III: 178).

  4

  Introduction and transcription by GERMAN E. BERRIOS* History of Psychiatry, 17(2): 223-235 Copyright © 2006 SAGE Publications (London, Thousand Oaks, CA and New Delhi) www.sagepublications.com [200606] DOI: 10.1177/0957154X06065699