Fevered Decisions: Race, Ethics, and Clinical Vulnerability in the Malarial Treatment of Neurosyphilis, 1922-1953

Hastings Center Report

Volumn 45, Issue 4, 2015, Pages 39-50

  Gambino, Matthew ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ANTIINFECTIVE AGENT; PENICILLIN DERIVATIVE;

AFRICAN AMERICAN; BRAIN; DECISION MAKING; DISEASE COURSE; ETHICS; HISTORY; HUMAN; HUMAN EXPERIMENT; HYPERTHERMIC THERAPY; INFORMED CONSENT; ISOLATION AND PURIFICATION; MALARIA; MALPRACTICE; MEDICAL ETHICS; MENTAL DISEASE; MENTAL HOSPITAL; MICROBIOLOGY; MORALITY; NEUROSYPHILIS; PERSUASIVE COMMUNICATION; PRISONER; RESEARCH ETHICS; SEXUAL BEHAVIOR; TREPONEMA PALLIDUM; UNITED STATES;

AFRICAN AMERICANS; ANTI-BACTERIAL AGENTS; BRAIN; COERCION; DECISION MAKING; DISEASE PROGRESSION; DISTRICT OF COLUMBIA; ETHICS, MEDICAL; ETHICS, RESEARCH; HISTORY, 20TH CENTURY; HOSPITALS, PSYCHIATRIC; HUMAN EXPERIMENTATION; HUMANS; HYPERTHERMIA, INDUCED; INFORMED CONSENT; MALARIA; MALPRACTICE; MENTAL DISORDERS; MORALS; NEUROSYPHILIS; PENICILLINS; PRISONERS; SEXUAL BEHAVIOR; TREPONEMA PALLIDUM; UNITED STATES;

EID: 84936891645     PISSN: 00930334     EISSN: 1552146X     Source Type: Journal    
DOI: 10.1002/hast.451     Document Type: Article

References (121)

1. W. Osler, "Internal Medicine as a Vocation," in Aequanimitas, with Other Addresses to Medical Students, Nurses, and Practitioner of Medicine (Philadelphia: P. Blakiston's Son and Co., 1905), 140
2. A. M. Brandt, No Magic Bullet: A Social History of Venereal Disease in the United States since 1880 (New York: Oxford University Press, 1987).
3. S. Reverby, Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill: University of North Carolina Press, 2009
4. W. W. Eldridge et al., "Treatment of Paresis: Results of Inoculation with the Organism of Benign Tertian Malaria," Journal of the American Medical Association 84 (1925): 1097-101
5. M. Whitrow, Julius Wagner-Jauregg (1857-1940) (London: Smith-Gordon and Company, 1993
6. G. S. Belkin, "Toward a Historical Ethics," Cambridge Quarterly of Healthcare Ethics 10 (2001): 345
7. During the Civil War, physically injured soldiers convalescing at what was then known as the Government Hospital for the Insane were reluctant to associate themselves with an asylum for the mentally ill. Instead, they began referring to the hospital by the name of the colonial land tract on which it was situated. Soon administrators joined them in referring to the St. Elizabeth Hospital or St. Elizabeth's, and an act of congress officially changed the name to St. Elizabeths Hospital in 1916. Here I follow this counterintuitive formulation (using "St. Elizabeths," rather than "St. Elizabeth's"), which appears throughout the subsequent historical record.
8. M. Gambino, "Mental Health and Ideals of Citizenship: Patient Care at St. Elizabeths Hospitalin Washington, D.C., 1903-1962" (Ph.D. dissertation, University of Illinois at Urbana-Champaign, 2010
9. W. A. White, Mechanisms of Character Formation: An Introduction to Psychoanalysis (New York: The Macmillan Company, 1916
10. White, The Principles of Mental Hygiene (New York: The Macmillan Company, 1917)
11. White, Lectures in Psychiatry (New York: Nervous and Mental Disease Publishing Company, 1928
12. M. Gambino, "'These Strangers within Our Gates': Race, Psychiatry, and Mental Illness among Black Americans at St. Elizabeths Hospital in Washington, D.C., 1900- 40," History of Psychiatry 19 (2008): 387-408
13. A. B. Evarts, "The Ontogenetic against the Phylogenetic Elements in the Psychoses of the Colored Race," Psychoanalytic Review 3 (1916): 287
14. M. Summers, "'Suitable Care of the African When Afflicted with Insanity': Race, Madness, and Social Order in Comparative Perspective," Bulletin of the History of Medicine 84 (2010): 58-91
15. These percentages are averages over the years in question. Data are derived from the hospital's Annual Reports during the periods 1909 to 1918 and 1925 to 1930. St. Elizabeths remained under the Department of the Interior's administrative authority throughout this period. The Annual Reports therefore appear in that agency's reports to Congress at the end of each fiscal year, which are available in print and online as part of the U.S. Congressional Serial Set.
16. W. A. White, Outlines of Psychiatry, 8th ed. (Washington, D.C.: Nervous and Mental Disease Publishing Company, 1921), 142-65
17. St. Elizabeths Hospital, Annual Reports 1925-1930
18. Jones, Bad Blood, 78-86
19. Reverby, Examining Tuskegee, 33-37
20. M. O'Malley, "Psychoses in the Colored Race: A Study in Comparative Psychiatry," American Journal of Insanity 71 (1914): 330
21. L. D. Hubbard, "A Comparative Study of Syphilis in Colored and in White Women with Mental Disorder," Archives of Neurology and Psychiatry 12 (1924): 201-2
22. C. Crenner, "The Tuskegee Syphilis Study and the Scientific Concept of Racial Nervous Resistance," Journal of the History of Medicine and Allied Sciences 67 (2012): 244-80
23. O'Malley, "Psychoses in the Colored Race," 318
24. E. Fee, "Sin Versus Science: Venereal Disease in Twentieth- Century Baltimore," in AIDS: The Burdens of History, ed. E. Fee and D. M. Fox (Berkeley: University of California Press, 1988), 121-46
25. Whitrow, Julius Wagner-Jauregg, 161-62
26. Eldridge, "Treatment of Paresis," 1098
27. N. D. C. Lewis, "The Present Status of the Malarial Inoculation Treatment for General Paresis," Journal of Nervous and Mental Disease 61 (1925): 345
28. M. K. Amdur, Journal of the American Medical Association 84 (1925): 1374-75
29. Journal of the American Medical Association 84 (1925): 1515
30. W. A. White, "The Malarial Therapy of Paresis (2)," International Clinics 4, 41st series (1931): 65
31. Nolan D. C. Lewis placed the mortality rate at closer to 25 percent. Lewis, "Present Status," 348
32. St. Elizabeths Hospital, Annual Report 1910, 339 Annual Report 1920, 52; Annual Report 1921, 27; Annual Report 1930, 10; Annual Report 1936, 399
33. 22104: clinical record (October 20, 1915); case 27909: clinical record (September 16, 1920); case 32092: ward notes (February 7, 1925; February 16, 1925); case 32906: clinical record (August 27, 1927; November 26,); case 36025: clinical record (August 15, 1930); case 36339: medication and treatment form. The records of patients admitted to St. Elizabeths seventyfive years ago or more are available at the National Archives and Records Administration (NARA) in Record Group (RG) 418 (St. Elizabeths Hospital): Entry 66 (Records of the Medical Records Branch).1927
34. N. D. C. Lewis, L. D. Hubbard, and E. G. Dyar, "The Malarial Treatment of Paretic Neurosyphilis," American Journal of Psychiatry 81 (1924): 206-7
35. When a patient's name is known and accessible in publicly available documents, I have assigned a pseudonym that preserves the first letter of his or her given name and surname. Case 36025: admission note (n.d.); information from niece (n.d.); initial assessment (n.d.); clinical record (May 13, 1930; July 2, 1930
36. M. S. Pernick, "The Patient's Role in Medical Decisionmaking: A Social History of Informed Consent in Medical Therapy," in U.S. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Making Health Care Decisions: Studies on the Foundations of Informed Consent (Washington, D.C.: Government Printing Office, 1982), 1-35
37. R. R. Faden and T. L. Beauchamp, A History and Theory of Informed Consent (Oxford: Oxford University Press, 1986): 119-25
38. R. Baker, Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution (Oxford: Oxford University Press, 2013), 233
39. S. E. Lederer, "Hideyo Noguchi's Luetin Experiment and the Antivivisectionists," Isis 76 (1985): 34-38
40. S. E. Lederer, "'The Right and Wrong of Making Experiments on Human Beings': Udo J. Wile and Syphilis," Bulletin of the History of Medicine 58 (1984): 386-89
41. Baker, Before Bioethics, 268-72
42. Baker, Before Bioethics, 270
43. This was the claim of both Eldridge and Lewis in their publications at the time; Eldridge, "Treatment of Paresis," 1097
44. Lewis, "Present Status," 345. Eldridge gave a slightly different account in 1960, recalling that "[c]onsent of patients' relatives was obtained in every case, where there were relatives." Eldridge's historical essay contains a number of minor facts that are at odds with the original reports, however, and it is not clear that it should be taken as an accurate account. W. W. Eldridge, "History of the Medical and Surgical Branch, St. Elizabeths Hospital," 10, NARA RG 418 Entry 7 (Administrative Files: History of St. Elizabeths Hospital, Material on). The records of patients included in the original series have unfortunately not survived. I have found no reason, however, to doubt Eldridge and Lewis's original claim.
45. Case 32906: untitled document (January 7, 1925 [1926])
46. Gambino, "Mental Health and Ideals of Citizenship," 49-50
47. See e.g. case 36025 and case 36372.
48. Case 32578: admission note (August 17, 1925); clinical record (November 27, 1925
49. Wilson Ashby to William A. White (on or about September 23, 1925
50. P. A. O'Leary, "Treatment of Neurosyphilis by Malaria," American Journal of Psychiatry 89 (1927): 100
51. P. De Kruif, "The Pale Horror III: Wagner Jauregg's Fever Cure," The Forum 88 (October 1932): 225-30
52. White, "Malarial Therapy (2)," 47
53. M. D. Hathaway to Herbert C. Woolley (25 Feb 1931), NARA RG 418: Entry 18 (Treatment Files: General Paresis).
54. G. N. Grob, Mental Illness and American Society, 1875-1940 (Princeton, NJ: Princeton University Press, 1987), 294
55. E. W. Cooke (October 15, 1931). NARA RG 418, Entry 7 (Administrative Files: Syphilis, Treatment of ). This was almost certainly due to the absence of a critical protein on the erythrocytes of black patients through which P. vivax enters the cell. Researchers did not recognize this fact, however, until many years later. M. Humphreys, "Whose Body? Which Disease? Studying Malaria While Treating Neurosyphilis," in Useful Bodies: Humans in the Service of Medical Science in the Twentieth Century, ed. J. Goodman, A. McElligott, and L. Marks (Baltimore, MD: Johns Hopkins University Press, 2003), 64-66
56. St. Elizabeths Hospital, Annual Report 1934, 375
57. T. C. C. Fong, "Therapeutic Quartan Malaria in the Therapy of Neurosyphilis among Negroes," American Journal of Syphilis, Gonorrhea, and Venereal Diseases 24 (1940): 134
58. T. C. C. Fong, "The Diathermy Treatment of Dementia Paralytica: A Second Survey," Medical Record 143 (May 6, 1936): 387
59. NARA RG 418 Entry 7 (Administrative Files: Diathermia Report).
60. Fong, "Therapeutic Quartan Malaria."
61. Humphreys, "Whose Body? Which Disease?," 56-58
62. W. A. White, "The Malarial Therapy of Paresis (1)," International Clinics 3, 41st series (1931): 299
63. M. Kaufman, "The American Anti- Vaccinationists and Their Arguments," Bulletin of the History of Medicine 41 (1967): 471-472
64. K. L. Walloch, "'A Hot-Bed of the Anti-Vaccine Heresy': Opposition to Compulsory Vaccination in Boston and Cambridge, 1890-1905" (Ph.D. dissertation, University of Wisconsin-Madison, 2007), 45, 89-93
65. N. Durbach, Bodily Matters: The Anti-Vaccination Movement in England, 1853-1907 (Chapel Hill, NC: Duke University Press, 2004), 131-133
66. S. Williamson, The Vaccination Controversy: The Rise, Reign and Fall of Compulsory Vaccination for Smallpox (Liverpool: Liverpool University Press, 2007), 223-231
67. S. E. Lederer, Flesh and Blood: Organ Transplantation and Blood Transfusion in Twentieth-Century America (Oxford: Oxford University Press, 2008), 48-50
68. See the case of a white government clerk and former clergyman who, when his wife learned during her pregnancy that she had contracted a sexually transmitted infection from him, attributed it to black laborers who had handled his tools. Case 32612: information obtained from mother (August 30, 1925
69. G. N. Grob The Inner World of American Psychiatry, 1890-1940: Selected Correspondence (New Brunswick, NJ: Rutgers University Press, 1985), 124-25
70. NARA RG 418: Entry 7 (William Alanson White Personal Correspondence: 1930 A-F).
71. Grob, Inner World, 124.
72. This is based on a review of all publications relating to malarial fever therapy listed in the hospital's Annual Reports between 1922 and 1940. Medical reformers in this period still faced resistance convincing physicians of the need to include such controls in their research
73. H. M. Marks, The Progress of Experiment: Science and Therapeutic Reform in the United States, 1900-1990 (Cambridge: Cambridge University Press, 2000
74. Winfred Overholser to Louis Belinson (January 6, 1939), Ernesto Quintero to Riley H. Guthrie (April 28, 1941), NARA RG 418: Entry 18 (Treatment Files: Blood)
75. Fong, "Therapeutic Quartan Malaria," 139
76. Case 36038: admission note (May 12, 1930); clinical record (July 1, 1930). All references in the account that follows are to this case.
77. Initial assessment (September 25, 1930).
78. Clinical record (July 7, 1933; March 2, 1937; October 16, 1935; October 11, 1940
79. Clinical record (March 17, 1938; September 27, 1938). In 1942, Hussein was transferred to a Public Health Service hospital in Fort Worth, Texas. His fate there remains unknown. Clinical record (April 30, 1942
80. Clinical record (December 12, 1939
81. It remains unclear just how many of these inoculations produced fevers, as well as how many patients received Hussein's blood. Clinical record (March 27, 1931; April 21, 1931; April 9, 1934; April 11, 1934; February 7, 1938). Clinical record (March 27, 1931; April 21, 1931; April 9, 1934; April 11, 1934; February 7, 1938
82. While Wagner-Jauregg Specifically investigated the role of blood types in malarial fever therapy, I have encountered no evidence of such concerns in the publications that emerged from St. Elizabeths, nor have I encountered documentation of blood typing in the clinical records. The volume of blood involved in malarial inoculation was generally not large enough to prompt worries about transfusion reactions. Lederer, Flesh and Blood.
83. L. Marks to E. P. Van Hise (July 11, 1932
84. Mueller was identified as the "donor" in the treatment of Wilson Ashby. Case 32578: clinical record (December 4, 1925). Both patients were white. My inference that Mueller served as a reservoir in the same manner as Hussein is supported by the hospital's correspondence with Ashby's wife, in which an official related that a case of malaria had been located and the parasites "have been inoculated into healthy individuals," with plans to use their blood to inoculate her husband as soon as possible. Case 32578
85. Arthur P. Noyes to Mrs. Wilson Ashby (October 1, 1925).
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88. Previously listed as a boarder in the 1900 District of Columbia census, Mueller appears as a patient at St. Elizabeths in the censuses of 1910, 1920, and 1940. (The 1930 census is unavailable.)
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