This post is an off-shoot from Strange Medical Treatments in History.

Introduction

I began digging deeper into many of those treatments but then got stuck on what was termed ‘Physician Assisted Paroxysms‘ (PAP). I became totally flabbergasted by what I found. It would have been too much to add to that post, so I decided to pull all that I could find into this one. In essence PAP was actually and originally manual masturbation of the clitoris. That was seen as valid treatment for a range of female psychological disorders that came under the umbrella of hysteria. How could this happen? It boggled my mind! [Just to be clear PAP has nothing to do with pap smear test which is a modern screening procedure for cervical cancer.

My searches were triggered even deeper by the film ‘A Dangerous Method‘ (2011) – the review is a movie-killer. Click here to view the whole movie for free (with minor adds). The film dramatises the little known relationship between Carl Jung and Sabina Spielrein. Little was known about her until publication of the book, A Secret Symmetry: Sabina Spielrein between Jung and Freud (Carotenuto, Aldo, ed. (1982). More was to unfold in Jung in Love: The Mysterium in Liber Novus by Lance S. Owens, (Gnosis Archive Books, 2015), 27-35. ISBN 978-0692578278 (freely available online.)

There was a medical sub-culture of the time (1800s to early 1900s), that a condition called ‘hysteria‘ was to be treated with PAP. By today’s standards we can see how that sort of thing is a serious violation of boundaries. This will be explored later.

But wait – what has any of this to do with modern-day psychiatry? Some will argue that sort of stuff was from a different time when psychiatry was in its infancy – and only just being coined as a recognised discipline in 1808 by German physician Johann Christian Reil. Yes the horrors of psychiatry emerged in a different time. But I marvel at how psychiatrists of yesteryear came to their conclusions, beliefs and theories which they acted on. They even fought among themselves to prove they were each right or part of a group that was right!

In the last few years I recognised in retrospect that I have been seeing faded strands of those historical ‘mindsets’ still operating today. In the nebulous world of ‘mind’ and ‘mental’, robust scrutiny of psychiatric practice has fallen by the wayside. ‘We’ psychiatrists are allowed to try out whatever treatments we think may whimsically ‘work’; hence my pre-occupation with unlicensed prescribing. I see into the mistakes made in history. I see the ‘stage’ as set for similar mistakes, though probably not as shocking. I see too much comfort and confidence in regulation by the likes of the General Medical Council and the CQC. Every single day I see glaring breaches of well known medical standards which are published in the pubic domain. So, all that and more drives me to explore what happened with PAP. I almost collapsed when I discovered that as a result of excessive demand for PAP and doctors suffering the occupational hazard of ‘chronic hand fatigue’ from manual masturbation of their patients, that the the vibrator was invented. Back then it was called ‘the Manipulator‘. If you who reads this happens to be in state of shock and disbelief, know that what I document here is true.

History of PAP

Timeline

1. Around 2000 BC: Ancient Egyptian medical texts mention diseases specific to women, which could be considered early references to what would later be known as “hysteria.”
2. Classical era (5th-4th Century BC): Greek philosophers like Hippocrates and Plato mention hysteria in gynaecologic medical accounts. Theories of female hysteria often revolve around the idea of a “wandering womb.”
3. Early to mid-1800s: The concept of “female hysteria” was widely accepted in medical and societal circles. The condition was a catch-all diagnosis for a wide range of complaints and symptoms that women reported, which couldn’t be explained by any other diagnosis at the time.
4. Mid-1800s: Hydrotherapy, or water therapy, was one of the first technological advancements in treating hysteria. Hydrotherapy treatment involved the pelvic douche, an apparatus that originated in France during this period. The treatment involved aiming a powerful jet of water at a woman’s inner thighs and genitals. Health specialists claimed the device could cause hysterical paroxysm (orgasm) in under four minutes. Women frequently reported feeling extreme relief from hysteria after the treatment.
5. 1869: American physician George Taylor patented one of the first medical vibrators, known as “The Manipulator.” This device was a large, coal-powered machine. Patients sat on a padded table with a hole cut out to reveal their lower abdomen, through which a vibrating sphere massaged the woman’s genitals. Because the apparatus was large, heavy, expensive, and required a fair amount of power to operate, it was primarily purchased and maintained by large spas and physicians with large practices for their guests and patients.
6. Early 1880s: Physician Mortimer Granville invented the first portable, battery-powered vibrator. However, Granville wrote in 1883 that he did not intend for his device to treat hysteria. Instead, he intended its use only for male muscle fatigue. Granville believed women might mimic hysterical symptoms in order to gain treatment, despite not needing it for medical reasons. In other words, Granville did not want women to have orgasms after using his vibrator device.
7. 1899: The Merck Manual, a medical reference book, listed pelvic and genital massage as a treatment for hysteria. This further legitimised the use of such treatments in the medical community. Around the same time, twentieth-century physician Samuel Howard Monell described gynaecological pelvic massage as having positive results in treating hysteria. Monell’s comments reflect the widespread acceptance of these treatments during this period.
8. Late 1800s to early 1900s: The use of vibrators for the treatment of female hysteria becomes more widespread. This practice was a product of the Western Industrial Revolution, which saw the introduction of electric machines in medicine. The use of vibrators allowed physicians to treat hysteria more efficiently and without the physical exertion required for manual massage. The devices were also thought to be more consistent and reliable in inducing “hysterical paroxysm.“
9. Present day: The term “hysterical paroxysm” is no longer used, and the relief of tension achieved through external genital manipulation is referred to as a female orgasm.

No one should be in any doubt that the above was about ‘experts’ masturbating women to treat what was conceptualised as hysteria.

Hysteria from 1800s

1. Definition and symptoms: In the 1800s, “hysteria” was a catch-all diagnosis for a wide range of symptoms that couldn’t be explained by any other medical condition. These symptoms could include anything from anxiety, irritability, and fainting to nervousness, sexual desire, and even “a tendency to cause trouble”. Women suffering from hysteria would often be described as displaying a tendency towards irrational behaviour, emotional excess, and self-indulgence.
2. Origins of the term: The term “hysteria” comes from the Greek word “hystera,” meaning uterus. This reflects the ancient belief that hysteria was a specifically female condition caused by disturbances in uterine function. This belief persisted into the 19th century, with many physicians attributing hysteria to a “wandering womb,” the idea that the uterus could move around within the body causing various symptoms.
3. Treatment: The primary treatment for hysteria during the 19th century was pelvic massage, which was performed by physicians with the goal of inducing “hysterical paroxysm” – a term now understood to refer to orgasm. This practice was not considered erotic or sexually stimulating at the time, but rather a medical treatment. The invention of the vibrator in the late 19th century was a direct result of these treatments, as it provided a way for physicians to perform the massage without the physical exertion required for manual stimulation.
4. Cultural and social context: The diagnosis of hysteria was deeply intertwined with the social norms and expectations of women during the 19th century. Women were expected to conform to certain standards of modesty and decorum, and those who deviated from these norms were often labelled as hysterical. The condition was also often associated with the upper classes, as it was thought that women of lower social standing were too occupied with physical labour to suffer from such a disorder.
5. Decline of the diagnosis: By the late 19th and early 20th centuries, the concept of hysteria began to be questioned by some in the medical community. Advances in psychology and a better understanding of women’s health led to a shift in how these symptoms were understood and treated. The American Psychiatric Association removed hysteria as a diagnosis in 1952.

Perpetuation of PAP

The question that must boggle the mind is “How on earth could such an outrage have continued for so long?“.  The practice of physician-assisted paroxysm, or the manual stimulation of female patients to orgasm, was able to “fall under the radar” during the 19th and early 20th centuries due to a combination of societal norms, medical misconceptions, and a lack of understanding about female sexuality. The following is an attempt at explanation (not a list of excuses):

1. Lack of understanding of female sexuality: In the 19th century, there was a significant lack of understanding about female sexuality. The prevailing belief was that women did not experience sexual desire or pleasure. Therefore, the manual stimulation of the genitals was seen as a purely medical procedure, not a sexual act. The orgasm, referred to as a “hysterical paroxysm,” was not understood to be a sexual response but rather a medical outcome – or so they said.
2. Medicalisation of women’s behaviour: “Hysteria” was a catch-all diagnosis for a wide range of symptoms and behaviours that were not well understood and were often associated with women. The treatment of hysteria through genital stimulation was seen as a legitimate medical response to a recognised medical condition.
3. Medical beliefs: The medical community believed that hysteria was a condition related to the uterus and female reproductive system. The symptoms of hysteria, which included anxiety, sleeplessness, irritability, and sexual frustration, were thought to be relieved by inducing a “hysterical paroxysm” or orgasm.
4. Effectiveness of the treatment: The manual stimulation of the genitals was an effective way to relieve the symptoms of hysteria. Women who received this treatment often reported feeling better afterwards, which reinforced the belief in its effectiveness. So effective was the treatment by many women who had the ‘treatment’ that clinicians of that time made very good earnings. They and the treatment were in high demand, so much so that the ran the occupational risk of developing ‘chronic hand fatigue’. The latter is what led to the development of mechanised vibrators. See ‘The Manipulator‘ below that was patented by George Taylor.
5. Economic Factors: The treatment of hysteria was a lucrative practice for many doctors in the 19th century. Women diagnosed with hysteria – usually from the upper classes – would return regularly for treatment, providing a steady income for physicians.
6. Technological Developments: The invention of the vibrator in the late 19th century made the treatment of hysteria easier and more efficient. These devices could induce a hysterical paroxysm more quickly than manual stimulation, and they reduced the physical exertion required of the doctor.
7. Lack of Women’s Agency: In the 19th and early 20th centuries, women had limited agency in society and in their own healthcare. Doctors, who were almost exclusively male, held a great deal of authority, and their practices were not often questioned.
8. Lack of Oversight and Regulation: The medical profession was not as tightly regulated in the 19th and early 20th centuries as it is today. There were no clear ethical guidelines or oversight bodies to monitor the behaviour of physicians.

What about Carl Jung?

Jung was known to have had intimate relationships with several women during his lifetime. However, the exact number is not known, and much of the information about his personal life comes from letters, diaries, and second-hand accounts, which can be subject to interpretation. The relationship between Jung and Sabina Spielrein, a Russian physician and one of the first female psychoanalysts, has been a subject of much debate and speculation.

Their relationship began when Spielrein became Jung’s patient at the Burghölzli Hospital in Zurich in 1904. She was diagnosed by Jung as suffering from hysteria. Jung used Sigmund Freud’s psychoanalytic methods in her treatment. She was discharged on 1st June 1905.  Spielrein made significant progress under Jung’s care and eventually became a physician and psychoanalyst herself. But the latter sentence papers over the course of her recovery and her mental states along the way. Those were contained in her diary and in letters.

The nature of their relationship beyond the doctor-patient dynamic is said to be a topic of controversy. Some reviewers said that there was no definitive evidence of a sexual relationship. Other sources suggest that they may have had a romantic and possibly sexual relationship.

In a letter to Freud, Jung admitted to an “unethical” relationship with Spielrein, but he did not provide specific details. Spielrein’s letters and diaries also suggest a deep emotional bond and possibly a physical relationship, but they do not provide conclusive evidence of a sexual relationship. Having said that, does one expect to find details like in modern erotica? I think not. It was a different time. ‘Kiss and tell gory details‘ was not part of the culture – and people had some respect for their own privacy and that of others.

Here are some of the women with whom Jung is known or believed to have had other intimate relationships:

1. Toni Wolff: Wolff was another of Jung’s patients who later became a psychoanalyst. She and Jung had a long-term relationship that lasted for many years, even while Jung was married to Emma. Wolff became a close collaborator with Jung and significantly influenced his work.
2. Maria Moltzer: Moltzer was a psychoanalyst who was part of Jung’s inner circle. Some sources suggest that they may have had an intimate relationship, but the evidence is not clear.

Supporters of Jung will reach for the ‘no evidence’ clause. Those who dislike Jung will say, ‘Obviously – he shagged them!‘

Whilst I admire Jung’s works and I take no sides in defence or prosecution I need to come to a conclusion. Where there is insufficient evidence I can still make a reasonable inference based on the probabilities. I do that by considering:

1. The prevailing culture at the time – which was very loose: no enforced ethical standards, huge power differentials, and no regulation.
2. Hysteria was widely accepted – in its broad definition at the time as something that should be treated by physical manipulation of female genitals.
3. Numerous diaries and letters have emerged over the last 20 years all amassing words and emotions from their writers (who experienced Jung), that he was sexually loose.
4. The wider culture among people of those historical times was not to write about pornographic details as we know today. Hence the ‘sufficient evidence’ that many search for is unlikely ever to be found.
5. To make it worse he was a married man who fathered five children with one woman, his wife Emma Jung, when he had the ‘deep emotional bonds’ (as it was categorised) to other women.

When I weigh up the probabilities I come to a conclusion that Carl Jung did have intimate sexual relations with one or more of his patients whilst he was married.

Closing remarks

Confusion: This exploration of this part of history rocked my ‘world’ in many ways. I was in a state of disbelief that those things actually happened. I had studied many of Carl Jung’s works between 1986 and 2003. I incorporated some of the principles successfully in my practice. I had knowledge from my early psychiatric training that ‘masturbation’ was once used to treat hysteria. But as psychiatric trainee, I was too overworked and had to devote my time to ‘passing exams’. There were so many  other competing interests that I did not have time to dig deep into the history of psychiatric treatments. So – now I’m in a mess, to discover the ‘dark side’ of Carl Jung.

Medical practice issues: I come to realise that regulation alone is insufficient in modern times to prevent doctors from abusing patients. I suggest randomised direct inspections of medical practice.

Symptom improvement: One of the key factors that perpetuated PAP was that many women felt better for having it. Then they became repeat customers for more of it. The physicians of the time would have been held in high regard by those who felt better, and the physicians themselves would have felt psychologically and materially rewarded for their efforts and results. That was the dyadic foundation of a delusion.

In amongst all the science today about placebo effect, there is a lack of recognition of its power. There is a cognitive-attitudinal mismatch. Psychiatrists are still very willing, based on their individual theories and feelings to ‘try a certain’ medication, for some condition knowing that there is no proven efficacy, yet take some sense of achievement if the patient happens to improve on that trial. The issue is about ‘what works’ – and what does that mean? To that certain group of psychiatrists it means that the patient’s symptoms or patterns of behaviour improves. Every properly trained psychiatrist ought to know that symptom improvement does not readily translate into efficacy. But then there is an intellectual sleight of mind that comes into play, which is to say, “It worked for that particular patient.” Hence if some homeopathic treatment was given to a patient with acute gout and they improved then “It worked.”

Temporary or short-lived improvements do not mean efficacy. As I explained in other posts, efficacy is about making a fundamental difference to some core aspect of patient’s illness or mental disorder. Benzodiazepines are the classic example i.e. patients suffering with chronic insomnia will on first use of something like lorazepam, have wonderful sleep. The relief and rest is the powerful reinforcing factor. They will return for more. I’ve never seen this not happen (in the prescribing of other doctors).

What’s worse is when polypharmacy with several medications is taken to be effective.

Scientific methodology:  Notable in almost all that went on in PAP was a lack of true science. In the film ‘A Dangerous Method‘ (freely available online), there was discussion about science. But what sort of science was that? It appeared to me that the ‘therapists’ (or whatever) unknowingly took ideas in their own minds as things holding a certain reality or even objectivity. They clearly had merged ‘subjective reality‘ with ‘objective reality‘. If I assume that’s correct then it begs deeper questions: ‘How could they do that?‘ and ‘Could we be doing that today?‘.  Delusion rests on belief. The more distant a belief is from some true reality outside of heads, the more delusional the belief is.

The ultimate problem for psychiatry today (and all therapeutic roles that do not primarily involve biological treatments), is that it deals in the ‘world of mind’ – that thing that cannot be ‘blood tested’ or put in a scanner, to show thoughts, memories or emotions. The training of UK psychiatrists from my experience places much emphasis on mind as originating from brain – and brain becomes a disproportionate focus for treatment in the psychiatric appreciation of the biopsychosocial model. This is not to say that psychiatrist do not use psychological principles or are hands-off with psychosocial treatments. But when patients are given biological treatments, the psychiatrist often becomes the judge and jury of efficacy or effectiveness; not arrived at by some set of objective testing (except in the best funded centres of excellence). See Factors limiting robustness of psychiatric assessment.

Being the judge and jury in any treatment is a recipe for losing contact with science. And for sure, I have no issue in recognising that there is an ‘art of medical practice’.