Peter J. Tyrer

In 1959 I had finished my last term at school and had 3 months of freedom before going off to university. So what did I do? Nothing dramatic. I cycled 3 miles from my home to Rubery Hill Hospital, formerly the Birmingham City Asylum (this is Birmingham, England, not Birmingham, Alabama), to ask if I could work there as a volunteer.

I was not accepted. The union representative said it would “undermine their negotiating position,” and so I left. But I did notice 1 thing while I was waiting there: the hospital was exceptionally clean. I now know the bloody story behind the cleanliness. Its main character was still present, just down the road, only a mile or 2 from my house.

Thomas Chivers Graves was born in 1883 in Cambridgeshire. He was the grandson of Stephen Chivers, the founder of the famous 

, but his family was not close enough to the successful fruit entrepreneurs, so Thomas grew up indigent. If his family had been wealthier, he would probably have had nothing to do with psychiatry, as he only went into the profession late.

 (FRCS) in 1914, expecting to become a surgeon. But after the war he concluded he did not have the financial resources to become a surgeon, changed over to psychiatry, quickly qualified, and became medical superintendent of Rubery Hill and Hollymoor Hospitals in Birmingham. In retrospect he did not change; he retained the thinking of a surgeon.

He developed the idea, together with Henry Cotton, a psychiatrist from Trenton, New Jersey, that mental illness was a reaction to illness elsewhere in the body, now encapsulated in the words “auto-toxicity” and “

.” Cotton had trained in Europe and also at Johns Hopkins Hospital, where he was a pupil of Adolf Meyer, who was the dominant figure in American psychiatry in the early years of the 20th century.

Cotton was nothing if not bold. He started by removing patients’ teeth as an obvious cause of focal sepsis, but if this failed to cure the psychiatric disorder, he removed tonsils, testicles, ovaries, appendices, gall bladders, spleens, and colons. Thomas Chivers, essentially a surgeon manqué, embraced Cotton’s theory with equal enthusiasm, and as he was an excellent politician, he attracted long-term interest in the subject in the United Kingdom. But Cotton was lionized in the United States, too. In June 1922 the 

"At the State Hospital at Trenton, N.J., under the brilliant leadership of the medical director, Dr Henry A. Cotton, there is on foot the most searching, aggressive, and profound scientific investigation that has yet been made of the whole field of mental and nervous disorders... there is hope, high hope... for the future.”

Cotton was also supported by Adolf Meyer, as the focal sepsis theory fit in with Meyer’s psychobiological approach.

Cotton and Chivers presented their findings jointly at the Medico-Psychological Meeting in London (this was the equivalent of the Royal College of Psychiatrists Annual Congress today) in July 1923. Cotton was the more expansive presenter. He told the meeting that focal sepsis in the teeth, tonsils, and stomach were the cause of so-called functional illness, and that only an “aggressive response against infection” was needed. He was the gung-ho pioneer and had absolutely no doubts. He told the assembly:

"As a result of our decision we were finally convinced, in 1918, that chronic sepsis should be eliminated in this group of patients (ie, functional disorders, including schizophrenia). As a result of our decision we started to literally “clean up” our patients of all foci of chronic sepsis . . . and were able to increase our recoveries from 37% to 85% in the first year.)"

He finished by showing tables of proportions of sepsis in teeth, tonsils, stomach, and “vaccine-treated” patients (those injected with ad hoc streptococcal antigens). Graves was more circumspect in his paper, confining more of his discussion to sepsis in the jaw, with its tendency to chronicity. He modestly concluded that “long-continued infection with these organisms produced a varying degree of emotional reaction.”

Development and expansion of the auto-toxicity theory

Graves took this theory much further than Cotton. He was riding the wave of the English anti-psychoanalytic movement of the 1920s. He was a powerful figure in psychiatry, and he was showing, to all who wanted to listen, that psychiatry belonged within the fold of general medicine, not apart. This allowed Thomas Graves to realize his surgical ambitions. Not only dentists, but surgeons (particularly specializing in abdominal surgery), gynecologists and ENT surgeons, were all visitors to the new operating theater created at Rubery Hill Hospital, where the eradication of focal sepsis became the main focus of treatment.

This process was accompanied by much fanfare. The Mental Hospitals Committee of the Birmingham City Council was highly impressed by Graves, as was Sir Gilbert Barling, Vice Chancellor of Birmingham University, who helped him to set up a mental health research department at the University. But the main subject of the research was surgery. Tonsillectomies, complete dental extractions, appendectomies, and other similar operations became commonplace for depression and schizophrenia at the hospital in the late 1920s and 1930s. The hospital observed scrupulous hygiene in the hope that all extraneous bacteria could be removed. Such was his prestige that eventually he was appointed chief medical officer of all the mental hospitals controlled by the City Corporation in Birmingham. In 1940 he was elected president of the Royal Medico-Psychological Association and continued in his office for the next 4 years, longer than any other president.

as “Diphasic Vascular Variation in the Treatment of Mental Inefficiency Arising from a Common Somatic Cause,” is one of the most unintelligible papers ever published in the journal. By this time, he was almost completely isolated academically. He maintained that the main reason for “mental inefficiency” (ie illness) was “closed sepsis.” Diphasic vascular variation referred to the circulatory stimulus created by open sepsis, which allowed an increase in blood flow so that “the potential toxaemia and bacteriaemia are reduced to minor values and there is a rise in mental efficiency.”

 Where was the evidence for this therapeutic flushing of blood to relieve all mental suffering? None, there were only 2 references in this rambling shambles of a paper, both articles published by Graves himself.

After penicillin was first produced in 1945 it was reserved for military purposes. Graves was desperate to obtain supplies and when he failed he made his own penicillin cultures in the laboratory at Rubery Hill and injected them into patients. Consent was never discussed.

After the war Graves lost all influence but his focal sepsis theory was a highly respected element of psychiatric practice for over 20 years. Though he accumulated many devotees, he had several powerful critics, including David Henderson from Gartnavel Hospital, who pointed out that Graves largely relied on case reports to demonstrate the effectiveness of surgical interventions instead of any formal comparisons. Andrew Scull,

 who has written a comprehensive review of Graves and his influence, points out that the critics were not on the firmest of ground, as nobody could claim that infection should not be treated. So they could easily be dismissed as uncaring.

Thomas Graves continued to practice until 1950, and his influence persisted locally,which explains why the environment at Rubery Hill Hospital impressed me by its cleanliness 9 years later. He seemed to have taken no notice of the famous Northfield experiment carried out by Bion and Rickman on group psychotherapy at Rubery Hill and Hollymoor Hospitals (collectively called Northfield) during World War II.

He must have known at some level, as he remained medical superintendent at both hospitals until 1948, but he regarded all psychotherapy as abhorrent. Scull comments that Graves never lost his enthusiasm for his focal sepsis theory and worked persistently on his theories until his death in 1964.

Are there lessons to learn now from this long-held error?

Psychiatry has long been under attack for being too divorced from general medicine, and many now exhort it to become a distant branch of neurology linked to neuroscience. The case of Thomas Chivers is a warning to all of these individuals, as well as a reminder that changes in practice cannot be based on untested theory. Many of Graves’ patients would have been better off if he had found his way back into the family jam business.

is emeritus professor of Community Psychiatry at Imperial College, London. He was editor of the 

3. Cotton H. The relation of chronic sepsis to so-called functional mental disorders. 

4. Graves TC. The relation of chronic sepsis to so-called functional mental disorders. 

5. Graves TC.Diphasicvascular variation in the treatment of mental inefficiency arising from a common somatic cause. 

6. Scull A. Focal sepsis and psychosis: the career of Thomas Chivers Graves (1883-1964). In: Freeman H, Berrios GE, eds. 

150 Years of British Psychiatry: Volume II, The Aftermath. 

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