07Chapter 5. Healing with Fire: From Malaria to Sulfazin

In Baku in the year 2000, I began my internship at Clinical Hospital No. 2—the city’s largest psychiatric institution. I was twenty-four. Bursting with enthusiasm, I saw myself as a future doctor who needed to learn everything this profession demanded. I was assigned to the male chronic psychosis ward—a place with 120 beds. Patients stayed there for years, some for decades.

From the very first weeks, I witnessed the practice of sulfosinotherapy.

Sulfosin. An oily suspension of purified sulfur in peach oil. It is warmed—precisely to body temperature. No higher. And then, slowly, millimeter by millimeter, it is injected deep intramuscularly. Beneath the skin. Into the muscle. Into the depths. Why? The answer lies in the method itself. It entered Soviet psychiatry in the 1920s. The name—pyrotherapy. Treatment by fire. Treatment through induced fever. The logic is impeccable. Almost alchemical. Raise the patient’s body temperature. To 39. To 40 degrees Celsius. And then—fever. Fever will shock the central nervous system. Shock it so hard that psychosis will retreat. A boiling cauldron in the blood. Salvation. Remission. Is it really so? Or did the artificial fire burn something human out of the mind?

I saw it with my own eyes. Two buttocks. Sometimes—plus both shoulder blades. Four points on a human body. They formed a shape with its own name: the “sulfosin cross.” It sounded almost ritualistic. In essence, it was. The pain came hours later—not immediately, delayed, like a sentence you already know is coming but still hope might pass you by. It never did. The agony lasted for days. Fever spiked, the body burned from within. A person couldn’t stand. Any movement—shifting, sighing, trying to sit up—sent searing pain flaring where the needles had gone in. Under the skin, a different process took hold. Infiltrates settled deep into major muscle groups. Repeated injections caused patches of necrosis. Dead tissue. Inside a living person. And this was called treatment.

The patients were unanimous about this procedure. They hated it. They feared it. They saw it not as treatment but as punishment. And medically speaking, they were closer to the truth than some of my colleagues.

Because by the year 2000—when I stood there witnessing this—no randomized controlled trials had existed for decades in global scientific literature confirming sulfosin’s efficacy for schizophrenia. Not a single one. The method persisted purely through clinical inertia, Soviet-era textbooks, and phrases like “that’s how it’s done,” “that’s how it works,” “we see results.”

I was a young doctor. I looked at it and understood: this is not medicine. This is something else. This is a ritual echoing the logic of a bygone century. This is a practice that came to us from an era when psychiatry had no alternatives, now stuck within our walls because it was never officially abolished.

But it was still being used.

To understand how this came about, we need to go back to the late nineteenth and early twentieth centuries. To an era when the word “schizophrenia” had only just appeared in medical dictionaries, when a fair amount was already known about it, but how to treat it—that was anyone’s guess.

Psychiatric hospitals at the time were bleak. Patients lay there for decades. Decades! They deteriorated. They died. From opportunistic infections. From s•••••••••s. From sheer physical depletion. Doctors stood beside them—literally right there—but could do almost nothing but isolate, restrain, observe. No effective medications. No psychotherapy for psychosis. Just barbiturates for sedation. And long corridors. Corridors full of suffering.

In 1917, when Julius Wagner-Jauregg, professor of psychiatry at the University of Vienna, published his groundbreaking work on treating progressive paralysis (tertiary neurosyphilis) by inducing malaria, it sent shockwaves through the medical community.

Wagner-Jauregg truly achieved something remarkable. Progressive paralysis, a form of neurosyphilis affecting the brain, was both fatal and incurable in the early 20th century. It was one of the most horrifying manifestations of mental illness: patients suffered agonizing deterioration and died within a few years. Wagner-Jauregg deliberately infected such patients with malaria. The high fever induced by a malarial attack killed the Treponema pallidum, the bacterium causing syphilis, within the nervous tissue. Many patients experienced significant improvement, and some even recovered fully.

In 1927, Wagner-Jauregg received the Nobel Prize in Medicine — the first Nobel Prize ever awarded for a psychiatric treatment method. The second — and the last — would be the prize for lobotomy, which we’ll come to later.

And from that point on, psychiatry latched onto an idea: if fever had worked for neurosyphilis, maybe it could work for other psychoses too?

The logic was false. Completely. Hopelessly. General paresis—that’s an infection. It has a pathogen. Alive, concrete, tangible. That pathogen dies when temperature rises. It makes sense. It works. Schizophrenia isn’t an infection. It’s an endogenous disorder. At the start of the 20th century, nothing was known about its nature. Even now, understanding is partial. There’s no pathogen. Never was. Never will be. But the idea had already taken root. The idea of “pyrotherapy” as psychiatry’s universal cure. It latched onto minds with a death grip. Why? Because it looked scientific. Because it stood in the shadow of a Nobel Prize. Because who would dare argue with a Nobel laureate? It was dragged everywhere. Into every clinic. Every ward. Places it couldn’t work. Places it had nothing to treat. A false premise. An impeccable reputation. And patients whose bodies were wracked with fever—for no reason at all.

In the 1920s, Danish psychiatrist Knud Schröder proposed using a simpler and more controlled fever-inducing agent than malaria: injections of sterile sulfur in an oil suspension. The drug was named sulfozin. Unlike malaria, it didn’t require “cultivation” in the patient’s body—a single injection was enough to induce a fever of up to 40°C for two to three days.

The method quickly spread to the Soviet Union. By the 1930s, sulfozin was being widely and routinely used in Soviet psychiatric hospitals—first as a pyrogenic therapy for schizophrenia and manic states, then increasingly as a means to “overcome therapeutic resistance,” i.e., in cases where other methods had failed.

By the middle of the 20th century, sulfosin acquired yet another function that cannot go unmentioned. It became a tool of punitive psychiatry.

This chapter of history has been documented by many. Soviet dissidents like Leonid Plyushch, Vladimir Bukovsky, Pyotr Grigorenko, and Viktor Nekipelov all recounted their experiences in psychiatric hospitals, where they were confined for their political beliefs. In their memoirs, they particularly emphasize the use of sulfosin.

Vladimir Bukovsky described it this way: orderlies in psychiatric wards treated sulfozin as a disciplinary tool. Any “disobedience”—refusing food, attempted protests, or even a sharp word—could result in an injection. The pain was so severe that the patient remained physically immobilized for days. It was perfect for an institution that demanded compliance.

Leonid Plyushch, a mathematician and dissident, wrote in his memoirs: “They injected me with three cubic centimeters of sulfosin. The pain knocked me out. Sulfosin proved effective when it was necessary to break a person’s will, to turn them into a frightened animal.

In 1984, these accounts were presented at hearings of the Commission on Security and Cooperation in Europe (CSCE) in Washington. American psychiatrists, after reviewing Soviet sulfozin practices, concluded that the method was used more for punitive purposes than therapeutic ones. They noted the characteristic effects of the injections: “excruciating pain, immobility, high fever, muscle necrosis.”

In 1983, the All-Union Society of Psychiatrists was forced to withdraw from the World Psychiatric Association—preempting inevitable expulsion after harsh criticism from the international community. Officially, the reason given was the abuse of psychiatry for political ends. In reality, it was for generations of repression in which sulfozin had played a key role.

In 1989, during the era of perestroika, the use of sulfosin in the USSR was officially restricted. In Soviet Russia, it was formally removed from the list of recommended methods.

But as I saw for myself in Baku in 2000, it was in fact still being used.

And here we need to be honest — this is one of the most delicate aspects of the subject.

In 2017, the academic journal Siberian Journal of Life Sciences and Agriculture published an article by Israeli psychiatrist Roman Becker and Russian psychiatrist Yuri Bykov titled “Sulfozin—A Product of the Soviet Psychiatric School: Therapeutic Agent or Tool of Punitive Psychiatry?” The authors conducted a detailed historical and literary review. Their position: despite its dark reputation, sulfozin was not solely a punitive instrument—in certain narrow clinical cases, it could also be a viable method for overcoming therapeutic resistance. They cited evidence that sulfozin therapy continues to be used in post-Soviet countries to this day and, they claim, sometimes with positive effects.

Their work is a scientific article in a peer-reviewed journal. It cannot be dismissed as mere “propaganda.” But neither can it be accepted uncritically. And here lies the first crack in the argument. The authors themselves admit: no placebo-controlled studies of Sulfosin have been conducted. Not a single one. There are no comparative trials with modern methods either. The entire body of evidence consists of clinical observations. Decades of Soviet psychiatry. Years, hospital wards, thousands of patients. But—no controlled experiments. No randomized sampling. No blind protocols. Observations. Nothing but observations.

From the standpoint of rigorous evidence-based medicine, this does not constitute proof of efficacy. At best, it provides grounds for a hypothesis—one that must be tested using controlled methods. No such testing has ever been conducted.

This raises the question: If the method lacks rigorous scientific evidence, causes severe pain, muscle necrosis, and high fever, if patients fear it and perceive it as punishment, if it was actively used for decades as a tool of repression—on what basis was it still being administered intravenously to patients in the 2000s and 2010s?

The honest answer is this: it’s all about inertia. It’s about “that’s how we were taught.” It’s about “we see that it works.” It’s about patients having no voice.

This isn’t scientific psychiatry. This is psychiatry stuck in its own past.

I’ll return to the memory that opened this chapter.

I remember the face of that patient in Baku in 2000 who was about to receive a sulfosin injection. He was thin, around thirty years old. He had been suffering from schizophrenia for ten years and had been admitted to the same hospital multiple times. He knew exactly what was coming. When the nurse arrived with the ampoule, he silently lay down on his stomach and turned his head toward the wall.

He didn’t shout. He didn’t protest. He didn’t complain. He knew nothing would change. This learned helplessness—perhaps the most distinctive symptom of patients with chronic schizophrenia in Soviet and post-Soviet psychiatric culture. They knew what would be done to them. They couldn’t change it. They became voiceless.

I stood by the window and watched. A young doctor, just an intern. I knew enough to understand that what was happening made no scientific sense. But I didn’t know enough to say no—no one would’ve listened to an intern anyway. So I stood there in silence.

This is my silence. The very same one I spoke of in the preface. Silent consent. An invisible mechanism. The cog without which all the vileness of the past could never have carried over into the present. That day, I became its accomplice. I stood in line with hundreds of young doctors. Nearby—syringes, burning hot with sulfozin. Nearby—patients sinking into the icy abyss of insulin coma. Nearby—electroshock without anesthesia, searing the flesh. We stood there in silence. Why? Because that was the way it was done. Because there was no one to argue with. Because no one ever showed us an alternative.

This book, among other things, is an attempt to break that belated silence. To tell what I should have said back then. Even if only in hindsight.

Mid-1950s. The point of no return. Chlorpromazine was synthesized in laboratories—1952. The first antipsychotic, truly capable of halting the chaos. And in that very moment, pyrotherapy, including sulfosin injections, becomes obsolete. Every scientific justification crumbles like a house of cards. Why burn the mind with fever when there’s a key to the lock? Psychiatry finally has a weapon. It helps most. Not all. Not always. But—it helps. Symptoms retreat, visibly weakening. Delusions lose their torturous edge, ceasing to ravage the flesh. Hallucinations grow fewer. And patients emerge from the darkness. They can return to life.

In Western Europe and the United States, with the advent of neuroleptics and modern electroconvulsive therapy, sulfosin and other forms of pyrotherapy quietly faded from clinical practice. By the end of the 1960s, they had virtually disappeared.

In the Soviet Union and some post-Soviet countries, they have not disappeared.

Here is one of my core thoughts, and I want it to be heard loud and clear. Post-Soviet psychiatry has, in many ways, not yet become psychiatry at all. It’s a hybrid. Inside it, you’ll find everything that exists in global psychiatry: modern antipsychotics, ICD diagnostics, protocols, ethics committees. Everything is present. But beneath that layer—there’s another. Layers of the past that no one has cleared away. Sulfosin. In certain hospitals, it is still used today. Insulin comas. Electroshock without proper anesthesia. Prolonged hospitalizations, long abandoned by the rest of the world in favor of outpatient care. Practices that are unthinkable outside the post-Soviet sphere. On the surface—a modern clinic. Inside—a past that never left. And it’s not somewhere else. It’s right here.

And here we must be honest: this is precisely where psychiatry went wrong. Not psychiatry as a whole—but its specific regional form, one that has never fully managed to break free from its past.

Reform requires more than changing methods. It demands a cultural shift. A culture where young doctors speak up against unethical practices. Where patients have agency and the right to refuse. Where the very notion of “punitive treatment”—even the tone of voice suggesting it—is met with instant rejection.

Until this culture is firmly established, we will continue to see young doctors standing by the window, silent. Like me. And we will still have aging patients lying face down, waiting for the injection they cannot refuse.

The formula’s trail. A pinch of truth—then an explosion. Fever did indeed kill the syphilis spirochete. But in only one specific group: patients diagnosed with general paresis. And here came the fatal overgeneralization: “Fever cures all psychoses.” No evidence. Just blind faith. The method? Malaria inoculations. Then sulfa drug-induced fevers. Pyrotherapy for pyrotherapy’s sake. Not a single controlled trial. The machinery creaked into motion—seventy years of fever therapy. Wards. Careers. Textbooks. An assembly line. And who footed the bill? Patients. Generations condemned to this scorching torment. Including the man whose story opened this book.

In the next chapter, we’ll examine another method born from that same era of desperate schizophrenia treatments. One that also gained widespread use, rooted in unproven theory—and later deemed obsolete with the rise of antipsychotics. Yet at its peak, it seemed so revolutionary that its inventor became a global celebrity.

The subject: Manfred Sakel’s insulin coma therapy.