Category Archives: General History

The Problem of Inebriates

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A Temperance Poster by Frank Bellew, 1874

A Temperance Poster by Frank Bellew, 1874

In the 19th-century mind, excessive use of or dependency on alcohol was closely related to insanity. Dr. Hills, superintendent of the Central Ohio Lunatic Asylum wrote in 1888, “Intemperance is a frequent direct cause of insanity . . . but many instances come to light in which even temporary intemperance in the parent has caused constitutional defects in the offspring–sometimes physical and at other times mental.”

Hills went on to relate a case in which a father with six sons had been a hard drinker in his earlier years. One son was born with a dull intellect, another went insane at age 30 “and is probably incurable” the third “was demented from an early age,” and the fourth was epileptic and “is imbecile.” Two older sons were married and had children, said Hills, “some of whom can hardly hope to escape the penalty in after years.”

Americans imbibed huge quantities of liquor beginning with colonial times, but frowned on public drunkenness. In general, society considered excessive drinking a sin and a moral failure. Eventually medical men (and others) began to look on alcoholism in a different way. Many could not keep from feeling that because drinking was voluntary it had to be a related to morals, but eventually people came to take a more hybrid view that it was a moral failing that led to a physical condition that couldn’t be controlled.

The Victims of Alcohol, Film Poster, 1911

The Victims of Alcohol, Film Poster, 1911

People who became alcoholics or met with public attention during a binge were often sent to insane asylums and diagnosed with “alcoholic insanity.” Reformers began to call for separate inebriate asylums where people with alcohol problems could be helped in a deliberate way. They could make the same arguments that had been made for treatment in asylums: it was cheaper to cure a man than for the public to absorb a lifetime of costs associated with drunkenness; medical staff could provide better care than family members could; alcoholics could be watched at all times and intoxicating drinks kept out of their hands, and so on.

New York State Inebriate Asylum

New York State Inebriate Asylum

As with the insane, alcoholics could be committed to an asylum against their will. It took affidavits from two physicians and two “respectable citizens” that the person in question was lost to self-control, unable to attend to business, or “dangerous to remain at large,” to send that person before a judge for determination. For the New York State Inebriate Asylum, there was at least one safeguard: An involuntary commitment could not be for longer than one year.

Could Anyone Be Cured Here?

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New York City Asylum for the Insane, Men, Ward's Island

New York City Asylum for the Insane, Men, Ward’s Island

Conditions for newly-arrived immigrants judged to be insane (see last post) were dismal. The emigrant hospital on Ward’s Island was completely inadequate, and it was discontinued after only a few years. New York’s insane population (immigrants included) continued to be housed on these islands, however, and even the most oblivious visitor must have seen that it would be nearly impossible to cure any patient under the conditions there.

“The overcrowding on Blackwell’s Island, even after 400 male patients had been transferred to Ward’s Island, was unbelievable,” says one writer (either a Dr. Parson or Dr. Rowe, who both contributed to a history of New York’s insane asylums). “Not less than 400 beds were made up nightly on the floor.”

Women Eating at Bellvue Hospital, Blackwell's Island, circa 1896, courtesy Museum of the City of New York. 93.1.1.4918

Women Eating at Bellevue Hospital, Blackwell’s Island, circa 1896, courtesy Museum of the City of New York. 93.1.1.4918

Ward’s Island sounds even worse. There were too few attendants, too little food and clothing, inadequate seating–and so few common necessities that patients often had to eat with their fingers. “Nights were hideous with noises and profanity,” the doctor continues. “Patients were locked in their rooms . . . straw-filled ticks, reeking and filthy, lay heaped about. Nurses were unknown and the attendants were coarse and inexperienced.”

The litany of failures went on and on. Of course, no one who could get a better job wanted to work there, and the city was forced to hire convicts as attendants. One can only imagine how these employees “managed” their patients. Finally, a new superintendent in charge worked energetically on the patients’ behalf, and conditions began to change.

Crowded Dining on Blackwell's Island, circa 1896, courtesy Viewing NYC.com

Crowded Dining on Blackwell’s Island, circa 1896, courtesy Viewing NYC.com

My final post on this topic will detail some of the new superintendent’s work.

Welcome to America

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View of New York's Emigrant Refuge and Hospital, Ward's Island, courtesy Arno Press and the New York Times, 1969 and Original circal early 1880s

View of New York’s Emigrant Refuge and Hospital, Ward’s Island, courtesy Arno Press and the New York Times, 1969. Original circa early 1880s

When immigrants processed through New York, some were inevitably sick–and some were judged to be insane. Both groups were sent to a hospital on Ward’s Island in New York until they either got well or five years went by. If the insane had not recovered by then, they were sent to the New York City Asylum on Blackwell’s Island.

The hospital on Ward’s Island was a nightmare. The ratio of nurses to patients was typically 1:30, and graduate physicians worked there–usually without pay–simply to gain experience. Obviously, they had little to no experience caring for the insane and only stayed for a short time anyway, thereby depriving patients of any continuity in care.

Inebriate Asylum, Ward's Island, 1869

Inebriate Asylum, Ward’s Island, 1869

The hospital was overcrowded despite occasional attempts to transfer insane patients elsewhere, such as to Randall’s Island and Hart’s Island. Randall’s Island first used an old inebriate hospital for the overflow (1875), but two years later had to use an unoccupied building and also lease an old barrack building from the Emigration Department. This latter building was extremely primitive, being without either individual rooms or “conveniences”. In all these places, cheapness reigned.

Pens at Ellis Island Registry Room. These People Have Passed the First Mental Inspection, courtesy Miriam and Ira Wallach Division of Art, Printing, and Photography Collection, New York Public Library

Pens at Ellis Island Registry Room. These People Have Passed the First Mental Inspection, courtesy Miriam and Ira Wallach Division of Art, Printing, and Photography Collection,1902 – 1913, New York Public Library

In my next post, I will discuss some of the conditions there and attempts to change them.

 

 

 

New Era, New Ideas

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Patient in Bethlem Royal Hospital, aka Bedlam, Before Moral Treatment

Patient at Bethlem Royal Hospital, aka Bedlam, in a Time Before Moral Treatment

Societies have always recognized mental illness–however they might define it–and early treatments for insanity were usually swift and somewhat brutal. As time went on most governing bodies realized that insane persons were not responsible for their actions; however, they found it difficult to do anything more than house patients somewhere until they either got better or died. These mentally ill people generally lived in harsh conditions at the mercy of their “keepers.” Even after so-called treatments for insanity became available, they remained largely unpleasant: bleeding, whipping, spinning, chaining, isolating from others, etc.

Male Ward at Athens Lunatic Asylum, courtesy Ohio University Libraries, University Archives

Male Ward at Athens Lunatic Asylum, courtesy Ohio University Libraries, University Archives

In the early 1800s, reformers such as Dr.  Philippe Pinel began to view the insane as people who had lost their reason because of exposure to severe stress or shocks. Victorians had terms like brain fever and shattered nerves to describe this kind of condition. Patients were seen as needing protection from society for a time so they could recover, and many alienists began using fewer restraints and stressful physical treatments. They believed that patients could be helped by moral treatments. These included friendly discussions of the patients’ problems, chores or occupations to discipline their time, and guidance for their interactions with others.

Glore Patients Out For a Stroll, 1902, courtesy Glore Psychiatric Museum

Glore Patients Out For a Stroll, 1902, courtesy Glore Psychiatric Museum

When the public began to see insane people recover, they finally discovered hope for their own loved ones. Asylums became less feared, and even the most reluctant families found them a blessing if a loved one had become violent or too difficult to treat at home. Unfortunately, the public’s embrace of asylums and their modern treatments caused overcrowding. In turn, this led to asylum under-staffing and a deterioration in the staff’s ability to give moral treatment. Soon, patients were merely being “kept” again.

Believing Their Own Hype

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Compilation Portrait of Members of the Association of Medical Superintendents of American Institutions for the Insane, courtesy National Library of Medicine

Compilation Portrait of Members of the Association of Medical Superintendents of American Institutions for the Insane, courtesy National Library of Medicine

Practitioners in the new field of psychiatry made some expert moves early on that both enhanced their reputations and brought them better incomes than the average physician. In 1844, a gathering of asylum superintendents met to form an exclusive group: the Association of Medical Superintendents of American Institutions for the Insane. They quickly set themselves up as the only doctors–in the only proper setting–who had the knowledge to diagnose and treat mental problems. These  asylum superintendents quickly convinced the public that they and their institutions were the real solution to the problem of treating insanity.

The association’s stated objectives were “to communicate their experiences to each other, cooperate in collecting statistical information relating to insanity, and assist each other in improving the treatment of the insane.”

The New York State Lunatic Asylum at Utica Was One of Only 25 Public and Private Mental Hospitals in America in 1844

The New York State Lunatic Asylum at Utica Was One of Only 25 Public and Private Mental Hospitals in America in 1844

It was an appropriate goal, because most of these “experts” had little true expertise in running asylums. Many years later, in 1885, Dr. Pliny Earle brought up the question of allowing assistant physicians at insane asylums to join the Association. In his discussion, Earle reminded the organization’s members that in the Association’s early years, only one physician had even ten years’ experience in healing the insane in a public institution. Only five others had five years or more experience as heads of institutions. The reality was, most men running asylums at that early time only had two to four years of experience doing so.

Dr. Pliny Earle, courtesy National Library of Medicine

Dr. Pliny Earle, courtesy National Library of Medicine

Dr. Earle suggested that assistant physicians who had worked continuously five years or more in institutions for the insane be admitted to the Association. This proposal was voted on and adopted.

Care for the Insane in Utah

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Map Showing Utah Territory

Map Showing Utah Territory

Though most people going West to follow their dreams (or spouses) into U.S. Territories might have been particularly hardy or adventurous, some succumbed to mental illness along the way or after arriving. These insane were taken either to county poorhouses or admitted to private institutions in Salt Lake until the legislature created the Territorial Insane Asylum in Provo. (Utah did not become a state until January 4, 1896.) The bill to create the asylum was introduced in February, 1880, and the institution opened its doors to admit patients five years later on July 15, 1885.

Of course this insane asylum admitted the insane, but it also accepted feeble-minded patients and non-insane epileptics who were capable of improvement. It would not accept the feeble-minded who couldn’t improve, the senile, “a person in an unconscious condition,” infants, children under ten, and people suffering from contagious diseases.

State Mental Hospital in Provo, Utah, circa 1900, courtesy Utah Department of Human Services

State Mental Hospital in Provo, Utah, circa 1900, courtesy Utah Department of Human Services

Whether the rules were actually carried out or not, Utah seemed to protect its citizens a bit better than some other states. Anyone wanting a person committed had to fill out an informational form and then face an examination under oath before the district judge. If he were satisfied that there was “reasonable cause” for a person’s admittance to the asylum, the judge held a hearing that required the district attorney to represent the state. The judge had to “summon two practicing physicians” to certify under oath whether or not the person in question was insane. Additionally, any citizen (of the county in which the hearing took place), friend, or relative could oppose the application and appear at the hearing with counsel.

Patients at Utah Territorial Insane Asylum, circa 1900s, couresty Utah State Hospital Museum, courtesy Utah Department of Human Services

Patients at Utah Territorial Insane Asylum, circa 1900s, courtesy Utah State Hospital Museum

Anyone could submit an affidavit to the Board of Insanity saying that a committed patient was not insane or not a proper person to be placed in an asylum. The Board then had to make inquiries. If the person was found to be sane, he/she would be discharged. However, if the patient was deemed insane, the judge “must order his continued detention, and may order the parties demanding the inquiry to pay its cost.” [Emphasis added.]

The latter provision very likely deterred indigent patients and their friends from contesting even unfair commitments to the institution.

Asylum Patients Under a Doctor’s Care

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Indiana Hospital for the Insane

Indiana Hospital for the Insane

In 1884 Dr. Joseph G. Rogers, superintendent at the Asylum for the Insane in Indianapolis, wrote in an article (see last post) that nothing remarkable in either the treatment of insanity or recovery of patients had occurred recently. His suggestions for the primary care of acute (recent) mania were rest and nutrition, with the addition of soothing baths and perhaps a dose of medicine to help the patient sleep. These treatments could just as easily be done at home if a family wanted to–so why would they send their loved one to an asylum?

If patients didn’t immediately recover their sanity, of course stronger measures would be necessary. That’s when medical professionals took on more than most families could comfortably embrace.

William Green, a Patient With Acute Mania, Bethlem Hospital

William Green, a Patient With Acute Mania, Bethlem Royal Hospital

Rogers, and most other alienists of the time, believed that patients almost always needed their bowels cleared by a good enema, and he suggested using gallon portions if necessary. The enema should be repeated until deemed successful by seeing proof of the “evacuation of the entire canal.” He called this dramatic enema “hydraulic mining so to speak” and what it would have been like for family members to administer can only be imagined. To aid in the complete cleansing of the patient, Rogers also suggested an active purgative of ten grains of calomel with three of gamboge.

Calomel is a mercury compound which could have devastating side effects and actually kill patients who consumed too much of it over time. Gamboge is a strong laxative (that can also expel worms) with side effects that include vomiting, stomach pain, and loss of potassium–which can damage the heart.

Union Soldier Carlton Burgan, Whose Upper Mouth, Palate, Right Cheek, and Right Eye Were Effected by Calomel Poisoning, courtesy National Museum of Medicine and Health

Union Soldier Carlton Burgan, Whose Upper Mouth, Palate, Right Cheek, and Right Eye Were Affected by Calomel Poisoning, courtesy National Museum of Medicine and Health

Though laypeople of the time probably wouldn’t have known about these side effects, they might still have felt uneasy giving these stronger kinds of medicines to their relatives. And, if patients needed these stronger interventions, it would be because they were becoming increasing difficult to manage–another reason to send them to an asylum.

Though asylums took much of the care-taking burden off families’ shoulders, they may not have actually given the patient better care. In my next post, I will discuss some of the medicines available to doctors caring for the insane.

 

Nostalgia and Insanity

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Thomas Nast's Picture of a Homesick Soldier

Thomas Nast’s Picture of a Homesick Soldier

America’s Civil War left many soldiers with lingering mental ailments that degraded their quality of life or disrupted it so violently they were considered insane. Today we would likely call these problems post-traumatic stress disorder, but in the 19th century it would have been called soldier’s heart or irritable heart.

Another syndrome that affected soldiers during the war was called nostalgia. Men (and boys) who had never traveled far from home were suddenly in a strange place away from family and friends. Many were so homesick that they fell into depression and despair, stopped responding to the people and stimuli around them, and sometimes became so lethargic and apathetic that they died.

John Clem, a 12-Year-Old Union Drummer Boy, Would Surely Have Had a Hard Time Coping With Homesickness

John Clem, a 12-Year-Old Union Drummer Boy, Would Surely Have Had a Hard Time Coping With Homesickness

Nostalgia was recognized in the 1863 Manual of Instructions for Enlisting and Discharging Soldiers. The manual said: “Nostalgia is a form of mental disease which comes more frequently under the observation of the military surgeon… it belongs to the class Melancholia.”

The typical camp treatment for nostalgia was to shame soldiers for it, increase their drilling and other training, or push them into combat to stimulate them. Letting them take leave, or furlough, was also an option, but camp physicians had little use for it. Many were more concerned about the physically ill and wounded–whose symptoms could not be faked–than they were with uninjured soldiers who had symptoms that could.

It Would Have Been Impossible to Treat Nostalgia in a Civil War Hospital Like This

It Would Have Been Impossible to Treat Nostalgia in a Civil War Hospital Like This

This cold attitude was driven more by the wartime situation than the prevailing attitude of the era. Moral treatment, with its kinder outlook and sympathetic treatment of the mentally ill still dominated treatment in asylums. Unfortunately, the Civil War demanded soldiers so relentlessly that physicians found it hard to justify releasing a relatively able-bodied soldier from the army, for any reason.

Nostalgia was a very old term for the illness it represented, and the Civil War was the last war in which Americans used it as a diagnosis.

Mental Illness and the Civil War

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Civil War Soldier Angelo Crapsey, 1861, Who Committed Suicide in 1864 After a Period of Mental Illness, courtesy Kutztown University of Pennsylvania

Civil War Soldier Angelo Crapsey, 1861, Who Committed Suicide in 1864 After a Period of Mental Illness, courtesy Kutztown University of Pennsylvania

Societies have always observed that participating in wars/battles could affect both the soldiers and civilians caught up in the violence, and not only through physical wounds. After America’s Civil War, people called this change in veterans the “soldier’s heart” phenomenon. At the time, observers believed the negative changes were caused by actual physical changes in the heart that had occurred during war, or that the affected soldiers had longed for home so much that the fixation or focus  had affected their minds.

Lunatic asylums had been available to the public for over two decades by the time the Civil War ended, but many families were ashamed to send relatives to them. When soldiers returned from the war, however, families sometimes faced overwhelming problems trying to care for them. If the soldiers were badly wounded, for example, physical care would be demanding and expensive, and mental problems in addition might make giving home-care nearly impossible. Some soldiers returned home with alcohol or morphine dependencies which could also make them difficult to nurse. And, many families–particularly in the South–were too impoverished to provide adequate care for their loved ones.

Milledgeville Lunatic Asylum, GA, Received its First Patient in 1842

Milledgeville Lunatic Asylum, GA, Received its First Patient in 1842

Some of these issues may have driven families to place their veterans in an asylum. At the time, treatments for the insane consisted primarily of rest, occupational therapy, and adequate care for any existing physical problems. Receiving these things would have helped many patients, as would the relative peace that came from the stability and routine found in an asylum. Little besides some light labor and observance of the rules would have been expected from these patients, and many soldiers possibly welcomed the change and the chance to rest from the uncertainty and stress of the battlefield. Asylum cure rates during this period after the war could be around 30 to 40 percent–high, but possibly accurate.

Soldiers Could Be Traumatized When They Saw Friends and Comrades Die, photo courtesy Library of Congress, 1861

Soldiers Could Be Traumatized When They Saw Friends and Comrades Die, photo courtesy Library of Congress, 1861

Though many families continued to resist asylums and could not get beyond the stigma of insanity, others who used the asylums possibly saw a benefit. At the very least, many families may have felt that under post-war circumstances, they could have provided no better care, themselves.

Medical and Mental

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Dr. Howard W. Haggard

Dr. Howard W. Haggard

Writing in 1929, Dr. Howard W. Haggard, an associate professor at Yale University, said: “. . . the treatment of mental disease is not so well developed as the treatment of other diseases because insanity has only recently been recognized as a medical problem.” Until shortly before that time, insanity was considered (among other theories) the result of moral failures, harmful actions on the body from outside factors like sunstroke, overwork, a terrifying experience, etc., or heredity weakness.

Dr. Haggard also noted that insanity was the only disease that went through a court of law. Though this precaution was presumably taken because the diagnosis could deprive victims of their liberty, Haggard pointed out that a diagnosis of a communicable disease like smallpox could also deprive victims of their freedom through an enforced quarantine. No one required a legal ruling on a smallpox diagnosis, so why the distinction? Haggard believed that insanity had to pass through a court of law primarily because its diagnosis was “not as positive as is the diagnosis for other diseases.”

An Example of Diagnosing Insanity Via the Legal System

An Example of Diagnosing Insanity Via the Legal System

Early Psychiatrists Had Little Idea What Caused Insanity

Early Psychiatrists Had Little Idea What Caused Insanity

In this telling statement, Haggard pinpoints the reason we are still arguing today about the validity of diagnosing mental illness. What test is available for a particular mental illness? Whose standards need to be met for a person to be considered free of mental illness? If mental illness is a real condition, why does its definition change over time? A strong sex drive in women used to be considered a form of mental illness, for example, as was epilepsy and syphilis. What currently acceptable behavior will be considered an illness down the road, or what “mental illness” today will science discover is actually a physical illness?

Because these questions cannot be easily answered and have an enormous impact on an individual’s freedom, we as a society will doubtlessly continue the debate for many years.