Category Archives: Mental Health Theory

New Era, New Ideas

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

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

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.

A New Term for War-Time Trauma

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Patient Suffering From War Neurosis in WWI

Nostalgia (see last post) had been used since ancient times to describe a debilitating depression that sometimes affected soldiers. This was more than a simple longing to see loved ones or get away from the stress of battle; instead, it was an overwhelming emotional condition that could actually lead to illness and sometimes death. The term dropped out of favor after the U.S.’s Civil War, but medical personnel recognized that soldiers faced particular mental challenges during wartime. During WWI, “shell shock” was a descriptive term for the physical effects that constant bombardment took on soldiers in the trenches. Physicians recognized that soldiers could also suffer mentally from war, and called this condition “traumatic neurosis.” However, the public tended to use “shell shock” to describe any after-effects soldiers suffered.

Still From a 1917 Documentary of War Neuroses, Netley Hospital in Southampton, Hampshire, England

WWI-era physicians understood more about war-related mental trauma than their Civil War counterparts, and they knew that it would occur if the U.S. entered the war. In 1917, the National Committee for Mental Hygiene formed a task group called “the committee on furnishing hospital units for nervous and mental disorders to the United States Government” which began to canvas likely facilities in which to house mentally ill soldiers. Veterans Hospitals were obvious sites, but the committee also contacted the officials at the federal government’s two insane asylums: St. Elizabeths Hospital in Washington, DC and the Canton Asylum for Insane Indians in South Dakota.

Volunteers at St. Elizabeths Hospital Working With Shell Shocked Soldiers, courtesy George Washington University

St. Elizabeths had been created specifically for the military’s insane (and the indigent insane of the District of Columbia), but the Canton Asylum was created solely for Native Americans and had far fewer resources to treat shell-shocked veterans. Most soldiers who went to a government-run asylum went to St. Elizabeths.

Nostalgia and Insanity

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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

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

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.

Medical and Mental

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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

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.

Thoughts on Religion

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Causes of Insanity Included Religious Excitement

Discovering the reasons for insanity proved difficult for early alienists. For many years, these mental health experts attributed the origins of insanity to what modern medicine would call laughable causes: excessive novel-reading, masturbation, smoking, religion and so on. Eventually, a few medical men began to question these sorts of factors as true causes of mental issues.

Dr. John Gray, superintendent of the State Lunatic Asylum in Utica, New York, wrote in 1885 that, “Religion, strange to say, is sometimes set down as a cause of insanity . . . . To some it means that a person is insane on the subject of religion; to others that the insanity was caused by religion.”

Dr. John Gray

Gray recognized that the idea of “Religious Insanity” actually meant that religion caused insanity to many people. His belief, though, was that: “What people talk about when they become insane, has rarely anything to do with the real cause of the disease.” Gray gave a couple of examples concerning his theory, one being the case of a severely overworked minister who finally broke down and began raving that he was Zerubbabel and had been appointed by God to preach “to the spirits in prison” and that he had descended into hell to preach the gospel of salvation and redemption.

“This was not Religious Insanity,” said Gray, “but insanity from exhaustion, religion having nothing to do with it except to give tone and character to his delusions.” Gray found that many people who appeared insane due to exhaustion or broken health could often recover when given rest and proper medical treatment.

State Lunatic Asylum, Utica, New York, courtesy National Library of Medicine

His point of view was a refreshing counterpoint to others in his field who would have labeled a patient like this insane and perhaps never expected a recovery.

Writing Madness

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Sir Arthur Conan Doyle

Though modern readers can find old treatments for mental health laughable, they made sense to a generation just beginning to move away from even more archaic thought on the topic. Victorian-era conceptions about “madness” are wonderfully illustrated in Sir Arthur Conan Doyle’s Sherlock Holmes stories. Doyle had a medical degree (University of Edinburgh, 1881) and had practiced medicine before writing these mysteries, so his presentation of mental illness and its causes likely reflected his own, educated views on it.

Rather than look at madness as a permanent state deriving from physical roots, newer thought allowed for events like shock, overwork, and stress to precipitate bouts of insanity that could hopefully prove temporary if given correct–and timely–care. This idea played out well in “The Adventure of the Naval Treaty.” In the narrative, a young man in a trusted position lost valuable papers and felt himself ruined over it. He tells Holmes and Watson that upon trying to go home after his discovery: “I had a fit in the [train] station, and before we reached home I was practically a raving maniac.”

Illustration from Doyle’s Story Concerning Temporary Madness

Woman Admitted to Bedlam Hospital for Acute Mania, courtesy The Sun

He went on to tell the two that he had been “raving with brain fever” for nine weeks, but that with the tender care of his fiance and doctor, he had just recovered his reason. This episode clearly fit the modern idea that shocks and emotional turmoil could cause insanity–and that so-called acute (recent/short) episodes of insanity, if acted upon quickly, could be cured.

Schools for Insanity

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Alienist Dr. Isaac Ray

People today wonder how physicians and other educated people could have believed excessive smoking, masturbation, or reading novels might lead to insanity. Though anything in excess is probably not as healthy for a person as that same thing in moderation, how could something like “excessive study” cause insanity? An extremely prominent alienist, Dr. Isaac Ray, explained:

“Though hard study at school is rarely the immediate cause of insanity, it is the most frequent of its ulterior causes, except hereditary tendencies.” Ray further declared that the chances of recovery [from insanity] were far fewer in the “studious, intellectual child” than in the opposite type. The reason for this, Ray explained, was that “though the immediate mischief may have seemed slight, but the brain is left in a condition of peculiar impressibility, which renders it morbidly sensitive to every adverse influence.”

irls From Glen Eden Boarding School for Girls, circa 1911

Students From Glen Eden Boarding School for Girls, circa 1911

Ray’s remarks appeared in a September, 1859 issue of the The Atlantic Monthly, within an article strongly admonishing the then-present system of excessive schoolwork for children. A typical schedule in a well-run girls’ boarding school could be something like this: Rise at 5:00 a.m., study for two hours, eat breakfast, spend six more hours in the schoolroom, eat lunch, then spend two hours sewing, writing letters, completing other small tasks, and perhaps walking if weather permitted. Afterward there would be another hour of study, supper, and then two more hours of study–eleven in all. The author later mentioned popular Sunday School contests throughout the country, in which winners memorized up to 5,000 Bible verses.

$An 1854 Math Book by Joseph Ray$

An 1854 Math Book by Joseph Ray

It’s no wonder that many children fell into ill health, whether or not the excessive study actually led to insanity. However, with this kind of tasking in mind, it’s a bit easier to believe the (unnamed) author’s statement that he had recently heard of “a child’s dying insane, from sheer overwork, and raving of algebra.”

Confusion About Insanity

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This Delusional Woman Believed Her Friends Wanted to Hurt Her

Though many alienists (a term for early psychiatrists) felt perfectly competent to treat insanity, few felt that they could actually define it. In his book, A Treatise on Insanity in its Medical Relations (1883), Dr. William Hammond demonstrated the difficult of defining insanity by citing various experts:

“According to Hoffbauer, an individual is insane when the understanding is diverted . . . when he is powerless to avail himself of his intellectual facilities, or to make known his wishes in a suitable manner.” However, Hammond pointed out, this definition would include conditions like “apoplexy and concussion and compression of the brain.”

“The late Professor Gilman . . . declared that ‘insanity is a disease of the brain by which the freedom of the will is impaired.'” As with the previous definition, however, Hammond declared that “this definition neither covers the subject nor excludes other diseases.”

Insanity Could Lead to Unthinkable Crimes

Several alienists Hammond quoted declined to define insanity at all, saying that no definition in any kind of general terms would be useful. Even common manifestations of insanity such as illusions, hallucinations, and delusions could not definitively diagnose it, since there were reasons why these conditions might occur whether a person was insane or not.

Alienists Did Not Necessarily Believe Insanity Caused All or Most Crime (January 19, 1919 Issue of the Chicago Tribune)

One of the issues surrounding the diagnosis of insanity through the ages is that the condition can’t really be defined the way a case of measles or a broken leg can be. Culture, custom, expectations, and so on constantly refine what is acceptable behavior or what will be tolerated through the ages and across cultures.

That leaves the question: What is insanity?

Theories About Insanity

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Dr. Edouard Toulouse

Today’s newspapers very seldom discuss the actual causes of mental illness, but experts in the past were much more confident about their ability to dig out the reasons behind a patient’s problems. In 1922, The Washington Post ran an article in which a Professor Edouard Toulouse stated that there were three primary causes of madness: sorrow, thyroid deficiency, and vice.

Upon checking into his clinic, patients were interviewed, then given a physical exam to see whether they were born “with an excess of thyroid matter” or whether they had become addicts to vice, which included drugs. The good news was that Toulouse believed patients could be cured no matter how their madness originated.

Vice Was Considered A Cause of Insanity

Sorrow, of course, had many origins, but Dr. Toulouse particularly spoke about the difficulty of curing a patient whose sorrow derived from loss of wealth. He said that “practically the only sedative for a person who has once been wealthy and who finds himself suddenly poverty-stricken is to provide him again with wealth.” This course was often impossible, but diversion and time could be effective in healing.

Though Toulouse may have over-simplified the causes and treatments of insanity, his views gave patients’ families great hope. Toulouse firmly believed that nearly all cases of madness could be cured, which had to be comforting to a patient’s loved ones. Furthermore, he thought many cases of madness could be prevented, and said: “It remains now to coordinate our work so that prophylaxis [meaning the prevention of madness] will become legally obligatory.”

Good Mental Hygiene Was Recognized as a Way to Prevent Insanity

The article did not say what all these preventatives might be, but Dr. Toulouse was president of the Paris League for Mental Hygiene and Prophylaxis and surely had many programs and practices in mind. At least one primary avenue he and the League proposed was to stop sending patients immediately to an asylum, and instead assess their condition in a dispensary first and offer outpatient care in milder cases. This one step would likely have alleviated much sorrow and anxiety for patients and their families.

Predicting Madness

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Issue of the American Journal of Insanity

“I am tempted sometimes to think that no person goes mad . . . who does not show more or less plainly, by his gait, manner, gestures, habits of thought, feeling and action that he is predestined to go mad.”

This quote (by a Professor Maudsley) in the October,1872 issue of the American Journal of Insanity, shows clearly that many noted psychiatrists–called alienists at the time–believed they could predict who might eventually go insane. Unfortunately, alienists had little ability to prevent this madness, beyond advising potential patients to avoid certain triggers that might bring it on. Such triggers included overwork, over-excitement, riotous living, worry, financial setbacks, grief, and so on.

Group of Prominent German Alienists

Even more unfortunately, many alienists believed that insanity was rooted in physical causes that could be hereditary. This view had the potential to put anyone who had mental illness within the family in limbo, waiting to see if the illness would manifest. And because it was so often considered hereditary, having a family member with insanity was a barrier to marriage unless its cause could be positively attributed to an unusual circumstance like a blow to the head, sunstroke, or other purely physical cause.

This Eugenics Certificate Shows the Public’s Fear of Undesirable Hereditary Traits, courtesy Robert Bogdan Collection

It is certainly sad to think that many people waited and worried their entire lives over an issue that had no potential to materialize.

Healing, Hell, and the History of American Insane Asylums

The History of Insane Asylums

Category Archives: Mental Health Theory

New Era, New Ideas

A New Term for War-Time Trauma

Nostalgia and Insanity

Medical and Mental

Thoughts on Religion

Writing Madness

Schools for Insanity

Confusion About Insanity

Theories About Insanity

Predicting Madness