Category Archives: Patients

The Dangers of Injury

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Two Men Cooling Off in a Park During the 1911 Heat Wave that Drove Some People to Suicide and Insanity, courtesy New England Historical Society, Library of Congress

Two Men Cooling Off in a Park During the 1911 New England Heat Wave that Drove Some People to Suicide and Insanity, courtesy New England Historical Society, Library of Congress

Alienists (early psychiatrists) believed madness could result from a long list of issues such as heredity, strong emotions, sudden shocks, illness, and physical injury. The latter played a part in many patients going to insane asylums, as newspaper accounts and case studies show:

In 1897:

Maggie Mc. —The doctor in the case testified that she can’t be trusted in public, her conduct not being proper. Five years ago she had a fall that left her unconscious for several hours; her wrist was broken at the time, and now there is a suspicion that her skull must have been fractured. The 28-year-old woman was sent to an asylum.

Phineas Gage Underwent a Personality Change After a Tamping Iron Pierced His Skull in 1848

Phineas Gage Underwent a Personality Change After a Tamping Iron Pierced His Skull in 1848

Timothy O’B. — . . . had acquired a big head, ordering dry goods jewelry in great abundance, with no cash to pay; he also imagines he has valuable property. His trouble began by falling from a ladder two years ago and hurting his back and side, and after developing rough behavior, it is said that he was struck over the head by a policeman, through which he has become a raving maniac.

Probable Causes of Insanity, Missouri State Lunatic Asylum, 1854, courtesy Missouri State Archives

Probable Causes of Insanity Included Injuries, Missouri State Lunatic Asylum, 1854, courtesy Missouri State Archives

Falls from horses, kicks from mules, accidents at work and the like, could all bring on insanity. Most alienists felt that people who did become insane after an injury were predisposed to it anyway, and that the injury brought it out, just as other life experiences like overwork or sudden shock might. An exception would be a traumatic injury to the head which in and of itself could have damaged the brain of an otherwise healthy person.

Changes at Last

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Collection of Dr. Alexander E. MacDonald's Papers, courtesy New York Academy of Medicine

Collection of Dr. Alexander E. MacDonald’s Papers, courtesy New York Academy of Medicine

In 1874 Dr. Alexander E. MacDonald accepted an appointment as superintendent for Ward’s Island’s insane asylum. Conditions there were dreadful (see last two posts) and MacDonald requested a new wing to the main building in 1878 to relieve some of the chronic overcrowding. Both patients and convicts worked on the new construction–not necessarily unusual for the period.

Cheapness had prevailed since day one, and professionals believed that many of the asylum’s cases became chronic because they had not been helped adequately from the start. Even meals were excessively frugal: “Dry bread was a staple article of diet, few accompaniments were permitted and much was diverted by the so-called “cook,” who was selected from the workhouse prisoners,” wrote one of the doctors compiling a history of New York asylums. His assessment is underscored by the fact that when an additional five cents was added to the dietary allowance, along with an improvement in cooking, more patients recovered.

A Supper of Bread, Butter, and Tea on Blackwell's Island, from an 1866 Illustration in Harper's Weekly

A Supper of Bread, Butter, and Tea on Blackwell’s Island, from an 1866 Illustration in Harper’s Weekly

Dr. MacDonald also improved patients’ clothing, bedding, and ward furniture and he fought for a “more liberal” amusement fund to help divert patients’ minds from their problems and give them some enjoyment during their stay. He also fought for attendants, saying that “$20 a month with board was too small compensation for 15 hours [a day] spent in the companionship of the insane.” He called for a whopping 50% increase in pay to $30 a month. Along with this, MacDonald protested using convicts as attendants and managed to get at least the female ones withdrawn. By 1880 he had stopped the use of restraints like manacles, wristlets, and seclusion.

Nellie Bly Posed as an Insane Woman for Her Expose

Nellie Bly Posed as an Insane Woman for Her Exposé

Though MacDonald tried with probably the best will in the world, the four institutions in the Manhattan region were often investigated for a variety of failures. Nellie Bly’s exposé in 1887 is probably the best-known, though many other scandals made it into public knowledge.

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.

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.

 

A New Term for War-Time Trauma

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Patient Suffering From War Neurosis in WWI

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

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

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.

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.

Other Ways to Help the Insane

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Wet Sheet Pack, 1902

Wet Sheet Pack, 1902

Alienists considered light labor a welcome change of pace for patients and a great boon to their recovery (see last post) during the Civil War era. However, they also realized that every patient needed an individual plan that might include other therapeutics than labor, or no labor at all. Most specialists hoped that a calm, supportive environment would bring a patient back to health, but did recognize that sometimes more aggressive measures were needed.

If a patient showed signs of violence, there were several courses open to attendants. Restraint might be necessary, but what kind? “The worst form is where patients are held by the attendants,” said Dr. J. Paragot in his article, “General Mental Therapeutics.”

Restraints Could Be Horrifying For Patients

Restraints Could Be Horrifying For Patients

The next worst form of restraint was a cell, because attendants had to use force to place a patient in one, and then left him/her there in a state of frustration. In Dr. Paragot’s opinion, the best form of restraint was a leather strap around the wrists. “. . . the patient may enjoy the liberty of walking in the fields. . . . the patient may be left alone, no offered active violence overpowers him, it is but a passive resistance which annihilates his efforts.”

Moral restraint, imposed through “love, kindness, and reward” could also motivate patients to change their behavior. Hydrotherapy of various sorts–including swimming in tepid pools–could be beneficial, especially if a patient had the will to change but not the ability. Air baths (rambling about in the open air) could take the place of hydrotherapy for “the higher classes” in order to avoid any type of violence to the patient. Finally, a nutritious diet often helped patients enormously, particularly when they had physical problems as well as mental issues.

Elixer of Opium Promoted Restful Sleep and Composure and Relieved Nervous Excitement

Elixer of Opium Promoted Restful Sleep and Composure and Relieved Nervous Excitement

Tonics and stimulants had their place for patients needing that kind of help, but Paragot generally urged the mildest means possible when doing anything more than counseling a patient. He recognized that hydrotherapy and various types of restraint options were often accompanied with violence toward a patient, which he found particularly negative in terms of a therapeutic outcome. If his enlightened views had prevailed, asylums might not have earned the disdain and dismay that haunt them to this day.

Ways to Treat the Insane

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Leisure Time at Southwestern Lunatic Asylum, circa 1890, courtesy Southwestern Virginia Mental Health Institute

Leisure Time at Southwestern Lunatic Asylum, circa 1890, courtesy Southwestern Virginia Mental Health Institute

Around the time of the Civil War, alienists were still hammering out the best ways to treat the mentally disturbed. Asylums were much more common, and a great majority of alienists felt that removal to one would benefit most patients more than home care. What they particularly stressed was an immediate change of scenery–either to an asylum or by travel–for a patient in the first stage(s) of insanity. By getting this person away from the environment that had brought on the problem, doctors could often snap the person out of the state of mind causing the insanity.

Labor of some kind was also beneficial for the physical health and mental recovery of the insane, which led most asylums to set up gardening and workshop programs for their patients. The author (Dr. J. Parigot) of an 1864 article “General Mental Therapeutics,” did stress that labor must be voluntary. “Free-will labor has the advantage that patients instinctively choose occupations in accordance with their state of health,” Pargot noted. But he also gave the following caveat: “. . . patients ought never to be converted into machines and tools for private speculation.” He was very much against using patient labor to keep down expenses so that an asylum could be self-paying or profitable.

Interior of Shoe Shop, Willard Asylum for the Insane

Interior of Shoe Shop, Willard Asylum for the Insane

Unfortunately, therapeutic labor soon came to include drudge work and difficult farm and dairy tasks that most patients probably did not enjoy. As asylums took in more patients with less per capita state funding, they had to rely on patient labor to offset the costs of food and other goods.

Patients Picking Cotton at Alabama Insane Hospital

Patients Picking Cotton at Alabama Insane Hospital

My next post will continue to discuss therapeutics during the Civil War era.