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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.

Work and Money

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Clarinda State Hospital Was Impressive

Clarinda State Hospital Was Impressive

Even new insane asylums–presumably built by the demands of a state’s constituents–often had money woes. For many institutions, funds were only provided every two years via legislative appropriations. This meant that they were built piecemeal, seemingly always a step or two behind the real needs of patients and their families. Clarinda State Hospital in Iowa is probably typical.

Iowa’s General Assembly passed an Act to establish the asylum in April, 1884 and the Iowa Grand Lodge of Masons laid the cornerstone in July. A central building and supervisor’s department were nearly finished by December, but it wasn’t until the 1886 session that money was appropriated to go further. The institution opened late that year and accepted its first patients: 222 males received from other asylums. As legislative sessions continued, the asylum received additional funds for building and continued to complete the design which had been planned for it. Finally, in 1897, the asylum stood as a complete entity.

Patients Working in Laundry Room at Fulton State Hospital circa 1910, courtesy Missouri Archives

Patients Working in Laundry Room at Fulton State Hospital circa 1910, courtesy Missouri Archives

As soon as patients arrived, they began working. They graded, sodded, planted, and farmed–hard work rather than the “light” therapeutic work that alienists sincerely believed helped patients occupy their time, divert their minds, and heal both mind and body. Besides the outdoor toil, patients helped a hired tailoress make all the clothing worn by patients (except for white dress shirts, hose, and hats). The asylum’s residents also made their own furniture and shoes, brooms, and mattresses under the supervision of professionals assisted by patients.

Patients Worked at Useful Tasks at Most Asylums, photo courtesy Buffalo Psychiatric Center

Patients Worked at Useful Tasks at Most Asylums, photo courtesy Buffalo Psychiatric Center

Though work did help patients–especially if they wanted to do it–the probability remains high that many patients were subtly coerced into labor they would not have done otherwise. For superintendents charges with controlling costs, the proximity of so much free labor was likely a temptation they didn’t always resist.

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.

Plight of the Attendant

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Stephen Smith, State Commissioner of Lunacy in New York, courtesy Appletons Encyclopedia

Stephen Smith, State Commissioner of Lunacy in New York, courtesy Appletons Encyclopedia

Most asylum accounts deal with the hardships patients faced, but the employee side had difficulties as well. Dr. Stephen Smith, the State Commissioner of Lunacy in New York, wrote about a particularly difficult type of patient for a paper submitted to the National Conference of Charities and Corrections in 1885. In his “Care of the Filthy Cases of Insanity,” Smith explained the problems caused by this particular “class” of patients.

Filthy patients were those who constantly soiled themselves (whether by accident or design) and required a great deal of any conscientious attendant’s time. In his paper, Smith wrote:  “I have seen patients in the asylums of this State who were thoroughly bathed, and had a complete change of under-clothing, and two or three times of their external clothing, eighteen times in a single day. And this occurred in spite of constant watchfulness to anticipate their wants.”

Male patients being washed by hospital orderlies. Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org Male patients being washed by hospital orderlies, Long Grove Asylum, Epsom. In the Royal College of Psychiatrists. circa 1930? Published: - Copyrighted work available under Creative Commons by-nc 2.0 UK, see http://wellcomeimages.org/indexplus/page/Prices.html

Male patients Being Washed by Hospital Orderlies, courtesy Wellcome Library, London. Wellcome Images
images@wellcome.ac.uk

Smith encouraged asylums to place filthy patients on a toilet training and personal care program. He also recommended that sufficient staff for a “night service” be employed, their duties being to help with this training program and to ensure messes were promptly cleaned so as not to disturb other patients in the room. When these measures were adopted, Smith had seen wonderful improvements in ward cleanliness, neat and tidy patients, and a much more pleasant atmosphere. Though constant vigilance would have been burdensome, it is still easy to believe attendants would rather have watched these patients closely than clean them up after an accident.

Executive Committee of the National Conference of Charities and Correction, courtesy of the social welfare library, vcu.edu

Executive Committee of the National Conference of Charities and Correction, courtesy of the social welfare library, vcu.edu

Because many asylums cut their night staffs to provide simple monitoring rather than active care, the financial burden to provide more attendants was likely rejected by most asylums. Day attendants were also stretched thin to save money, but without these measures in place,  the stress of time-consuming and unpleasant clean-ups very likely caused more than a few attendants to snap–either at the offender or a handy target.

Plight of the Sane

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Part of the Original Asylum, Previously Known as the Asylum for the Insane. The Facility Opened in 1818 as a Division of Massachusetts General Hospital

Part of the Original Asylum, Previously Known as the Asylum for the Insane. The Facility Opened in 1818 as a Division of Massachusetts General Hospital

People who were tricked into an asylum by relatives or friends have given heartbreaking accounts of the experience, and Elizabeth T. Stone was no exception. After attending a family gathering on Thanksgiving, she went with her brother to what she thought was a boarding house. She was puzzled by the odd way she was treated upon arrival, the barred windows, and the regimented meals and bedtimes, but it was not until her second day that she learned she was at McLean Asylum and that her brother had had her committed there.

Stone’s despair was enormous, but she had the wit not to show her frantic emotions. She knew her protests and defensive statements would be put down to her “derangement” and that this easy label would not help her with the physicians there. Stone attributed her commitment to the asylum from the religious disagreement she had with her family, but her experience is so much more a lens on the easy commitment laws that prevailed at the time.

A Gilbert Stuart Painting of John McLean, Who Bequeathed a Fortune to the Asylum

A Gilbert Stuart Painting of John McLean, Who Bequeathed a Fortune to the Asylum

A Sketch of the Life of Elizabeth T. Stone and of her persecutions

A Sketch of the Life of Elizabeth T. Stone and of her persecutions

Stone apparently broke down within a short time and and made up her mind to commit suicide by tearing off a strip of her sheet so she could hang herself. The sheet gave way before she actually died, but the incident brought her more restriction. She continued to deteriorate mentally and lost a degree of self-control, though she was always aware of her surroundings. Stone eventually was released to one of her brothers and wrote a bitter account of her stay at McLean. Her book, A Sketch of the Life of Elizabeth T. Stone, was published in 1842.

Asylum Superintendent’s Job Included Danger

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American Journal of Insanity

American Journal of Insanity

Dr. John Gray (see last post) was an influential, well-known alienist, long-time editor of the American Journal of Insanity, and superintendent of the State Lunatic Asylum at Utica, NY. He was also the chief medical expert who had testified for the prosecution at the trial of Charles J. Guiteau, the assassin of President James Garfield in 1882. While sitting in his office one evening of that same year, Gray was shot through the upper jaw by Henry Remshaw in the presence of three other people (including his son, John Gray, Jr.).

Assassination of James Garfield, courtesy Smithsonian Magazine

Assassination of James Garfield, courtesy Smithsonian Magazine

Remshaw’s deed was thought to have been provoked by some aspect of the Guiteau’s trial, and he had apparently made several threats against Dr. Gray previous to the actual shooting. Remshaw ran outside the asylum to avoid capture, fired at his pursuers, and finally reached his home. There, he told a woman living on the lower floor that he had killed Gray, then “danced about, showed her four revolvers, a dirk, and piles of cartridges” and then told her he would give himself up.*

Inmates in Lockstep at Auburn Prison

Inmates in Lockstep at Auburn Prison

When Remshaw did give himself up at the Mohawk Street jail, he turned over his four loaded weapons and cartridges, plus a bottle of acetic acid and opium. Remshaw raved that he was an ambassador sent from heaven to kill Gray, but observers seemed to consider him a “crank and a fraud” more than someone who was insane. A court commission did find him insane, though, and recommended he be sent to an asylum. Remshaw was sent to the Insane Department of the State Prison at Auburn.

Gray died November 29, 1886 from causes attributed to his decline in health following the shooting.

 

*Quoted from an article from the Journal of Psychological Medicine and Mental Pathology.

Thoughts on Religion

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Causes of Insanity Included Religious Excitement

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

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

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.

Central Lunatic Asylum

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Howard's Grove Hospital

Howard’s Grove Hospital

Virginia’s Central Lunatic Asylum was the country’s first asylum designated exclusively for the “colored insane.” The institution’s first report explained that the state of Virginia had established the asylum for “colored persons of unsound mind” on the grounds of Howard’s Grove near the city of Richmond.

Howard’s Grove Hospital–a former Confederate possession–had been taken over by the Freedman’s Bureau in 1865. The agency used it as a hospital for African-Americans in the area and also for any who wandered in from other places. The Freedman’s Bureau allowed insane patients to stay at the hospital, and in December 1869 the facility was organized as an asylum by order of the military governor of the state, General Canby. At that time, there were 24 males and 45 female patients.

Building for Chronically Ill Females at Central Lunatic Asylum

Building for Chronically Ill Females at Central Lunatic Asylum

Virginia took control of the asylum in 1870 and its governor appointed an 11-person court of directors to oversee it; they supported the superintendent’s request for more money to build additional wards in his first report of November 1870. By then, an additional 110 patients had been admitted (December 1869 – November 1870). Eighteen patients had been discharged, fifteen had died, several “idiots” had been sent to alms-houses while a few remained, and altogether 150 persons were in the asylum for treatment on November 1, 1870.

Shenandoah County Alms House, courtesy Shenandoah County Library Archives

Shenandoah County Alms House, courtesy Shenandoah County Library Archives

Records on many of the patients were incomplete, but besides “unknown” the two primary causes of admission were “religious excitement” and “congenital idiots and imbeciles.” The two primary forms of mental disease were “chronic mania” and “dementia” with “paroxysmal (temporary) insanity” running a close third.

Asylums Were Economical

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Exercise Yard at the Oregon State Insane Asylum, circa 1905, courtesy Mental Health Association of Portland

Exercise Yard at the Oregon State Insane Asylum, circa 1905, courtesy Mental Health Association of Portland

Besides the humanitarian reasons to create asylums–which included more success in curing insanity than any family attempts could hope to achieve–supporters could also point out solid savings for the states which funded them.

By the time asylums became popular for the care and treatment of insanity, states had accepted responsibility for citizens who had no means of support or who caused undesirable disruptions in society. Early on, many of the insane wound up in jails because they had no families or their families simply could not give them proper care. Violent cases, of course, were the most problematic for families to handle.

Willard Asylum Patients Working in the Sewing Room

Willard Asylum Patients Working in the Sewing Room

Asylums were able to hold costs down by using patient labor on a much wider scale than most city or county jails could. Many asylums grew their own food and made or manufactured necessities like clothes and shoes. Charities, clubs, and individuals were far more likely to provide amenities (newspapers and magazines, concerts, clothing, etc.) to asylums than to jails, and states generally could provide the insane better care at less expense in asylums than regional jails.

Central Lunatic Asylum

Central Lunatic Asylum

The Central Lunatic Asylum in Virginia had filled almost as soon as it opened, and after only four months of operation, its first Board of Directors pleaded for money to build additional wards so they could take in patients who had been turned away for lack of space. After making a case for more appropriations based on humanity and the higher quality of care found in asylums versus jails, the Board also said:

“Besides the plea of humanity, economy may be urged as a reason for granting the appropriation. It will cost less to support the colored insane at the Asylum than in the county jails, and the prospect of relieving the State of all expense in each case is increased by promptly affording the Patient the benefits of the Asylum.”

 

What Can We Do?

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1800s Plasters to Induce Blisters, courtesy Library of Virginia

1800s Plasters to Induce Blisters, courtesy Library of Virginia

For much of psychiatry’s history, experts were only able to treat symptoms, rather than the causes of mental illness. When insane asylums first came into public use, most alienists had largely abandoned Dr. Benjamin Rush’s (considered the Father of American Psychiatry) depleting treatments, but they still had to find ways to deal with their patients’ moods and behaviors.

One treatment popular in this beginning era of psychiatry was to use a counter-irritant on patients. Doctors would blister someone who was manic in order to divert his/her attention; they would also blister someone who was melancholic in order to “divert the mind from its morbid train of thought.”

Tartar Emetic Was Definitely Potent

Tartar Emetic Was Definitely Potent

For recent cases of insanity–also called acute cases and the most hopeful of recovery–alienists applied tartar emetic ointment to the back of the neck. This ointment consisted of potassio-tartrate of antimony added to one ounce of lard or other carrier; the compound “will produce an eruption on the skin very similar to small-pox in appearance.” Presumably the pain of the treatment would keep a patient’s mind off his original problem. Cold compresses to the head, cold baths or showers, and warm baths with vigorous rubbing of the extremities were also useful treatments for insanity.

Water Therapy Could be as Confining as Restraints

Water Therapy Could be as Confining as Restraints

Readers will note that all these treatments were uncomfortable if not actually painful for the patients. However, inflicting pain seldom deterred alienists intent on “helping” their patients with mental issues.

(These treatments are discussed by Dr. Edward Cowles in the July, 1894 issue of the American Journal of Insanity in his review of psychiatry’s progress over the past few decades.)