The Mentally Ill in America: A History of Their Care and Treatment from Colonial Times 9780231895484

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T H E MENTALLY ILL IN AMERICA

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THE MENTALLY ILL IN AMERICA A HISTORY OF THEIR CARE AND TREATMENT FROM COLONIAL TIMES

By ALBERT DEUTSCH W I T H AN INTRODUCTION BY

WILLIAM A. WHITE, M.D., D.Sc., LL.D. Late Superintendent, St. Elizabeths Hospital, Washington, D. C. ; Professor of Psychiatry, George Washington University

I94Ó

COLUMBIA UNIVERSITY PRESS NEW YORK

Third

Printing, FOREIGN

¡945,

Columbia

University

Press,

A G E N T : OXFORD U N I V E R S I T Y PRESS,

Krtv

Yort

Humphrey

M i l f o r d , A m e n House, L o n d o n , E . C . 4, E n g l a n d , AND Β . I. B u i l d i n g , Nicol R o a d , B o m b a y ,

First

and

second

Doubleday,

printings,

Doran

COPYRICHT, BY

THE

AMERICAN

FOUNDATION ALL

RIGHTS

1937,

& Company,

India

1938 Inc.

1937 FOR

MENTAL

RESERVED

HYGIENE,

INC.

CONTENTS PACE

I N T R O D U C T I O N BY WILLIAM A . WHITE, M . D . AUTHOR'S

IX XV

FOREWORD

CHAPTER

I. II. III.

PROPHETS, DEMONS AND W I T C H E S COLONIAL AMERICA: HERITAGE

THE

OLD

WORLD 24

C O L O N I A L P R O V I S I O N S FOR T I I E III:

I

PUNISHMENT,

MENTALLY

REPRESSION

AND

INDIFFERENCE IV.

J9

RATIONAL HUMANITARIANISM: THE

BEGIN-

N I N G S OF R E F O R M V.

BENJAMIN

RUSH: THE

55 F A T H E R OF

AMERI-

CAN PSYCHIATRY VI. VII.

THE

72

R I S E OF M O R A L

RETROGRESSION:

OVER

88

TREATMENT THE

HILL

TO

THE 114

POORHOUSE VIII.

THE

CULT

OF

CURABILITY

AND THE

OF S T A T E I N S T I T U T I O N S IX.

DOROTHEA

LYNDE

DIX:

.

.

.

MILITANT

RISE 132

. CRU-

158

SADER X. XI.

M I D - C E N T U R Y PSYCHIATRISTS CONFLICT

OF

THEORIES:

.

.

.

RESTRAINT

186

. OR

213

NON-RESTRAINT? XII.

T H E T R E N D TOWARD STATE CARE

229

.

XIII.

S T A T E C A R E : E X O D U S FROM T H E POORHOUSE

246

XIV.

P S Y C H I A T R Y E M E R G E S FROM ISOLATION

272

XV.

THE

MENTAL

HYGIENE

MOVEMENT

AND 300

ITS FOUNDER V

vi

CONTENTS

CHAPTER

XVI.

PAGE

HISTORICAL

BACKGROUNDS

OF

MENTAL 331

DEFECT XVII. XVIII. XIX. XX.

C H A N G I N G CONCEPTS I N M E N T A L D E F E C T

O U R COMMITMENT L A W S

4/7

M O D E R N TRENDS I N I N S T I T U T I O N A L

CARE 4.4.0

AND TREATMENT XXI.

TOWARDS M E N T A L H Y G I E N E

353 386

I N S A N I T Y AND T H E C R I M I N A L L A W

.

.

.

.

463

BIBLIOGRAPHY

497

INDEX

5/Ç

I L L U S T R A T I O N S PIXEL

AT THE SALPÊTRIÈRE

.

.

.

.

Frontispiece FACING PAGE

EIGHTEENTH-CENTURY MENTALLY

III

BENJAMIN

RUSH

DOROTHEA

LYNDE

HOSPITALS

FOR

THE

IN A M E R I C A

68 76

DIX

160

THE

ORIGINAL

THIRTEEN

192

OLD

METHODS

OF

ERN

RESTRAINT

SUBSTITUTE

CLIFFORD

W .

AND

A

MOD224

BEERS

304

HYDROTHERAPY, O L D AND N E W

vii

448

INTRODUCTION T T IS with deep satisfaction that I introduce this important book to the reading public. If the lessons it teaches are understood and taken to heart by its readers, society will be the author's debtor. M r . Deutsch's book, the preparation of which has been made possible by the American Foundation for Mental Hygiene, might be described in a very few words by saying that it traces the evolution of a cultural pattern as represented by the way in which people through the years have thought and felt about the so-called insane. It is an exceedingly illuminating presentation and because of the dramatic material with which it deals, it may well prove to be a spearhead for the penetration of important social facts and the understanding of social processes which, presented with less appealing or less startling illustration, might fail to attract attention. It is altogether fitting that in the presentation of this extraordinary and important story of man's struggles with himself, the illustrations should be taken more particularly f r o m their American setting. In this way the whole matter is brought home to us who live in this country and we see what has actually been taking place, more especially since early colonial days, and we can feel that we ourselves are a p a r t of the whole story and that the victories that have been won and the ground that has been gained are assets of which we can avail ourselves. It is always an illuminating procedure to trace the path along which we have come, to become acquainted with the historical forces that are driving us, and their directions, because after all we have to conquer, not by opposing these forces, but by conforming to them. M r . Deutsch's story, therefore, while it may make us ashamed of some aspects of our past and proud of others, ix

χ

INTRODUCTION

offers hope for the future through the realization that the goals toward which we have directed our vision can be attained, but only at the price of unremitting and indefatigable effort. I f we are willing to undertake the task, we can feel assured of the future. It is but another instance of the necessity for eternal vigilance if past gains are not to be lost. It is and has been the function of the National Committee for Mental Hygiene, through all the years since its beginning, to symbolize and to exercise this very function of vigilance, sustained by the unflagging faith of its prescient creator, Clifford W . Beers. Though very different in content and approach, this book resembles in a significant way M r . Beers's classic autobiography, A Mind That Found Itself, since it is intended not merely to entertain or inform, but to stimulate to constructive action. A great amount of research has gone into the making of this book. Hundreds of treatises, reports, articles, and pamphlets have been consulted by M r . Deutsch in its preparation. His approach to the subject as a social historian rather than as a psychiatrist makes possible an objective view free from the temptations of professional partisanship. His data have been gathered with scrupulous care. Interpretations, where they occur—and they are more often implicit in the text than explicit—flow naturally from the facts. " M a n ' s inhumanity to man" is an old theme, so old, in fact, that people repeat the phrase with little appreciation of what lies behind the words in terms of actual human suffering. T h e inhumanity, however, has its foundations in a background of ignorance and misconceptions. Thus in this book we see that inhumanity, with all the ugly facts of ignorance from which it takes root, expressing itself in the end results, not only of neglect, but of actual abuse directed against the helpless and those unable to defend themselves or to retaliate. T h e average reader, as he follows the presentation from chapter to chapter, will find that the whole ugly story is only too easy to understand. Personal ambition, cupidity, cowardice, all the selfish and hateful passions of man, are seen unleashed here in all their fury; we have only to read the daily press today to see instances

INTRODUCTION

χ!

of the same kind staring at us f r o m its pages. But, as M r . Deutsch is at pains to point out, the conditions described in this book are primarily attributable, not to the emotional and mental make-ups of particular individuals, but to broadbased public attitudes corresponding closely to the general manners and mores and to society's phase of development at each stage of its evolution. In the final analysis, too, the effects of such conditions are rather social than individual in their implications. In the somewhat vague terms of oriental mysticism, this might very well be expressed in the words of Buddha, who said: " N o t in the sky, nor in the midst of the sea, nor in the clefts of the mountains, is there known a spot where a man can be freed f r o m an evil act." T o put this concept in somewhat more concrete and understandable terms, I will point an analogy. T h e public health movement came originally into existence by no means as a pure, altruistic effort to save the lives and health of the factory workers who were laboring fourteen,'sixteen, and more hours a day under atrocious conditions of light, ventilation, food, poverty and filth. T h e real impelling force that started movements in this direction was the fact that these degraded human beings were the easy prey of disease. Contagions and infections spread rapidly among them, and when they lived, as they often did, in close proximity to the rich man's home, disease, being proverbially no respecter of persons, o f t e n found its m a r k there. T h e factory owner and the man of wealth, therefore, found in this roundabout way that in order to protect themselves it was necessary to produce different conditions among their employees. This was simply self-preservation. H e r e in this book, therefore, the reader may see unfold before him with reference to a particular cultural pattern, a form, model or paradigm into which probably all social movements might reasonably fit. H e will see how great personalities stand out as nuclear points about which latent tendencies accumulate and become active by way of their leadership. H e will see that progress does not take place in two o r even three, but in four dimensions, that the historical unfoldment of a story such as this can not be understood solely

xii

INTRODUCTION

f r o m its linear presentation page a f t e r page, but must be thought o f in all these dimensions, r e f o r m s in certain places having progressed f u r t h e r than in others, r e f o r m s at certain times having advanced more rapidly and accomplished more than similar efforts at o t h e r times. A n d so he will be prepared to understand the whole complex picture as it is distributed in time and space as the author presents it, and he will realize t h a t the classification o f what has happened through the years by chapter headings is but a convenient method o f presenting the material which the author, f r o m his point o f view, with his vision and background, feels to be most desirable and most practicable. In integrating, wherever possible, the historical process in one particular field o f human endeavor with the general cultural p a t t e r n , M r . Deutsch makes an impressive contribution to this kind o f historical literature. H e has, with much success, resisted the temptation to t r e a t his subject as an entity isolated f r o m the social stream. P e r h a p s no single impression will be stronger than the realization one gets f r o m reading these pages o f the terrific effort t h a t man must make in order to go ahead. T h o u g h it may be temporarily checked here and there, this progressive effort can not be subdued o r destroyed by any obstacles, no m a t t e r how g r e a t . I t carries man along the path o f what we are pleased to call civilization, sometimes even against his will, perhaps, and accomplishes o v e r and over again results which at the inception o f the enterprise, m a y have seemed impossible o f achievement. T h u s as the reader peruses these pages, he will get two pictures o f man, diametrically opposed to one a n o t h e r . H e will see man in all his weaknesses, the minutest o f specks in a gigantic universe, struggling against cosmic forces so great that it seems impossible that he should even survive. H e will see him stumbling and blundering along, being eliminated and eliminating himself in vast numbers as the result o f his mistakes, but nevertheless somehow continuing to exist. On the o t h e r hand, he will see him as exemplifying, incarnating those very cosmic forces which are o f such stupendous power, expressing them in his acts and in his

INTRODUCTION

xiii

thoughts, and surviving in spite o f all, a really gigantic character because o f what he represents, no longer minute, but cosmic in proportions. A n d t h a t which survives survives in the thin line that lives on f r o m generation to generation, and t h a t which perishes by the million perishes, at least to some extent, in o r d e r that the others may live. I t is a marvelous picture that the author paints, a significant p a r t o f the g r e a t story o f man as illustrated in the particular set o f circumstances so vividly set f o r t h in these pages. I t is fitting, perhaps, t h a t a final word be said about the future. W h i l e man and his affairs present problems infinitely too complex to w a r r a n t prophecy in detail, still it is f a i r to assume that the results in the future, quantitatively at least, will be comparable to results t h a t have been reached elsewhere when science has been brought to bear upon the particular problem involved. T h o s e who can look back in their experience over a period o f time will realize that, as a matt e r o f fact, enormous progress has been made and t h a t perhaps the most significant o f all results has been attained, namely, the widespread recognition o f the existence, the importance and the significance o f the problems o f mental health. W i t h this recognition and the added f a c t that science is turning its effort in the direction o f their solution, the future may reasonably be considered assured. A n d so this b o o k o f M r . Deutsch's is not only a record o f past atrocities and o f g r e a t accomplishments, but a presentation o f developing cultural patterns and trends o f thought which presage wondrous accomplishments f o r the future. I t is hoped that the readers o f this book will not only be intrigued by its contents as dramatic appeal, but will also be able to read the implications between the lines. Such a s t a g e o f civilization as we have thus f a r reached has not been attained by a process o f drifting, but only by the hardest kind o f sustained effort o v e r long periods o f time. T h e primitive instincts with which man originally battled his way a m o n g the crude forces o f nature have not perished. T h e y still exist, but man must no longer be at their mercy. H e must be able to recapture f o r socially constructive ends the energies that they represent. T h a t is the lesson o f mental

xiv

INTRODUCTION

hygiene and that is the lesson which this book teaches. I t should be widely read, f o r its message is of the utmost significance.

WILLIAM A .

January 7, IQ37 St. Elizabeths Washington,

Hospital D. C.

WHITE

Foreword

T

H R O U G H O U T the greater part of human history the role of the medical man in the care and treatment of the mentally ill has been a minor one. Only in recent decades has the medical approach assumed a dominant position in this field. For many centuries the insane were regarded as demoniacs and were consequently often handed over to the exorcist or even to the executioner, when they were not completely abandoned. In later times they were frequently treated as criminals and paupers and as such came under the supervision of penal and poor law authorities. T h e story of the mentally ill falls largely within the penumbra of social w e l f a r e development; this relationship has served as a major frame of reference in my approach to the subject. I have tried to bring into sharper relief the important though often obscure social factors that have conditioned attitudes toward, and treatment of, mental disease through the centuries. Since the care and treatment of the mentally ill in America have been profoundly influenced by men and movements abroad, I have traced foreign developments wherever necessary for the clarification of trends in this country. I have also included an introductory chapter outlining the history of the insane from early times to the founding of the American colonies. In dealing with the medical aspects of the history of the mentally ill, I have been fortunate in receiving the generous aid and advice of a number of specialists in the field. M a n y technical details in psychiatric development were clarified f o r me, and many errors avoided, through their valuable suggestions. I am indebted to the following psychiatrists for reading parts of my manuscript submitted to them for criticism: Drs. Earl D. Bond, C. Macfie Campbell, Clarence O. IV

xvi

FOREWORD

Cheney, Clarence B. F a r r a r , Samuel W . Hamilton, Clarence M . Hincks, Nolan D . C. Lewis, W i n f r e d Overholser, H o w a r d W . Potter, M o r t i m e r M . Raynor, A r t h u r H . Ruggles, William L . Russell, George S. Stevenson, and E d w a r d A. Strecker. D r . William A. White, whose lamented death occurred shortly before publication of this book, was of great assistance to me during the preparation of my manuscript. Professor Clarence G. Dittmer of N e w Y o r k University read my manuscript with an eye to sociological content. P r o f e s s o r Sheldon Glueck read the chapters on insanity and the law. D r . Stanley P. Davies and M r . H a r r y L . Lurie also read parts of the manuscript. D r . H o r a t i o M . Pollock of the N e w Y o r k State Department of M e n t a l Hygiene read the entire work in galley proof. Of course, none of the aforementioned individuals is responsible for errors that may appear in this book, or f o r interpretations and conclusions. I am obligated to the staff of the National Committee f o r M e n t a l Hygiene, particularly Miss M a r g a r e t H . Wagenhals and M r . Paul O. Komora, f o r their splendid cooperation. D r . George L . Banay, medical librarian of the Worcester State Hospital, compiled the index. F o r their many courtesies in affording research facilities I am indebted to the staff members of several libraries, particularly to M r . Charles F. McCombs of the New York Public Library, M r s . Bertha C. Hulseman of the Russell Sage Foundation Library, D r . Jacob Shatzky of the Library of the N e w York State Psychiatric Institute and Hospital, and D r . W a l t e r R. Bett, Librarian of the College of Physicians and Surgeons, Columbia University. I gratefully acknowledge the grant awarded to me by the American Foundation f o r Mental Hygiene, which m a d e possible the preparation of this work. Above all, I am deeply indebted to M r . Clifford W . Beers f o r his innumerable services during the planning and preparation of the book. H e has given unstintingly of his time and energy, facilitating my work at many points, opening up valuable channels of assistance that otherwise would have

FOREWORD

xvii

been difficult of access. H i s infectious enthusiasm and helpful counsel were constant sources of stimulation to me. Any return that I could make f o r his splendid cooperation could best be measured in terms of the success this book attains in attracting attention to the cause of the mentally ill—a cause which he has made his life-work. ALBERT DEUTSCH

THE MENTALLY ILL IN AMERICA

CHAPTER

I

Prophets, Demons and Witches

B

E F O R E medicine, there w a s magic.

Primitive man peoples the w o r l d about him with g o d s and demons. H e sees spirits in the trees, in the winds and the moving clouds, in storms and lightning, in the running rivers, in sun and moon, in the v e r y stones he treads upon. T h e s e spirits, benevolent and malevolent, control his destiny f o r g o o d or ill. T h e y are particularly responsible f o r his misfortunes. T h e primitive mind does not r e g a r d sickness, disease, o r even death as the consequence of natural phenomena. R a t h e r are they looked upon as the results of supernatural intervention on the part o f the spirits which fill his world. In his naïveté primitive man feels confident that by learning certain secrets and mysteries, certain rituals and incantations, he can in turn gain control o f the supernatural spirits and manipulate them to his own purposes and desires, or at least to neutralize t h e m — t o w a r d off illness, f o r instance. H i s efforts to manipulate external forces t h r o u g h supernatural means o r k n o w l e d g e constitute the kernel o f magic. T h e explanation o f disease is simple and all-inclusive; it may be brought on by a " g o o d " deity o r spirit as a punishment f o r some sin o r s l i g h t ; m o r e o f t e n it is ascribed to an evil demon acting out o f sheer malevolence. Sometimes it operates at a distance; at other times it actually enters the body of the intended victim and carries on its nefarious w o r k f r o m within. Disease thus becomes identified with a personal demon. If this theory could serve to explain physical diseases, how much more reasonable must it appear to the untutored mind when applied to mental disorders, which manifest themselves in such awesome and mysterious f o r m s ?

2

T H E MENTALLY ILL IN AMERICA

Obviously, the ascribed causes of disease in any age determine the methods a d o p t e d f o r prevention and cure. Since mental diseases, along with other f o r m s of illness, are supernaturally induced, p r o p h y l a x i s and cure are sought in magic. T o w a r d off disease, talismans and amulets are w o r n , and other magic protective devices are utilized. Sickness is cured by exorcising the demon f r o m the person possessed, t h r o u g h incantation and p r a y e r , t h r o u g h propitiation, cajoling, and even threats. On occasion, when the possessing demon is reg a r d e d as a c o r p o r a l being, physical torture, such as squeezing o r scourging the body, m a y be resorted to in driving him out. In time, the study and practice of magic f o r healing and other purposes becomes the specialty of a f e w in the community, and thus is e v o l v e d the sorcerer, w i z a r d , medicine man, priest, and priest-physician—all f o r e r u n n e r s of the m o d e r n doctor. It is s a f e to assume that mental disease has always existed among mankind. O f course, w e h a v e no means of ascertaining its prevalence in e a r l y times. In all probability, h o w e v e r , it w a s less p r e v a l e n t in ancient d a y s than it is now. T h e mental and nervous strains arising f r o m participation in a progressively complex civilization w e r e absent, life was m o r e stratified, competition between individuals less fierce, and b r e a k d o w n s attributable to social causes of this kind w e r e probably much less frequent. D r . D . H a c k T u k e , in a treatise on this subject, concluded that present-day civilization, with its increasing demands on the individual, and the extreme complexity and divergences of its socio-economic relationships, inevitably carries in its w a k e an increase in the rate of mental d i s o r d e r s . 1 F r o m time i m m e m o r i a l , the confounding of mental illness with demoniacal possession has existed. It survives tod a y o v e r g r e a t a r e a s of the earth, not only a m o n g primitive tribes in A f r i c a , the E a s t Indies and A u s t r a l i a ( w h e r e the belief is f o u n d in its most pristine f o r m s ) , but even a m o n g highly civilized people, either openly espoused o r concealed under the cloak of religion. I t is interesting to note that not N O T E : B i b l i o g r a p h i c a l references indicated in the text may be found on pages 497 to 514.

PROPHETS, D E M O N S A N D W I T C H E S

3

many years ago a brochure by a respectable London physician was published which vigorously defended the belief in demoniacal possession as the cause of mental illness, and advocated exorcism as its cure. 2 M a n y instances of possession are mentioned in the Bible. Most familiar, perhaps, is the story of Jesus casting out the devils f r o m two possessed men, and causing the evil spirits to enter into a herd of swine, which forthwith plunge headlong over a cliff to their destruction. ( M a t t h e w , viii, 28.) In the Old Testament, the melancholia of King Saul is ascribed to an "evil spirit" sent down by God to trouble him, and is cured by the harp-playing of D a v i d — t h e first record of music used as a therapeutic agent in mental illness. ( I Samuel, xvi.) Another famous Biblical instance of insanity is the case of the Babylonian King, Nebuchadnezzar, who seems to have been stricken with madness f o r a period of seven years. Some authorities interpret his disorder as lycanthropy (a condition in which a person imagines himself to be, and imitates, a wolf or some other animal), since it is stated that he roamed the fields as a beast, and "did eat grass as oxen, and his body was wet with the dew of heaven, till his hairs were grown like eagles' feathers, and his nails like birds' claws." (Daniel, iv, 3 3 . ) Popular belief among the ancient Hebrews also attributed mental derangement to the "seizure" of a person's body by the soul of a wicked or murdered man which could find no rest elsewhere. Among the ancient Egyptians, who attained a remarkably high degree of civilization long before the great age of Greek culture burst upon the world, the care and treatment of the mentally ill was naturally conditioned by the prevailing notion of demoniacal possession. T h e y seem to have regarded all diseases as literally personal demons or spirits. It is interesting to note, in this respect, that the words " c u r e " and "relieve" seldom occur in the papyrus prescriptions that have been preserved to us. Rather do we find such significant terms as "banishing," "driving out," " t e r r i f y ing," "destroying" and "shattering" the disease, expressions in which the implication of possession by personal beings is obvious.

4

T H E M E N T A L L Y ILL IN

AMERICA

In E g y p t the a r t of healing was exclusively practiced by the priesthood, who jealously guarded the secrets of their c r a f t as sacred mysteries. T o the temples came those suffering f r o m mental and physical ailments, to be exorcised by the priest-physicians. E l a b o r a t e , stylized invocations were used in the resulting ceremonies, the potency of which was greatly heightened if the name of the indwelling demon were known to the exorcist. A common invocation used f o r head ailments began : " O , enemy, male o r female ! O dead, male or female 1 Descend not on the head of M , the son of N , " and went on to name the protecting gods of the sufferer in order to strike t e r r o r into the possessing spirit. 3 At times, the exorcist would don the disguise of a powerful god to deceive the disease-demon, and to drive him out with dire threats in the name of the deity represented. W i t h the passing of centuries, incantations came to be accompanied more and m o r e by physical remedies such as herbs, vegetables, and ointments. Precious stones were also prescribed; lapis-lazuli seems to have been a favorite remedy f o r hysteria. 4 T h e s e concoctions, it was believed, had no therapeutic values per se, but were imbued by supernatural agencies with magical properties. T h r o u g h an age-long process of elimination and selection, however, remedies which experience proved to be most efficacious naturally survived the others, and thus there were preserved some really beneficial medicaments, some of which, like hyoscyamus, are still used in the treatment of certain mental diseases. T h u s did the pharmaceutical aspects of healing gradually grow in importance, though the mystical and ritualistic trappings continued to dominate the healing art. Nineteenth century commentators on the history of insanity were prone to regard the practices of ancient E g y p t as a "golden a g e " in the care and treatment of the mentally ill, a tendency which still persists. T h i s idealization of Egyptian practices has resulted in some amusing exaggerations. Thus, one commentator writes : In remote times enlightened views of insanity were entertained ; intelligent and humane treatment was taught and practiced, first by the

PROPHETS, DEMONS A N D W I T C H E S

5

learned priests of Egypt . . . ( w h e r e ) . . . melancholies were brought in considerable numbers to the temples. W h a t e v e r gifts of nature or productions of art were calculated to impress the imagination were there united to the solemnities of an imposing superstition. Games and recreations were instituted. T h e most voluptuous productions of the painter and sculptor were exposed to public view. Groves and gardens surrounded these shady retreats, and invited the distracted devotee to refreshing and salubrious exercise. Gaily decorated boats sometimes transported him to breathe, amid rural concerts, the pure breezes of the Nile. In short, all his time was taken up with some pleasurable occupation, or by a system of diversified amusements enhanced and sanctioned by a pagan religion.'

Unfortunately this rhapsodic, romantic picture of the treatment accorded the insane has little basis in real fact. Nevertheless, it has been accepted as veritable by many eminent writers on psychiatry, including the most famous of all, Philippe Pinel, whose own description of Egypt's treatment of mental illness is paraphrased in the above quotation. T h e "golden a g e " myth probably originated at the time archaeologists first began to disclose the true wonders and glories of the long-lost Egyptian civilization to an astonished world, swinging the pendulum of historical opinion to the extreme of over-estimation of certain aspects of that civilization. Mistranslations, misinterpretations, and corruptions of ancient texts have also played a part in furthering this legend. Its main flaw lies in the imputation that insanity was recognized by the ancient Egyptians as distinct from other kinds of disease, and was specifically treated as such, an assumption without the slightest foundation in authenticated evidence. On the contrary, the eminent Egyptologist, Sir John Gardner Wilkinson, indicates that insanity was not distinguished by the ancient Egyptians from other diseases, nor could it have been given specific treatment, and subsequent medical evidences bear him out.® In early Greece, as in Egypt, mental disorders were looked upon as divine or demoniacal visitations. T h e r e are numerous references in Greek mythology to madness sent down upon human beings by angry and displeased deities. " W h o m the gods would destroy, they first make m a d , " runs a popular

6

THE MENTALLY ILL IN AMERICA

Greek saying. P e r h a p s the best-known instance of insanity in classic myth is that of Hercules, whom the goddess H e r a causes to be seized by Madness (literally, Lyssa, a personal d e m o n ) . In the midst of this seizure, which would today be diagnosed as epileptic f u r o r , Hercules goes on a murderous rampage, slaying his own children, and also those of his b r o t h e r . N o t always, however, did insanity indicate the illwill of a god. In some cases, where mental illness was characterized by certain forms of religious delusions, the afflicted one was looked upon as being favored by the gods, and in communication with them, and consequently was revered as a holy man or prophet. T h e r e is, indeed, reason to believe t h a t the far-famed oracles at Delphi may have been partly recruited f r o m this category of the mentally ill. Therapeutic measures in mental illness were based on the prevailing theory of causes. Greece, like Egypt, had her healing shrines, the temples of Aesculapius, god of healing, whose emblem was a serpent coiled round a staff. A t the height of influence of the Aesculapian cult, these temples numbered more than three hundred, the most renowned of which were located at Epidaurus and Cos. T h e y were presided over by the Asklepiads—priest-physicians who claimed descent f r o m the god himself, and through him the power of healing. H e r e , too, ritual and incantation served at first as the only forms of curative treatment, to which pharmaceutic remedies were gradually added. Undoubtedly mental sufferers were brought to these shrines along with other ailing persons, and were subjected to the same mystical ministrations of the Asklepiads. A f t e r undergoing an elaborate and impressive ritual of purification, the diseased were taken to the temples at night to partake of the famous "temple sleep", f o r which cots were provided. H e r e they awaited the god who would appear to them in their dreams, tell them the nature of their ailments, and deliver instructions for treatment and cure. Customarily, an attendant, dressed as a god, would walk slowly and sedately through the temple as morning approached and, by touching the ailing devotees, indicate where their ills were seated, and perhaps bend down to whisper a remedial

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formula in their ears. T o the tense, excited and anticipatory minds of the sick, it was not difficult to believe that they were being visited by a bona fide divinity. It cannot be doubted that the salubrious and stimulating environment in which these temples were usually located had the effect of sending many a sick sojourner home cured. On the other hand, lest we draw an incorrect corollary from the fact, it should be kept in mind that these environmental influences on prospective patients were most probably never taken into consideration when the temples were built, and that their location was purely accidental in its effect on the sick. T h e central idea in therapeutic theory and practice was the appeal to supernatural agents. Ritual was paramount, and the curative role of nature was deemed insignificant, if it was recognized at all. Moreover, if the unlucky patient did not respond, within a short period, to the priestly rites and incantations, he was unceremoniously cast out from the temple as one accursed and unworthy of cure, since the gods, in failing to expel the disease from his body, had unmistakably signified their displeasure with him. By this device, incidentally, the wily priests created an iron-bound alibi f o r all failures, f o r successful treatment depended not only on their potency, but on the patient's own standing with the gods. Thus, at first, the healing art was inextricably bound up with religion, and in truth served only as an adjunct of the latter; the priest and physician were one. Gradually, however, medicine freed itself from the domination of religion. With the development of the Greek spirit of inquiry, which burst into full flower in the fourth century B.C., the general theory and practice of medicine, and its psychiatric application, made tremendous strides forward. T h e contributions of the Greek physicians and philosophers (there was a close relationship between the two) to our subject during this period consist mainly in ( ι ) the recognition of natural phenomena as the causes of mental diseases; ( 2 ) attempts, however crude, to classify the various mental afflictions; ( 3 ) location of the brain as the center of intellectual activity; and ( 4 ) the formulation of specific remedies in the treatment of mental illness.

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It was an Asklepiad of Cos, Hippocrates ( 4 6 0 - 3 7 0 ) , known as the f a t h e r of medicine, who laid the basis f o r the rational and scientific treatment of diseases, including those comprehended under the term insanity. Born into that great age of Pericles, which saw perhaps the finest flowering of genius the world has ever known, Hippocrates earned the gratitude of future generations in stripping medicine of much of its supernatural trappings, although superstition and magic were to play an important, if not dominant, role in therapeutics f o r centuries a f t e r his time. H e ridiculed the current notion that mental diseases were supernaturally induced. Discussing epilepsy, then commonly known as the "sacred disease", he w r o t e : " T h e sacred disease appears to me to be no wise more divine nor more sacred than other diseases; but has a natural cause f r o m which it originates like other affections. M e n regard its nature and cause as divine f r o m ignorance and wonder, because it is not at all like other diseases." H e also attacked the popular notion that cure could be effected merely by the rites of purification and incantation, remarking with wisdom that "they who first attributed this disease to the gods seem to me to have been just such persons as the conjurors, purificators, mountebanks and charlatans now a r e . " 7 W i t h remarkable acumen (when we consider that even that expert anatomist, Aristotle, regarded the brain as a mass of inert, functionless m a t t e r ) , Hippocrates s a i d : " M e n ought to know that from nothing else but the brain come joy, despondency and lamentation . . . and by the same organ we become mad and delirious, and fears and terrors assail us, some by night and some by d a y . " A sharp observation f o r that age, even if falling short of complete accuracy. Hippocrates explained mental illness according to his system of humoral pathology, whereby all diseases were caused by disproportions of the four humors—black bile, yellow bile, mucus and blood—affecting the heat, cold, dryness and moistness of the body. Purging and blood-letting came into general use about this time in the treatment of mental diseases, and were to continue as popular remedies well into the nineteenth cen-

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tury. Hellebore was the most widely used drug in the treatment of the insane, and great healing power was attributed to it. Among the Greek physicians who made important contributions to the advance of psychiatric knowledge and practice was Asclepiades of Prusa (born B.C. 1 2 4 ) who prescribed diet, massaging, bathing and exercise f o r mental patients under his care. H e berated his contemporaries who placed their patients in dark chambers on the supposition that darkness was conducive to peace and quiet of mind, and prescribed light, sunlit rooms for his own patients, reasoning that their delusions and fears could be dispelled by the perception of concrete reality. T o Aretaeus the Cappadocian, who lived in the second century A.D., we are indebted for progress in the field of classification. In pointing out the relationship between mania and melancholia, he anticipated Kraepelin's classification of manic-depressive psychosis by nearly two thousand years. He also differentiated between cerebral and spinal paralysis, and described accurately the symptoms of epilepsy, apoplexy and hysteria. This was a long step forward from the simplified classification of the pseudo-Plato, author of Alcibiades II, who thus classified the "different kinds of unsoundness of mind" : "Those who are afflicted by it in the highest degree are called mad. Those in whom it is less pronounced are called wrong-headed, crotchety, or—as persons fond of smooth words would say—enthusiastic or excitable. Others are eccentric, others are known as innocents, incapables, dummies. . . . All these kinds of unsoundness of the mind differ from one another as diseases of the body do." Soranus of Ephesus (fl. 2nd century) adopted many of the beneficial aspects of Asclepiades' theory, and added a number of original contributions which, for humane understanding of mental illness, were barely approached until the time that Pinel struck off the chains from the insane at the Bicêtre. Some of his directions could serve even today as the basis of an attendants' manual in the most modern mental hospitals. H e advised that patients be placed in light rooms with regulated temperatures, under conditions of utmost sanitation and comfort. They were not to be irritated or exasperated

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by r o u g h handling o r unnecessarily h a r s h c o m m a n d s ; f r e quent c o m i n g s and g o i n g s of s t r a n g e r s w e r e to be strictly f o r b i d d e n . Sixteen centuries b e f o r e J o h n C o n o l l y c a u s e d a f u r o r e by p r e a c h i n g his " n e w " and d a r i n g d o c t r i n e o f " n o n r e s t r a i n t " , the gentle S o r a n u s o b s e r v e d : " M e a n s o f r e s t r a i n t , e m p l o y e d w i t h o u t m a n a g e m e n t , increase a n d e v e n o r i g i n a t e f u r y i n s t e a d of calming i t . " In his f o o t s t e p s w a l k e d a w o r t h y successor, C a e l i u s A u r e l i a n u s (fl. 5th c e n t u r y ) , a R o m a n physician w h o s e w r i t ings a r e n o w r e g a r d e d as consisting mainly o f p a r a p h r a s e s o f lost o r i g i n a l s by S o r a n u s . T h e f o l l o w i n g specimen pass a g e , in which A u r e l i a n u s bitterly a r r a i g n s the m e t h o d s of s o m e o f his c o n t e m p o r a r i e s , is r e m a r k a b l e f o r its h u m a n e insight : They seem mad themselves, rather than disposed to cure their patients, when they compare them to wild beasts, to be tamed by deprivation of food and the tortures of thirst. Doubtless led by the same error, they want to chain them up cruelly, without thinking that their limbs may be bruised or broken, and that it is more convenient and easier to restrain them by the hand of man than by the often useless weight of irons. They go so far as to advocate personal violence, the lash, as if to compel the return of reason by such provocation. T r u l y , here w e r e sentiments t h a t w o u l d h a v e s e e m e d f a r m o r e a d v a n c e d than the practices existing little m o r e t h a n a c e n t u r y a g o ! W o u l d t h a t they h a d never been n e g l e c t e d by l a t e r g e n e r a t i o n s , as they w e r e f a t e d to be. T o i n f e r , h o w e v e r , that the t h e r a p y a d v o c a t e d b y S o r a n u s a n d C a e l i u s A u r e l i a n u s w a s r e p r e s e n t a t i v e of t h e i r t i m e s w o u l d b e h a r d l y less m i s l e a d i n g than to conclude f r o m a r e a d i n g o f J e s u s ' s e r m o n on the M o u n t t h a t it s u m m e d up the ethics of H i s time. M o r e likely the m e t h o d s a g a i n s t w h i c h A u r e l i a n u s h u r l e d his s h a r p lance in the p a s s a g e j u s t q u o t e d w e r e the v e r y ones receiving widest a p p l i c a t i o n . F u r t h e r m o r e , even the m e t h o d s a d v o c a t e d by p i o n e e r s like A s c l e p i a d e s , S o r a n u s and A u r e l i a n u s c o m p r i s e d in e f f e c t a leisure-class t h e r a p y f o r that time, a t h e r a p y a v a i l a b l e to only a small, insignificant p o r t i o n of the p o p u l a t i o n . S u r e l y ,

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in a land where the majority of people were destitute not only of comfort, but of what would today be considered the barest necessities of life, the elaborate and costly treatment of Soranus, which included theatrics, music, and leisurely voyages, could hardly have found universal application. It is more reasonable to conclude that the methods advocated by Celsus (fl. ist century) in his epitome of the medical thought and practice of his day were the ones in general vogue. Celsus, who was otherwise a keen and enlightened observer, advocated chains, flogging, semi-starvation diet and the application of terror and torture as excellent therapeutic agents. In both Greece and Rome the slaves invariably constituted the great bulk of the population. In view of the extreme cruelty and indifference with which this class was treated generally, it is inconceivable that the insane among them would receive enlightened care. T h e great majority of insane persons had little or no opportunity f o r cure, except through the inexpensive vis medicatrix naturae. There is, indeed, a strong suspicion, corroborated by early Christian writers, that among the poorer classes of Greece and Rome, mentally diseased persons were frequently put to death as undesirable or intolerable burdens, in the absence of public provision f o r their care. T w o notable names stand out in the centuries immediately following the fall of Rome—Alexander of Tralles ( 5 2 5 6 0 5 ) and Paulus Aegenita (c. 6 3 0 ) , both of whom carried on the humane traditions of Soranus, although neither made any important contributions to psychiatric practice. Some of the recorded "sympathetic" cures of Alexander are amusing. H e tells us, f o r example, that one of his patients who suffered under the delusion that his head had been cut off by order of the king, was cured when the good doctor fashioned f o r him a leaden hat, the great weight of which convinced him that his head had been restored to his shoulders. Another patient thought she had swallowed a serpent which she could feel wriggling about in her stomach. A f t e r racking his brains f o r a remedy, the doctor finally gave her

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an emetic, and d e f t l y slipped a snake into the vomit basin. H e convinced her t h a t it was the one she had swallowed, a n d thus (so he claims) effected a complete cure. F a n t a s t i c as the a f o r e m e n t i o n e d therapeutical methods m a y a p p e a r in the light of modern knowledge, they seem r e m a r k a b l y rational when compared with the general attitudes t o w a r d insanity, its causes, and cure, that prevailed d u r i n g the middle ages and succeeding centuries. Certainly, if the sound f o u n d a t i o n s of inquiry and practice laid down by the p a g a n apostolate of mental medicine had been built upon by their Christian successors, a mighty bulwark could h a v e been erected against the appalling wave of primeval superstition which swept over E u r o p e a n civilization f o r a millennium and m o r e . T h e physician once more surrendered his a r t to the priest; science was submerged by superstition, o p e r a t i n g u n d e r the convenient guise of religion. W h i l e recording this melancholy fact, we have no desire to f u r t h e r t h e erroneous impression t h a t the middle ages represent a totally static interlude in the general advance of civilization. T h e contributions of the medieval era to such fields as practical invention, geographic and astronomical discovery, commerce and s t a t e c r a f t , were of lasting i m p o r t a n c e : imperceptibly they laid the bases f o r many of our m o d e r n institutions. But it is also t r u e that a wide area of scientific e n d e a v o r was o v e r s h a d o w e d by the d a r k clouds of superstition. In t h a t field of medical science which t r e a t s with mental illness, particularly, the tide of progress was not only halted but washed back. A long period of retrogression set in t h a t lasted not only t h r o u g h the middle ages, but f o r centuries afterward. D u r i n g this period the natural therapy of earlier centuries was succeeded by a superstitious mixture of astrology, alchemy, and a r e t r e a t to theology, magic rites and exorcism, with the accompanying belief in demoniacal possession. A tenth century prescription f o r insanity, cited in t h a t excellent collection, of Leechdoms, Wortcunning and Starcraft of Early England, by the Rev. Oswald Cockayne, reads as f o l l o w s : " I n case a m a n be lunatic; t a k e a skin of mereswine (sea-pig) or porpoise, work it into a whip, swinge t h e

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man therewith, soon he will be well. A m e n . " F r o m the same source, we obtain the following prescription: A drink for a fiend-sick man, to be drunk out of a church bell; githrife, cynoglossum, yarrow, lupon . . . flower de luce, fennel, lichen, lovage ; w o r k up the drink off clear ale, sing seven masses over the worts, add garlic and holy water, and let the possessed sing the psalm, Beati Immaculati . . . then let him drink the drink out of a church bell and let the mess priest sing this over him, Domine, Sánete Pater Omnipotens."

A s a cure f o r epilepsy, Peter of Spain, a prominent physician of the 1 3 t h century, who became Pope J o h n X X I , prescribed the liver of a vulture drunk f o r nine days, " o r the gall still warm f r o m a dog who should have been killed the moment the epileptic fell in the fit.'" T h e astrological influence whence came the term lunatic (i.e., " m o o n s t r u c k " ) may be perceived in this medieval remedy f o r the same disease: F o r the falling sickness (epilepsy) take berries of this w o r t , which w e name asterion, administer it to be eaten when the moon is on the wane, and let that be when the course of the sun is in the constellation named V i r g o ; that is, in the month which is called A u g u s t ; and let him have the same w o r t hung on his swere (neck) ; he will be cured. 10

In E n g l a n d of the 16th century, a favorite prescription f o r "gathering the remembrance of a lunatic" was to beat and cudgel him until he had regained his reason. T h e efficacy of scourging as a remedy is affirmed by no less a personage than the gentle Sir T h o m a s M o r e . Relating the case of a man who, a f t e r apparently recovering, had relapsed into insanity, Sir T h o m a s writes with satisfaction : " I caused him to be taken by the constables and bound to a tree in the street before the whole town, and there striped him till he waxed weary. Verily, G o d be thanked, I hear no harm of him n o w . " In harmony with the spirit of the times, healing wells and shrines were scattered throughout Europe, some of which claimed miraculous curative powers f o r the mentally

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diseased. Treatment f o r mental illness at special holy wells was popular in Great Britain, where St. Fillan's and St. Ronan's wells, St. W i n i f r e d ' s in Wales, and G r e a t Nun's Pool were among those widely known f o r the healing potency of their waters. On the continent were shrines dedicated to various saints, the miraculous cures of which were likewise f a m e d in medieval times. T h e most famous of the shrines consecrated to the cure of mental illness was located at Gheel in Belgium, and was dedicated to St. Dymphna. According to tradition, the princess Dymphna had been driven insane by the behavior of an incestuous father, and had fled to Gheel, where she was martyred. L a r g e numbers of lunatics were brought to this shrine to partake of its cure, and thousands were reputed to be healed by its miraculous virtues. T h a t many of these cures were real can hardly be doubted; the efficacious influence of that intangible something variously known as faith, the will to believe, auto-suggestion, etc., in mental therapeutics is no longer considered a matter of mere credulity, but a scientifically demonstrated fact. F r o m its "miraculous" beginnings, the village of Gheel has become a world-famous colony, to which mentally ill f r o m many lands come to avail themselves of the family system of treatment f o r which it is noted. H o w e v e r absurd were the remedies mentioned above, it must be admitted that they were at least characterized by tolerance, and even sympathy, toward the insane. T h e s e characteristics stand out prominently in the earlier centuries of the medieval period. In the great 14th century poem, The Vision of Piers Plowman, lunatics are referred to as " G o d ' s T r u e Minstrels." T h e violent insane were commonly thrown into prison, heavily manacled, and treated generally as criminals, but the mildly insane were often permitted to roam about the countryside. Though uncared f o r , they were at least unmolested, and were allowed to live on the fruits of nature and the occasional charity of their fellow men. Indeed, some whose mental aberrations were manifested by religious exaltation were placed upon pedestals as "divinely inspired" saints or prophets, as in former ages.

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H e r e and there monasteries were open f o r the reception of lunatics, and the first asylums f o r their exclusive custody sprang up during this period. A s early as 1 3 6 9 a certain English chaplain, Robert Denton, obtained a royal charter to found a hospital in honor of the Virgin M a r y in the parish of All Hallows Barking. It was intended to house "priests and others, men and women, who suddenly fell into a frenzy and lost their memories, until such time as they should recover." There is no record that this hospital ever materialized, however. Lunatics were probably being treated in Bethlehem Hospital, London, in the late 14th century. A t least six male lunatics were in confinement there in 1 4 0 3 . In that year the porter, Peter T a v e r n e r , absconded with " 2 pairs of stocks, 4 pairs of iron manacles, 6 chains of irons with 6 locks" and other items which ominously reveal the type of treatment afforded the inmates. 11 Bethlehem, originally founded in 1 2 4 7 , became in later centuries (under its corrupted name of Bedlam) a byword f o r cruelty to the mentally ill. Nowhere during the medieval period did the mentally ill find more understanding and better treatment than at the hands of the "heathen" Moslems. In Western Europe the spirit of inquiry which had motivated the ancient Greek physicians, philosophers and scientists was almost dead; the medical man, f o r the most part, had surrendered his craft to the theologian and witch-doctor. But in the Mohammedan E a s t the torch of medical science lit by Hippocrates was still held aloft, dispelling the darkness of superstition in the treatment of mental and physical diseases. While the insane in Europe were being sent to churches and monasteries to be exorcised of possessing demons, the great A r a b physicianphilosopher, Avicenna, was insisting that they were simply suffering from mental maladies, and should be treated as sick persons. Quite probably, the first asylums f o r the insane in the world were built by the Moslems. ( T h e claim that such an institution was built at Jerusalem in the fifth century is without substantial foundation in history. T h e legend that a morotrophium, or house f o r lunatics, existed at Constantinople as early as the fourth century is likewise unverifiable.)

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B e n j a m i n o f T u d e l a , the f a m o u s Jewish traveler o f the t w e l f t h century, gives us a v e r y interesting account of an asylum f o r the insane that he saw in the city of B a g d a d , w h e r e p o o r patients w e r e maintained and treated at the expense o f the C a l i p h a t e . N o t w i t h s t a n d i n g the mention of iron chains, his description speaks well f o r attitudes of the A r a b s t o w a r d insanity, as contrasted with their contemporaries in Christian E u r o p e : Here [in B a g d a d ] is a building which is called Dar-al-Maristan, where they keep charge of the demented people who have become insane in the towns through the great heat of the summer, and they chain each of them in iron chains until their reason becomes restored to them in the winter-time. W h i l s t they abide there, they are provided w i t h food from the house of the Caliph, and when their reason is restored they are dismissed and each of them goes to his house and his home. M o n e y is given to those that have stayed in the hospices on their return to their homes. E v e r y month the officers of the Caliph inquire and investigate whether they have regained their reason, in which case they are discharged. A l l this the Caliph does out of charity to those that come to the city of Bagdad, whether they be sick or insane. 12

T h e first E u r o p e a n asylum d e v o t e d exclusively to the care o f the insane of which w e h a v e indisputable record was that built at V a l e n c i a , Spain, in 1408 by F r a y G o p e G i l a b e r t o . A number o f other asylums w e r e established in various parts of E u r o p e during the sixteenth century. 1 3 It should be remembered, in connection with these early asylums, that the ministrations to their inmates w e r e more likely to be featured by ceremonial rites than by medical attention, and that severe chastisement rather than gentleness w a s the rule in treatment. Since the monks and priests to w h o m the therapeutic functions were usually entrusted did not hesitate to scourge their own persons mercilessly w h e n e v e r they sensed even partial surrender to the wiles of the g r e a t T e m p t e r , they w e r e hardly calculated to entertain kindly sentiments t o w a r d their charges, w h o were felt to be completely possessed by the E v i l O n e . T h e belief in demoniacal possession, in its old f o r m s and

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some newer and more frightful ones, captured the imagination of the medieval mind to a degree seldom approached before. Properly to comprehend its scope, and its profound effects on prevalent attitudes towards the insane, it is necessary to dip into the dominant theological speculations of the time. An integral part of this theology was the principle of dualism, which had spread into Europe from the East through the medium of neo-Platonism. T o its exponents the world was seen as a huge battle-ground over which two antagonistic powers, good and evil, light and darkness, God and Satan, were engaged in a struggle for mastery. It was quite consistent with the anthropomorphic conception of the universe to believe that the immortal souls of men were the chief prizes sought in this cosmic conflict. Everywhere Satan and his infernal demons were at work striving to gain possession of human souls by every ruse possible. Just as the theology of the time surrounded God with choirs of angels, so did it credit Satan with legions of devils and imps, who iurked in every chimney and corner watching f o r an opportunity to jump into human bodies in unguarded moments and "possess" them. Since the insane were usually thought to be possessed, they were brought to the priest rather than to the physician for treatment. Amid elaborate ceremonies that outdid the ancients for impressiveness, the rites of exorcism were performed. Filthy and rank-smelling drugs were frequently made use of. A t times, reasoning and coaxing were employed in ridding the victim of the possessing devils. More often the demons were driven out with frightful epithets and curses. The Treasury of Exorcisms, a widely used work of the 17th century, contains hundreds of pages of the vilest epithets imaginable, to be hurled at the devil in expelling him. Great wonders were often claimed for the power of exorcism. For instance, a certain bishop of Beauvais exorcised with such skill that he not only forced five demons to relinquish possession of a victim, but actually made them sign an agreement not to molest him again! Likewise, some holy men of Vienna, in 1583, announced that they had that year cast out 12,652 living devils. 14

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Such w e r e the lighter aspects of the treatment of the ins a n e ; a blacker side existed that d e g r a d e d E u r o p e a n civilization f o r centuries, and l e f t in its w a k e a huge sea of human blood. A c c o r d i n g to the p r e v a l e n t superstition, a f a v o r i t e device of the devil w a s to induce human beings to sell their souls to him in exchange f o r s u p e r n a t u r a l p o w e r s enjoyed o v e r a stated number of y e a r s . W i t c h e s , w h o thus entered into league with S a t a n , could w o r k all deeds of the black art. T h e y could m a k e themselves invisible, fly through the air, f o r e t e l l the f u t u r e , t r a n s f o r m themselves and others into animals, and visit m i s f o r t u n e s upon their enemies. I f the devil could not obtain souls t h r o u g h b a r g a i n i n g , he w a s e v e r alert to seize them by stealth. P o p u l a r belief had the earth teeming with witches and bewitched, purchased o r captured by S a t a n , w h o s e presence w a s a constant d a n g e r to the community. N e i g h b o r suspected neighbor, and even a b r o t h e r might be denounced should he be seen to act queerly. T o seek out and eliminate witches became not only a social but religious duty. T h e m e t h o d of punishment w a s plainly prescribed in that terrible p a s s a g e in the B i b l e : " T h o u shalt not suffer a witch to l i v e . " ( E x o d u s , xxii, 1 8 . ) H o w many lives w e r e sacrificed t h r o u g h the literal translation of this text will never be k n o w n with any degree of accuracy, but the most c o n s e r v a t i v e estimates cannot place at less than 1 0 0 , 0 0 0 the total of those executed as witches between the middle of the fifteenth century and the end of the seventeenth, when the m a n i a r a g e d at its w o r s t . T w e n t y thousand " w i t c h e s " a r e said to h a v e been burned or otherwise executed in S c o t l a n d alone during the seventeenth century. T e n s of thousands m o r e w e r e put to death in E n g l a n d , F r a n c e , G e r m a n y and elsewhere in E u r o p e . F i v e hundred w e r e burned at the stake in G e n e v a within three months in the y e a r 1 5 1 5 . Such heights of intensity did the delusion reach, t h a t witch-finding became a lucrative p r o f e s s i o n . One c h a r l a t a n , M a t t h e w H o p k i n s , w h o b o r e the imposing title, W i t c h f i n d e r - g e n e r a l , w a s alone instrumental in having one hundred " w i t c h e s " executed in 1645—47 ' n E n g l a n d .

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O f this period, which has frequently been termed psychopathic, the historian L e c k y writes : Never was the power of imagination . . . more strikingly evinced. Superstitious and terror-stricken, the minds of men were impelled irresistably towards the miraculous and the Satanic, and they found them upon every side. T h e elements of imposture blended so curiously with the elements of delusion, that it is now impossible to separate them . . . Madness is always peculiarly frequent during great religious and political revolutions; and in the i6th century, all its forms were absorbed in the system of witchcraft, and caught the colour of the prevailing predisposition. 14

I t is a significant commentary on the unbalanced progress o f the revival o f learning that the witch mania, f a r f r o m being confined to the middle ages, not only raged undiminished through the Renaissance but actually reached its most intense form during the l a t t e r period. U n f o r t u n a t e l y , the rediscovery o f classic learning did not extend t o those humane G r e e k medical pioneers who taught the rational t r e a t m e n t o f mental illness. N o r did the concurrent religious revolution known as the R e f o r m a t i o n bring about an abatement in the persecution o f " w i t c h e s . " O n the contrary, it had the effect o f throwing added fuel on the witch-pyres, as P r o t e s t a n t vied with Catholic in bringing the D e v i l ' s agents to judgment. T h e belief in witches and demoniacal possession was by no means confined to the ignorant and vulgar. I t was implicitly accepted by scholars like E r a s m u s and M e l a n c t h o n , jurists like M a t t h e w H a l e and Blackstone, and scientists like Kepler, T y c h o B r a h e and R o b e r t B o y l e . M a r t i n L u t h e r , who was subject to all sorts o f fantastic hallucinations, became quite used to having the Devil follow him around. H e tells us that he was one night awakened by a noise, but upon finding out that it was only Satan, he turned back and went to sleep. A black stain on the wall o f a r o o m in the W a r t b u r g castle at Eisenach still marks the spot where L u t h e r is said to have hurled an ink-well at the D e v i l . H i s own illnesses, and f o r that m a t t e r all diseases o f the human body, were in L u t h e r ' s opinion entirely due to the nefarious machinations o f the E v i l One.

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But what of the medical men of the time? Did they cry out against the superstition which was heaping up this terrible toll in human lives? D i d they snatch the insane f r o m the stakes where they were being burned as witches? D i d they recognize the symptoms of insanity, and treat it as a naturally caused illness? Sad to tell, so great was the pressure of the prevailing superstition that even the most reputable physicians subscribed to it wholeheartedly. A s late as 1 6 6 4 , Sir T h o m a s Browne, eminent doctor and author of Religio Medici, by giving " e x p e r t " evidence against two unfortunate women accused of witchcraft, was instrumental in convicting them and sending them to their death. 1 6 M r . Robert Burton, speaking of witches and magicians in his classic Anatomy of Melancholy ( 1 6 2 1 ) , writes : " T h e y can cure and cause most diseases . . . and this of melancholy amongst the rest." In support of his thesis he cites the case of a young man, who by eating cakes that a witch g a v e him "began to dote on a sudden, and was instantly m a d / ' H e also mentions a doctor of Hildesheim who, consulted about a "melancholy" man, thought that his disease was "partly magicall, and partly naturall, because he vomited pieces of iron and lead, and spake such languages as he had never been taught." 1 7 In the words of M a x i m e du C a m p ( " L e s aliénés à P a r i s . " Revue des Deux Mondes, 1 8 7 2 , v. 1 0 1 , p. 7 8 8 ) : W e may say that doctors shared the insanity of the maniacs. T h e lunatic w a s no longer a patient, he was no longer even a man, but a kind of wild and formidable beast, half animal, half demon. In the horror that he inspired, they declared him to be possessed of Satan, and threw him into the flames.

T h e records of witch trials that have come down to us offer convincing evidence that a large percentage of those accused and convicted of witchcraft were really insane. M a n y were burned in consequence of their suspiciously " q u e e r " behavior, f o r which the dominant ideology of the time offered no natural explanation. Of those who confessed voluntarily without the application of torture, and they constituted a large number, many reveal themselves unmis-

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21

takably to us by their testimony as victims of various psychoses—dementia praecox, manic-depressive psychosis, paranoia, etc.—usually accompanied by self-accusatory and guilt delusions, and a consuming desire f o r expiation. T o o often did these u n f o r t u n a t e deluded individuals implicate other persons in satanic plots t h a t existed only in their own fevered imaginations, and d r a w these persons to the stake with them. W h a t percentage of the victims of the witch mania were mentally unsound is of course beyond calculation, but on the basis of the records it would seem no exaggeration to judge t h a t they comprised at least one-third of the total executed. H e r e and there the voice of reason and science was raised against the witchcraft belief, but f o r the most p a r t it was a voice crying in the wilderness, lost on the winds of delusion that swept over E u r o p e . H e r e and there men of science could be found groping through the thick fogs of ignorance, f e a r and superstition t h a t enshrouded in mystery the phenomena of mental disease. Imperceptibly they were piling up contributions to the knowledge of the subject f o r f u t u r e generations to build upon. A m o n g the earliest of these was that strange genius, Paracelsus, dabbler in alchemy and astrology, an eccentric and b r a g g a r t — a n d a great physician. B e f o r e meeting death in a tavern brawl in 1541, Paracelsus had rendered medical science a great service by repudiating Galenism and the humoral pathology t h a t had dominated medical practice f o r more than fifteen centuries. H e ridiculed the notion of demoniacal possession. " M e n t a l diseases," he declared, " h a v e nothing to do with evil spirits or devils; the individuals who are mentally sick merely drink more of the 'astral wine' than they can assimilate. T h e experienced [ d o c t o r ] should not study how to exorcise the devil, but r a t h e r how to cure the insane . . . T h e insane and the sick are our brothers. L e t us give them treatment to cure them, f o r nobody knows whom among our friends or relatives this misfortune may strike." 1 8 T h e s e were surely wise and courageous words f o r those days, the mystic aroma of the "astral wine" notwith-

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standing. W h y , we might even say that Paracelsus was almost as modern as Soranus. H i s therapeutics, however, was unfortunately not quite as admirable as his kindly sentiments. F o r Paracelsus, like many of his successors of the eighteenth century, placed his whole faith in bloodletting as the cure of cures. " W h a t avails in mania," he wrote, "except the opening of a vein? T h e n the patient will recover. T h i s is the arcanum: not camphor, not sage and marjorum, not clysters, not this or that, but bleeding." In 1 5 6 4 , D r . Johann W e y e r of Cleves published a vigorous, if cautiously worded, polemic against the cruel consequences of the prevailing witch mania and pleaded f o r gentler and more rational treatment of the insane who were among its chief victims. H e artfully paid lip service to the belief in demoniacal possession, going so f a r as to classify with meticulous care the legions of demons,* but held that the possessed were blameless and entitled to sympathetic treatment; it was the demon who should be punished. T o combat the generally accepted notion that nails, stones and the like were introduced into possessed bodies by demons he demonstrated that lunatics, when unattended, are sometimes irresistibly inclined to swallow these indigestible objects. Reginald Scot, a progressive and fearless soul, published in 1 5 8 4 his famous Discoverie of Witches in which, with consummate skill, he laid bare and ridiculed the childish impostures and absurdities involved in the witchcraft superstition. M a n y of the poor creatures accused of witchcraft, he wrote, required relief f r o m disease rather than chastisement f o r supposed sins; physicians to help them rather than executioners or torturers to hang and burn them. H o w e v e r , as Lecky records, his work had no appreciable influence. Samuel Harsnett, Archbishop of Y o r k , showed himself to be surprisingly free of the delusions that seized most of his brothers in the cloth wh .n he wrote in 1 5 9 9 : " T h e y that have their brains baited and their fancies distempered with the imaginations and apprehensions of witches, conjurors • I n this book, De pracstigiis daemonum, W e y e r placed the total number of demons at 7,405,926, these being divided into seventy-two companies, each headed by a demonic captain.

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and f a i r i e s , and all that lymphatic chimera, I find to be m a r s h a l l e d in one of these five r a n k s : children, f o o l s , women, c o w a r d s , sick o r black melancholic discomposed wits." D a n i e l Sennert of W i t t e n b u r g (fl. 1 5 7 2 - 1 6 3 7 ) f o u n d it possible to accept the current belief in witches, and to state quite seriously that maniacs evacuated stones, iron and living animals placed in their bodies by demons, and yet, at the same time, to record some keen observations on the b e h a v i o r of the insane. H e also m a d e an attempt to c l a s s i f y the mental diseases, dividing them into t w o m a j o r g r o u p s — m a n i a and melancholia. F a r more scientific than his observations and classifications w e r e those of his contemporary, F e l i x P l a t e r of B a s l e ( 1 5 3 6 - 1 6 1 4 ) . P l a t e r was one of the f e w w h o d a r e d l i f t his voice in an appeal f o r a m o r e humane and enlightened attitude t o w a r d s the insane. T h e late seventeenth century witnessed a g r o w i n g revolt, participated in by philosophers and physicians, against the superstitions of w i t c h c r a f t and demoniacal possession and their cruel effects on the insane. B u t all this outcry reached a stage of real effectiveness only in the f o l l o w i n g century. A s late as 1 7 1 6 a w o m a n and her nine-year-old daughter w e r e h a n g e d at H u n t i n g d o n , E n g l a n d , a f t e r being convicted of selling their souls to the devil. It was not until 1 7 3 6 that the l a w s against w i t c h c r a f t w e r e repealed in the U n i t e d Kingdom, and local persecutions against the insane suspected of practicing w i t c h c r a f t and sorcery continued intermittently f o r a long time t h e r e a f t e r . W e shall have occasion to note in the next chapter the s p r e a d of the w i t c h c r a f t mania to the newly-settled soil of A m e r i c a , and of its consequences on attitudes t o w a r d , and treatment o f , the mentally ill in this land.

CHAPTER

II

Colonial America: the Old World Heritage

T

H E early colonists w h o set sail f r o m E u r o p e to find f r e s h p a t h s of life in the N e w W o r l d c a r r i e d o v e r with them, along with their w o r l d l y possessions, the a s s o r t e d cultural accumulations of t h e lands of their nativity. T h i s body of culture, comprising social, economic and political attitudes, they t r a n s p l a n t e d t o the virgin soil of America, w h e r e it was subjected to t h e m o d i f y i n g influences of a new and vastly different e n v i r o n m e n t . T h e seventeenth-century E u r o p e t h a t the colonists l e f t behind was passing t h r o u g h a p e r i o d of turbulent transition. T h e walls of the f e u d a l o r d e r w e r e crumbling; on its ruins the m o d e r n capitalist era was rising t o w a r d its place in the historic procession of social systems. W e s t e r n civilization was experiencing all the b i r t h pains a t t e n d i n g the incoming of a new o r d e r . E u r o p e was being racked by religious w a r s , political u p h e a v a l s and p r o f o u n d economic changes, conflicts t h a t w e r e t o find their synthesis in the f o l l o w i n g cent u r y . T h e pace of p r o g r e s s w a s very uneven and, as always, cultural change lagged f a r behind the m a t e r i a l advances t h a t serve as its s p e a r h e a d . I n its d o m i n a n t a t t i t u d e s t o w a r d existence, t h e seventeenth century still lay within t h e p e n u m b r a of medieval t h o u g h t . It was weighed d o w n by the same superstitions and h a u n t e d by the same specters of the s u p e r n a t u r a l world t h a t seemed so strangely i n t e r t w i n e d with the world of every-day events. T o w a r d the p h e n o m e n o n of m e n t a l illness, as we h a v e indicated, it exhibited an even h a r s h e r and m o r e i g n o r a n t a t t i t u d e t h a n the centuries t h a t p r e c e d e d it. D e m o n i a c a l possession was the common explanation of most f o r m s of m e n t a l disorder, and the scourge, t h e rack, t h e stake and the g a l l o w s 24

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were the common methods of treatment. T h e fate of the mentally ill who managed to escape the accusation of being witches or bewitched was hardly better. If "violent," they were thrown into prison dungeons like common criminals; if "harmless," they were sometimes permitted to wander about the country aimlessly, with never a public thought f o r their welfare. Shakespeare gives us a vivid glimpse of these wandering " T o m s o' Bedlam" when he speaks of "poor Tom, that eats the swimming frog, the toad, the tadpole, the wall newt and the water newt, that in the fury of his heart, when the foul fiend rages, eats cow-dung f o r sallets, swallows the old rat and the ditch dog, drinks the green mantle of the slimy pool; who is whipt from tything to tything, and stocked, punished, and imprisoned . . . " ( K i n g Lear, Act I I I , Scene 4.) In the isolated instances where cure was sought, the mentally ill were more likely to be taken to the clergyman f o r exorcistic treatment than to the physician f o r medical care. M o r e o v e r , so low was the estate of medicine, that it is problematical whether the ministrations of its practitioners were more effective than the clergy's. T o the European physician of the time, Hippocrates and Galen were the omnipotent authorities in materia medica. Few dared to dispute the dicta handed down by the ancients. Those who did were frowned upon as heretics, and ostracised. It was truly ironic that the two great figures who had done most to advance medicine in antiquity were thus fated to serve as checks to progress centuries later in an age that paid slavish, even fanatical, homage to their teachings. True, the seventeenth century witnessed some great medical discoveries—discoveries that were to lay the foundations f o r modern medicine—but these were largely isolated from the main stream of contemporary practice. In 1628 H a r v e y published to the world his discovery of the circulation of the blood. During the same century, Jean Baptiste van Helmont was applying chemistry to the study of physiology with highly beneficial results. Characteristic of the age was his curious blend of mysticism and science, which led him to propound the doctrine of an anima sensitiva motivaque (sensitive motive soul) residing in the pit of the stom-

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ach whence it directed the entire system. Sanctorius Sanctorius, with that infinite patience which enabled him to carry on a painstaking thirty years' experiment upon himself in bodily weight changes, was paving the way f o r the modern science of metabolism. T h e great T h o m a s Sydenham was contributing to medical progress through his acute powers of observation, and earning the right to the title "master of clinical medicine." Lesser luminaries were building solidly on the foundations laid in a preceding century by the great anatomist, Vesalius. But the influence of these pioneers on the general medical theory and practice of their day was almost nil. H a r v e y , in setting f o r t h his theory of blood circulation, brought down upon his head the ridicule of his contemporaries, who accounted him "crack-brained" f o r daring to assert that he had discovered something unknown to Aristotle. W e are told that his own practice "fell mightily" as a result. F o r the general practitioner medicine remained static. It was still held in the thrall of Galenism, t h a t confused blend of scientific fact and travellers' tales, careful clinical observation and demonological lore, sound pharmacology and " g r a n d m o t h e r " remedies. Panaceas, confidently set f o r t h to cure all ills, were plentiful. M i t h r i d a t e was widely supposed to cure not only madness and epilepsy, but all the ills that flesh was heir to. T h e antimonial cup and Oriental bezoar stone were among the other universal antidotes of the time. T h e most widely consulted pharmacopoeias included among the favorite remedies such delectable items as crab's eyes, f r o g ' s spawn, powder f r o m dog's lice, human perspiration and saliva, earthworms and viper's flesh. T h e most curious remedy of all, perhaps, was the famous "powder of sympathy" f o r wounds, concocted f r o m sixty-one strangely assorted ingredients, including some of those we have just mentioned. T h i s was applied, not to the wound itself, but to the weapon or implement that h a d inflicted it, in the confident expectation that the wound would thereupon heal in sympathy. As f o r attitudes toward mental illness and its treatment, we have noted in the preceding chapter how it was generally attributed to demoniacal

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possession, and treated accordingly. Such, then, was the state of medicine in the world from which our early settlers journeyed. In the colonies medical practice was on an even lower plane, f o r several obvious reasons. F o r one thing, there was little incentive f o r the skilled European-trained physician to chance the practice of his profession in America. T h e thin, scattered settlements discouraged hopes of a large clientele, while the poverty-stricken inhabitants, comprising the great majority of the population, could ill afford the luxury of physicians' fees. Throughout most of the colonial period there existed no opportunity to study medicine in halls of learning: not until 1 7 6 5 was a medical school established in America.* T h e colonial physician rarely earned the academic right to the title " d o c t o r . " Ordinarily his art was learned through apprenticeship and the dubious benefits which the medical books of the time afforded. Dipping into one of the popular treatises on materia medica of his day, he would likely as not find the famous "Spirit of Skull" described as a potent remedy f o r epilepsy. Spirit of Skull was concocted from an elaborate preparation of "moss from the skull of a dead man unburied who had died a violent death," mixed with wine. It is a noteworthy fact that this was one of the last remedies administered to King Charles I I of England in his fatal illness. T h i r t y drops of the Spirit were prescribed f o r "convulsive fits, epilepsy, vapours and pains in the head." T h e inquiring colonial doctor might find a similar formula f o r epilepsy, somewhat more difficult to compound, originated by Paracelsus and named by him Confectio AtitiEpileptica. T h e Paracelsan cure required no less than three human skulls of unburied men who had met violent death, which were to be dried and pulverized, and mixed with several liquids. 1 Other gruesome cures f o r epilepsy that might be suggested to the colonial physician by contemporary pharmacopoeias had f o r their bases pulverized human hearts, "brains of a young man under 2 4 , " and human blood. T h e last-named substance had been a favorite prescription in Roman times when, according to Celsus, some • F o u n d e d at P h i l a d e l p h i a College, later the University of P e n n s y l v a n i a .

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were cured of epilepsy by drinking "hot blood taken from a gladiator who had just been slain." Handicapped by the rigors of environment, isolation, and the lack of communication, the average colonial men of medicine fell f a r below the most backward country doctors in England in medical skill and knowledge. T h e works of the great medical discoverers and reformers of their day reached the colonial physician but seldom, and influenced him even less. In accordance with time-old tradition, he still diagnosed by the rule of the four humors—black bile, yellow bile, phlegm and blood. Diseases were still attributed to too much moisture, dryness, heat or cold. Mental diseases, when treated as medical problems, which was seldom, were commonly regarded as the result of an excess of bile. By looking into his Gerard's H erbati (first published in 1 5 9 7 ) , which was considered a fairly indispensable item in every practitioner's library, the colonial physician would find, as a sure remedy f o r mental diseases, that favorite cure of the ancient Greeks, black hellebore (also known as melampode, because tradition ascribed its discovery to Melampos, who cured his mad daughters with it). " A purgation of Hellebore," counseled Gerard, "is good f o r mad and furious men, for melancholy, dull and heavie persons, and briefly f o r all those that are troubled with the falling sickness, and molested with melancholy." 2 Like their European fellows, the colonial physicians were inclined to judge the efficacy of their prescriptions largely by the complexity and nauseating character of the ingredients involved. Venesection was universally applied: ill persons of all ages, from the infant to the octogenarian, were bled freely and often. Almanacs of the day recorded f o r their convenience the phases of the moon most favorable to bloodletting. All the vile and noxious remedies prescribed by their European fellows were imitated here. M a n y simples were administered. Some of these remedies were truly effective, as attested to by long experience; others, while not beneficial, were quite harmless, while still others had little more effect than to speed the unfortunate patient to his last rest. 3

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29

H o w e v e r poorly versed in his craft the average physician might be, there was yet a dearth of the profession in colonial America. Medicine was commonly administered by amateurs —mainly clergymen, barbers, civil officers, and plantation owners. T h u s we find Michael Wigglesworth, the noted clergyman-poet of the 17th century, described by a contemporary as attending the sick "not only as a Pastor, but as a physician too." 4 Cotton M a t h e r called this fusion of minister and physician an "angelical conjunction." Of the seventeenth-century public officials skilled in the practice of physic, none was more renowned than John Winthrop, J r . , governor of Connecticut Colony and fellow of the R o y a l Society. Possessing a wealth of intellectual curiosity, he was fond of dabbling in alchemy, astrology and other mystic sciences, which he mixed generously with his medicine. H e had in his repertory several remarkable remedies, among them this "infallible" cure f o r all sorts of agues: " P a r e the patient's nails when the fever is coming on; and put the parings into a little bag of fine linen or sarenet; and tie that above a live eel's neck, in a tub of water. T h e eel will die and the patient will recover." 5 Governor Winthrop enjoyed a wide reputation as an administrator of medicine, and was constantly deluged with requests f o r remedies f r o m all corners of his colony. H e was frequently referred to as D r . Winthrop, and he used that title himself on occasion. So great was his interest in the healing art that he kept in touch with the most respected London physicians in order to avail himself of contemporary knowledge of curative treatment. Of interest to our particular study is a message received by Winthrop in 1 6 4 3 f r o m D r . E d w a r d Stafford of London, informing him of many remedies. It begins: F o r my W o r t h y Friend M r . W i n t h r o p : F o r Madnesse : T a k e ye herbe Hypericon ( : in English St. John's W o r t ) and boile it in W a t e r or drink, untili it be strong of it, and redd in colour ; or else, putt a bundle of it in new drinke to W o r k e , and give it ye patient to drinke, permitting him to drinke nothing else. First purge him well with 2 or 3 seeds ( ; or more, according to ye strengthe of the partie;) of Spurge. L e t them not eat much, but

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keep dyet, and you shall see Wondrous effects in fewe dayes. I have knowne it to cure perfectly to admiration in five dayes.'

St. J o h n ' s w o r t w a s a f a v o r i t e r e m e d y f o r mental illness in those days. Its herbs, a f t e r b e i n g blessed, w e r e w r a p p e d up in a " h a l l o w p a p e r " and c o m m o n l y carried about " t o be smelled at against the invasions of the d e v i l . " In addition to his w o n d r o u s r e m e d y f o r madness which could cure in five days, D r . S t a f f o r d lists a cure f o r " y e f a l l i n g sickness." F o r this ailment he prescribes the ancient and r e v e r e d remedy, black hellebore, to be p r e p a r e d in the same manner as St. J o h n ' s w o r t w a s f o r madness. H o w e v e r , his expression of f a i t h in his t r e a t m e n t f o r epilepsy is s o m e w h a t m o r e cautiously w o r d e d : " U s e it as a b o v e , and G o d willing he [ t h e p a t i e n t ] shall be p e r f e c t l y cured in short o r l o n g e r time, according as the disease hath taken r o o t . " In his communication D r . S t a f f o r d reveals to W i n t h r o p his chefd'œuvre, a panacea consisting of live t o a d s boiled o u t d o o r s in the month o f M a r c h and then pounded into black p o w d e r , which can be used both to prevent and cure many diseases. T h e a s t r o l o g i c a l note w a s sounded v e r y f r e q u e n t l y in medical prescriptions of colonial times, and it is not surprising that w e find it mentioned in the treatment of epilepsy as late as 1 7 6 4 , in a case administered by D r . J a m e s G r e e n h i l l of V i r g i n i a . A f t e r describing the u n s a t i s f a c t o r y results obtained f r o m the usual bleeding and p u r g i n g applications to his epileptic patient, D r . Greenhill tells of " b l i s t e r i n g " the latter on the nape of the neck. " T h i s succeeded," he continues s o m e w h a t u n g r a m m a t i c a l l y , " a n d the next C h a n g e of the M o o n e x p e c t i n g the fit, as usual, he missed t h e m . T h e M e d i c i n e s has been continued and he has missed the fits this last full m o o n again. T h e blister is almost dry but I intend . . . to d r a w a f r e s h one. It is s o m e t h i n g r e m a r k a b l e t h a t the fits has U s u a l l y returned w h e n the M o o n w a s in the Sign o f C a p r i c o r n even when it w a s a w e e k b e f o r e o r a f t e r the full or c h a n g e . " 7 T h i s w a s evidently quite b e y o n d the comprehension o f the w o r t h y d o c t o r , w h o had been t a u g h t to expect epileptic recurrences only at the full of the m o o n ! Several colonial d o c t o r s seem to h a v e gained r e p u t a t i o n s

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as specialists in the treatment of mental illness. Among these was Dr. Thomas Kittredge of North Andover, Massachusetts. T o w a r d the end of the colonial period we find him treating as many as ten or twelve mentally ill patients at a time. These he boarded out with two or three families in Andover, where they were closely supervised by members of each family. Apparently little restraint was applied, although the patients were subjected to occasional bloodletting in order to weaken them and thus render them more manageable. 8 Few of the colonial doctors were acquainted with the real nature of mental disorders, or of positive methods of care and treatment. Not untypical of the absurd conceptions of mental illness is the case cited in John Hale's Modest Inquiry into the Nature of Witchcraft, published in 1 7 0 2 . A man "afflicted with hallucinations" sent f o r a physician some miles away. The doctor was unable to come but sent a diagnosis and remedy by messenger. " T h e vapours ascending from his sore L e g g " ran the diagnosis, "caused a water in his Eyes, and disturbance in his Braines, by means whereof he was troubled with such Visions." T o treat the disturbed brain, the doctor sent "an eye water to wash his eyes with, and a cordial to take inwardly; upon the use of these, this disturbance vanished in half a quarter of an hour." A miraculous feat indeed, albeit our own skeptical age would attribute this "cure" less to the remarkable eyewash than to the commentator's credulity. With true Puritanical zeal H a l e draws a moral lesson from this case, for he ends his narrative with the observation: " I f a disease may do this, what may Satan, working upon bodily distempers and vapours, impose upon the Imagination?" 9 Here was a significant sentiment that was entertained as widely in the colonies as it was in contemporary Europe. T h e belief in demoniacal possession was practically universal in seventeenth-century America. It reached its apogee in the famous Salem witchcraft mania of 1692, and died down thereafter, although witch trials continued to recur throughout the first half of the eighteenth century. T h e common tendency of the time to identify mental illness with dia-

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bolical possession is well illustrated in Cotton Mather's biographical sketch of William Thompson, a N e w England divine who died in 1666. " S a t a n , " he writes, "who had been after an extraordinary manner irritated by the Evangelic Labours of this H o l y Man [Thompson], obtained the Liberty to sift him; and hence, after this Worthy M a n had served the L o r d Jesus Christ in the Church of our N e w England Braintree, he fell into that Balneum Diaboli, a black melancholy, which f o r divers years almost wholly disabled him f o r the exercise of his Ministry." 1 0 T h e name of Cotton Mather is commonly identified with the Salem witchcraft craze of 1 6 9 1 - 9 2 . Upon him, as the most influential member of the community, has been placed the burden of responsibility f o r the twenty-two lives that were sacrificed at Salem. This narrow judgment lacks historical perspective, although we cannot hold Mather free of all blame f o r the part he played in the tragic episode. In his firm conviction in the reality of diabolical possession, M a t h e r was merely sharing a dogma that was adhered to by most of the educated and advanced men among his contemporaries. T h e witchcraft mania had raged before his time elsewhere in New England. T h e first of the two well-defined periods of epidemic witch hunting in America had taken place in 1 6 4 7 - 6 3 (the second being that of 1 6 8 8 - 9 3 , * n which M a t h e r played so prominent a p a r t ) . T h e earliest recorded execution f o r witchcraft had occurred in Connecticut in 1 6 4 7 , when M a r y Johnson was hanged under the law enacted five years before: " I f any man or woman be a witch, that is hath or consulted with a familiar spirit, they shall be put to death." 1 1 Persecution of persons suspected of being witches or " f a m i l i a r s " was of common occurrence in most of the other colonies as well, although nowhere did the delusion reach such a pitch of intensity as it did in Puritan N e w England. Puritanism, with its stern repression of healthy human instincts, its abnormal orientation around religion, and its exaggerated expressions of alternate suspicion and credulity, offered a fertile soil f o r the development of this mania. A n y variation from the norm in nature, however trivial, was

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33

looked upon by the Puritan mind as a supernatural manifestation. Comets, thunderstorms and meteorites were regarded as solemn signs direct f r o m either G o d or Satan. T h e y were full of portent f o r N e w England, which was prone to regard itself as the special concern of the spiritual powers at w a r . Deviations f r o m the norm in human behavior were likewise looked upon as suspicious. T h e causes of strange or irregular conduct (such as a mentally ill person might manifest) were sought in the supernatural, and the answer was commonly found in demoniacal possession. Such was the atmosphere in which the Salem witchcraft mania originated. B e f o r e it had run its course, it was to seize a whole community in its terrifying grasp. It cannot be said that all the witchcraft cases are attributable to insanity on the part of the accused or the accusers. Undoubtedly, many were due to the maliciousness of persons impelled to accuse troublesome or undesirable neighbors. Others resulted f r o m rank imposture, or sheer ignorance and superstitious credulity. But, as the records of the trials impressively show, there were unmistakable manifestations of diseased minds among a large number of the participants—accusers, accused, and witnesses. T h e case of M a r y G l o v e r of Boston, who was tried and executed in 1 6 8 8 , served as a fitting prologue to the great Salem drama. In microcosm it illustrates very clearly the presence of mental illness in both accused and accusers. M r s . G l o v e r , a laundress in the Goodwin household, was accused by the four children of the family of having bewitched them. T h e children all exhibited well-marked evidences of hysteria. A t different times they would appear to be d e a f , dumb and blind. T h e i r tongues would sometimes be drawn down their throats or hang down their chins. T h e i r bodies were spotted with anaesthetic and hyperaesthetic areas. T h e y were subject to all sorts of convulsions and contortions. T h e y would shriek with pain and cry out that they were in turn being suffocated, burned, pricked and bitten by devils. A t least one of the children continued to have " f i t s " long a f t e r the case had been concluded with a witch-hanging. A s f o r the accused woman, f a r from denying the accusa-

34

T H E MENTALLY ILL IN AMERICA

tion, she readily confessed to being in league with the devil. She is described by a contemporary historian as being a "wild Irish woman," and the circumstances of the trial strongly indicate that she was mentally unbalanced. Cotton Mather, narrating the trial and execution in his Memorable Providences ( 1 6 8 9 ) , tells us that among the items found in her home were "several images, or puppets, or babies, made of rags and stuffed with goat's hair," articles not infrequently found in the possession of insane women. When asked by the judges whether she had any one standing by her, she replied that she had, but "looking very pertly into the air, she added, 'No, he's gone.' " She acknowledged that the Devil was her " P r i n c e " and paramour, and stated that he had served her so basely and falsely that she had decided to confess all. H e r absurd and incoherent statements, instead of revealing to her judges the illness which she suffered, were, on the contrary, accepted by them as indisputable evidences of her guilt. T h e witchcraft mania in Salem grew out of the quite innocent frolics of a group of young girls who used to gather at the village minister's house. Here they were wont to play at fortune-telling and palm-reading and to discuss the supernatural. Ghosts, devils and witches were favorite subjects of their discussions. In the tense, repressed atmosphere of Salem, where the "invisible world" seemed even to the soberest adults as immanent and real as the visible world, the over-wrought imaginations of these sternly repressed children began to break through the bounds of sanity. T h e y started to see strange things, hear preternatural voices, and dream strange dreams. Their condition soon came to the attention of the village elders, who investigated and solemnly concluded that the girls were "afflicted," or bewitched. Stimulated and excited by the attention they had attracted —the craving for attention is a common cause of hysteria in young girls—the children began to manifest in heightened degrees all sorts of hysterical symptoms; they barked and mewed, they went into frequent "fits" of catalepsy and convulsions, they jumped and screamed, uttered wild gibberish (this was called "speaking in tongues"), leaped on tables

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AMERICA

35

and crawled under them, and cried out that they w e r e being choked, weighed down, pricked and slashed by the devil and his witches. P r e s s e d f o r the names o f those who were casting evil spells over them, they named first one, then another, of the inhabitants of Salem until it seemed that fully half the village had signed their souls o v e r to the devil. T e r r o r seized the villagers. T h e hysteria became contagious, and others w e r e soon exhibiting the same symptoms and hurling wild accusations against their neighbors.* In that one y e a r ( 1 6 9 1 - 9 2 ) , 2 5 0 persons were arrested and tried in Salem on w i t c h c r a f t c h a r g e s : fifty were condemned; nineteen were executed; two died in prison; and one died of torture. T h e type of testimony that w a s accepted as truth by the unbelievably credulous j u d g e s , and that w a s instrumental in sending a score of innocents to their death, is exemplified in the interrogation of S a r a h C a r r i e r , eight, whose mother M a r t h a w a s hanged as a witch. A w e d by the solemnity of the inquisitors, her mind excited by f e a r s and fancies intensified by leading questions, the child testified in this v e i n : ' H o w long hast thou been a w i t c h ? ' ' E v e r since I was six years old.' ' H o w old are you n o w ? ' ' N e a r eight years old.' ' W h o made you a witch ?' ' M y mother. She made me set my hand to the book.' ' Y o u said you saw a cat once. W h a t did the cat say to you ?' 'It said it would tear me to pieces if I would not set my hand to the book.' [that is, the " D e v i l ' s B o o k . " ] ' H o w did you know that it w a s your mother?' ' T h e cat told me so, that she was my mother.' 11 • E p i d e m i c s of d e m o n i a c a l possession such as that at S a l e m w e r e of f r e quent o c c u r r e n c e d u r i n g the m i d d l e a g e s , notably the d a n c i n g m a n i a s that o c c u r r e d t h r o u g h o u t E u r o p e f o l l o w i n g the B l a c k P l a g u e . I n f a c t , such e p i d e m i c s h a v e been e x p e r i e n c e d in quite recent times. O n e of the best k n o w n instances of so-called d e m o n o m a n i a is that w h i c h seized the t o w n of M o r z i n e s in S a v o y d u r i n g 1 8 5 7 - 6 2 . H e r e , too, the e p i d e m i c w a s b e g u n by h y s t e r i c a l c h i l d r e n a n d s p r e a d r a p i d l y to t h e i r e l d e r s . F o r five y e a r s intermittently, scores of i n h a b i t a n t s w e n t m a d l y a b o u t the t o w n , c e r t a i n t h a t they w e r e possessed of d e v i l s and that t h e i r souls w e r e i r r e t r i e v a b l y lost. It is interesti n g to note that o c c a s i o n a l c l e r i c a l attempts to e x o r c i s e the v i c t i m s of d e m o n s

36

THE MENTALLY ILL IN AMERICA

A s f o r the accused, many of them were first suspected, naturally enough, because of strange behavior and antics on their p a r t . W e gain an insight into the mental state of many of them through the testimony of Samuel W a r d w e l l , w h o himself confessed that he w a s guilty of covenanting with the devil. H e related that some y e a r s b e f o r e he " h a d fallen into a discontented state of mind because he w a s in love with a m a i d named B a r k e r w h o slighted his l o v e . " W h i l e in this state of melancholy, he continued, he saw one day " s o m e cats t o g e t h e r , " one of which assumed the f o r m of " t h e black m a n . " T h e latter promised him that " h e should live c o m f o r t a b l y and be a c a p t a i n " if he would sign the D e v i l ' s B o o k , a f t e r which W a r d w e l l w a s induced to affix his signature to it. 1 3 T h e hapless man l a t e r retracted his confession, but his explanation that he w a s not in his right mind when questioned went f o r naught, and he w a s hanged, along with seven others, on September 22, 1 6 9 2 . * W e can readily comprehend the mental state of women w h o confessed at Salem to riding broomsticks through the a i r ; consorting with devils and having carnal relations with them, pinching and otherwise annoying their neighbors abed by means of their " s p e c t e r s " , and visiting illness and death upon others through their black magic. T h e records include a revealing statement signed by six women, renouncing their confessions of h a v i n g practiced w i t c h c r a f t . Residents of A n d o v e r , they had been a r r e s t e d as witches and brought to S a l e m , where they w e r e all tried and convicted. " B y reason of that sudden s u r p r i s a l , " their repudiation reads, " w e w e r e resulted only in f a n n i n g the flames of the mass hysteria to a still higher degree. It subsided only a f t e r psychiatric knowledge and treatment were applied to the town's ailment. •Incidentally, Cotton Mather, who kept a kind of clinic for the "possessed" at his home, w h e r e he might keep them under close surveillance and o f f e r up therapeutic p r a y e r f o r their release, presents us with a remarkable case history of hysteria in a little-known work of his: A Brand Pluck'J from the Burning ( 1 6 9 3 ) . In this work, he describes the "bewitchment" of M e r c y Short, a maid-servant who testified in several of the witch trials at Salem, and w a s taken to Mather's home f o r observation and possible cure. H e r actions, which are minutely and f a i t h f u l l y described by M a t h e r as the w o r k ings of possessing demons, offer a v e r y interesting, if unintended, contribution to psychiatric lore.

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AMERICA

all exceedingly astonished and a m a z e d , and consternated and a f f r i g h t e d even out of our reason . . . O u r understanding and o u r faculties almost gone, w e w e r e not capable of judging our condition, but said everything they (the j u d g e s ) desired."14 T h e mental illness aspect of the w i t c h c r a f t delusion, the aspect to which our particular interest is d r a w n , is p e r h a p s best summed up by T h o m a s B r a t t l e , a c o n t e m p o r a r y eyewitness to the Salem t r a g e d y . B r a t t l e w a s one of the v e r y f e w w h o m a n a g e d to keep his common sense clear of the mental storm that swirled all about him. Significantly enough, he w a s constantly under suspicion of being an infidel and apostate because of his enlightened views. In a letter sent by him to an anonymous clergyman in October, 1 6 9 2 , at the height of the witch-hunt hysteria, B r a t t l e gives a minute description of the goings-on at S a l e m . Of the fifty-five persons held in jail under the c h a r g e of w i t c h c r a f t at the time, he states that " s o m e of them a r e known to be distracted, crazed w o m e n . " B r a t t l e could not escape completely the current superstitions, and in his letter he affirms his general belief in sorcery, w i t c h c r a f t and evil demons. But having c a r e f u l l y observed the p a r t i c u l a r " w i t c h e s " w h o had confessed to horrible deeds at S a l e m , Brattle remarks : " T h e y are deluded, imposed upon, and under the influence of some evil spirit ; and therefore unfitt to be evidences either against themselves, or any one else. T h e s e confessours ( a s they are c a l l e d ) do v e r y often

contradict

themselves,

as inconsistently

as is usual

for

any

crazed, distempered person to d o . "

T u r n i n g to the accusers—the " b e w i t c h e d " — B r a t t l e finds reason to doubt their mental soundness also, and offers these keen o b s e r v a t i o n s : M a n y of these afflicted persons w h o have scores of strange fitts in a day, yet, at the intervals of time are hale and hearty, robust and lusty as if nothing had afflicted them. I strongly suspect that the

Devili

imposes on their brains, and deludes their fancye and imagination ; and that the D e v i l l ' s B o o k ( w h i c h they say had been offered t h e m ) is a mere f a n c y e of theirs, and no r e a l i t y . 1 5

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T h e h o r r o r s and absurdities of the w i t c h c r a f t trials, with their involved tragi-comic contradictions, finally registered on the public mind and ultimately a halt w a s called to the proceedings. T h e wholesome reaction w a s indubitably hastened by the f a c t that, with the mounting hysteria, some of the " a f f l i c t e d " were beginning to point accusatory fingers at prominent and substantial citizens. T h i s personal d a n g e r quickly frightened the latter into their senses, and impelled them to suppress the mania. In M a y , 1 6 9 3 , G o v e r n o r Phips of Colony issued a proclamation releasing f r o m custody all persons, numbering about 1 5 0 , still confined in prison on w i t c h c r a f t charges. T h u s ended the most intense phase of the delusion of demoniacal possession, with its consequent persecution of the insane. A n d with i t — t h o u g h w i t c h c r a f t trials occurred sporadically in the colonies f o r some score of y e a r s t h e r e a f t e r — a d r a m a t i c chapter in the treatment of the mentally ill in A m e r i c a passed into history.

CHAPTER

III

Colonial Provision for the Mentally 111: Punishment, Repression and Indifference " ^ [ E I T H E R the cultural nor material conditions of early ^ colonial America offered fertile ground for the introduction and development of a liberal, well-integrated system of social w e l f a r e t h a t would include special provision f o r persons handicapped by physical, mental and economic ills. T h e settlements were generally sparse and scattered, populated f o r the most p a r t by an impecunious people who lived on the ragged edge of existence, engaged in constant struggle to wrench a bare living f r o m the soil. In these circumstances, they were too likely to be burdened with their own immediate problems of existence to give much thought to the welfare of their more needy neighbors. A certain degree of communal stabilization and a relatively close gathering of people in large groups are indispensable requisites f o r the development of a permanent welfare system of wellrounded p r o p o r t i o n s : in the colonial settlements these were lacking. In accordance with the dominant ideology at home and abroad, the sufferings of the handicapped members of the community were looked upon as the natural consequences of a stern unbending Providence, meting out judgment to the wicked and the innately inferior. Contempt, cold and narrow, r a t h e r than sympathy and understanding, characterized the attitudes t o w a r d s the destitute and dependent classes. Public provision for the latter was based not so much upon humane considerations as upon social expediency and economy. T h e individual in need of assistance was apt to receive public attention only when his condition was 39

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THE MENTALLY ILL IN AMERICA

looked upon as a social danger or a public nuisance—and he was then "disposed o f " rather than helped. T h e s e general attitudes and conditions were reflected and accentuated in provisions f o r the insane. W e may conveniently divide these provisions into two categories: private and public. Mentally ill persons who had relatively well-todo families or friends were usually cared f o r in their own homes. In the rare instances when the affliction was recognized as a disease produced, not by supernatural intervention, but by natural causes, and hence amenable to curative measures, they received whatever medical treatment was available (such as has been described in the preceding chapt e r ) . If violent or troublesome, even the propertied insane were without compunction locked up and chained by their families in strong-rooms, cellars, and even in flimsy outhouses. In some cases, where the illness manifested itself in a mild and harmless manner, the individual was permitted a degree of freedom of movement. But often enough, even harmless persons were confined f o r years on end in attic rooms, very much like Sam E v a n s ' aunt in O'Neill's Strange Interlude, so that the family "disgrace" might be hidden from the public eye. Until the closing years of the colonial period there were no hospitals where they might be cared for. Not until 1 7 5 2 was the first general hospital established, while the first asylum f o r the exclusive reception of the insane was opened two decades later. T h e plight of the propertied insane came to the public notice only in so f a r as their estates were concerned. Significant in this respect is the fact that several of the colonies passed laws regarding the estates of insane persons long before enacting legislation concerned with their personal well-being. T h i s condition harked back to the days of Ciceronian Rome, when elaborate provisions were made f o r the protection of an insane man's property, while none at all existed for the protection of his person. T h e responsibility f o r determining insanity was always placed in the hands of civil officers—never of medical men—and the guardianship of estates was variously entrusted to governors, town selectmen, churchwardens, vestrymen, justices of the peace, and

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41

so on, depending on the civil set-up of the several colonies. So much f o r mentally ill persons who were not dependent on the public f o r economic assistance. A s f o r the dependent insane, their lot was h a r s h e r still. By a peculiar twist of logic (which h a s n o t been completely dispelled in our d a y ) those afflicted with mental diseases were generally t r e a t e d as if they h a d been thereby stripped of all human attributes, t o g e t h e r with their rights and privileges as human beings. T h i s pernicious and all-too-prevailing attitude was bluntly summed up by a well-known English jurist of the early eighteenth century who did n o t hesitate to liken a " m a d m a n " to a " b r u t e or a wild b e a s t . " W h e n insanity w a s publicly recognized, it was usually f o r the purpose of punishing or repressing the individual; when it was not, indifference to his f a t e was the dominating note. T h e r e was no u n i f o r m theory f o r dealing with the mentally ill. T h e y were disposed of in a number of ways. Provision was of the r o u g h and ready n a t u r e t h a t characterized pioneer l i f e : individual cases were considered and decided on as they arose. A number of f a c t o r s were here involved, a m o n g the principal ones being the level of community intelligence and social-consciousness, and the kind and degree of insanity m a n i f e s t e d in the patients. T h e " v i o l e n t " insane a m o n g public dependents were ordinarily t r e a t e d as comm o n criminals, while the " h a r m l e s s " were disposed of in a m a n n e r differing only in degree of severity f r o m t h a t accorded to all o t h e r paupers. T h e l a t t e r cases were h a r d l y m o r e f o r t u n a t e t h a n the f o r m e r , f o r in colonial times and long a f t e r pauperism was looked upon as merely a lesser type of crime. Public provision, in so f a r as it was extended to the mentally ill, was mainly directed to the problem of safely disposing of violent cases. Incarceration in jail was t h e comm o n solution. But there were many localities which could n o t boast the luxury of a jail in the early days, when the pillory, the whipping post and the gallows—all placed convenieniently near the c o u r t h o u s e — a f f o r d e d simple and inexpensive means f o r punishing the r e f r a c t o r y in short o r d e r . Such a lack of institutional accommodation, however, was

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not likely to d e t e r o u r ingenious f o r e f a t h e r s . T h u s , the first k n o w n p r o v i s i o n f o r the m e n t a l l y ill in P e n n s y l v a n i a , mentioned in the U p l a n d C o u r t r e c o r d s of 1 6 7 6 , took the f o l lowing f o r m : Jan Vorelissen, of Amesland, Complavning to ye Court that his son Erik is bereft of his naturall Senses and is turned quvt madd and yt, he being a poore man is not able to maintaine him; Ordered: yt three or four persons bee hired to build a little block-house at Amesland for to put in the said madman. 1 T o meet the cost o f building the block-house and the maintenance of E r i k , a s m a l l t a x w a s l e v i e d on the community. N o less e n t e r p r i s i n g w e r e the inhabitants of the t o w n of B r a i n t r e e , M a s s a c h u s e t t s , w h o in 1 6 8 9 v o t e d That Samuel Speere should build a little house 7 foote long & 5 foote wide & set it by his house to secure his Sister good wife Witty being distracted & provide for her.2 T h e t o w n o b l i g a t e d itself t o r e p a y the said S a m u e l S p e e r e the expenses of m a i n t a i n i n g his sister in this kennellike h a b i t a t i o n . L i k e w i s e , in N e w Y o r k , the first "institut i o n " f o r the insane w a s a special structure which w a s o r d e r e d to be built in 1 6 7 7 incarceration o f P e t e r P a u l i , a " l u n a t i c k " , w h o w a s to " b e e confined into prison in the h o l d " pending the completion o f the strong-house f o r his special care. 3 W h e t h e r this one-man asylum w a s e v e r built, the records do not r e v e a l . W e learn in the l a t e r annals o f N e w Y o r k C i t y that the city jail w a s c o n s i d e r e d quite a s a t i s f a c t o r y place f o r the custody of the insane. In 1 7 2 5 the t o w n m a r s h a l , R o b e r t C r a n n e l l , J r . , w a s p a i d t w o shillings six pence a w e e k by the c h u r c h w a r d e n s " f o r to Subsist R o b e r t B u l l m a n a M a d m a n in P r i s o n . " 4 N o t i n f r e q u e n t l y the u n f o r t u n a t e p e r s o n spent decades i n c a r c e r a t e d like a common criminal. B u t when some h o p e w a s held out f o r his r e c o v e r y , only temp o r a r y confinement w a s o r d e r e d . In 1 7 2 0 , f o r e x a m p l e , the s a m e m a r s h a l w a s g i v e n the custody of one H e n r y D o v e , " a D a n g e r o u s M a d m a n , untili he shall R e c o v e r his s e n s e s . " 5 A n earlier instance o f this policy t o w a r d the " d a n g e r o u s "

COLONIAL

PROVISION

43

insane is contained in the records of Y o r k County, V i r g i n i a , f o r 1 6 8 9 . I t concerns a n o t h e r " m a d m a n " , J o h n Stock, whoe keepes running about the neighborhood day and night in a sad Distracted Condition to the great Disturbance of the people, therefore for the prevention of his doeing any further Mischeife It is Ordered by the C o u r t that M r . Robt. Read, High S h e r r : doe take C a r e that the said Stock bee L a d e hold of and safely kept in some close Roome, where hee shall not bee suffered to go abroad until hee bee in a better condition to G o v e r n e himselfe, and that ye said Robert Read is to pvide such helps as may bee Convenient to Looke after him. 8

T h e repressive principle underlying special provision f o r the mentally ill is explicit in early colonial legislation. F o r example, the first M a s s a c h u s e t t s statute specifically concerned with the insane, enacted in 1 6 7 6 , reads in p a r t : Whereas, T h e r e are distracted persons in some tounes, that are unruly, whereby not only the familyes wherein they are, but others suffer much damage by them, it is ordered by this C o u r t and the authoritye thereof, that the selectmen in all tounes where such persons are are hereby impowred & injoyned to take care of all such persons, that they doe not damnify others. 7

T h i s statute, subsequently amended in 1 6 9 4 , served as a m o d e l f o r legislation concerning the insane in other N e w E n g l a n d colonies. T h e f e a r of " d a m n i f i c a t i o n " appears as a prime f a c t o r in attracting public interest to the mentally ill in the early d a y s . A singular e x a m p l e of this f a c t o r as a stimulus to public action is f o u n d in the records of A l b a n y , N e w Y o r k , f o r 1 6 8 5 , when t w o gentlemen citizens sent an urgent request to the C o m m o n Council that it o r d e r " t h e old Poorm a n " to be r e m o v e d f r o m their neighborhood "because of the d a n g e r of houses taking fire because of his c r a z y n e s s . " 8 Special p r o v i s i o n f o r the insane poor, as we h a v e noted, w a s r a r e and w a s chiefly confined to the violent type reg a r d e d as social d a n g e r s . A s f o r the non-violent dependents, they w e r e o r d i n a r i l y classified and treated, not as mentally ill, but simply as paupers, one yardstick ordinarily being used f o r all p a u p e r classes under the p o o r laws.

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T h e p o o r relief pattern in the colonies f o l l o w e d minutely the lines set down by the f a m o u s E l i z a b e t h a n P o o r L a w A c t of 1 6 0 1 . Its outstanding f e a t u r e w a s the fixing of local responsibility f o r the support of the p o o r ; its guiding spirit was the repression, r a t h e r than r e l i e f , of pauperism. A n insight into the principle underlying this local relief system may be obtained through a r e p o r t sent by G o v e r n o r D o n g a n of N e w Y o r k in 1 6 8 6 to the m o t h e r country, in which he boasted that " e v e r y T o w n and C o u n t y are obliged to maintain their own p o o r , which m a k e s them bee soe caref u l that noe V a g a b o n d s , B e g g a r s , nor I d l e P e r s o n s a r e suffered to live h e r e . ' " Indeed, the most repressive measures w e r e a d o p t e d to keep out p o o r strangers, including the dependent insane, through the medium of harsh settlement l a w s . It w a s no accident that the first legislation respecting the p o o r w e r e l a w s of settlement intended to exclude them f r o m the several colonies and local communities. T h e earliest of the colonial settlement l a w s w a s enacted in M a s s a c h u s e t t s in 1 6 3 9 . T h e titles generally given to such a c t s — " F o r the P r e venting of V a g a b o n d s , " " F o r the P r e v e n t i n g of P o o r Pers o n s , " e t c . — a r e significant indications of their repressive intent. S t r a n g e r s a r r i v i n g in a town w e r e looked upon with suspicion, and w e r e invariably subjected to immediate and searching investigation. Inhabitants w e r e f o r b i d d e n to lodge strangers without n o t i f y i n g the authorities, so that their economic status might be checked. P a r e n t s could not even entertain their own children as guests, nor children their parents, without official permission. A definite term of "quiet and undisturbed" residence in a locality, v a r y i n g usually f r o m three months to a y e a r , g a v e a person legal settlement, carrying with it the t o w n ' s obligation to support him should he t h e r e a f t e r require public r e l i e f . H e n c e , if there seemed the least likelihood of a s t r a n g e r ' s becoming a public charge at some f u t u r e time, he w a s unceremoniously " w a r n e d o u t . " A s a f u r t h e r b u l w a r k against dependency, towns usually required newcomers, o r inhabitants entertaining them, to furnish bond against the possibility of their becoming public charges. In some colonies, public whippings

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faced all destitute persons who dared to return to a locality after once having been driven out. In N e w Y o r k , according to a law enacted in 1 7 2 1 , such persons might receive, when caught, " 3 6 lashes on the bare back if a man, and 25 if a woman." In others, still harsher laws provided f o r the whipping of poor strangers or vagabonds (the terms were used interchangeably) even before expulsion. T h e custom of " w a r n i n g o u t " was unsparingly practiced in the colonies. Francis S. D r a k e , the historian of Roxbury, Massachusetts, tells us that warnings were frequent up to the close of the 18th century, and that "Indian stragglers and crazy persons were in the early days often driven f r o m the town." 1 0 In its application, little consideration seems to have been given to those who had previously held positions of respectability and affluence—men who had "known better d a y s . " Witness the sad case of an ex-chaplain who had become mentally ill, as recorded in the Boston Selectmen's Minutes f o r 1 7 4 2 : Complaint being made by mr. Cooke that mr. Samuel Coolidge formerly chaplain of the Castle is now in this T o w n & in a Distracted Condition & very likely to be a T o w n Charge, Voted, that mr. Savell W a r n him out of T o w n acording to l a w . u

T h e dependent insane in particular suffered from the hardships occasioned by the settlement laws. It seems to have been a frequent practice f o r towns to spirit away mentally ill paupers under the cover of night, and to place them in a distant town or neighboring county in the hope of thus ridding themselves of the burden of supporting them. Frequently, the mentally ill were permitted to wander f r o m place to place, or were hurriedly "passed o n " by callous authorities in f e a r of their " f a l l i n g on the town." Cast out by unfeeling families and niggardly communities, they strayed on aimlessly, like the T o m s o' Bedlam who tramped through England, begging their bread, laying their heads wherever they might do so unmolested, the butts of ridicule of village children and idlers, and more rarely, the objects of charity of some humane individual. T h e shocking state to which these wanderers were permitted to descend is viv-

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idly illustrated in an o r d e r of the G e n e r a l Assembly of Connecticut Colony as late as 1 7 5 6 , w h e r e it is r e c o r d e d : T h e r e is n o w at W a l l i n g f o r d a strolling w o m a n that has been sometime w a n d e r i n g f r o m t o w n to t o w n , c a l l i n g herself Susannah R o b e r t s of Pennsylvania, w h o is so disordered in her reason and understanding that she passeth f r o m place to place naked, w i t h o u t any regard for the l a w s and rules of d e c e n c y . 1 2

T h e A s s e m b l y o r d e r e d the selectmen of W a l l i n g f o r d to clothe the insane w o m a n and to commit her to the care of " s o m e discreet person that she m a y labour f o r her s u p p o r t , " and agreed to p a y the difference between her earnings and the cost of her keep. T h e town of W a l l i n g f o r d , incidentally, seems to h a v e been lax in assuming legal obligations t o w a r d s its own dependents, f o r t w o y e a r s later ( 1 7 5 8 ) we find one of its residents, a " d i s t r a c t e d p e r s o n " named M a r y H a l l , " a l l o w e d to stroll f r o m town to town and place to place, to the g r e a t disquiet of many p e o p l e , " and the town is directed to take on her support. If she is t h e r e a f t e r again found wandering outside the confines of W a l l i n g f o r d , the A s s e m b l y o r d e r s that she be returned at the town's expense. 1 3 It sometimes happened that the expense of providing f o r the insane w a s too g r e a t f o r one town to bear, as witnessed in an amendment to the D u k e of Y o r k ' s law instituted 1 6 6 5 , soon a f t e r N e w N e t h e r l a n d w a s captured f r o m the D u t c h : I n regard to C o n d i t i o n s of distracted persons, they may be both v e r y chargeable and troublesome and so w i l l prove too greatc a burthen f o r one T o w n e to bear alone, and each T o w n e , in the rideing w h e r e such person or persons shall happen to be, is to contribute t o w a r d s

the

charge which may arise upon such ocasion. "

In accordance with the terms of this act, the C o u r t of Sessions f o r K i n g s County, N e w Y o r k , in 1 6 9 5 , o r d e r e d " t h a t M a d J a m e s be kept by K i n g s County in G e n e r a l and that the deacons of each town within the said county doe f o r t h w i t h meet together and consider about their propercons f o r maintainence of said J a m e s . " 1!1 T h i s is the earliest recorded instance of county care f o r the insane that has come to my notice.

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In instances w h e r e the insane w e r e not punished o r repressed f o r the crime of losing their reason, we usually find that they w e r e treated with an icy indifference. M a n y localities w e r e not above resorting to scurvy methods in ridding themselves of the responsibility of public care. B u t here and there, in r a r e and isolated instances, we do find evidences of sympathetic understanding. It is an interesting f a c t that the earliest known colonial champion of the right of the mentally ill to humane treatment w a s R o g e r W i l l i a m s , that sturdy fighter f o r liberty and tolerance in general. In a touching letter to the town council of Providence in 1 6 5 0 , W i l l i a m s appeals to the latter to minister to the needs of a distracted w o m a n , M r s . W e s t o n , so that " s o m e publike act of mercy to her necessities stand upon record amongst ye merciful acts of a merciful town yt hath received many mercies f r o m H e a v e n , and remembers yt we know not how soon our own wives may be w i d o w s and our children orphans, yea, and ourselves be deprived of all or most of o u r reason b e f o r e we goe f r o m hence, except mercy f r o m ye G o d of mercies prevent i t . " 1 8 W h e n charity w a s granted the insane p o o r , it w a s usually on a basis identical with that of the other classes of dependents. Since almshouses did not come into general use until the end of the eighteenth century, it w a s customary to " h o u s e " mentally ill paupers in private dwellings at public expense. H e r e , in embryo, w a s a f o r m of the " b o a r d i n g o u t " plan. B u t it w a s f a r r e m o v e d in aim and accomplishment f r o m the system of f a m i l y care f o r the mentally ill which later was to achieve such impressive results in Belgium, Scotland and elsewhere in recent times. T h e term "neighb o r l y " m a y be applied to this colonial f o r m of relief only in a g e o g r a p h i c sense. In essence it w a s " c o l d c h a r i t y " ; expediency and not humanitarianism w a s the determining factor. T o w n officers w e r e o f t e n c h a r g e d with the duty of maintaining the mildly insane in their homes. T h u s , the colony of N e w H a v e n in 1 6 4 5 made provision f o r distracted G o o d w i f e L a m p s o n " s o f a r f o r t h as her husband is not able to do i t , " and committed her to the care of the town marshal.

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(Incidentally, this case offers one of many instances where dependent insane were only partly relieved by public f u n d s . ) T h r e e years later, finding his charge too burdensome, the marshal begged the authorities to relieve him of his responsibility, whereupon the court ordered G o o d w i f e L a m p s o n ' s husband either to take her back home or seek another place where she might be kept. 1 7 Feebleminded dependents were also disposed of in this manner at times. Witness the action of the commissioners of Surrey County, Virginia, in 1 6 6 1 , contracting with R o b e r t H o u s e to board J o h n Deanne, an " I d d i o t t " , and to provide him with f o o d and clothing. 1 8 T h e latter seems to have earned at least part of his keep, f o r in the following y e a r he appears in the records in the relation of " s e r v a n t " to his " m a s t e r " , M r . H o u s e . Public provision f o r the indigent insane very seldom included medical treatment. On the rare occasions when it w a s prescribed it arose more f r o m the motive of economy than of kindness. T h i s calculating approach to the problem is exemplified in the case of A b i g a i l N e a l , a distracted w o m a n of Braintree, Massachusetts. F o r at least a decade following 1 6 9 7 , this woman was boarded out at public expense among several physicians in succession, in the hope that she might be cured and thus relieve the town of her support. 1 0 T h e town attempted to wash its hands of a public charge by granting lump sums to each doctor in turn " p r o v i d i n g he give the town noe further trouble about h e r , " but in 1 7 0 7 , poor Abigail remained uncured, and the town w a s still paying f o r her keep. In 1 7 0 1 the trustees of the town of Southampton, L o n g Island, voted that Samuel B a r b o r ' s w i f e "being distracted and out of her r e a s o n , " be confined in the prison, adding this provision: " W e do order C a p t . T o p p i n g to speak to D r . W a d e to come and see her, and to administer that which is proper f o r such a Person according to his skill and cunning." 2 0 H o w this prisoner-patient responded to D r . W a d e ' s cunning, history does not reveal, but our survey of medical care f o r the mentally ill at the time leaves us little room f o r optimistic conjecture. During the latter part of the colonial period l a w s were passed making it mandatory, upon penalty of fine, f o r rela-

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tives within certain degrees of consanguinity to provide f o r the mentally ill. But in the earlier years it was not unusual f o r towns to bear the expense of boarding this class of dependents with their own parents, brothers, wives or husbands. F o r example, at a Providence, Rhode Island, town meeting of November 3rd, 1 6 5 5 , presided over by R o g e r Williams, it was ordered: Since our neighbor Pike hath divers times applied himselfe with complaints to ye towne for helpe in this his sad condition of his wife's distraction, he shall repair to ye T o w n e Treasurer, w h o is hereby authorized and required to pay unto ye said Pike unto ye sume of fifteen shillings; and ye T o w n e promiseth upon his further w a n t and complaint he shall be supplied though to ye value of ten pounds or more. 2 1

One method of providing f o r the dependent insane in colonial times was to grant an individual a lump sum f o r assuming permanent responsibility f o r some particular unfortunate, as in the case of Abigail Neal. In this manner the towns sought to rid themselves of the necessity f o r indefinite provision. In 1699, the town of Braintree ordered the Selectmen to treat with Josiah O w e n about Ebenezer O w e n s distracted daughter and give him T w e n t y pounds money provided he gives bond under his hand to clear the T o w n for ever of salde girle. 2 2

But in this instance, too, the town was unsuccessful in the attempt to rid itself so easily of its proper charge, f o r further sums were voted to Josiah f o r M a r y Owen's support in 1 7 0 2 and again in 1 7 0 6 . In the latter year Braintree finally became resigned to its fate, and set aside a definite amount of money to maintain this dependent f o r the ensuing ten years. T h e confused and haphazard nature of colonial relief f o r dependent insane is manifested in N e w Y o r k City records of the early 18th century. In 1 7 1 2 , f o r example, we have an instance of provision by indirect loan when the churchwardens were ordered to "lend Phillip Batten, butcher, thirty shillings in order to go on with his trade,

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(he being reduced to great poverty by reason of his w i f e being delirious)." 2 3 H a r d l y less casual was the aid given to one Susan, "commonly called M a d S e w , " in 1 7 2 1 , when she was supplied by order of the M a y o r ' s Court with " a good pair of Shoes & Stockings & other Necessary W a r m Clothing. She being V e r y Old P o o r & N o n Compos Mentis & an Object of Charity." 2 4 In 1 7 2 9 , the f e a r was expressed by the M a y o r ' s Court that Timothy Dally, who "is by intervals perfectly distracted & non Compos M e n t i s , " might lay violent hands upon himself "if no C a r e be taken to prevent it." Daily's trouble was evidently induced by economic worries, f o r the Court adopted an unusual solution f o r warding off the danger of suicide by providing his w i f e six shillings per week to maintain him at home. 25 Whether this "prevent i v e " measure succeeded in curing him of his suicidal mania, we have no means of knowing. A sore problem that confronted our colonial fathers was how to dispose of insane persons who committed offenses against the criminal laws. F r o m the historical evidences available we may conclude that in general practice, if not in theory, no differentiation was made between insane and sane offenders, and that the former were held responsible f o r criminal acts, and were made to suffer the penalties inflicted upon common criminals. E v e n in relatively advanced communities where the irresponsibility of the insane was recognized, a hazy notion prevailed as to how to deal with their cases. T h i s confusion resulted in decisions that seem strange and inconsistent f r o m our present perspective. In 1 6 7 4 , f o r example, a case was considered in N e w Y o r k province wherein the defendant was charged with running amok, breaking down doors, setting fire to houses and beating women and children. T h e judges decided that the defendant, "not being in his right reason", could not be held responsible—an enlightened opinion f o r those times. But we can only express mystification at the final disposition of the case, f o r the judges ordered the defendant banished f r o m Flushing to Staten Island, there to be put to work by order of the local magistrate " w h o is hereby empowered, if the defendant behave badly, to punish him according as he

COLONIAL PROVISION 29

51

may deserve." All of which would indicate that although insanity might be considered a mitigating factor in the first offense, it could not save the afflicted person from punishment on future occasions. T h e r e is also the curious disposition of the case of one Roger Humphry, a colonial soldier of Simsbury, Connecticut who, in 1 7 5 7 , "became delirious and distracted and in his distraction killed his mother." Humphry was acquitted on account of his manifest insanity, but was ordered confined f o r life in a "small place" to be erected by his father at his home. T h e expense f o r building this home-prison and maintaining its inmate was to be borne by the public treasury. 27 With the growth and concentration of population in the towns, the need f o r institutional provision f o r the criminal and dependent classes became more and more imperative. T h e haphazard disposition of each individual case on its merits was quite suitable f o r a thinly populated community where the entire roster of inhabitants could convene on town meeting days to decide public problems, but in a thriving and growing town or city, the old-fashioned methods proved increasingly cumbersome. Gradually corporal punishment by means of stocks, pillories and whipping-posts was supplanted by confinement in jails, bridewells, houses of correction and prisons. Outdoor relief, in the form of individual boarding-out, gave way to workhouses and almshouses— the earliest types of institution exclusively devoted to the custody of dependent classes. Houses of correction and workhouses sprang up in the more thickly populated districts of the American colonies during the second quarter of the eighteenth century. T h e workhouse was invariably a combination penal institution and poorhouse, and within its walls petty offenders and paupers were herded indiscriminately. In theory, it was a most useful and beneficial institution, fulfilling a number of functions. It was considered as a penal establishment f o r rogues and vagabonds, idle and vicious; a means f o r profitably employing the able-bodied poor; a deterrent to those who might not resist the temptation of pauperism were it not f o r the threat of forced labor and the stigma of work-

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house confinement; and an asylum f o r the impotent p o o r and the insane. T h e first of these institutions to be built in the province of N e w Y o r k ( 1 7 3 6 ) stated its mixed purpose explicitly in the title " P o o r - H o u s e , W o r k - H o u s e , and H o u s e of C o r r e c t i o n of N e w Y o r k C i t y . " H e r e the mildly insane w e r e set to w o r k at picking o a k u m , spinning flax and wool, knitting and sewing, a l o n g with the other inmates. F o r the " u n r u l y " insane, special dungeons were built in "the w e s t e r m o s t division of the c e l l a r — t o be confined and imprisoned in." 2 8 T h u s w e r e the mentally ill disposed of in a typical w o r k house. N e e d l e s s to say, this all-embracing type of institution, f a r f r o m realizing the f o n d hopes of its p r o g e n i t o r s , p r o v e d a dismal f a i l u r e . In some communities, houses of correction w e r e built f o r the confinement of criminals and misdemeanants. Into these institutions the mentally ill w e r e o f t e n thrown, no differentiation being made between them and offenders against the law. F o r instance, w h e n the act ordering the building of Connecticut's first house of correction w a s passed in 1 7 2 7 , it p r o v i d e d f o r the incarceration therein of all rogues, vagabonds and idle persons going about in town or country begging, or persons . . . feigning themselves to have knowledge in physiognomy, palmistry, or pretending that they can tell fortunes, or discover where lost or stolen goods may be found, common pipers, fidlers, runaways . . . common drunkards, common night-walkers, pilferers, wanton and lascivious persons . . . common railers or brawlers . . . as also persons under distraction and unfit to go at large, whose friends do not take care for their safe confinement. 2 " (Emphasis mine—A.D.)

U p o n entrance into this house of correction each prospective inmate w a s automatically whipped on the b a r e back not exceeding ten lashes, unless the w a r r a n t directed otherwise. T h i s act, grouping the mentally ill with rogues, v a g r a n t s and other petty offenders, w a s by no means an unusual one. T w o y e a r s earlier, in 1 7 2 5 , a similar l a w had been enacted in R h o d e Island e m p o w e r i n g the mainland towns to erect a

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common house o f correction f o r the punishment o f rogues and vagabonds " a n d to keep mad persons in." 3 0 T h e r e remain to be discussed three other types o f institutions, and one custom, affecting the mentally ill in the colonial period. T h e almshouse ( a s distinguished from the workhouse or house o f correction), which was later to become the m a j o r custodial institution f o r the insane, first appeared on the American scene late in the seventeenth century, but did not come into general use until the end o f the colonial era. A s f o r the first hospital employed partly as a reccptacle f o r the mentally ill, and the first asylum for their exclusive care, these appeared at the dawn of the American Revolution, as we have already noted. T h e custom o f literally bidding off the insane on the auction block, along with other dependent classes, arose in rural districts just before the birth of the new nation, and was to continue in use for many years after. A l l these aspects will be described in subsequent chapters. A summary o f the care and treatment of the mentally ill in colonial times cannot but impress one with the hopeless confusion prevailing. W e have seen that neither the nature nor proper treatment o f mental disease was understood. In the isolated instances when it was recognized as a naturally produced disease and treated therapeutically, the diagnoses and prescriptions given were little less fantastic and ineffectual than the medieval nostrums. During the witchcraft delusions in Salem and elsewhere, the mentally ill were hanged, imprisoned, tortured and otherwise persecuted as agents of Satan. Regarded as sub-human beings, they were chained in specially devised kennels and cages like wild beasts, and thrown into prisons, bridewells and jails like criminals. T h e y were incarcerated in workhouse dungeons, or made to slave as able-bodied paupers, unclassified from the rest. T h e y were left to wander about stark naked, driven from place to place like mad dogs, subjected to whippings as vagrants and rogues. Even the well-to-do were not spared confinement in strong rooms and cellar dungeons, while legislation usually concerned itself more with their property than their persons. Boarding-out the mentally ill with private families

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or maintaining t h e m at their own homes at public expense did not always result in b e t t e r t r e a t m e n t , as we have n o t e d in cases w h e r e kennel-like structures w e r e attached to h o m e s f o r their confinement. W h e n e v e r public provision was m a d e —usually f o r the purpose of s a f e g u a r d i n g the community f r o m " d a n g e r o u s m a d m e n " — i t generally boded ill f o r the hapless victim of mental disease. Complete indifference to his lot was in most cases the best he could hope f o r , since in t h a t event he suffered little m o r e at the hands of a callous society than the taunts, teasings, and t h e occasional brickbats of village and town bravos. I t is not a bright or cheerful picture t o contemplate in retrospect. I t must be said, however, in defense of our forebears, t h a t the attitudes and the modes of t r e a t m e n t we have described were by no means peculiar to the American colonies, but grew out of, and reflected, conditions in the O l d W o r l d . Besides, the men of this period could plead complete ignorance of the nature, causes a n d cure of m e n t a l illness as the r o o t of their harshness, an excuse t h a t could hardly be advanced by authorities of a l a t e r century when conditions were h a r d l y improved, and in m a n y respects were even worse. T h u s m a t t e r s stood on the eve of the Revolution. M e a n while an upheaval in the concepts of h u m a n relationships was shaking E u r o p e , an upheaval t h a t was to have p r o f o u n d repercussions here and was destined to reshape m a n ' s t r e a t ment of man in general, and the t r e a t m e n t of the less f o r t u nate strata of society in particular.

CHAPTER

IV

Rational Humanitarianism : the Beginnings of Reform Λ Τ Α Ν is born free, and everywhere he is in chains 1" I V I W h e n Rousseau uttered that despairing cry, in the midst of eighteenth century ferment, he spoke in a figurative sense, having no particular group in mind, least of all the mentally ill. Still to no other dependent class of his time could the latter part of his statement be applied with more tragic accuracy. Everywhere they could be found in chains, in conditions f a r more miserable than those of the lowest incarcerated criminal. T h e jails, workhouses and other receptacles into which the insane were thrown were bad beyond description. Ironically enough the asylums f o r their special care then springing up in Europe, hailed as great reforms in the treatment of mental illness, were in many respects even worse than the f o r m e r . Describing these eighteenth century asylums, J o h n Conolly, the f a m o u s English advocate of nonrestraint, w r o t e : These were but prisons of the worst description. Small openings in walls, unglazed, or whether glazed or not, guarded with strong iron bars, narrow corridors, dark cells, desolate courts, where no tree nor shrub nor flower nor blade of grass grew; solitariness, or companionship so indiscriminate as to be worse than solitude; terrible attendants armed with whips . . . free to impose manacles, and chains and stripes at their own brutal will ; uncleanliness, semi-starvation, the garrote, and unpunished murders—these were the characteristics of such buildings throughout Europe. 1

So f a r as prolonged physical and mental torture were concerned, the period of repressive confinement, covering SS

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most o f the eighteenth century, w a s the w o r s t in the h i s t o r y of the m e n t a l l y ill. B u t in the l a t t e r p a r t of the century p r o g r e s s i v e f o r c e s w e r e a f o o t which w e r e r a d i c a l l y to influence the t r e n d of social w e l f a r e , including that branch concerned w i t h the c a r e and t r e a t m e n t o f the insane. F i r s t and f o r e m o s t a m o n g these f o r c e s w e r e the political a n d social r e v o l u t i o n s in A m e r i c a a n d F r a n c e ( 1 7 7 6 a n d 1 7 8 9 ) t h a t acted as l i b e r a t i n g a g e n t s f o r a multitude o f r e f o r m m o v e m e n t s . I t w a s at this time, t o o , that the g r e a t I n d u s t r i a l R e v o l u t i o n , destined t o b r i n g about t r e m e n d o u s changes in the economic and s o c i a l r e l a t i o n s h i p s of men, w a s beginning to m a k e itself f e l t . In the r e a l m o f ideas a n e w e r a h a d d a w n e d . T h o m a s P a i n e a p p r o p r i a t e l y t e r m e d his p e r i o d the " A g e of R e a s o n " ; the m o s t significant intellectual m o v e m e n t o f the time w a s j u s t as a p t l y c a l l e d the " E n l i g h t e n m e n t . " I t did not, o f course, b r e a k u p o n the w o r l d f u l l - b l o w n . I t r e p r e s e n t e d , r a t h e r , the accumulation o f f o r c e s t h a t h a d been g a t h e r i n g f o r scores o f y e a r s . B u t it w a s in this h a l f - c e n t u r y that the E n l i g h t e n m e n t r e a c h e d its g r e a t e s t v i g o r . I t s l e a d i n g a p o s t l e s t o o k f o r their text P o p e ' s g r e a t m a x i m : " T h e p r o p e r study o f m a n k i n d is M a n . " A restless spirit o f inquiry i m p e l l e d them to e x a m i n e minutely the w o r l d in w h i c h they l i v e d . M a n y w e n t f a r t h e r ; within t h e m b u r n e d a d e s i r e to change t h a t w o r l d f o r the b e t t e r . T h e p r i n c i p a l spirits o f the m o v e m e n t — m e n like V o l t a i r e , R o u s s e a u a n d the E n c y c l o p a e d i s t s in F r a n c e , G o e t h e , K a n t and L e s s i n g in G e r m a n y , H u m e and G o d w i n in E n g l a n d , a n d F r a n k l i n , J e f f e r s o n , and T h o m a s P a i n e in A m e r i c a — r e f u s e d to h a v e their minds f e t t e r e d by n a r r o w g e o g r a p h i c a l b o u n d a r i e s . L i k e D i d e r o t , one of their chief s t a l w a r t s , each could p r o u d l y d e c l a r e : " I a m a citizen of t h a t town they call the w o r l d . " T h e y w e r e t r u l y light-bringers, b e a r e r s o f a new Weltanschauung, a new w o r l d o u t l o o k . T h e i r concern e m b r a c e d all h u m a n i t y . T h e y f e a r l e s s l y p e n e t r a t e d into the d a r k e s t corners of society, w h e r e an u n f e e l i n g c i v i l i z a t i o n h a d t h r u s t its p a r i a h s — t h e o f f e n d e r s a g a i n s t its h a r s h l a w s , the impotent and p o o r , the sick in m i n d a n d b o d y . I n their w a r on p r i v i l e g e they f o u n d effective a m m u n i t i o n in the c o n t r a s t

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afforded by ostentatious luxury on one hand and abject suffering on the other, and they were not backward in exposing the latter to the g a z e of their fellow men. Paine remarked with bitterness t h a t wherever his eyes fell, he saw "age going to the workhouse and youth to the gallows." Such evidences of man's inhumanity to man were everywhere discernible. Like the o t h e r rationalists of his age, Paine believed that ignorance was at the bottom of all human misery; before the all-conquering light of reason this misery would soon disappear. All that was necessary was to subject social evils to a reasoning-out process and the world would be rid of them. This, briefly, was the spirit of what may be called rational humanitarianism. T r u e , the logic of its representatives was somewhat naïve. T h e men of reason were generally more sensitive to the existence and effects of social dislocations than they were to their causes. At times, the remedies they proposed proved worse than the ills they sought to cure. But essentially theirs was a most beneficial influence in the upward climb of civilization. They believed in the inherent goodness and nobility of m a n : the principle of "natural rights" f o r every living individual was part of their credo. A n d if they had handed down nothing more to their age and to posterity, their influence in raising mankind —even its lowliest m e m b e r s — t o a new plane of dignity, was in itself an epoch-making contribution to social progress. Never a f t e r was civilized society to sink to the level of indifference and apathy to human suffering that had existed before. If the social, political and economic revolutions of their time served as liberating forces f o r social r e f o r m , it was their rational humanitarianism that gave guidance and direction to the r e f o r m s effected. In some fields of welfare, as in penal r e f o r m , they and their disciples managed to achieve immediate and extensive gains. In others, as in the care of the insane, progress was slower, and took the f o r m at first of individual and somewhat isolated experiments. N o t e w o r t h y in this period was the part in r e f o r m played by the Quakers, both here and in England. An extremely practical people, they were uncommonly successful in what-

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ever they undertook, whether it were business enterprise or social service. With them theory was never divorced f r o m practice: whatever they believed they tried to carry out, with the moderation that was characteristic of the sect. Good will and good works were principal tenets in their religious belief, and they were not inclined to regard these as dead letters. John H o w a r d , renowned as the father of prison reform, was a Quaker. T h e great anti-slavery pioneer, John Woolman, was likewise a Friend, and Thomas Paine was the son of a Quaker father. In America, many of the early experiments in social welfare were initiated by Quakers. Appropriately, Philadelphia, the center of the disciples of Fox in this country, was also the chief center of humanitarian reform during the latter half of the eighteenth century. In that historic city, a group of distinguished Friends formed an active nucleus f o r social welfare work throughout the country. N o t the least accomplishment of this remarkable group was the founding of the first general hospital in A m e r i c a — the Pennsylvania Hospital—where, among other classes of sick persons, the mentally ill were received.* Its claim to prominence in our history is established by the fact that it was the first institution where cure, rather than custody and repression, was the underlying principle in the treatment of the insane. Among its founders two men stand out: Thomas Bond, a distinguished physician of his day; and that most versatile of Americans, Benjamin Franklin. In an account of the origin and early years of the Pennsylvania Hospital, written by Franklin himself, we learn that it had its beginnings in I 7 5 ° > a t a meeting of citizens who gathered together to consider the advisability of building a "convenient House, under one Inspection, and in the hands of skillful Practitioners," f o r the reception of the sick, and f o r persons "disordered in their Senses . . . there being no place (except the House of Correction or Almshouse) • I n 1 7 0 9 , at a m o n t h l y m e e t i n g of the Society of F r i e n d s in P h i l a d e l p h i a , the e r e c t i o n of a h o s p i t a l f o r such m e m b e r s of the S o c i e t y as should f a l l sick o r i n s a n e h a d been p r o p o s e d . T h i s p l a n d i d not m a t e r i a l i z e , h o w e v e r , e i t h e r b e c a u s e f u n d s w e r e l a c k i n g o r necessity w a s not s u f f i c i e n t l y p r e s s i n g .

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in which they might be confined, and subjected to proper treatment f o r their R e c o v e r y . " 2 A proposal for " a n Infirmary, or Hospital, in the manner of several lately established in G r e a t B r i t a i n " gained general approval, and the launching of a province-wide subscription campaign together with a plea to the Assembly f o r financial aid was forthwith agreed upon. On J a n u a r y 2 3 , 1 7 5 1 , a petition drawn up in Franklin's own handwriting w a s presented to the provincial Assembly. Its opening p a r a g r a p h s r e a d : T h a t with the N u m b e r s of People, the number of Persons distempered in Alind and deprived of their rational Faculties, hath greatly increased in this Province T h a t some of them going at large are a T e r r o r to their Neighbours, who are daily apprehensive of the Violences they may commit; And others are continually wasting their Substance, to the great I n j u r y of themselves and Families, ill disposed Persons wickedly taking Advantage of their unhappy Condition, and drawing them into unreasonable bargains, etc. T h a t few or none of them are so sensible of their Condition, as to submit voluntarily to the treatment that their respective Cases requires, and therefore continue in the same deplorable state during their Lives; whereas it has been found, by the experience of many Years, that above t w o T h i r d s of the M a d People received into Bethlehem Hospital, and there treated properly, have been cured.* On M a y 6, 1 7 5 1 , the Assembly passed an act " t o encourage the establishing of a Hospital f o r the Relief of the Sick Poor of this Province, and for the Reception and Cure of Lunaticks." Its first paragraph, of great significance in the history of the mentally ill, reads in p a r t : W H E R E A S , the saving and restoring useful and laborious M e m bers to a Community is a W o r k of publick Service, and the Relief of the Sick Poor is not only an Act of Humanity, but a religious D u t y : A N D W H E R E A S there are frequently in many Parts of this Province poor distempered Persons, who languish long in Pain and Misery, ' T h i s estimate of the cures effected at Bethlehem Hospital in London ¡9 obviously a gross exaggeration. T h e error may be attributable to an acceptance of the number of discharges as the actual number of cures. It is known that m a n y were discharged f r o m Bethlehem uncured.

60

T H E

under various

ΛIE N T A L L Y

Disorders

of

Body

ILL

IN

and

abroad in different and v e r y distant

AMERICA

Mind,

and

Habitations,

being cannot

scattered have

the

B e n e f i t of regular A d v i c e , A t t e n d a n c e , L o d g i n g , D i e t and M e d i c i n e s , but at a great E x p e n s e and therefore o f t e n suffer for W a n t thereof ; which

Inconveniency

might

be happily

removed

by

collecting

the

P a t i e n t s into one c o m m o n provincial Hospital, properly disposed and appointed, w h e r e they m a y be c o m f o r t a b l y subsisted, and their H e a l t h taken C a r e of at a small C h a r g e , and w h e r e by the Blessing of G o d or the E n d e a v o u r s of skillful Physicians and Surgeons, their Diseases m a y be cured and r e m o v e d . 3

T h e A s s e m b l y offered m a t e r i a l aid to this w o r t h y project in the f o r m of a g r a n t of £ 2 , 0 0 0 f o r the initial expenses of the institution, p r o v i d e d that a like amount w e r e raised by p r i v a t e subscription. T h a n k s l a r g e l y to the energy and prestige of F r a n k l i n , this w a s soon accomplished. P e n d i n g the erection of a suitable building, a " t e m p o r a r y h o s p i t a l " w a s set up in a p r i v a t e home hired f o r that purpose. O f the first t w o patients received there in F e b r u a r y , 1 7 5 2 , one w a s a " l u n a t i c k " sent by the city V i s i t o r s of the P o o r . T h e insane patients w e r e relegated to the basement of the house, w h e r e m a k e s h i f t cells were p r o v i d e d f o r them, so d a m p and unwholesome as to result in a number of deaths f r o m pulmonary diseases a m o n g the patients. W h e n the Pennsylvania H o s p i t a l proper w a s completed in 1 7 5 6 , it seemed but natural that the mentally ill should again be consigned to the cellar. T h e r e they w e r e subjected to medical treatment which, h o w e v e r dubious its benefits, constituted the best that the time afforded. A s succinctly stated by M o r t o n , " T h e i r scalps w e r e shaved and b l i s t e r e d ; they w e r e bled to the point of syncope; purged until the alim e n t a r y canal f a i l e d to yield anything but mucus, and in the intervals, they w e r e chained by the waist or the ankle to the cell w a l l . " 4 In o u t w a r d appearance their condition differed but little f r o m that of the insane in prisons. " C e l l - k e e p e r s " w a s the t e r m appropriately applied to the attendants of that day. T h e i r duties more closely resembled those of prison g u a r d s than servers of the sick. T h e i r chief task l a y in g u a r d i n g the insane and preventing escapes. T h e y were also expected to p e r f o r m a variety of menial duties in

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their " s p a r e " time, such as cleaning the premises, shopping, gardening, and " d i v e r s e other services," as stated in a regulation of 1 7 5 7 . Discipline set down f o r mental patients w a s rigidly e n f o r c e d , and those w h o broke rules w e r e punished with severity. M o r t o n tells us that the insane w e r e o f t e n chained in iron rings to the floor o r w a l l of their cells, o r were restrained in handcuffs o r ankle-irons, and that the strait waistcoat, o r " M a d d - s h i r t " , was a much used appliance. T h i s " m a d d - s h i r t " w a s " a close-fitting cylindrical g a r ment of ticking, canvas o r other strong material without sleeves, which, d r a w n o v e r the head, reached below the knees, a n d l e f t the patient an impotent bundle of w r a t h , deprived of effective m o t i o n . " In the earlier years, says M o r ton, " i t w a s not considered improper o r unusual f o r the keeper to carry a whip and use it f r e e l y . T h e s e methods beg a t violence and disorder in the insane, who w e r e then, f o r that reason, a much m o r e violent and dangerous class than they now are, and the keeper's l i f e w a s neither an idle nor a happy o n e . " 5 A n echo of the clanging chains that P e t e r the p o r t e r purloined f r o m Bethlehem in 1 4 0 3 is perceptible in the f o l l o w ing blacksmith's account against Pennsylvania H o s p i t a l in 1 7 5 2 , an impressive sidelight on the manner of dealing with the mentally ill : J o h n Cresson, blacksmith, against ye hospital, 1 pair of handcuffs, 2 legg locks, 2 large rings and 2 large staples, 5 links and 2 large rings and 2 swifells for legg chains.

D e s p i t e the heroic regimen imposed on the insane in the early d a y s of the H o s p i t a l , the important f a c t w a s that f o r the first time in A m e r i c a n h i s t o r y — i n principle at l e a s t — a public institution was receiving the mentally ill, not to be confined as m a l e f a c t o r s , but to receive curative treatment as sick patients. A new ideal, a revolutionary departure f r o m the purely repressive traditions of the past, w a s being introduced although, unfortunately f o r the objects of concern, the practice l a g g e d f a r , f a r behind the principle. I t is difficult, in viewing the barbarities and h o r r o r s o f a past age, to j u d g e them in the light of a p r o p e r historical

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perspective. In this particular instance it is doubly difficult to realize that, whatever its shortcomings, the treatment of the insane at the Pennsylvania Hospital was approved by the foremost authorities of the period, and that its progenitors were motivated by a spirit of human kindness no whit inf e r i o r in degree to ours. In the same sense that we regard with perfect complacency many conditions that a future generation will undoubtedly look back upon with horror, so things that now seem relics of savagery were in those days looked upon as marks of radical progress, and praised accordingly. A n interesting illustration of this truth is implicit in the journal notes of a visitor to the Pennsylvania Hospital in 1 7 8 7 , the good R e v . Manasseh Cutler. A f t e r describing the wards f o r the sick, he continues in this vein: W e next took a view of the Maniacs. T h e i r cells are in the lower story, which is partly underground. T h e s e cells are about ten feet square, made as strong as a prison. O n the back part is a long entry, from which a door opens into each of them ; in each door is a hole, large enough to give them food, etc., which is closed with a little door secured with strong bolts . . . H e r e were both men and women . . . Some of them have beds, most of them clean straw. Some of them were extremely fierce and raving, nearly or quite naked. T h i s would have been a melancholy scene indeed, had it not been that there was every possible relief afforded them in the power of man. From this distressing view of what human nature is liable to, and the pleasing evidence of what humanity and benevolence can do, w e returned . . . etc., etc.® (Emphasis m i n e — A . D . )

Patients were committed to the hospital with an amazing ease and informality, f o r it was not until some years a f t e r Pennsylvania had reached statehood that a general statute providing f o r the proper commitment of the insane was enacted. A l l that was necessary was f o r a relative, a friend — o r , perhaps, an enemy—to apply to one of the managers or physicians f o r an order of admission. A few words hastily scribbled on a chance scrap of paper (such as " J a s . Sproul is a proper patient f o r the Pennsylvania H o s p i t a l " ) , and signed by one of the physicians, and the deed was done. Should the prospective patient make too vigorous remon-

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strance, it was a simple matter to place him in chains or irons or otherwise to pacify him effectively. Apparently, occupational therapy was applied to the mentally ill as well as to other classes of patients at the very beginning. F o r this innovation the Friends must have been mainly responsible, since their faith in work as a characterand health-building agent was almost part of their creed. T h e mentally ill who were able to do so were set at some light labor such as spinning wool or flax. In this implicit recognition of the value of occupational therapy, the founders of the Pennsylvania Hospital anticipated modern psychiatry by many years. T r u e , the insane had been put to labor b e f o r e this time, but f o r a quite different reason, namely, to get as much return f o r their keep as possible, and not at all as a therapeutic measure. In striking contrast to the rigorous regimen that ordinarily governed the hospital routine, there occurred in 1 7 6 5 a remarkable instance wherein a patient's whim played havoc with the institutional sense of propriety, much to the amusement and wonderment of Philadelphia's populace. In that year, a sailor, T h o m a s Perrine, was admitted to the hospital as a lunatic, and placed in one of the underground cells. H e r e he proved very troublesome, quarrelling incessantly with his fellow patients and the keepers. One day he escaped f r o m his basement cell, rushed to the top of the house and barricaded himself in a cupola, where he successfully defied all efforts to dislodge him. Attempts to remove him were finally given up and bedding was brought up to the cupola, which was now transformed into sailor Perrine's private domain. In this small space he lived f o r nine years until his death in 1 7 7 4 . I t is recorded that H e never left these cramped quarters for any purpose ; he was also noted for his long nails, matted beard and hair and for his insensibility to cold since he never, in the coldest weather of nine winters, came near to a fire.7

A most shocking custom, one continuing at least to the end of the eighteenth century, was that of exhibiting the insane patients to the gaze of curious sightseers f o r a set

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admission f e e . S t r a n g e as it m a y seem, h o w e v e r , the decision to exact admission f e e s to the insane w a r d s originated f r o m a desire to protect the mental patients r a t h e r than to exploit them. It a p p e a r s that when the hospital w a s first opened the public w e r e permitted to enter at will and to w a n d e r about the grounds as they pleased. T h e hospital then stood in an open lot with no fence or wall to set it off. It w a s customary, particularly on Sundays and holidays, f o r idlers and thrill-seekers to g a t h e r about the cell windows of the insane which stood at ground level and to take turns at " t e a s i n g the c r a z y p e o p l e , " with the aim of rousing them into r a v i n g f u r y . G r a d u a l l y the insane department of Pennsylvania H o s pital became k n o w n as one of the show places of Philadelphia, as c o n t e m p o r a r y B e d l a m w a s of L o n d o n . It w a s quite the thing f o r inhabitants to entertain their out-of-town guests by bringing them to observe, or to participate in, the sport of baiting the madmen. S o g r e a t did this evil become that in 1 7 6 0 the authorities w e r e constrained to curb it by ordering the erection of " a suitable P a l l i s a d e Fence, either of I r o n o r W o o d , the I r o n being p r e f e r r ' d , in O r d e r to prevent the Disturbance which is given to the L u n a t i c s confin'd in the Cells by the g r e a t N u m b e r s of people w h o f r e quently resort and converse with t h e m . " B u t this device does not seem to have noticeably lessened the scandalous situation, f o r t w o y e a r s later the m a n a g e r s again complained that " t h e g r e a t crowds that invaded the H o s p i t a l give trouble and create . . . much disturbance." T h e y f o u n d it necessary to o r d e r the building of " a suitable hatch d o o r and get an inscription thereon n o t i f y i n g that such 'persons w h o come out of curiosity to visit the house should p a y a sum of money, a G r o a t at least, f o r admittance.' " In 1 7 6 7 , this rule apparently being d i s r e g a r d e d , it w a s again urged that no curious visitor be permitted entry without the payment of a fee, " F o u r Pence, as f o r m e r l y a g r e e d u p o n . " B u t the admission fee p r o v e d a p o o r deterrent to those seeking entertainment at the expense of the mental patients, and the crowds continued to flock to the institution on Sundays in undiminished numbers. F i n a l l y , in

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1 7 9 1 , in response to complaints of the physicians that the patients w e r e being seriously h a r m e d by the indiscriminate admittance of visitors, the authorities v o t e d that no person be a l l o w e d entry to the insane quarters without express permission f r o m one o f the m a n a g e r s o r physicians o r f r o m the s t e w a r d . H o w e v e r , the practice of exhibiting patients f o r a price continued in f o r c e , and as late as 1 8 2 2 w e r e a d of an o r d e r raising the admission f e e f r o m 1 2 ^ 2 to 2 5 pence. A t B e d l a m , w h e r e , until the y e a r 1 7 7 0 , visitors paid a f e e at the f a m o u s " p e n n y g a t e s " to gain entrance to what w a s considered L o n d o n ' s most amusing " r a r e e - s h o w " , the practice seems to h a v e been introduced mainly as a means of replenishing the institutional income. It is said that m o r e than £ 4 0 0 w e r e netted in admission f e e s at B e d l a m in one year.* D u r i n g the first half-century of the Pennsylvania H o s pital's existence, insane patients w e r e quartered in cells scattered t h r o u g h o u t the building, underneath the sections w h e r e o t h e r sick g r o u p s w e r e maintained. W i t h the increase of patients this a r r a n g e m e n t p r o v e d progressively unsatisf a c t o r y . A m o v e m e n t w a s set a f o o t to obtain separate provision f o r the mentally ill. A new w i n g in the western part of the hospital w a s accordingly erected, to which the insane w e r e r e m o v e d in 1 7 9 6 . T h e y still remained under the same r o o f with all o t h e r sick persons, h o w e v e r . I t w a s not until nearly a n o t h e r half-century h a d passed that a s e p a r a t e building w a s p r o v i d e d f o r them.f T h e P e n n s y l v a n i a H o s p i t a l represented a tremendous step f o r w a r d in t h a t it w a s the first A m e r i c a n public insti• I v e s g i v e s this i n t e r e s t i n g a c c o u n t of the p r a c t i c e in E n g l a n d : " I n the e i g h t e e n t h c e n t u r y — u p to 1 7 7 0 — a n d in some p l a c e s doubtless, e v e n in l a t e r t i m e s , the m a d p e o p l e w e r e r e c k o n e d a m o n g the 'sights'. T h e p u b l i c p a i d to g o r o u n d the a s y l u m s , a s t h e y do n o w to g a z e upon w i l d b e a s t s . T h e b a s e r a n d m o r e m i s c h i e v o u s a m o n g t h e m w o u l d i r r i t a t e and p u r p o s e l y e n r a g e the s e c u r e d p a t i e n t s , a s t h e i r d e s c e n d a n t s tease c a g e d a n i m a l s to this d a y , a n d thus r e p r o d u c e d f o r the g h a s t l y d i v e r s i o n exhibitions of m a d n e s s w h i c h a r e no l o n g e r to be f o u n d . " ( I v e s , G e o r g e C . , History of Penal Methods. Lond o n , 1 9 1 4 . 409 pp., p. 89.) f i n 1 8 4 1 a n e w b u i l d i n g , c a l l e d the D e p a r t m e n t of the I n s a n e of P e n n s y l v a n i a H o s p i t a l , w a s o p e n e d in W e s t P h i l a d e l p h i a , on the outskirts of the city, a n d the m e n t a l l y ill w e r e r e m o v e d thereto f r o m the old b u i l d i n g at P i n e Street.

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tution where the mentally ill w e r e received specifically f o r the purpose of treatment and cure. It w a s also the first w h e r e a humane approach to the problems of insanity w a s attempted. B u t there still remained the problem of p r o v i d ing an asylum exclusively devoted to the care and treatment of the insane. Such institutions w e r e a l r e a d y in existence in E u r o p e long b e f o r e the eighteenth century although, as w e h a v e noted, they w e r e f a r f r o m being models of p e r f e c t i o n . T o V i r g i n i a belongs the distinction of h a v i n g erected the first A m e r i c a n asylum exclusively f o r the mentally ill. I t w a s opened in 1 7 7 3 at W i l l i a m s b u r g , then the capital of the colony. Y e a r s b e f o r e the hospital at W i l l i a m s b u r g w a s established, proposals f o r erecting such an institution had been discussed in several colonies, particularly in those g r o w i n g centers of population where the trend t o w a r d institutionalization first became m a n i f e s t . B u t s o m e h o w such plans had n e v e r b e f o r e gone beyond the embryonic stage of development. O n at least t w o occasions during colonial times, B o s t o n h a d been on the v e r g e of building a s e p a r a t e institution f o r the insane. A b o r t i v e plans f o r this purpose date back to 1 7 3 0 . In 1 6 6 2 B o s t o n had established w h a t w a s p r o b a b l y the first almshouse in N e w E n g l a n d . A s w a s the custom (one, incidentally, which w a s to continue well into the nineteenth c e n t u r y ) , indigents and petty offenders w e r e herded indiscriminately into this p o o r h o u s e — t h e sick and well, the ablebodied and impotent, the law-breaking and law-abiding, y o u n g and aged, " w o r t h y " p o o r and v a g r a n t s , sane and insane. A t t e m p t s w e r e made as early as 1 7 1 6 to achieve some measure of segregation, and a bridewell w a s built f o r the housing of the " u n w o r t h y " p o o r and petty offenders a p a r t f r o m the " w o r t h y and p i o u s " inmates of the almshouses. H o w e v e r , another sore problem remained unsolved. T h e insane in the almshouse w e r e m a k i n g l i f e unbearable f o r the others by their cries and antics, and the town selectmen and overseers of the p o o r w e r e deluged with urgent pleas that the poorhouse be relieved of the presence of this troublesome element. T h e town authorities seem to h a v e

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lent a sympathetic ear to these appeals f o r on the agenda of a town meeting held in 1 7 3 0 , we find this item among others : " t o Consider of making Some adition to the Alms House, f o r keeping Distracted Persons Separate f r o m the P o o r . " 8 Nothing further appears to have been done, however, until M a r c h , 1 7 4 6 , when the overseers proposed to the town inhabitants of Boston that "the T o w n purchase the Bridewell house &c. f o r a mad house." 9 T h r e e weeks later the overseers were commissioned to inquire into the practicability of transforming the old bridewell into an asylum f o r the insane poor. It is worthy of note that the comfort and better care of the insane was not a dominating motive behind this proposal f o r a separate building to house them, as the suggested use of the bridewell indicates. T h e proposal sprang f r o m a desire, laudable so f a r as it went, to afford greater comfort f o r the other classes of almshouse inmates. A p parently the overseers experienced a change of mind regarding the use of the bridewell f o r this purpose, since their original proposal was never acted upon. T h e plan f o r providing a separate structure f o r the mentally ill continued to be pressed. By M a y , 1 7 4 6 , the project had advanced to the stage where a committee was formed at a town meeting to "endeavor to obtain a Subscription f o r building or purchasing a House proper f o r Reception of Distracted Persons." 1 0 T h e attempt to raise funds in this manner evidently failed, and five years later the complaint was again repeated that the "Distracted, helpless and infirm people" still comprised a majority of the workhouse population, which was primarily intended f o r the ablebodied. 1 1 In 1 7 6 4 the idea of erecting an institution f o r the mentally ill was again revived, under such circumstances that its materialization now seemed a certainty. August of that year witnessed the decease of Thomas Hancock, uncle to that John who so boldly inscribed his name to the Declaration of Independence. Hancock's will carried this provision : I give unto the T o w n of Boston the sum of six hundred pounds l a w f u l money towards erecting and finishing a convenient House for

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the reception and more comfortable keeping of such unhappy persons as it shall please G o d in his Providence to deprive of their reason in any part of this P r o v i n c e ; such as are inhabitants of Boston a l w a y s to have the preference . . . A n d in case said H o u s e shall not be built and finished in three years after m y decease, I then declare this legacy to be void ; or if I should in my lifetime erect it, this bequest then to be v o i d . *

W e may infer, f r o m the wording of the last clause, that M r . Hancock had intended to build an asylum f o r the mentally ill before his death, a desire that probably arose f r o m the fact that during his later years he himself was so greatly troubled with "nervous disorders" as to force his almost complete withdrawal f r o m business life. Hancock's legacy was gratefully accepted by the town of Boston, and a committee was appointed at once to determine what steps should be taken to comply with its terms. Serving on this committee was J a m e s Otis, who played such an important role in the events leading up to the Revolution and who, curiously enough, was himself fated to become a mental case due to a head injury sustained in 1 7 6 9 . T h e committee's report, which was unanimously adopted by the townspeople, recommended that Hancock's name be inscribed among those of Faneuil, Boston's honor roll, in gratitude f o r his donation. A s f o r the hospital, it voted that "such House when erected shall be called and known by the name of Hancock's Hospital. T h u s , while the poor Unfortunates therein provided f o r shall be insensible f r o m whose H a n d s they derive their only possible alleviation of their miseries in the power of humanity, those in all A g e s who may enjoy the inestimable blessing of a sound mind shall rejoice in the bountiful provision f o r the distressed." 1 2 Although Hancock, in drawing up his bequest, had apparently believed that £ 6 0 0 would closely approximate the cost of erecting the institution, it soon became evident that this sum fell f a r short of the required amount. A n effort • T h o m a s Hancock w a s one of the most successful merchants of the eighteenth century. In his will containing the quoted provision he left the bulk of his huge estate, valued at some £70,000, to his nephew, John Hancock, making the latter one of the wealthiest men in the colonies.

E I G H T E E N T H - C E N T U R Y HOSPITALS FOR T H E M E N T A L L Y ILL A. Sketch of the Pennsylvania Hospital, 1752—the first hospital in this country to admit mental patients for curative treatment. B . A n early print of the Eastern Lunatic Hospital at Williamsburg, Virginia—the first public hospital in America exclusively for the treatment of the mentally ill.

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was launched to raise the additional funds required f o r building the " B e d l a m " (as the proposed structure was frequently referred t o ) by means of private subscriptions. But, as had happened a score of years earlier, the campaign did not arouse sufficient interest and was finally dropped. Meanwhile the three-year limit set in the will f o r the completion of the building was drawing to a close. A s a last resort the town authorities decided to petition the provincial Assembly f o r financial aid, on the ground that the hospital was intended as a sanctuary f o r all the mentally ill of the province. T h e petition was presented to the General Assembly on June 20, 1 7 6 6 , but was withdrawn six days later, f o r an unexplained reason. 1 5 W a s it because Boston was given an unmistakable sign of the legislature's disapproval? A t any rate, the Hancock legacy was finally rejected by the town selectmen, who adopted what was in all probability a facesaving reason: " T h e r e are not enough insane persons in the province f o r the erection of such H o u s e . " B y such narrow margins did Boston twice miss the distinction subsequently gained by Virginia. T h e first American hospital exclusively f o r the insane had its beginnings in November, 1 7 6 6 , when the governor of Virginia Colony, Francis Fauquier, made an earnest appeal f o r such a hospital in an address to the H o u s e of Burgesses. It is interesting to note the striking resemblance that the phrasing of his appeal bears to the Philadelphia petition of 1 7 5 1 : It is expedient I should . . . recommend to your Consideration and Humanity a poor unhappy set of People who are deprived of their Senses, and wander about the Country, terrifying the Rest of their Fellow Creatures. A legal Confinement and proper Provision ought to be appointed for these miserable Objects, who cannot help themselves. Every civilized Country has an Hospital for these People, where they are confined, maintained and attended by able Physicians, to endeavour to restore to them their lost Reason."

Within two weeks the legislature, acting upon the governor's humane recommendation, passed a resolution favoring the erection of a hospital f o r "the reception of persons who

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are so unhappy as to be deprived of their reason," and ordered a committee to bring in a bill embodying this proposal. But a delay ensued: the House was embroiled in weighty affairs of state. T h e r e was serious trouble with the mother country; the first s o f t mutterings of revolution were swelling into ominous rumblings; the r a f t e r s of the House of Burgesses were ringing with the fiery speeches of Patrick H e n r y and others. In the swirl toward the decisive conflict, r e f o r m in the treatment of the mentally ill was temporarily thrust aside. But Governor Fauquier seems to have been determined on action. On April n , 1 7 6 7 , he again brought before the assembled delegates in the H o u s e the "case of the poor lunaticks." Expressing his disappointment at the failure of the House to f r a m e a bill f o r the establishment of an insane hospital, he declared that this was " a measure which . . . I was in hope humanity would have dictated to every man, as soon as he was made acquainted with the call f o r it." H e pointed out that, because of the lack of propei provision f o r the mentally ill, he had been forced to authorize the confinement of lunatics in the Williamsburg jail, against both his conscience and the law. " A s a point of some importance to the ease and comfort of the whole community, as well as a point of charity to the unhappy objects," he again urged the enactment of a suitable bill on the subject. 15 Despite his strong plea nothing further was accomplished by the legislature until 1 7 6 9 when it passed an act " t o make Provision f o r the Support and Maintenance of Ideots, Lunatics and other persons of unsound M i n d s . " 1 8 It was set forth in the act that "whereas several persons of insane and disordered minds have been frequently found wandering in different parts of this colony, and no certain provision having been yet made toward effecting a cure of those whose cases are not become quite desperate, nor f o r the restraining others who may be dangerous to society," the "Public Hospital f o r Persons of Insane and Disordered M i n d s " (incorporated the preceding y e a r ) was ordered erected f o r their future care and treatment. It authorized the purchase of a piece of ground at or near W i l l i a m s b u r g — " t h e most healthy in situation that can be p r o c u r e d " — b y the trustees of the

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newly-established hospital. On this plot a "commodious house or houses" was to be built. Among the original trustees were such distinguished citizens as John Blair, George Wythe, T h o m a s Nelson, Peyton Randolph, John Randolph, Robert Carter, John Tazewell, Dudley Digges and Benjamin Waller. Several of these men became signers of the Declaration of Independence a few years later. An appropriation of £ 1 , 2 0 0 was voted to d e f r a y the initial cost of building the institution f o r the insane, and provision was made f o r personnel consisting of a keeper, a matron, guards, nurses and visiting physicians. Determination of insanity was left to the judgment of three magistrates; no provision was made f o r examination by a physician. T h e hospital was opened f o r the reception of its first patients October 1 2 , 1 7 7 3 . J o h n de Sequeyra, a leading doctor of Virginia, served as the first visiting physician, retaining his post until 1 7 9 5 . J a m e s Gait was appointed the first keeper. T h e functions of keeper and physician remained distinct until the year 1 8 4 1 , when they were combined in the person of D r . John M . Gait, the first superintendent. Incidentally, the Gait family was connected with the Williamsburg institution f o r nearly a century after its inception, resembling somewhat the long and memorable record of the Tukes in the history of the Y o r k Retreat in England. Unfortunately, no record of the early methods of treatment has come down to us, but Wyndham B . Blanton, the historian of medicine in Virginia, ventures the opinion that "undoubtedly the old reliance on chains and confinement in cells prevailed here as elsewhere," 1 7 and he is probably correct. N o t the least distinctive feature of this, the first separate institution f o r the insane in America, is the fact that f o r a period of fifty years, until the Eastern Lunatic Asylum at Lexington, Kentucky, was opened in 1 8 2 4 , it remained the only state hospital of its kind in the country.

CHAPTER

V

Benjamin Rush—the Father of American Psychiatry Π Π Η Ε y e a r 1 7 8 3 , which witnessed the climax of the R e v o lution and the transition of a rebel people to a sovereign nation, w a s also portentous in the history of A m e r i c a n psychiatry. In that y e a r D r . Benjamin R u s h joined the staff of physicians at Pennsylvania H o s p i t a l , beginning a thirtyy e a r period of service that w a s f r a u g h t with g r e a t significance to the mentally ill in A m e r i c a . A r m e d with those indispensable tools of science—a capacity f o r assimilating knowledge, keen observation and inductive r e a s o n i n g — h e was able to cut a w a y thick layers of superstition, h e a r s a y and ignorance, and to raise the study and treatment of mental diseases to a scientific level f o r the first time in this country. H e w a s the first A m e r i c a n teacher to institute a comprehensive course of study in mental disease; he w a s the first A m e r i c a n physician to attempt an original systematization of the subject. T h e theoretic structure that he erected w a s decidedly unsteady, as we shall see, but it m a r k e d a real beginning, and an honest one. H e wrote the first g e n e r a l treatise on psychiatry in A m e r i c a , and it is no mean tribute to his genius that it remained the only A m e r i c a n w o r k of its kind f o r seventy y e a r s a f t e r publication. H e f u l l y earned the title by which he w a s known to later g e n e r a t i o n s — " t h e F a t h e r of A m e r i c a n P s y c h i a t r y . " Rush w a s no o r d i n a r y innovator. H e w a s one of the m o s t remarkable men of his time. In many respects his v a r i e d career paralleled that of his illustrious townsman, B e n j a m i n Franklin. H i s accomplishments in diverse fields w e r e outstanding even in that age which probably produced the m o s t 72

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brilliant constellation of versatile geniuses the world has ever known. A s with Franklin, there was hardly a reform movement of his day which did not bear the impress of Rush's personality. A glance at a bibliography of his published writings reveals at once the wide range of this man's interests : his works included dissertations on politics, finance, medical theory and practice, ethics, war and peace, slavery, philosophy, philology, anthropology, religion, immigration, penology and criminology, education, agriculture, meteorology, etc., etc. 1 Rush was born at Philadelphia in 1 7 4 5 of Quaker parents, although oddly enough, both his father and his grandf a t h e r were gunsmiths by trade. A precocious child, he graduated from Princeton (then N e w Jersey College) bef o r e reaching the age of fifteen. Six years of medical apprenticeship followed, a f t e r which Rush journeyed to the University of Edinburgh, at that time the chief center of medical education, where he received his M . D . degree in 1 7 6 8 . Following an additional year's stay in Europe, the young doctor returned to Philadelphia, where he set up practice and rose rapidly to prominence. A few months a f t e r his return he was made professor of chemistry at America's first medical school, founded at Philadelphia College in 1 7 6 5 , and later became professor of theory and practice of medicine there. H e r e he attracted a larger number of students than any other medical teacher during the last quarter of the century. H i s teachings were carried to every part of the country by his pupils. H e was the fifth member of a distinguished faculty that included Drs. J o h n M o r g a n , William Shippen, A d a m Kuhn, and T h o m a s Bond. Upon the outbreak of the Revolution he became a member of the Continental Congress and (at the age of thirty) a signer of the Declaration of Independence. Congress appointed him surgeon-general and later physician-in-chief of the middle department of the continental army. Differences arose and he resigned, resuming his private practice at Philadelphia. A n original thinker, and a reformer by nature, Rush soon involved himself in the various humanitarian movements then being carried f o r w a r d on the crest of the révolu-

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tionary wave. T o these movements he lent not only his name, but his time, money and seemingly inexhaustible energy. H e was imbued with that sense of rational humanitarianism characteristic of the period's leading reformers, fortunately coupled with a will-to-do and backed by a tremendous store of physical and mental vitality. Optimism, the fruit of a newly born and lusty social order, he had in abundance—a valuable adjunct to a person of his pursuits, since it served as a constant stimulus to action. Benjamin Rush was a member of the famous reform group in Pennsylvania which included Benjamin Franklin, Roberts Vaux, Caleb Lownes, William B r a d f o r d , and other pioneers in American humanitarianism. It was this group which formed the first prison reform society in America,* and succeeded in having the death penalty in Pennsylvania abolished f o r all crimes except murder in the first degree. T h e y also brought about improvement in the treatment of imprisoned poor debtors who at that time were made the victims of barbaric laws, and laid the foundations f o r the famous Pennsylvania prison system, which f o r many years served as a model f o r penal institutions in America and Europe. In the field of education Rush was one of the earliest advocates of free public schools f o r the poor. H e championed the then radical cause of higher education f o r women, and was largely instrumental in the founding of Dickinson College in western Pennsylvania. Like many of the advanced thinkers of his day he was an ardent advocate of temperance, and vigorously preached against spirituous liquors as being harmful not only to the body, mind and morals of individuals, but to society itself. H e was a principal founder of the first free dispensary in America (the Philadelphia Dispensary for the P o o r ) , established in 1786. From 1799 to his death in 1 8 1 3 he was treasurer of the United States Mint. H e passionately favored the abolitionist cause, and served as president of the Society f o r the Abolition of Slavery. • T h e Philadelphia Society f o r A l l e v i a t i n g the M i s e r i e s of Public Prisons, organized in 1787.

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Rush was fond of literature, as evidenced by the liberal— too liberal, one might say—use of quotations from the classics throughout his writings. Although his own style was too ornate and discursive f o r modern tastes, he was no mean literary man himself, his publications comprising scores of books, pamphlets, articles and addresses. Besides, his correspondence alone fills some " 4 3 stout volumes." In truth, he wielded his pen with the same facility as he did his lancet, if not with quite the same degree of skill. H i s works were widely read in his time, and gained him a reputation as a leading man of letters. In every movement he championed he proved an able propagandist, as attested by his numerous reform pamphlets. A masterful polemicist, he never shrank f r o m a fight, a trait that nearly proved his undoing on several occasions. Few of his contemporaries were engaged in such bitter debates and none, perhaps, over so wide a front. Right or wrong (and he was by no means always right) he was a man of strong convictions. H a v i n g once formed an opinion on a subject, he felt no hesitancy in bringing f o r w a r d his views to the public and denouncing in no uncertain terms those who held opposite views. Naturally, this characteristic earned him many enemies, particularly in his own profession. During and a f t e r the great yellow fever epidemic which decimated Philadelphia's population in 1 7 9 3 , Rush (who was at the time probably the busiest physician in the country, visiting upward of 1 5 0 patients on many days) found time to engage in one of the most acrimonious medical controversies in American history, on the subject of the proper cure f o r yellow fever. A principal point of dispute was the efficacy of calomel, which Rush prescribed in copious quantities f o r fever victims. H e called this favorite remedy his " S a m s o n " because of its supposed potency, although his unkind critics said it was aptly named because it " h a d slain its thousands." T h e medical system built up by Rush fell f a r short of modern standards, and in some respects was more harmful than curative. Nonetheless, it can scarcely be denied that he provided more impetus to medical progress in America

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than any of his contemporaries, above whom he towered like a giant. Through his original methods and theories and his ability to stimulate interest and discussion in medical problems, he raised the practice of medicine in his country to a far higher plane than it had ever known before. His own practice was largely based on the teachings of the two most eminent medical theorists of the period—the Hollander, H e r m a n Boerhaave, and the Englishman, William Cullen, under whom he had studied in Edinburgh. From the former, he derived an abounding faith in the efficacy of depleting agents in treating diseases; from the latter, the necessity for simplifying medicine and freeing it of the mystical trimmings with which it had become enshrouded. H e was also influenced by the celebrated clinician of a preceding century, Thomas Sydenham, whose emphasis on the superiority of observation and experience over abstract theory became a distinctive feature of Rush's own methodology. In effect then, Rush's medicine represented a synthesis of the teachings of these men, together with many original contributions of his own. H e showed no hesitancy in discarding accepted theories when he felt that personal experience had disproved them, and his characteristic indifference to authority several times brought him into violent conflict and disfavor with his fellow practitioners. Although he showed the greatest respect f o r Cullen throughout his career, he regarded his teacher's system of classification as too elaborate. His emendations of Cullen were generally beneficial, but in his quarrel with the latter's methods he was not always consistent. For example, as a substitute for Cullen's simple definition of hydrophobia, Rush suggested a complex classification of phobias based on the names of each object exciting fears and aversions— thunder-phobia, ghost-phobia, cat-phobia, rat-phobia, etc. Some of his comments on other phobias are so refreshingly ironic, in contrast with his usually serious approach to such problems, that they are worth quoting: Solo-phobia is the dread of being alone. This distemper is peculiar to persons with vacant minds and guilty consciences . . . Rum-

Courtesy

of the Pennsylvania

BENJAMIN RUSH, FATHER OF AMERICAN PSYCHIATRY (Portrait

by Thomas

Sully)

Hospital

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phobia is a rare disease. I have known but five instances of it in the course of my life . . . Doctor-phobia is complicated with other diseases . . . I t might be supposed to be caused by the terror of a long bill, but that excites terror in f e w minds, for w h o ever thinks of paying a doctor's bill while he can use his money to advantage in another w a y ? . . . Church-phobia . . . has become an epidemic in Philadelphia, hence w e see half the city flying in chariots, phaetons, chairs and even stage wagons, as well as on horseback, f r o m the churches in summer as soon as they are opened for Divine worship. In winter they drown their fear of church in plentiful entertainment. 2

W h e n Rush entered upon his duties in the Pennsylvania H o s p i t a l in 1783 he w a s already the most f a m o u s physician in Philadelphia. H e immediately centered his attention on the mentally ill, firmly convinced t h a t " t h e patients afflicted by madness should be the first objects o f the care o f a physician of the Pennsylvania H o s p i t a l . " Rush divided mental diseases into t w o principal g r o u p s : general intellectual derangement, and partial intellectual derangement. H i s remedies f o r insanity were likewise placed in t w o general c a t e g o r i e s : remedies applied to the mind through the medium o f the body, and remedies applied to the body t h r o u g h the medium of the mind. D e p l e t i n g agents (bloodletting, p u r g a t i v e s and emetics) held a p r i m a r y place a m o n g his remedies. Venesection he applied to an excess that is truly appalling. H e tells us that he once extracted t w o hundred ounces of b l o o d f r o m one patient within a f e w months, and f r o m another 4 7 0 ounces in forty-seven bleedings.* In passing, it should be said that to judge Rush's therapy merely on the basis o f isolated passages and statements would not be f a i r either to his genius or to his hard-earned reputation. F o r a full appreciation of his place in mental therapy his m e t h o d s must be examined in the light of the psychiatric level o f his time, both in A m e r i c a and abroad. It is in this light that Rush's therapy and prac• R u s h w a s the f o r e m o s t p r o p o n e n t of v e n e s e c t i o n in A m e r i c a . I n his Medical Inquiries and Observations, p u b l i s h e d in 1809, he i n c l u d e d a r a t h e r l e n g t h y t r e a t i s e " I n D e f e n c e of B l o o d - L e t t i n g . " ( P h i l a d e l p h i a , 1809, v . 4., p. 2 8 5 - 3 8 2 ) .

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tice reveal themselves, on the whole, as f a r in advance of his age. Bloodletting was approved as a major therapeutic device by nearly all of Rush's contemporaries. Boerhaave, the most influential medical teacher of the time (and b e f o r e him, Sydenham), had constantly stressed the efficacy of venesection f o r all ills, including mental ones. D r . Bryan Crowther, a surgeon at Bethlehem Hospital, London, claimed in 1 8 1 1 to have bled 1 5 0 insane patients in one day without untoward result. Esquirol, the successor to the great Pinel at the Salpêtrière in Paris, wrote in 1 8 1 6 : " O n the discovery of the circulation of the blood, it was believed that we had discovered the cause of every disorder and a remedy f o r all ills. Blood was shed abundantly. T h e blood of the insane was the more freely shed, as by bleeding them to faintness it was believed that they were cured. T h i s treatment was extended to all the insane." T h e principle generally adopted in asylums, says Esquirol, was that "the blood being too abundant or too much heated, ought to be evacuated or cooled." 3 A s f o r Rush, his own liberal recourse to venesection was in harmony with his theory that "madness" is mainly an arterial disease, having its primary seat in the blood vessels of the brain. H e held that the disease represented " a great morbid excitement or inflammation of the brains; that an unrestrained appetite caused the blood vessels to be overcharged with blood; and that it is important to relieve the brain before obstruction and disorganization takes place." 4 Since the remedies flowed naturally f r o m the supposed causes, Rush also advocated low diet, purges, emetics and hot and cold showers as measures affecting the circulation of the blood. Enlightened though he was as a practitioner, D r . Rush could not entirely f r e e himself f r o m certain ideas representing curious survivals f r o m a previous epoch. Strongly reminiscent of the seventh century "snake-cure" of Alexander Trallianus, described in Chapter I , is Rush's stratagem f o r ridding patients of their delusions. " C u r e s f o r patients who suppose themselves to be glass," he says, " m a y easily be per-

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formed by pulling a chair upon which they are about to sit from under them, and a f t e r w a r d s showing them a large collection of pieces of glass as the fragments of their b o d y . " Rush was the inventor of two curious mechanical devices, the therapeutic values of which he prized highly. One, named by him the "tranquilizer", consisted of a chair to which the patient was strapped hand and foot, together with a device f o r holding the head in a fixed position. T h i s mechanism was intended to reduce the pulse through lessening the muscular action and motor activity of the patient's body. Although it would be viewed by moderns as a device of fiendish torture, it was really invented by Rush out of humane considerations. In a letter dated 1 8 1 0 , describing the purpose of his invention, he writes: " I n attending the maniacal patients in the Pennsylvania Hospital, I have long seen with pain the evils of confining them, when ungovernable, by means of what is called the mad shirt, or straight waistcoat." A f t e r relating the sufferings and inconveniences the latter appliance caused the patients, he continues: " T o obviate these evils, and at the same time to retain all the benefits of coercion, I requested . . . an ingenious cabinetmaker . . . to make f o r the benefit of the maniacal patients, a strong arm-chair, with several appropriate peculiarities. . . . F r o m its design and effects, I have called it a Tranquilizer." 5 T h e second of Rush's machines was called the " g y r a t o r " , and was a modification of a circulating swing introduced in England by D r . Cox, who attributed its original invention to Erasmus Darwin, g r a n d f a t h e r of the famous biologist. T h e gyrator consisted of a rotating board to which patients suffering f r o m "torpid madness" were strapped with the head farthest f r o m the center. It could be rotated at terrific rates of speed, causing the blood to rush to the head, and thus producing an effect opposite to that of the tranquilizer. Kindly and humane though he was, D r . Rush accepted without question the necessity of coercion by mechanical restraint and of certain forms of corporal punishment, even advocating whippings in extreme cases. T h e controversy over mechanical restraint and its complete abolition was a

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m a t t e r f o r a later generation to discuss : in his time the question was merely, " H o w much mechanical coercion is necess a r y ? " Cullen, the teacher of Rush, was like the latter an advocate of gentler f o r m s of mechanical restraint than the brutal ones then in general use, but he nevertheless taught the efficacy of inspiring f e a r in mental patients. W h e n Rush declared t h a t " t e r r o r acts powerfully on the body through the medium of the mind, and should be employed in the cure of madness," he was merely echoing the universally accepted doctrine of his age. A m o n g the terror-inspiring devices recommended by Rush were his own tranquilizer, a cold shower bath continued f o r fifteen or twenty minutes, and "pouring cold water under the sleeve, so t h a t it may descend into the arm pits and down the trunk of the b o d y " — a mode of treatment that sends a chill down one's spine merely in the reading. If these methods should fail in their intended effects, declared Rush, it would then be p r o p e r to resort to the f e a r of death. T o illustrate the efficacy of the latter stratagem he cited the case of an insane woman who had been frightened into her wits, so to speak, by being warned by her doctor t h a t he was preparing to drown her. A n d yet Rush's suggestions f o r "mild and terrifying modes of punishment" were truly gentle when compared with the methods sanctioned by many of his most celebrated contemporaries. It should be kept in mind that even at that advanced day, the insane, particularly the violent cases, were commonly looked upon as creatures who had descended to the level of wild beasts. In this condition it was thought necessary to " t a m e " them, to "break their spirits," in the same manner t h a t wild animals were subdued. Significantly Rush himself recommended the total deprivation of food in some cases of insanity, citing as his reason the fact t h a t in India, when wild elephants were captured, they were always tamed by depriving them of food until they were greatly emaciated and hence more amenable to domestication." Elsewhere he recommends f o r violent patients the same treatment used in " b r e a k i n g " wild horses. So deep-rooted was the trust in fear-inspiring methods that it o f t e n took no account of the patient's rank or station.

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George I I I of England, in one of his periods of insanity* was struck down with impunity at least once by an attendant, apparently with the approval of his physician, D r . Willis. T h e king was frequently placed under restraint in straitjackets during these periods. Strangely enough, tortures and terrors that had been applied as outright punishments in previous ages received in this particular age the blessings of respectable medical theory as praiseworthy therapeutic measures. Thus Cullen wrote: " F e a r , being the passion that diminishes excitement, may therefore be opposed to the excess of it, and particularly to the angry and irascible excitement of maniacs." 7 It was necessary to awe them, he declared, and "sometimes it may be necessary to inspire [ a w e ] even by blows and stripes." Physicians specializing in the care of the insane outdid themselves in devising ingenious mechanisms f o r terrorization. Burdett 8 tells us that one doctor invented a pump, worked by four men, which projected a stream of water with terrific force down the spine of the wretched patient. T h i s treatment usually continued f o r four minutes, although one physician who had the humanity to try it on himself declared that it was so agonizing that he could not endure it f o r sixty seconds. Another form of excruciating torture, playfully called the "bath of surprise", consisted of a trap-door which suddenly opened under the unsuspecting patient who had been induced to tread upon it, plunging him precipitately into a pool of cold water, from which "he was frequently extracted more dead than alive." Still another monument to human ingenuity (which, incidentally, seems to excel itself in inventing inhuman and destructive devices) was the well-cure; the hapless patient was chained to the bottom of an empty well, into which water was slowly poured to instill in him the terror of approaching death. • B e g i n n i n g with his 27th y e a r , in 1765, K i n g G e o r g e I I I w a s visited by no less than five attacks of mental illness. F r o m the last one, which occurred in 1 8 1 0 , he n e v e r recovered. T h e brutal treatment to which even the sovereign w a s subjected, as brought out in p a r l i a m e n t a r y investigations into his condition, had some effect in attracting public attention to the plight of the mentally ill generally, and exerted indirect influence on protective legislation f o r the insane.

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T h e A m e r i c a n psychiatrist, Isaac R a y , tells of a D r . W i l lard, w h o , about the beginning of the 19th century, maintained a p r i v a t e establishment f o r the mentally ill "in a little town on the line between M a s s a c h u s e t t s and R h o d e Isl a n d . " 8 One of the f u n d a m e n t a l tenets in his therapy w a s to break the patient's will by any means possible. On his premises stood a tank of w a t e r , into which a patient, packed into a coffin-like box pierced with holes, w a s l o w e r e d by means of a well-sweep. H e w a s kept under w a t e r until the bubbles of air ceased to rise, a f t e r which he w a s taken out, rubbed, and r e v i v e d — i f he had not already passed beyond r e v i v i n g ! One wonders whether this " w a t e r - c u r e " was not a direct descendant of the old witch-finding w a t e r test, whereby suspected witches w e r e bound and d r a g g e d through w a t e r in the belief that if they floated, they were guilty, and if they s a n k — l e t G o d have mercy on their souls I Conolly describes a weird, though romantic, mode of a l a r m and torture proposed by certain G e r m a n physicians of this period. A patient, just a r r i v e d at an asylum (which, we may infer, w a s built like a castle) w a s to be d r a w n across a bridge spanning a moat, then suddenly hoisted to the top of a tower, and as precipitously lowered into a d a r k and subterranean cavern. I f the patient could be m a d e to alight a m o n g serpents, they a v e r r e d , the result would p r o v e still more s a t i s f a c t o r y . 1 0 U p to the y e a r 1 8 0 8 , according to the E n g l i s h physician, J o h n H a s l a m , lunatics ( w h o w e r e still supposed to be under lunar influence) w e r e bound, chained and even flogged at particular phases of the moon, to prevent the accession of violence.* Rush himself subscribed to the belief in lunar influence on the insane, with qualifications. C h a r a c t e r i s t i c a l l y , he once set the attendants at the Pennsylvania H o s p i t a l to observe the behavior of patients through the night under various phases of the moon, in o r d e r to test its influence. F r o m the reports he received he thought it possible to g i v e • M o r e than seven centuries earlier, G i r a l d u s of W a l e s (b. 1 1 4 7 ) had w r i t ten: " T h o s e are called lunatics whose attacks are exacerbated every month when the moon is f u l l . " (Topographica Hibernica, v. 5, p. 79. Quoted by D. H. T u k e in his History of the ¡niant in the British Isles, p. 9.)

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a scientific e x p l a n a t i o n of the l u n a r hypothesis. " T h e r e a r e f e w cases in which m a d people f e e l the influence o f the m o o n , " he concluded, " a n d when they do, it is d e r i v e d chiefly f r o m an increase in its l i g h t . " H e a d d e d , h o w e v e r , t h a t " t h e absence o f its light m a y be attended with equal c o m m o t i o n s " in patients afflicted w i t h " t r i s t i m a n i a " ( a t e r m R u s h substituted f o r m e l a n c h o l i a ) . 1 1 I f w e h a v e d i g r e s s e d s o m e w h a t , it has been with the intention o f describing R u s h ' s inadequacies in their p r o p e r light, t h a t is, a g a i n s t the b a c k g r o u n d of the t h e o r y and practice o f his time. So much f o r the n e g a t i v e aspects o f his teaching a n d practice. O n the p o s i t i v e side, he a d v a n c e d the h u m a n e and intelligent t r e a t m e n t of the insane at the P e n n s y l v a n i a H o s p i t a l to a d e g r e e t h a t e a r n e d him a position side by side w i t h C h i a r u g i in I t a l y , P i n e l in F r a n c e and T u k e in E n g l a n d , in the t r e a t m e n t o f the m e n t a l l y ill. R u s h ' s a d v a n c e d i d e a s and his s y m p a t h y w i t h his patients i m p e l l e d him to c h a m p i o n at the h o s p i t a l m a n y innovations o f a f a r - r e a c h i n g c h a r a c t e r . U p o n j o i n i n g the h o s p i t a l ' s staff his attention h a d been d r a w n to the total lack of heating and v e n t i l a t i n g a r r a n g e m e n t s f o r the cells in which the insane w e r e h o u s e d . A s a result he a d d r e s s e d in 1 7 8 9 a communication to the m a n a g e r s c o m p l a i n i n g that it w a s impossible f o r physicians to i m p r o v e the condition of the m e n t a l l y ill while they r e m a i n e d in their existing q u a r t e r s : T h e s e apartments are d a m p in w i n t e r and too w a r m in s u m m e r . They

are, moreover, so constituted,

as not to admit

readily of

a

c h a n g e of air ; hence the smell of them is both offensive and u n w h o l e some. F e w patients h a v e ever been confined in these C e l l s w h o have not been affected by a cold in t w o or three weeks a f t e r their confinement, and several have died of C o n s u m p t i o n in consequence of this cold. T h e s e facts being clearly established, I conceive that the appropriati n g of the C e l l s any l o n g e r for the reception of mad people w i l l be dishonourable both to the Science and H u m a n i t y of the city of Philadelphia.12

T h i s criticism o f R u s h ' s stands out in bold c o n t r a s t to the t h e n widely p r e v a l e n t t h e o r y that the insane w e r e insensible

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to cold and heat alike, and that it was unnecessary to protect them against the extremities of the weather. This belief, which sanctioned the exposure of mental sufferers, ofttimes naked, to the harshest rigors of winter, persisted f o r decades a f t e r Rush's time. L a r g e l y because of Rush's personal agitation f o r an additional wing to house the insane apart from the other classes of patients and his success in marshaling public opinion behind the plan, the Pennsylvania legislature voted an appropriation in 1 7 9 2 f o r an extension to the hospital for this purpose. Upon its completion in 1796, the mental patients were transferred to the new west wing. Though f a r from perfect, it represented a decided improvement over the old quarters. In 1 7 9 8 Rush again addressed a plea to the managers " f o r the Benefit of the Asylum f o r M a d People" (i.e., the insane w a r d ) , consisting of two principal recommendations. First, he advocated the installation of two warm and two cold baths, together with an adequate water supply system. T h i s recommendation was favorably acted upon. His second proposal, which indicates that the original plan of the founders f o r the employment of patients had fallen into neglect, urged "Certain Employments to be devised f o r such of the deranged people as are capable of Working, spinning, sewing, churning, &c., might be contrived for the Women: Turning a Wheel, particularly grinding Indian Corn in a H a n d Mill, f o r food f o r the Horse or Cows of the Hospital, cutting Straw, weaving, digging in the Garden, sawing or planing boards, &c., &c., would be Useful f o r the M e n . " 1 3 Commonplace as these words may now seem to us, living as we do in an age when occupational therapy is accepted as an indispensable feature in all modern well managed institutions f o r the mentally ill, it is only necessary to recall that Rush's proposal seemed startlingly novel to his American contemporaries, in order to appreciate its historic importance. Kind treatment of mental patients was a major rule in Rush's practice. From the first he insisted that the cells and persons of his patients be kept as neat and clean as possible. If he advocated the use of terror as a therapeutic agent in

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certain cases, he also taught that the insane should generally be approached with the respect and deference that would be accorded them in ordinary social intercourse, and insisted that doctors be p e r f e c t l y honest at all times with their patients. H e stressed the value of little acts of kindness t o w a r d them, such as presents of f r u i t and sweet-cakes at frequent intervals. R e c o g n i z i n g the evils arising f r o m the universal practice of hiring ill-paid, coarse and o f t e n brutal attendants f o r the insane, he recommended, in 1 8 0 3 , the employment of " a well-qualified person . . . as a f r i e n d and companion to the lunatics, whose business it shall be to attend them . . . , " a request that w a s acceded to. It is significant that he listed " k i n d t r e a t m e n t " as one of his principal rules in ministering to the mentally ill. Anticipating in a sense the " m e n t a l c a t h a r s i s " ( p u r g i n g of obsessions, inhibitions, etc.) that plays such an important role in modern F r e u d i a n therapy, R u s h believed in h a v i n g patients write down all that troubled their minds, and then reading w h a t they had written. One of his patients, says R u s h , a f t e r reading what he had set down, w a s so disgusted with his ugly thoughts that he rid himself of them and doubtless w a s g r e a t l y relieved thereby. R u s h speaks also of the evil effects of repressed emotions on the mental processes. 1 4 H i s thoroughly practical nature, combined with his humane outlook, is r a t h e r amusingly illustrated by a l o n g and eloquent appeal to the hospital authorities urging, as an act of kindness to the patients, the substitution of a newlyinvented stool pan f o r the chamber pots then in use. " T h e inventor of this delicate and h e a l t h f u l contrivance," he exclaims, " d e s e r v e s more f r o m humanity and Science than if he had discovered a new p l a n e t ! " T o g e t h e r with this request, m a d e in 1 8 1 0 , Rush p r o p o s e d a series of improvements constituting sweeping and unheardof r e f o r m s f o r that time. T h e s e included: ( 1 ) the erection of separate buildings to house those in a " h i g h and distracted state of m a d n e s s " in o r d e r to protect the others, including convalescents, f r o m the possibility of sympathetic

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reaction or loss of sleep; ( 2 ) separation of the sexes; ( 3 ) the introduction of labor, exercise and amusements f o r the patients "which shall act at the same time upon their bodies and minds;" ( 4 ) the hiring of an intelligent man and woman to attend the different sexes, to share their activities, and to read and discourse with them; ( 5 ) the rigid exclusion of all visitors—even near relations—likely to have a disturbing effect on the patients; ( 6 ) furnishing the cells of pay patients with feather beds and hair mattresses. 1 5 In 1 8 1 2 there appeared Rush's magnum opus in the field of mental diseases, Medical Inquiries and Observations upon the Diseases of the Mind, the first American general treatise on the subject, and the only one of its kind up to 1 8 8 3 . * Based mainly on his thirty years of observation of mental patients at the Pennsylvania Hospital, it was hailed as a classic upon its publication, both here and abroad, and f o r decades remained a primary textbook f o r American students of mental diseases. Perhaps the most impressive tributes paid to Rush the man, upon his death in 1 8 1 3 , came f r o m two ex-Presidents, both of whom he had numbered among his dearest friends. E v e n discounting the possible exaggeration arising from a deeply stirred emotion, this characterization of Rush by John A d a m s retains a high degree of significance: " A s a man of science, letters, taste, sense, philosophy, patriotism, religion, morality, merit, usefulness, taken all together, Rush has not left his equal in A m e r i c a ; nor that I know in the world. In him is taken away . . . a main prop of my l i f e . " 1 6 N o less significant a personal tribute is that contained in a letter of T h o m a s Jefferson to A d a m s : " A n o t h e r of our friends of seventy-six is gone, my dear Sir, another of the co-signers of the Independence of our country. And a better man than Rush could not have left us, more benevolent, more learned, of finer genius, or more honest." 1 7 In evaluating the place of D r . Rush in psychiatric history, it is only f a i r to accept his shortcomings as the shortcomings • T h e latter y e a r witnessed the publication of W i l l i a m A . Hammond's A Treatise on Insanity in its Medical Relations and E d w a r d C. Spitzlta's Insanity.

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o f his a g e ; as f o r his progressive principles and practices, these were largely original with him. N o n e o f his contemporaries exercised a g r e a t e r influence than he did on American medicine in general and psychiatry in particular. I t is true that that influence was not altogether wholesome. Some o f his teachings were correctly discarded by his pupils and successors as either ineffective or injurious, but the good that remained was enough to make his influence on the whole a decidedly beneficial one. In the scientific aspects o f his therapy for the mentally ill he surpassed the generally accepted authorities o f his day, Cullen and B o e r h a a v e ; on the humanitarian side he was o f a stature approaching, if not quite equaling, his great chain-breaking contemporaries in E u r o p e — C h i a r u g i , Pinel, and T u k e .

CHAPTER

VI

The Rise of Moral Treatment 1 7 9 2 . T h e French Revolution was at its height. T h e tercentenary of the discovery of a new world was being celebrated. A n d a new epoch in the care and treatment of the insane was being ushered in. T h e opening salvos were fired on two different fronts simultaneously—at Paris, France, and at Y o r k , E n g l a n d — a n d were heard and heeded across the Atlantic. Paris in 1 7 9 2 was seething with revolutionary fervor. T h e heads of a king and queen were about to roll into baskets, and with them a whole class was falling. Old forms and traditions were being discarded; in their place new ones arose with breathless rapidity. T h e time was ripe f o r social experimentation. A n d , as always when the time f o r social change has come, there were men prepared to effect it. T w o principal institutions f o r the mentally ill had been established in P a r i s ; the Bicêtre, where male lunatics were kept, and the Salpêtrière, f o r female lunatics. T h e y were indifferently called "hospitals" and " p r i s o n s " f o r the insane. Of the two terms the latter best expressed their purpose, which was purely custodial, and their regimen, which was sternly repressive. T h e Bicêtre, particularly, owned a questionable distinction : it ranked with the worst asylums in the world. T h e r e the patients, or rather, inmates, were loaded down with chains and shackled to floors and walls with irons, at the mercy of cruel attendants armed with whips and the authority to use them freely. M a n y of the attendants were convicts serving out their sentences in this horrible way. Since the inmates were prejudged incurable, therapeutic treatment was entirely lacking. In 1 7 9 2 , thanks 88

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to the efforts of a hitherto obscure physician who dared to introduce an original method, this institution w a s suddenly and d r a m a t i c a l l y t r a n s f o r m e d in a manner that opened a new era in the history of mental illness. T h e man w a s Philippe P i n e l ; the method w a s that l a t e r designated as " m o r a l t r e a t m e n t . " Pinel had come to P a r i s in mid-life, a f t e r having f a i l e d to establish himself as a practitioner in a town of modest size. Some y e a r s before, a young friend of his in the throes of a mental breakdown had rushed off into the woods w h e r e his body w a s l a t e r found torn to pieces by wolves. T h i s t r a g e d y profoundly impressed Pinel, and drew his attention to the subject of mental diseases. A n erudite scholar, he delved deeply into the available literature on insanity, p a r t i c u l a r l y the longforgotten works by and about the ancient apostles of mild and kindly treatment—Asclepiades, A r e t a e u s , Soranus, Caelius Aurelianus, and the rest. T h e conviction g r e w upon him that their precepts w e r e sounder therapeutically, and much more desirable f r o m the viewpoint of humanity, than the brutal methods e v e r y w h e r e prevalent in his d a y . A t Paris Pinel had become connected with a small private asylum, the M a i s o n de Santé Belhomme. W h e n the French Revolution broke out, it found him occupied here in furthering his observations on mental diseases. H e w a s still unknown to all but a small, though select, circle of friends which included such distinguished men as Condorcet, Helvetius, D ' A l e m b e r t , H a l l e and L a v o i s i e r . T o these acquaintances he revealed his theories respecting the treatment of insanity. H i s arguments were very convincing. Consequently when two of them, T h o u r e t and Cabanis, were elevated by the revolutionary government to a t r i u m v i r a t e at the head of P a r i s ' s hospital system, they immediately thought of Pinel. H e r e was a chance to test his theories. H e r e w a s the man who could clean these A u g e a n stables, the miserable asylums f o r the insane. T h e y appointed Pinel physician to that notorious hell-hole, the Bicêtre. T h e asylum looked like a circle of the Inferno when Pinel entered upon his duties. T h e lunatics lay all about, raving, riveted with chains and irons. T h e y were r e g a r d e d as des-

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perate, dangerous animals* on a lower plane than criminals, f o r the latter were not stripped of all their human attributes as the insane were supposed to be. A n d in truth, the inmates of the Bicêtre had the appearance of wild animals—beards and hair were matted with straw and infested with lice; their clothes were tattered, their nails grown long like claws, their bodies encrusted with dirt and filth. T h e y presented pictures of complete neglect. T h e i r cries of anger, agony and frustration induced by intolerable confinement, mingled with the endless clanging of chains and the crack of keepers' whips. Pinel proposed a radical change. H e planned to strike off the chains f r o m these miserable creatures and to inaugurate a regimen based on kindness and sympathy. Couthon, chief aid of Robespierre, came to the Bicêtre to learn at first hand what Pinel was about. " C i t i z e n , " he exclaimed, " a r e you yourself mad to wish to unchain such b e a s t s ? " Pinel patiently explained his ideas. Couthon's scepticism vanished. " D o as you please," he said finally, and departed. Pinel was now free to put into practice the theories inspired by his classic predecessors. Almost his first act was to strike off the chains f r o m fifty-three lunatics, many of whom had been weighed down with fetters f o r years in the belief that they were exceedingly dangerous. A large proportion of those released proved to be perfectly harmless and mild. T h e i r violent behavior had resulted quite naturally from the oppressive tortures inflicted on them. One whose chains were thus removed, previously regarded as the most dangerous of all, afterward became Pinel's trustworthy and devoted servant. A new regimen based on a minimum of mechanical restraint and a maximum of intelligent understanding was at last in force at the Bicêtre. T h e results were most encouraging. T h r e e years a f t e r his dramatic entrance into the Bicêtre, Pinel's ministrations were extended to the Salpêtrière, the • T h i s conception w a s heightened by the occasional murders of keepers by patients within the Bicêtre's w a l l s . M a d d e n e d by the tortures inflicted by brutal attendants, inmates w e r e sometimes d r i v e n to kill as a means of revenge.

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second largest asylum in Paris, w h e r e supposedly incurable women lunatics were kept. It was this event that inspired R o b e r t F l e u r y ' s f a m o u s painting, " P i n e l à la S a l p ê t r i è r e " , which depicts the g o o d doctor superintending the r e m o v a l of chains and fetters f r o m the insane while a patient, whose manacles h a v e just been struck off, kisses his hand in gratitude. B y his demonstrations at the P a r i s asylums Pinel p r o v e d conclusively the fallacy of harsh treatment, and opened up new paths along the lines of sympathy and humanity d r e a m e d of by the founders of the Pennsylvania H o s p i t a l some forty-odd years b e f o r e and later p a r t l y reallized by Benjamin R u s h . It was Pinel w h o first f o r m u l a t e d " m o r a l t r e a t m e n t " into a system so soundly conceived and dramatically presented that it caught the attention of the public. I m p e r f e c t though his own system was, it served as a cornerstone upon which further psychiatric p r o g r e s s w a s built. In the medical aspects of his therapy Pinel hewed rather closely to the line set down by Cullen, whose w o r k he had translated into French. But he f r a n k l y expressed his scepticism of prevailing medical methods in the treatment of the insane, and sharply criticized the excessive use of bloodletting and drugs indulged in by most of his contemporaries. H e himself used medication very sparingly, placing his main reliance on m o r a l therapy. H i s system of moral treatment is expounded in his epoch-making Traité médico-philosophique sur l'aliénation mentale, published in 1 8 0 1 . B a s e d on sound observation (Pinel was a thoroughgoing clinician), and a scholarly acquaintance with classic and contemporary literature on mental diseases, this treatise exerted a tremendous influence, not only in France, but in G e r m a n y , G r e a t B r i t a i n and A m e r i c a . W h a t w a s the essence of this " m o r a l t r e a t m e n t ? " In a little dissertation published in 1 8 1 1 , D r . T . R o m e y n Beck of N e w Y o r k presented such a concise summary of this aspect of treatment, that we quote it in full : M O R A L M A N A G E M E N T . This consists in removing patients from their residence to some proper asylum; and for this purpose a

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calm retreat in the country is to be preferred: for it is found that continuance at home aggravates the disease, as the improper association of ideas cannot be destroyed. A system of humane vigilance is adopted. Coercion by blows, stripes, and chains, although sanctioned by the authority of Celsus and Cullen, is now justly laid aside. T h e rules most proper to be observed are the following: Convince the lunatics that the power of the physician and keeper is absolute; have humane attendants, who shall act as servants to them ; never threaten but execute ; offer no indignities to them, as they have a high sense of honour; punish disobedience peremptorily, in the presence of the other maniacs; if unruly, forbid them the company of others, use the strait waistcoat, confine them in a dark and quiet room, order spare diet . . . ; tolerate noisy ejaculations ; strictly exclude visitors ; let their fears and resentments be soothed without unnecessary opposition ; adopt a system of regularity ; make them rise, take exercise and food at stated times. T h e diet ought to be light, and easy of digestion, but never too low. When convalescing, allow limited liberty ; introduce entertaining books and conversation, exhilarating music, employment of body in agricultural pursuits . . . ; and admit friends under proper restrictions. It will also be proper to forbid their returning home too soon. By thus acting, the patient will "minister to himself." 1 T h e same y e a r ( 1 7 9 2 ) that Pinel's chainbreaking ref o r m s were introduced at the Bicêtre in the midst of whiteheat revolution, a similar step, less dramatic but just as f a r reaching, w a s being inaugurated by a layman in a more placid environment among the Quakers of Y o r k , E n g l a n d . A t the time the t w o principal English institutions f o r the insane were Bethlehem H o s p i t a l ( o r B e d l a m ) in L o n d o n , and the L u n a t i c A s y l u m of Y o r k . T h e horrible conditions then prevailing in these asylums were p r o v e r b i a l : in both institutions the patients were, quite appropriately, termed prisoners. In the y e a r 1 7 9 1 a Quakeress named H a n n a h M i l l s w a s admitted to the Y o r k A s y l u m . Some friends w h o came to visit her w e r e denied permission to do so, on the ground that she w a s in no condition to be interviewed. A f e w weeks later this patient died. In the minds of her Q u a k e r friends in Y o r k there was a strong suspicion that cruel treatment h a d caused or at least hastened her death. A m o n g them w a s W i l l i a m T u k e , who, like so many of his sect, was a " p r a c t i c a l idealist." It occurred to T u k e that it

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would be well f o r the Friends to establish an institution of their own where fellow-believers who fell prey to mental illness might find gentle and wholesome treatment.* T u k e presented his idea before a gathering of Yorkshire Friends in M a r c h , 1 7 9 2 . T h r e e months later a special meeting was held " f o r the purpose of taking into consideration the propriety of providing a retired Habitation, with necessary advice, attention, etc., f o r members of our Society, and others in profession with us, who may be in a state of Lunacy, or so deranged in mind (no idiots) as to require such provision." 2 T h e proposal met with some stiff opposition, but T u k e was a strong-willed man and pushed his project f o r w a r d with such determination that it was finally accepted. His staunchest supporter was Lindley M u r r a y , a noted grammarian, who had migrated from his native America some years before to make his permanent home among fellow Quakers at Y o r k . M u r r a y , as we shall see, was to f o r m an important link connecting reform movements in old Y o r k , his new home, and N e w Y o r k , his old home. A building was erected on a site near Y o r k , and was opened f o r the reception of patients in 1796. T h e institution was named " T h e Retreat," to avoid the stigma associated with the common terms asylum and madhouse. T h e name was intended " t o convey the idea of what such an institution should be, namely, a place in which the unhappy might obtain a r e f u g e ; a quiet haven in which the shattered bark might find the means of reparation and s a f e t y . " Among the principal objects of the founders were these : to provide a family environment f o r the patients, as manifested in the non-institutional aspect of the building and its surroundings; emphasis on employment and exercise as conducive to mental health (a principle put into practice from the very start) ; and the treatment of patients as guests • A n abortive step at founding such an institution had been taken more than a century e a r l i e r ( 1 6 7 1 ) when it had been resolved at a meeting of London Q u a k e r s : " T h a t Friends seek some place convenient in and about Y e Citty w h e r e they m a y put any person that m a y be distracted or troubled in mind that soe they m a y not be put among ye w o r l d ' s people or run about y e streets."

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r a t h e r than as inmates. Kindness and consideration formed the keystone o f the whole theoretical structure. Chains were absolutely forbidden, along with those resorts to terrorization that were still advocated in varying degrees by eminent medical men. T h e maxims o f the institution were taken from ancient t e x t s : Solomon's " A soft answer turneth away w r a t h , " and Aeschylus' " S o f t speech is to distemper'd wrath, medicinal." M e c h a n i c a l restraint was not completely abolished, however. Violent patients were sometimes bound with broad leather belts which secured the arms while permitting the free use o f h a n d s ; in extreme cases, the straitj a c k e t was used, t o g e t h e r with solitary confinement. T h e founders and early managers o f the R e t r e a t evinced a decided distrust o f medicines. In the light o f the generally ineffective, if not actually harmful, medical treatment o f mental sickness then prevailing, their attitude was not without justification. One positive advance introduced at the R e t r e a t was the complete abolition o f bloodletting, that bane o f centuries. In their minimization o f medical therapy the managers swerved too f a r to the extreme. Nevertheless, their direction probably represented, on the whole, the best to be found anywhere during the first two or three decades o f the R e t r e a t ' s existence. T h u s in different places, unknown to each other, two men were instituting similar r e f o r m s in the " m o r a l " treatment o f mental illness—one a layman whose approach was mainly humanitarian; the o t h e r a physician who had reached the same conclusion by way o f scientific study. T h e work o f both had far-reaching effects on mental hospital administration and practice. In paying h o m a g e to these two pioneers, however, we should keep in mind that the idea o f ameliorating the condition o f the insane did not originate with them as sparks o f pure inspiration. All the elements o f a r e f o r m movement in this field were already present, waiting only to be fused by the proper leaders. I f Pinel and T u k e had never lived, it is quite probable t h a t the same r e f o r m s would have been achieved by others about the same time. W e have already spoken of the progressive steps taken by Rush in America

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several years before the transformation of the Bicêtre or the founding of Y o r k Retreat. In Italy, too, another great humanitarian, Vincenzo Chiarugi, had struck off chains from his patients and freed them f r o m other torturesome restraints years before Pinel or T u k e . H i s name is less celebrated than theirs only by virtue of the fact that he operated at a distance too remote f r o m the flow of contemporary streams of thought to permit his work to become widely known, or to exert an appreciable influence on the practice of his day.* Joseph Daquin, a close friend of Pinel, introduced important humanitarian reforms when he became director of the insane department of the hospital at Chambéry in 1 7 8 7 , five years before Pinel came to the Bicêtre. It was Pinel, however, who formulated, systematized and dramatized moral therapy. T h e influence of Pinel and T u k e ran along strange geographical divisions. While Pinel was to exercise the stronger influence on psychiatric practice on the European continent, largely through the wide circulation of his classic work on the subject, Tuke's work played the more important role in America. Of the eight mental hospitals that sprang up in the United States during the first quarter of the nineteenth century, the establishment of two was directly inspired by the successful operation of the Y o r k Retreat, and the administration of at least two others was patterned a f t e r that in effect at the Retreat. T h e direct influence of T u k e and the Retreat was clearly manifested in the establishment of the second special institution f o r the mentally ill to be built in America, and the first built in the 19th century. T h i s was the Friends' Asylum, opened at F r a n k f o r d , Pennsylvania, in 1 8 1 7 . Its inception dates from 1 8 1 1 , when a proposal to erect an asylum " f o r such of our members as may be deprived of their reason" was brought before the Spring Quarterly Meeting of the • C h i a r u g i i n t r o d u c e d a n u m b e r o f s w e e p i n g h u m a n i t a r i a n r e f o r m s at the H o s p i t a l of St. B o n i f a c e in F l o r e n c e d u r i n g the y e a r s 1 7 7 + - 8 8 . H e a b o l i s h e d c h a i n s and fetters, e n c o u r a g e d occupational t h e r a p y , e n f o r c e d s a n i t a r y m e a s u r e s , a n d insisted t h a t the m e n t a l l y ill be t r e a t e d a? h u m a n b e i n g s .

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Philadelphia Society of Friends.* T h e r e is good reason to believe that the original proposal came from Thomas Scattergood, a minister of the Quaker faith. Scattergood had previously spent six years ( 1 7 9 4 — 1 8 0 0 ) traveling through Great Britain on a religious mission. During this time, he had visited the Retreat near Y o r k (January, 1 7 9 7 ) , conversed and dined with its founder, and had evidently been greatly impressed by what he saw and heard of the institution. 3 A constitution was drawn up in 1 8 1 3 , and a corporation formed under the name, "Contributors to the Asylum f o r the relief of persons deprived of the use of their reason." A subscription campaign was then launched, a notable feature of which was the wide circulation among prospective donors of an abridged version of Samuel Tuke's Description of the Retreat near York, orginally published in London in 1 8 1 3 . This little book, with its account of the moral treatment practiced by the Y o r k Friends, its general atmosphere of kindness and sympathy, and its note of optimism, proved an important factor in raising money. Not only money was solicited, but donations in kind as well. In a pamphlet issued 1 8 1 6 , it was urged that: " I n order to lessen the expense of furnishing the house, Friends in the country are informed that any articles of feather bedding, bed and table linen will be very acceptable. Donations in household furniture are expected from Friends in this city." 1 T h e institution was opened in 1 8 1 7 at Frankford, some five miles north of Philadelphia. This site, comprising about fifty-two acres, was chosen because of its retired and sheltered location, where the mentally ill could be protected from the gaze of the idly curious. T h e building was three stories high, and accommodated forty patients. T h e charge f o r the latter ranged from $ 3 . 5 0 per week up, depending on ability to pay, comforts required, etc. A t first reception was restricted only to members of the Society and professors with the Society, but in 1 8 3 4 it was made a non-sectarian institution. T h e Philadelphia Quakers placed great emphasis on pro• A s early as 1709 Philadelphia Friends had considered building a hospital f o r their siclc and insane members, but the project f e l l through.

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viding a proper religious atmosphere, which they believed to be inextricably bound up with the ultimate recovery of the patients. T h e constitution expressly stated that the asylum "is intended to furnish, beside the requisite medical aid, such tender sympathetic attention and religious oversight, as may sooth their agitated minds, and thereby, under the divine blessing, facilitate their restoration to the enjoyment of this inestimable g i f t . " 5 " T o fetter strong madness in a silken t h r e a d " was the ideal observed f r o m the start, and its managers could proudly boast two-score years later that no chain had ever been used there f o r the restraint of patients. In the minds of the founders the patients were not to be considered either as sub-humans or social pariahs, but as "men and brethren." T h e system of moral treatment instituted at the Y o r k Retreat was here closely followed in its essentials. A crude attempt was made at classification, the importance of which was becoming generally recognized. T h e upper stories of the building were reserved f o r mild and convalescent cases, while the "violent, the noisy and the incurable" were quartered in the lower story. T h e prevailing confusion concerning proper classification is evidenced in an early description of the F r a n k f o r d Asylum, in which it is stated: " I t is obviously disadvantageous to mingle the furious and the melancholy, the imperious and the f e a r f u l , the vociferous and the peaceful, the villainous and the religious, the clean and the unclean, the curable, incurable, and convalescent, together." 9 Another of the early American institutions f o r the mentally ill directly influenced by the Retreat at Y o r k was the Bloomingdale Asylum. Opened in N e w Y o r k in 1 8 2 1 as a separately operated institution, the origins of Bloomingdale may be traced back to the founding of the N e w Y o r k Hospital nearly fifty years earlier. In 1 7 7 1 a royal charter had been granted to the Society of the N e w Y o r k Hospital, the second general hospital established in America.* Erection of the institution was delayed by a disastrous fire, the • T h e f u l l title of the i n c o r p o r a t e d institution w a s : " t h e S o c i e t y of the H o s p i t a l in the city of N e w Y o r k in A m e r i c a . "

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R e v o l u t i o n a r y W a r , and the turbulent y e a r s of the p o s t w a r period, and it w a s not until 1 7 9 1 that the hospital w a s finally opened. T h e original building committee o f the hospital had been a u t h o r i z e d in 1 7 7 4 , " t o a p p r o p r i a t e the cellar p a r t of the N o r t h wing [ o f the p r o j e c t e d h o s p i t a l ] o r such p a r t of it as they m a y j u d g e necessary into w a r d s or cells f o r the reception of l u n a t i c s . ' " T h e first mental patient w a s received into the hospital S e p t e m b e r , 1 7 9 2 , some twenty months a f t e r its opening. A s in the early y e a r s of the Pennsylvania H o s p i t a l , the mentally ill w e r e confined in cells in the basement of the building. B u t by 1 8 0 6 this a r r a n g e m e n t had r e v e a l e d itself as so g l a r i n g l y inadequate and unwholesome that it was decided to erect on the hospital g r o u n d s a s e p a r a t e structure f o r the insane. T h i s building, called the " N e w Y o r k L u n a tic A s y l u m " , w a s opened in 1 8 0 8 , a generous g r a n t having been m a d e by the state legislature t o w a r d its construction and maintenance. In 1 8 0 9 an act of the legislature a u t h o r i z e d the overseers of the p o o r in towns and counties t h r o u g h o u t the state to contract with the g o v e r n o r s of the N e w Y o r k H o s p i t a l f o r the maintenance and care therein, at special rates, of lunatics c h a r g e a b l e to such communities. T h i s w a s the first legislative p r o v i s i o n in N e w Y o r k recognizing the pauper insane as a distinct class entitled to hospital care and treatment. B u t the new building erected at a cost of $ 5 6 , 0 0 0 , soon w a s c r o w d e d f a r beyond its capacity. T h e proposition w a s now r a i s e d : w h y not r e m o v e the institution to a m o r e spacious site some distance f r o m the city? T h e l e a d e r and guiding spirit behind this plan w a s T h o m a s E d d y , a Q u a k e r merchant w h o w a s then t r e a s u r e r and served subsequently as vice-president and president, of the N e w Y o r k H o s p i t a l . In m a n y respects E d d y r a n k e d among the most remarkable r e f o r m e r s of his d a y . L i k e R u s h in P e n n s y l v a n i a , he w a s actively associated with most of the p r o g r e s s i v e movements in his state, and w a s the a c k n o w l e d g e d l e a d e r and initiator of m a n y of them. T o g e t h e r with most social r e f o r m e r s of his d a y , E d d y

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kept in constant touch with reform developments abroad, particularly in England. Considering the lack of means of communication and the slowness with which news traveled —remember that the historic Battle of N e w Orleans in 1 8 1 5 was fought a fortnight a f t e r the treaty of peace had been signed due to the primitive means of transmitting mess a g e s — E d d y and the others managed to keep astonishingly well informed of contemporary European events in the field of social welfare. M a n y of the humanitarian reforms introduced in the early period of our country's growth were communicated to us from the British Isles through the interchange of pamphlets and letters. In Eddy's case, scarcely a letter passed between him and his correspondents abroad which did not contain a list of pamphlets or books being forwarded to him by the same mail. Quite probably it was in this wise that a copy of Samuel T u k e ' s Description of the Retreat fell into E d d y ' s hands. In April, 1 8 1 5 , E d d y placed before the governors of the Hospital an important plan, outlining his ideas f o r a new establishment, which was admittedly based on Tuke's work. " I n pursuing this subject," he said, "my views have been much extended, and my mind considerably enlightened, by perusing the works of Doctors Creighton, Arnold and Rush; but more particularly, the account of the Retreat near Y o r k . . . . T h e great utility of confining ourselves almost exclusively to a course of moral treatment is plain and simple, and incalculably interesting to the cause of humanity; and perhaps no work contains so many excellent and appropriate observations on the subject as that entitled, The Account of the Retreat."* E d d y laid down f o r the governors' consideration an eleven-point program, incorporating the ideas of moral treatment which we have already described. H e called f o r the complete elimination of corporal punishment, chains, and the rule of terror prescribed by such authorities as Cullen and Rush. A l l possible appeals, he urged, should be made to the better intellectual and moral sensibilities of the patient in therapeutic work. One of the most interesting features of E d d y ' s plan was

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his e m p h a s i s on the necessity f o r k e e p i n g case histories.® T h i s w a s in m a r k e d contrast to the p r e v a i l i n g d i s r e g a r d f o r r e c o r d i n g even the b a r e s t essentials o f d a t a concerning patients. ( S o m e institutions did not even trouble to set d o w n d a t e s o f admission and d i s c h a r g e , cures o r even d e a t h s o f patients.) In c o n c l u d i n g his Hints, E d d y r e c o m m e n d e d t h a t a site be p u r c h a s e d in a r e t i r e d situation, a f e w miles f r o m the city, l a r g e e n o u g h t o contain w a l k s , g a r d e n s , a f a r m , etc., f o r the exercise, e m p l o y m e n t and a m u s e m e n t o f the patients. E d d y ' s p r o p o s a l s w e r e f a v o r a b l y received by his f e l l o w g o v e r n o r s , w h o s e interest in the plan w a s f u r t h e r a r o u s e d by the s t a r t l i n g d e t a i l s o f b a r b a r i c abuses in public and priv a t e a s y l u m s in E n g l a n d then b e i n g exposed by parliament a r y i n v e s t i g a t i n g c o m m i t t e e s . * A g r e a t deal o f attention w a s t h e r e b y a t t r a c t e d to the p r o b l e m s o f the insane and the need f o r i m p r o v e m e n t in their care and t r e a t m e n t , as evidenced by the flood o f p a m p h l e t s on the subject circul a t e d at the time. M e a n w h i l e E d d y h a d w r i t t e n his f r i e n d , L i n d l e y M u r r a y , w h o w a s then r e s i d i n g near Y o r k , i n f o r m i n g h i m o f the plan to build a new institution, and requesting any advice M u r r a y ' s connection w i t h the Y o r k R e t r e a t m i g h t suggest. In his reply, d a t e d J u l y 20, 1 8 1 5 , M u r r a y w r o t e : I am pleased to perceive by thy letter, that many of you at N e w York are deeply interested in promoting the recovery and relief of insane persons, and I hope you will be encouraged in the pursuit of this benevolent and good work. I did not know how I could better answer thy views and wishes than by putting thy pamphlet [evidently Eddy's Hints] and letter into the hands of my benevolent and zealous friend, Samuel Tuke, who has paid great attention to this subject ; and I am gratified with introducing you to the acquaintance of each other. 10 * A n i n q u i r y into c o n d i t i o n s at B e d l a m in 1815 u n c o v e r e d the f a m o u s c a s e of W i l l i a m N o r r i s , a p a t i e n t w h o h a d been c h a i n e d i n a m a n n e r p r o d u c i n g i n d e s c r i b a b l e t o r t u r e f o r t w e l v e y e a r s . W h e n f o u n d he w a s e n c a s e d h a n d , f o o t and neck, in iron b a n d s and rings, and these in turn w e r e firmly s e c u r e d b y c h a i n s to an i r o n b a r f a s t e n e d to the w a l l of his cell. T h e r e a s o n g i v e n f o r t h i s p u n i s h m e n t w a s t h a t N o r r i s , t w e l v e y e a r s b e f o r e , h a d struck a d r u n k e n keeper, w h o h a d d r i v e n him to v i o l e n c e b y w a n t o n c r u e l t y .

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With this communication Murray sent a pamphlet that had lately been written by Tuke, entitled Practical Hints on the Construction and Economy of Pauper Lunatic Asylums. The comprehensive plan contained in this pamphlet had been awarded first prize in a competition f o r a model design f o r a public asylum to be built at Wakefield, England." Simultaneously, Eddy received a personal letter from Samuel Tuke. This contained modifications of the pauper asylum plans to conform with the requirements of the proposed institution in New York, which Tuke correctly judged to be intended primarily for middle-class patients who could afford to pay moderate fees f o r their maintenance. T h e letter, among other things, included an interesting discussion on the theory and value of occupational therapy: I observe with pleasure that one leading feature of your institution is the introduction of employment amongst the patients, an object which I am persuaded is of the utmost importance in the moral treatment of insanity . . . T h e employment of insane persons should, as far as is practicable, be adapted to their previous habits, inclinations and capacities and, though horticultural pursuits may be most desirable, the greatest benefit will, I believe, be found to result from the person being engaged in that employment in which he can most easily excel, whether it be an active or a sedentary one . . , 12

Thus fully equipped with theory concerning the planning and administration of the new hospital for the mentally ill, it now only remained to construct it. A site was selected along the Bloomingdale Road (now Broadway) upon Eddy's recommendation. The asylum, when completed, comprised several tracts of land totalling about 77 acres. T h e main building stood on the spot now occupied by the Columbia University Library, at 1 1 6 t h Street and Broadway.* T h e Bloomingdale Asylum (so named from its location on Bloomingdale R o a d ) was begun in 1 8 1 7 and was com• T h e purchase of this land f o r about $ 3 1 , 0 0 0 proved an excellent investment. W h e n the pressure of N e w Y o r k ' s r a p i d l y - g r o w i n g population forced the retreat of B l o o m i n g d a l e to its present location at White Plains, a suburb of N e w Y o r k , the original site w a s sold piecemeal at tremendous profits.

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pleted in 1 8 2 1 . On M a y 1 0 , 1 8 2 1 , the governors of the N e w Y o r k Hospital drew up and circulated an Address to the Public, announcing that the asylum would open the following month with accommodations f o r two hundred patients. " T h i s institution," ran the statement, "has been established with the express design to carry into effect that system of management of the insane, happily termed moral management, the superior efficacy of which has been demonstrated in several of the Hospitals of Europe, and especially that admirable establishment of the Society of Friends, called ' T h e Retreat,' near Y o r k , in E n g l a n d . " 1 3 N o n e but pay patients were received into the institution (which remained a department of the N e w Y o r k H o s p i t a l ) although paupers sent by poor relief authorities f r o m various towns, cities and counties throughout the State were maintained at very low rates. T h e executive direction of the hospital, except f o r medical treatment, was entrusted to the lay superintendent, L a b a n Gardner, who was the first to serve in that post. D r . J a m e s E d d y was appointed resident physician and D r . J o h n Neilson attending physician. T h e latter supervised the general medical aspects of care and treatment of the patients. T h r o u g h the ensuing years this institution, now known as the Westchester Division of the N e w Y o r k Hospital, has maintained a leading place among mental hospitals in America. L i k e Bloomingdale, the M c L e a n Asylum of Massachusetts (opened in 1 8 1 8 ) developed as part of a general hospital. In Chapter I V we have described the early efforts to found a hospital f o r the mentally ill in Boston, which had nearly reached a successful culmination in the 1 7 6 0 ' s through the bequest of T h o m a s Hancock. In 1 8 0 4 William Phillips, another notable citizen of Boston, left $ 5 , 0 0 0 to the city towards the building of a hospital f o r the sick poor and insane of the Commonwealth. Unlike the Hancock bequest, this one carried no time-limit specification. Interest in the project was again awakened, but it took several years to mature into an active movement. H o w e v e r , one rising

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young physician of Boston, D r . J o h n Collins W a r r e n , * w a s determined that the erection of a public hospital should no longer be delayed. In assaulting the r a m p a r t s of public indifference, D r . W a r r e n trained his guns first on G o v e r n o r W i l l i a m Phillips of Massachusetts, the son and heir of the donor. H i s enthusiasm p r o v e d infectious. In a letter dated J u l y 3 1 , 1 8 1 0 , the g o v e r n o r w r o t e him : I am impressed w i t h the importance of the subject upon which w e have repeatedly conversed—that of establishing in this t o w n an hospital for the reception of lunatics and other sick persons. T o place such an institution in a respectable and permanently useful situation, a large sum will be required. 1 4 T o this end Phillips offered to contribute $ 1 5 , 0 0 0 in addition to the $ 5 , 0 0 0 left in his f a t h e r ' s will, of which he w a s executor, provided that $ 1 5 0 , 0 0 0 in subscriptions be raised. T a k i n g up this challenge W a r r e n enlisted his friend and colleague, D r . J a m e s J a c k s o n , in the cause. T o g e t h e r they d r e w up a circular letter addressed to the most influential and richest men in the C o m m o n w e a l t h . T h e l e t t e r — a v e r y lengthy o n e — p o i n t e d out that the only public receptacles open f o r the sick and insane in the State w e r e the almshouses and jails, where confinement and safekeeping, with no opportunity f o r curative treatment, w e r e all that could be hoped f o r . It stated f u r t h e r t h a t : T h e virtuous and industrious are liable to become objects of public charity, in consequence of the diseases of the mind. W h e n those w h o are u n f o r t u n a t e in this respect are l e f t w i t h o u t proper care, a calamity, which might have been transient, is prolonged through life. T h e n u m ber of such persons w h o are rendered unable to provide for themselves is probably greater than the public imagine ; and of these, a large proportion claim the assistance of the affluent . . . Even those w h o can pay the necessary expenses w o u l d perhaps find an institution such as is proposed, the best situation in which they could place their u n f o r t u nate friends. It is w o r t h y of the opulent men of this town, and consistent with the general character, to provide an asylum for the insane f r o m every part of the C o m m o n w e a l t h . B u t if f u n d s are raised for • W a r r e n w a s to become one of the most renowned of Massachusetts' medical men. H e p e r f o r m e d the world's first operation employing ether as an anesthetic, in the v e r y hospital he helped to f o u n d .

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the purpose proposed it is probable that the legislature will grant some assistance, with a view to such an extension of its benefits. 15

T h i s circular met a speedy and generous response. T h e following year ( 1 8 1 1 ) the State legislature incorporated J a m e s Bowdoin and fifty-five others under the name, "Massachusetts General Hospital," and subsequently made liberal grants of land, money and the free use of prison labor f o r the project. 1 ® T h e W a r of 1 8 1 2 slowed up the progress of the hospital, but it was taken up with renewed vigor in 1 8 1 6 , when a house-to-house canvass was started. Within one week $ 1 0 0 , 0 0 0 in pledges was obtained, about half of which was specifically subscribed f o r the erection of the "insane hospital." It had been understood from the beginning that the hospital was to consist of two departments—one f o r mental, and the other f o r general diseases — a n d that each would occupy a separate building. In view of the fact that most of the ear-marked contributions were f o r the insane department, its construction was begun first, on a site at Charlestown, about two miles from Boston, and it was opened f o r the reception of patients on November 23, 1 8 1 8 . D r . R u f u s W y m a n was appointed resident superintendent, this being the first occasion when a medical man was placed in such a post in America. T h e theory of treatment adopted by D r . Wyman followed in general that advanced by Pinel and Tuke, as can be ascertained f r o m his early reports. Denouncing the cruel practices of the past, he wrote, in 1 8 2 2 : " I t is too true that such treatment [whips, chains, etc.] in time not long past, has been approved and often advised by medical men. A n entire revolution of opinion respecting the treatment of lunatics has been produced . . . Kindness and humanity have succeeded severity and cruelty." 1 7 It is interesting to note that the first patient admitted to the asylum was a young man believed to be "possessed of the devil." H i s father had labored mightily to exorcise him by regular whippings before he was brought to the institution. Superstition dies hard I Incidentally, this first patient was completely cured, became a pedlar and, thanks to a

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native Y a n k e e shrewdness, amassed a modest fortune b e f o r e retiring. In 1 8 2 1 , a Boston merchant, J o h n M c L e a n , bequeathed a sum of $ 1 0 0 , 0 0 0 to the Asylum f o r the Insane. In gratitude f o r this liberal g i f t the name of the institution soon a f t e r was changed to M c L e a n Asylum, and later to M c L e a n H o s pital. T h e asylum was managed on a modest scale during its early years : at the end of 1 8 2 0 it housed only 23 patients. Meanwhile, in 1 7 9 7 , six years a f t e r the opening of the N e w Y o r k Hospital, a general hospital had been founded in M a r y l a n d through an act of the State legislature " t o Encourage the establishing of a H o s p i t a l f o r the Relief of Indigent Sick Persons and f o r the Reception and C a r e of Lunatics." A charter f o r the hospital was given to a group of Baltimore citizens, headed by C a p t . J e r e m i a h Yellott. With an initial fund of $ 2 6 , 0 0 0 raised by state and city grants and through private subscriptions, a building was begun in 1 7 9 8 and was opened f o r the reception of its first patients, including the mentally ill, the same year. U n f o r t u nately, however, funds f o r the completion of the hospital were lacking, and it soon fell into a state of sad neglect, although continuing to receive patients. In 1 8 0 8 , two enterprising physicians, J a m e s Smythe and Colin Mackenzie, proposed to undertake the maintenance and direction of the uncompleted institution, and to make necessary repairs and additions, providing they were granted a lease of fifteen years. T h e i r proposal was accepted and they thereupon took over the institution on the basis of private control. A i d e d by two legislative grants totalling $ 4 8 , 0 0 0 , and granted permission to raise an additional $ 2 0 , 0 0 0 by lottery (which, incidentally, was a favorite means of raising money f o r social w e l f a r e projects at that t i m e ) , D r s . Smythe and Mackenzie enlarged and improved the hospital. A handsome profit was realized f r o m their joint endeavors. W h e n finally completed, the hospital accommodated 1 9 0 patients, of whom about f o r t y were mental cases. In 1 8 1 5 the lease of D r s . Smythe and Mackenzie was extended until 1 8 3 4 . Both the lessees died some years b e f o r e the expiration of the contract, however, and the control of

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the hospital passed into the hands of Mackenzie's son, D r . J o h n P . Mackenzie. A storm of protest had by this time arisen over the surrender of the institution to private enterprise, and in 1 8 2 8 its character as a public hospital was resumed by a legislative act. T h e new statute incorporated a group of representative laymen and physicians under the name, " T h e M a r y l a n d H o s p i t a l , " to supersede Mackenzie at the expiration of the private lease. T h i s group took over control in 1 8 3 4 . Five years later an act was passed directing that thenceforth the hospital should be devoted exclusively to the reception, care and treatment of the insane. T h i s law carried an appropriation of $ 3 0 , 0 0 0 f o r the changes required to adapt the institution to its new purpose, and provided that one-half of its accommodations be set aside f o r pauper lunatics sent there by various counties in the state, to be maintained at the rate of $ 1 0 0 each per year.* T h e years 1 8 2 1 and 1 8 2 2 witnessed the founding, in four different states, of f o u r new hospitals devoted wholly or in part to the reception of mental cases. Of these, two were founded as state asylums, one as an incorporated asylum, and the other as a general hospital admitting lunatics together with other classes of patients. T o Kentucky and South Carolina belongs the honor of opening the second and third state institutions exclusively f o r the mentally ill, although in both cases custody rather than cure was the dominating motive. Kentucky's asylum was established by a legislative act of December 7, 1 8 2 2 . ! A t that time it was customary in Kentucky, as in several other states, f o r the insane poor to be boarded out with individuals at public expense, by order of magistrates or justices of the peace. In a message to the legislature early in 1 8 2 1 , Governor A d a i r stated that this • I n 1852 selection of a new site f o r the M a r y l a n d Hospital w a s authorized by the legislature. S p r i n g G r o v e , M a r y l a n d , w a s chosen as the most f a vorable location but f o r v a r i o u s reasons—notably the C i v i l W a r — t h e new institution w a s not opened until a score of y e a r s later. t C a l l e d at first simply the " L u n a t i c A s y l u m " , and then the " E a s t e r n K e n tucky Lunatic A s y l u m " , its name w a s eventually changed to " E a s t e r n State Hospital."

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system of boarding out lunatics was wasteful f r o m the financial viewpoint,* and unsound f r o m the social angle since it provided no opportunity f o r curative treatment. H e proposed the erection of a state asylum, such as that in Virginia, to which Kentucky had occasionally sent her lunatics during her existence as a territory. " I f only one out of twenty of those unfortunate beings laboring under the most dreadful of all maladies should be restored," he asked rhetorically, "would it not be a cause of great gratulation to a humane and generous public?" H e also pointed out that such an institution would be of great value in affording practical experience to students at the medical school of Transylvania University. Following Governor A d a i r ' s suggestion, the legislature in 1 8 2 2 established a state asylum, and appropriated $ 1 0 , 0 0 0 to cover the expense of building and outfitting it. T h i s sum proved quite inadequate, particularly in view of the fact that the statute specified that accommodations f o r as many as 200 patients be provided. A tract of land near Lexington was selected, comprising about 1 7 acres. On this site stood an imposing, partly-completed brick edifice which had been begun some years b e f o r e as the Fayette Hospital, intended f o r "diseases of every chara c t e r . " f T h e new institution was opened f o r the reception of patients M a y I, 1 8 2 4 , as the E a s t e r n Kentucky Lunatic Asylum. Rigorous exclusion of the feebleminded—those who were "imbecile o n l y " — f r o m the institution was ordered by the legislature. Only the "lunatic" were to be admitted. 1 8 E v e n among this class, a distinction was made between "maniacs, or persons who are dangerous," and "such as are quiet and peaceable," it evidently being intended to confine only the f o r m e r group in the asylum, and to continue to provide f o r the latter by boarding them out as before. D r . T . O. Powell seems fully justified in stating that the institution, during its • T h e state expended $18,000 f o r this purpose in 1823. T h i s sum w a s reg a r d e d as a considerable outlay in that d a y . + T h e Fayette Hospital had been a g r o u p venture in public service that collapsed soon a f t e r its inception, l e a v i n g the building unfinished and unoccupied.

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first t w o decades, " w a s a madhouse f o r the safe-keeping of lunatics rather than an asylum f o r their care." 1 9 It appears, h o w e v e r , that the second superintendent (the first having resigned soon a f t e r entering upon his duties) at least attempted to put into practice the system o f moral treatment then in f o r c e at the Friends' A s y l u m at F r a n k f o r d , as evidenced by this quotation f r o m a letter written by him about 1826: W h e n I first entered on my charges, several [inmates] wore chains, and some straps with lock-buckles, &c. A t present the same are now freed from those manacles, and are peaceable. T h e only model presented to me for the internal government of this institution is a small pamphlet published by the trustees of the Friends' Asylum near Frankford. 2 0

T h e South Carolina State A s y l u m , erected at Columbia, w a s established in 1 8 2 1 , but w a s not opened until 1828. In one interesting respect the founding of this institution w a s unique. I t appears that a clamor f o r an asylum f o r the insane and a school f o r the deaf and dumb reached the ears o f the state legislature about the same time, and the solons conceived the idea of combining both services in one institution. A n act w a s f o r t h w i t h passed, in 1 8 2 1 , authorizing " t h e erection o f a suitable building f o r a lunatic asylum and a school f o r the deaf and dumb." 2 1 A n appropriation of $30,000 w a s voted f o r an institution with this t w o f o l d object. Fortunately, h o w e v e r , a commission appointed to study and d r a w up plans f o r the project reported that the association o f the t w o groups in one institution was impracticable, and the entire appropriation w a s t h e r e f o r e expended in building an asylum f o r the mentally ill. It w a s opened at Columbia, in 1828, under the management of nine trustees, or regents, appointed by the legislature. T h e asylum received both p a y patients and paupers, the maintenance of the latter being paid f o r by the counties to which they were chargeable. It w a s expressly provided that "idiots, lunatics and epileptics" were to be admitted alike to the asylum.* • I t is interesting, in t h i s respect, to note t h a t n e a r l y all the e a r l y m e n t a l h o s p i t a l s r e c e i v e d these t h r e e g r o u p s i n d i s c r i m i n a t e l y . T h e first institution in

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A n o t h e r public institution receiving mental patients w a s f o u n d e d in 1 8 2 1 , when the Ohio legislature passed a statute establishing " a C o m m e r c i a l H o s p i t a l and L u n a t i c A s y l u m f o r the State of O h i o " to be erected at Cincinnati. T h i s statute, like that enacted in South C a r o l i n a the same y e a r , carried an unusual provision. It directed that the p r o p o s e d institution, besides furnishing " s a f e - k e e p i n g , c o m f o r t and medical treatment of such idiots, lunatics and insane persons of this State as m a y be brought to i t , " should also accomm o d a t e f r e e of c h a r g e all sick boatmen of Ohio, t o g e t h e r with those of neighboring states reciprocally o f f e r i n g f r e e hospital treatment to boatmen w h o w e r e residents of Ohio. 2 2 T h e inception of this institution is credited to D r . D a n i e l D r a k e , one of the best known physicians of his d a y . A short time b e f o r e D r . D r a k e h a d founded the Ohio M e d i c a l College, of which he w a s president, and had set about immediately to h a v e a hospital established in connection with the M e d i c a l C o l l e g e as a means of affording clinical experience to his students. H e embodied this idea in a petition and presented it to the legislature, which acted f a v o r a b l y upon it. T e n thousand d o l l a r s in depreciated currency (which netted $ 3 , 5 0 0 in a l l ) in addition to one-half of the S t a t e ' s auction duties collected in Cincinnati, w a s a p p r o p r i a t e d by the state t o w a r d the erection of the hospital. I t s m a n a g e ment w a s placed in the hands of the trustees of Cincinnati T o w n s h i p . T h e f a c u l t y of the O h i o M e d i c a l C o l l e g e w e r e directed to r e n d e r services gratis to the mental patients, and in return their students w e r e given f r e e entry into the hospital f o r p u r p o s e s of observation. A l t h o u g h the C o m m e r c i a l H o s p i t a l w a s finished in 1 8 2 3 , it w a s not until f o u r y e a r s later that the other d e p a r t m e n t , the L u n a t i c A s y l u m , w a s opened f o r the reception of patients. T h e latter w a s a three-story building. T h e first s t o r y contained cells f o r the m a l e patients, the second a c c o m m o d a t e d f e m a l e patients, and the third was fitted out as a lecture hall f o r the students of the medical school. W h e n finally completed, it h a d accommodation f o r 1 6 0 patients. D e s p i t e its A m e r i c a exclusively f o r the feebleminded dates f r o m 1846, and the first f o r epileptics as recently as 1 8 9 1 .

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promising connection with the O h i o M e d i c a l College, we are told by Cincinnati's historians that the asylum w a s "designed rather as a place o f confinement than a hospital f o r the cure of the i n s a n e . " " T h i s estimate seems to be substantiated by the tenor of a resolution passed by the legislature in 1 8 3 1 , appointing a committee to visit the institution and to observe " w h e t h e r the cells and apartments o f the lunatic asylum are sufficiently separated f r o m one another by thick walls to prevent the inmates f r o m communicating with each other, and w h e t h e r means o f restraint and c o m f o r t . . . have been provided." 2 4 C o m m e n t on this resolution w o u l d be superfluous. M o r e closely allied to the progressive ideals enunciated at the turn of the century by Rush, Pinel and T u k e w a s the H a r t f o r d R e t r e a t , incorporated by the Connecticut Legislature in M a y , 1822. T h e name, R e t r e a t , was adopted f r o m the Q u a k e r s ' institution at Y o r k , E n g l a n d , along with many o f the principles practiced there. In 1 8 2 1 , a committee w a s appointed by the Connecticut State M e d i c a l Society to obtain data on the need of a public lunatic asylum within the state, and also w a y s and means of building one.* In its report the committee cited statistics indicating that there were more than one thousand insane persons residing in the state, which still lacked a single institution to afford them curative treatment. A hospital f o r the insane w a s undoubtedly necessary, and the committee proceeded to give a detailed description of the architecture and management of the proposed institution, based on the best models then available. A m o n g the recommendations contained in the report w e r e the f o l l o w i n g : Such an asylum should be the reverse of everything which usually enters into our conceptions of a mad house. It should not be a jail, in which for individual and public security the unfortunate maniacs * T h e m o v e m e n t f o r a n a s y l u m in C o n n e c t i c u t d a t e s b a c k to 1814, w h e n D r . N a t h a n i e l D w i g h t , t h e g e o g r a p h e r and p h y s i c i a n , sent a c o m m u n i c a t i o n c n l u n a t i c a s y l u m s to the M e d i c a l Society. In 1814, the Society a p p o i n t e d D r . M a s o n F . C o g s w e l l to g a t h e r i n f o r m a t i o n on the n u m b e r of insane in the state, and on m e t h o d s of p r o v i d i n g f o r them, but a q u e s t i o n n a i r e p r e p a r e d a n d c i r c u l a r i z e d b y h i m f a i l e d to elicit the d e s i r e d i n f o r m a t i o n .

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are confined. N o r should it be merely a hospital, where they may have the benefits of medical treatment—for without moral management, the most judicious course of medication is rarely sucessful . . . Its exterior should not exhibit the aspect nor even the faint resemblance of a prison ; and at the same time, in its formation the safety of its inmates should not be overlooked. 2 5

A s a model f o r the architectural design of the institution, the Committee pointed to the Lunatic Asylum at W a k e field, E n g l a n d (which, as we have noted, was built on plans submitted by Samuel T u k e ) . T h e Y o r k Retreat was praised as a model of asylum management, although, being composed of medical men, the Committee took exception to the extreme minimization of medical treatment at the Retreat. A m o n g the public advantages accruing f r o m the proposed establishment the Committee enumerated these: it would diminish the number of the insane in the State through curative measures; it would relieve the public of a source of danger; it would furnish an opportunity f o r recovery to the curable, and afford comfort and sympathy to the others; it would provide an economical means of maintaining lunatics at public expense. L a s t , but not least, it would serve as a valuable school of instruction f o r Connecticut's medical men. W h e n , w e ask, did C r o w t h e r , Haslam and C o x e become familiar with the diseases of the mind? Bethlehem hospital w a s the great school in which they were instructed. T o w h a t source do w e owe the masterly sketches of Pinel and R u s h ? T h e public charities of Paris and Philadelphia, which furnished the subjects of their observations, have been perhaps of more utility to the w o r l d at large than to their respective patients. 2 ®

T h e report of the committee—which included D r s . T h o m a s M i n e r , Eli T o d d , Samuel B . W o o d w a r d , William T u l l y and George Sumner—was approved by the Medical Society at its convention in October, 1 8 2 1 , and a constitution f o r a "Society f o r the Relief of the Insane" was drawn up and adopted. T h e following year a charter, together with a grant of $ 5 , 0 0 0 toward the erection of the institution (with the proviso that $ 1 5 , 0 0 0 additional be raised by subscription) was obtained f r o m the legislature. T h e subscription

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c a m p a i g n p r o v e d highly successful. A site w a s selected at H a r t f o r d , and the institution w a s opened A p r i l , 1 8 2 4 , under the name, " T h e R e t r e a t . " D r . E l i T o d d , w h o had played an active p a r t in f o u n d i n g the institution, w a s chosen its superintendent. T o the f o r e g o i n g institutions, established during the first q u a r t e r of the century, w e should a d d the W e s t e r n L u n a t i c A s y l u m f o r the Insane at Staunton, V i r g i n i a , established in 1 8 2 5 . D e s i g n e d to relieve the pressure of o v e r c r o w d i n g at the E a s t e r n S t a t e H o s p i t a l at W i l l i a m s b u r g , and to accomm o d a t e mentally ill persons in the western p a r t of the state, to w h o m the eastern hospital w a s all but inaccessible, the Staunton asylum w a s opened J u l y 2 5 , 1 8 2 8 . V i r g i n i a was thus the first state to b o a s t of m o r e than one state hospital f o r the insane. H a r d l y w a s the asylum at Staunton opened f o r the reception o f patients when it w a s filled to capacity, with a l a r g e number of applications p o u r i n g in, with the result that the authorities w e r e f o r c e d to issue an o r d e r restricting admission only to those cases " w h o are either dangerous to society f r o m their violence, o r w h o a r e offensive to its m o r a l sense by their indecency, and to those cases of d e r a n g e m e n t w h e r e there is r e a s o n a b l e g r o u n d to hope that the afflicted m a y be r e s t o r e d . " In summing up the m o v e m e n t f o r special institutions f o r the insane during the first q u a r t e r of the nineteenth century, w e find such institutions being established in eight different states f o r the first time. O f these, six w e r e f o u n d e d as semipublic institutions by i n c o r p o r a t e d g r o u p s , and t w o w e r e completely under state auspices. A ninth state, V i r g i n i a , established its second state hospital during this period. T h e initiative of l a y m e n w a s mainly responsible f o r the establishment of some, and the enterprise of medical men f o r others. W h i l e these institutions represented g r e a t strides f o r w a r d , they could a c c o m m o d a t e but a small f r a c t i o n of the total number of persons suffering f r o m mental diseases throughout the country. T h e dependent insane r e m a i n e d almost entirely neglected, although nominal provision f o r their reception at low rates w a s m a d e in all existing public and semi-public asylums. In practice m o s t p o o r l a w officials

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were loath to send their insane charges to these special institutions, being actuated by a sense of narrow-minded economy. In N e w York State, f o r example, while the weekly rates offered by the Bloomingdale Asylum f o r pauper lunatics were as low as two dollars, the dependent insane were being maintained in almshouses and jails throughout the State at costs ranging f r o m fifty cents to a dollar a week per person. In some communities the cost per individual was as low as twenty-five cents weekly; in others, as we shall see, they were disposed of by the barbaric custom of bidding them off on auction blocks to private individuals, sometimes bringing actual profit to towns and communities in exchange f o r their labor value. Hence, parsimonious communities often refused to send their pauper lunatics to hospitals, even though cure might await them there. On the other hand, too, hospital authorities were frequently reluctant to accept pauper patients at low rates while pay patients were applying for admission. W h a t of the dependent insane, who remained beyond the pale of hospital treatment?

CHAPTER

VII

Retrogression: Over the Hill to the Poorhouse " D R O G R E S S in social institutions and services seldom, if ever, travels in a straight, unbroken line of ascent. Rather does it follow a tortuous, spiral curve, registering checks and declines, in the road upward toward human betterment. In microcosm, this truth is abundantly reflected in the history of reform in the care and treatment of the mentally ill. W e have noted the centuries-long period of decline that followed the splendid psychiatric pioneering of the Greek and Roman physicians of antiquity. Fifteen hundred years later history was to repeat itself, though on a greatlyreduced scale, when a downward curve checked the progressive trend ushered in by those titans of psychiatry—Pinel, T u k e and Rush. T h e y had supplied a theoretical and practical groundwork sufficient for the building of a vigorous progressive movement. It seemed certain that this movement would be quickly carried f o r w a r d on an extensive scale. T h e institutions for the insane established in nine states of the Union during the first quarter of the century, augmenting the two 18th-century hospitals for the mentally ill, seemed to bear out this promise. But the small-scale experiments that they afforded, instead of being immediately carried into general practice, actually remained isolated amid a scene of widespread stagnation, and even retrogression. T h e main streams in public provision for the mentally ill continued to flow along the lines of least resistance, their courses determined principally by the dictates of expediency. A general trend toward institutionalization, a natural outgrowth of the increase and centralization of population, 114

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manifested itself during this period. T h e construction of special asylums f o r the mentally ill was but one minor aspect of this institutionalizing movement which, on the whole, was to take a quite different turn. F o r the great majority of the insane it meant participation in the long trek over the hill to the poorhouse—that dreary abode which drew all classes of dependents to itself like a magnet. M o s t of the states were still without special institutions f o r the mentally ill in the first quarter of the century. T h e few that made such provision could accommodate but a pitifully small proportion of the total insane (and a still smaller proportion of the pauper insane) residing within thjeir respective borders. F o r example, while there was an estimated total of 1,000 insane persons in Connecticut, when the H a r t f o r d Retreat was built, the latter institution (which remained the only one of its kind in Connecticut until 1 8 8 1 ) had provision f o r only f o r t y patients upon its completion in 1 8 2 4 . It seems, too, that the dependent insane reaped but little benefit f r o m the existence of corporate institutions such as the H a r t f o r d Retreat. Although nominal admission was usually provided f o r the pauper class, their reception was not encouraged. T h i s general attitude is explicitly stated in the annual report of the H a r t f o r d institution f o r 1 8 3 0 , wherein the medical visitors declare: W e are glad to learn that the funds of the Institution are gradually augmenting, and w e do most anxiously hope that ere long they w i l l enable the M a n a g e r s to admit a class of recent cases from amongst the poor at a lower rate. T h i s class, however, should not be numerous, as it is by no means desirable that the admissions to the institution should be gratuitous or even fixed for the generality of patients at very low rates. T h e inevitable consequence of this would be, that towns would crowd into the Institution pauper lunatics in numbers sufficient to fill it, and all other classes would be excluded. T h i s would lower the character of the Institution and greatly diminish its usefulness. 1

In other states, too, most insane persons who were reduced to the status of public dependents were denied even the meagre curative treatment then available. Besides, cases

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considered chronic or incurable were invariably excluded f r o m the benefits of hospital t r e a t m e n t . Because of the extremely limited facilities in most institutions only acute, or recent, cases were admitted as subjects f o r remedial treatment, while some public asylums (like that in Kentucky) frankly existed only f o r the confinement of " d a n g e r o u s " persons whose liberty constituted a public menace. I t was not until many years later that the question as to whether the chronic insane were entitled to medical treatment was even advanced as a m a t t e r meriting serious consideration. I t is a melancholy fact t h a t the g r e a t m a j o r i t y of the mentally ill who were public dependents remained unaffected by the great psychiatric r e f o r m s of the time. As f a r as they were concerned time stood still. T h e y were subjected to substantially the same methods of care and treatment existing in the late colonial period. T h e s e methods had changed but little in essence, although shifts in emphasis had taken place, corresponding to changing social conditions. F o r purposes of public provision, the insane p o o r were still commonly divided into two categories: the "dangerous and violent" on the one hand, and the "harmless and mild" on the other. As of yore, the dangerous insane were treated little better than criminals, while the harmless were regarded simply as " p a u p e r s " indistinct f r o m other classes of public dependents, and dealt with accordingly. T o obtain a true picture of the general treatment of the dependent insane during this period, it is necessary to comprehend the conditions of paupers as a whole. Sick poor, old poor, able-bodied poor, infant poor, insane and feebleminded—all were grouped together under the same stigmatizing label, " p a u p e r s " , and all were treated in very much the same manner. I f , then, we present in this chapter a r a t h e r extended analysis of the pauper system as it prevailed in the early decades of the nineteenth century, it is with the understanding that the care of the dependent insane was inseparable f r o m that system. Because of the prevailing lack of classification, and t h e r e f o r e of identity, this important and dramatic phase in the history of the insane has hitherto been generally overlooked or understressed.

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Four principal methods of caring f o r paupers existed at the time: ( ι ) provision in their own homes, usually granted when only partial or temporary public support was required; ( 2 ) auctioning off the poor to the lowest bidders, that is, to the person or persons willing to undertake their support at the lowest cost to the community; ( 3 ) contracting the support of all paupers to a single individual at a fixed price; ( 4 ) support in a public almshouse. T h e custom most shocking to modern thought, undoubtedly, was that of placing the poor on the auction block like so many chattel slaves—the only difference being that they were sold to the lowest, instead of the highest, bidder. However barbaric it may appear in our eyes, the system was at that time generally accepted with quite the same complacency that the average Southerner then showed toward the institution of slavery. A s a matter of record, the custom of bidding off the poor persisted over a wide area throughout the 19th century and survives to this day, in modified form, in at least one southwestern state. T h e guiding principle underlying this practice was to get rid of public charges at the lowest possible cost and the least amount of trouble to the community. T h e custom seems to have originated in the northeastern states, since it was popularly known as the " N e w England System." L e t us try to picture a typical auction of "town's paupers." T h e event takes place at the annual town meeting, usually held at the tavern. T h e " s a l e " has been widely advertised in advance, and many are present to participate in the diversion. A f t e r other business has been disposed o f , a town official (sometimes several took turns) mounts the rostrum as the auctioneer. Huddled on the auction block is a ragged, unkempt group—paupers on sale. M e n , women and children are there, ranging through all ages. A m o n g them may be seen one or two insane persons. T h e "town idiot" is in all likelihood present, standing side by side, perhaps, with an epileptic. In front of the block stand the prospective bidders. T h e y survey the unhappy group of humanity with shrewdlyappraising eyes, calculating the potential labor value of the

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human chattels about to be auctioned. F o r it is clearly understood that the successful bidder is entitled to as much work f r o m his charges as he might be able to extract f r o m them. T h i s factor is important. T h e insane and the feebleminded are o f t e n most eagerly sought a f t e r , f o r "strong backs and weak minds" make good f a r m l a b o r e r s — a n d the bidders are invariably f a r m e r s . (Remember, the auction system was almost completely confined to rural districts.) T w o classes of bidders are usually r e p r e s e n t e d : middling prosperous f a r m e r s in search of f r e e labor, and a little sum besides; and men themselves dangerously close to the line of destitution, hoping to get enough funds f r o m the public purse to sustain not only their charges but themselves and their families as well. T h e sale commences along lines contrary to ordinary auction procedure, since the bidding progresses downward. But the usual bag of tricks of the auctioneer is not neglected. T h e amount of potential labor represented on the auction block is a r t f u l l y set f o r t h as bait, the auctioneer permitting himself a comfortable degree of exaggeration. A plentiful supply of liquor is usually at hand to stimulate the bidding by offering a f r e e drink to the person lowering the price of the previous bidder. In some communities the system of disposing of the poor at auction did not o p e r a t e with quite this degree of callous brutishness. At times bond was required of the successful bidder to ensure "decent" treatment to his charges. Incompetent persons and those of dubious character were b a r r e d in many instances f r o m participating in the bidding. T o o o f t e n , however, the posting of bond was regarded as a mere formality. T h e town authorities breathed a sigh of relief upon seeing a responsibility lifted f r o m their shoulders f o r another year, and willingly closed their eyes to whatever conduct the purchaser might display toward his charges. T h e i r duty had ended with the successful completion of the auction sale. W h o l e families, pauperized through one circumstance or another, were frequently torn apart, as exemplified in the case of the U p t o n family, the members of which were "ven-

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d u e d " to the lowest bidders at G a r d n e r , Massachusetts, in 1789. A "committee to d r a w the conditions o f s a l e " w a s chosen, and E b e n e z e r E a t o n w a s appointed " v e n d u e m a s t e r . " T h e rest o f this d o l e f u l story is contained in the town records o f G a r d n e r : Oliver Upton and w i f e bid off by Simon Gates, at ten shilling per week. Oldest child bid off by Simon Gates, at one shilling per week. Second child bid off by John Heywood at ten pence per week. T h i r d child bid off by A n d r e w Beard, at one shilling, two pence per week. Fourth child bid off by Ebenezer Bolton, at one shilling, nine pence per week. 2

T h e p o o r w e r e usually auctioned off on a y e a r l y basis, though sometimes (as in the above instance) at weekly rates. Some towns sold them en masse to one b i d d e r ; others bid them off individually at v a r y i n g prices per person. In the latter case the reckoning depended on h o w much labor might be extracted f r o m the individual, o r h o w much trouble he might occasion through disability o f one kind o r another.* A t times a particularly robust man or w o m a n might actually be sold at a profit to the town, as witnessed in the records o f Fitchburg, Massachusetts, f o r 1 8 1 5 , when the Selectmen v o t e d to " l e t out the collection of T a x e s , & the P o o r , to the lowest bidder :" Ephraim Smith, bid off to Benja. Fuller, at g o f per week . . . Samuel French, bid off to David Baldwin, for whom, said Baldwin is to give one Cent per week . . . M a r y W a r e s , bid off to Abial H o l t , at 60 Cts. per week . . . Rebeccah Smith, bid off to Jos. C a r t e r at 20 Cts. per week . . . Jonas Spaldwin, bid off to Jona. W h e e l e r at 70 Cts. per week . . . O l i v e r Upton [the same individual sold a quarter-century earlier at G a r d n e r ] bid off to Joseph Phelps at 85 C t s . per week . . . Putnam Perley, bid off to Jona. Thurston, for w h o m Said T h u r s t o n is to give five Cents per week, and is not at liberty to dispose of him to any other person. 3 * I t is stated in the r e c o r d s of the O r p h a n s C o u r t o f St. C l a i r , I n d i a n a , f o r M a r c h , 1808, that " t h e i n s a n e b o y L e m a y w a s c r i e d d o w n to F r a n c o i s T u r cotte, f o r s i x t y - n i n e d o l l a r s f o r one y e a r f r o m t h a t d a t e . " T h e custom of f a r m i n g out i n s a n e p a u p e r s w a s p r a c t i c e d in I n d i a n a f o r m a n y y e a r s . ( E v e l y n C . A d a m s . " T h e G r o w i n g C o n c e p t of Social R e s p o n s i b i l i t y . . . i n I n d i a n a . " Indiana Magazine of History, 1936. v . 32, pp. 1-22.)

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T h e bidding-off system e x t e n d e d t h r o u g h o u t the r u r a l districts o f the c o u n t r y , and w a s a d o m i n a n t f o r m o f p o o r r e l i e f f o r a h a l f - c e n t u r y and m o r e f o l l o w i n g the b i r t h o f the n a t i o n . C o m m e n t i n g on this c u s t o m , F i e l d , the h i s t o r i a n o f R h o d e I s l a n d , m a k e s this p o i n t e d r e m a r k : " P r a c t i c a l l y it w a s o f f e r i n g a r e w a r d to the a v a r i c e a n d i n h u m a n i t y o f t h e m a n w h o w o u l d consent to n e g l e c t t h e m m o r e flagrantly a n d t o inflict u p o n t h e m a w o r s e abuse t h a n any o t h e r m a n in t o w n c o u l d be induced to p r a c t i c e . I t w a s useless to r e s o l v e t h a t only the bids o f g o o d m e n s h o u l d be t a k e n , and t h a t o v e r s e e r s should visit t h e m f r o m t i m e t o time, and t h a t b o n d s should be required f r o m t h e successful b i d d e r s f o r t h e i r p r o p e r t r e a t m e n t . T h e n as n o w , a b a d m a n w a s o f t e n a g o o d politician . . A n o t h e r m o d e o f d i s p o s i n g o f the p o o r w a s t h e c o n t r a c t system, whereby paupers were placed with i n d i v i d u a l s — a t l a r g e , singly, o r in f a m i l i e s — a t fixed p r i c e s f o r t h e i r upk e e p . T h i s m e t h o d w a s f a r less h u m i l i a t i n g t h a n a u c t i o n i n g t h e m off, but p r o b a b l y i n v o l v e d t h e s a m e a m o u n t o f r o u t i n e m i s e r y f o r the p o o r . In K e n t u c k y and n e i g h b o r i n g states, as w e h a v e n o t e d , it w a s the c u s t o m t o confine in institutions o n l y t h o s e m e n t a l cases w h o w e r e d e e m e d t o o d a n g e r o u s t o r e m a i n at l a r g e . A s f o r the " m i l d " insane, t h e y w e r e usually b o a r d e d o u t w i t h p r i v a t e f a m i l i e s at rates set b y j u d g e s in d e c i d i n g ind i v i d u a l cases, and p a i d f o r o u t o f l o c a l relief f u n d s . T h e o p e n i n g of the E a s t e r n K e n t u c k y L u n a t i c A s y l u m at L e x i n g t o n in 1 8 2 4 did not seriously i n t e r f e r e w i t h this c u s t o m , since t h e a s y l u m r e c e i v e d the " v i o l e n t a n d d a n g e r o u s " insane a l m o s t exclusively. In o t h e r states, w h e r e a l m s h o u s e s h a d b e e n e s t a b l i s h e d f o r the reception o f insane p a u p e r s a m o n g o t h e r s , such a s t r o n g p r e j u d i c e existed a g a i n s t s e n d i n g d e p e n d e n t s to these institutions t h a t public b o d i e s in c e r t a i n instances w e r e c o n s t r a i n e d to g i v e officiai r e c o g n i t i o n t o this d e e p - r o o t e d p r e j u d i c e , a n d to p r o v i d e a l t e r n a t i v e s t o m e e t it. In 1 7 9 3 , f o r e x a m p l e , one J u l i a n F o w l e r p e t i t i o n e d t h e M a r y l a n d l e g i s l a t u r e f o r m o n e t a r y a i d in s u p p o r t i n g h e r d a u g h t e r , R e b e c c a , w h o w a s d e s c r i b e d as " h a v i n g c o n v u l s i o n

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fits, is blind, and . . . has in a g r e a t measure been d e p r i v e d of the use of her senses, and that she, her mother, is no longer able to t a k e care of her, but desires to keep her out of the a l m s h o u s e . " 5 T h e twenty pounds required to keep Rebecca out of the p o o r h o u s e w a s duly a p p r o p r i a t e d by the obliging legislature. A b o u t the same time another petition w a s presented to the s a m e body by an a g e d couple, w h o requested an annual pension so that they could continue to support at home their f o u r imbecile children, " S o l o m o n , aged 3 0 , S a r a h and M a r y , a g e d 28 ( t w i n s ) , and E l i z a , aged 2 6 . " e T h e pattern of p o o r relief w a s still loose and multicolored, but the t h r e a d s w e r e g r a d u a l l y being d r a w n tog e t h e r in one direction. T h e general trend w a s leading ine x o r a b l y to i n s t i t u t i o n a l i z a t i o n — t o w a r d the poorhouse. T h e y o u n g nation w a s g r o w i n g r a p i d l y : new and thriving centers of population w e r e springing up. T h e old, h a p h a z a r d w a y s of communal l i f e , suitable enough f o r the rough patchw o r k existence of a pioneer people, w e r e p r o v i n g vexatious and inadequate in the settled areas. C l o s e r population g r o u p ings demanded g r e a t e r centralization and u n i f o r m i t y in the operation of social services. T o the class exercising its newly won authority, economy and t h r i f t w e r e g e n e r a l l y considered as the m a j o r virtues in public and p r i v a t e l i f e . T h o s e in public office w e r e constantly striving to attain these desiderata through the introduction o f n e w e r mechanisms. Searching inquiries w e r e launched in leading states with the view of f e r r e t i n g out and eliminating weaknesses in the p o o r relief structure, and to devise and substitute m o r e efficient methods in their stead. T h i s tendency in A m e r i c a w a s g r e a t l y stimulated by cont e m p o r a r y a f f a i r s in G r e a t Britain, which w a s still the " m o t h e r c o u n t r y " as f a r as social influences w e r e concerned. T h e r e the whole system of p o o r relief (and this included the care of the dependent insane) had stirred up a g r e a t deal of discussion. I n d e e d , it had become the most disturbing social problem in the land. T h e g r e a t Industrial R e v o l u tion, causing sudden changes in the economic relationships of the people and d r a w i n g tens of thousands of l a b o r e r s

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f r o m the countrysides into the newly-created industrial centers, was leaving in its wake a wide swath of pauperization among the working class. T h e old poor laws were found to be utterly inadequate in coping with the new conditions and needs. Authorities became distressingly conscious of sharp increases in expenditures: relief was in a hopeless state of confusion. So great became the alarm occasioned by mounting expenses that many leading social w e l f a r e theoreticians (quite unaware of the real roots of g r o w i n g pauperism) called f o r the total abolition of public poor relief, charging that it created paupers in the process of relieving them. T h e y demanded that charity be restored entirely to private hands, where it had reposed in earlier times. Others, while not subscribing to the extreme view that the poor laws be abandoned in loto, f e l t a need f o r radical changes. It w a s inevitable that this clamor (which finally found expression in the f a m o u s poor law r e f o r m s of 1 8 3 4 ) should be reflected across the Atlantic, though the conditions in A m e r i c a were not quite analogous as yet to those prevailing in G r e a t Britain. Demands f o r investigations into the poor laws, similar to those instituted abroad, were raised in the larger centers of population in the United States. In 1 8 2 0 the first state-wide inquiry into the subject w a s launched in Massachusetts. A legislative committee, headed by J o s i a h Quincy ( w h o later served as M a y o r of Boston and President of H a r v a r d U n i v e r s i t y ) , w a s delegated to "consider of the pauper laws of the C o m m o n w e a l t h , " and to prepare recommendations f o r improvement based on their findings. T h e committee submitted its report the following year. Chief among its recommendations w a s the erection, on a large scale, of local almshouses equipped with means f o r providing their inmates with employment. In support of this plan, the committee cited similar conclusions reached by investigating commissions in E n g l a n d , urging the universal establishment of poorhouses as the most s a t i s f a c t o r y solution of the pauper problem. 7 T h i s recommendation received the enthusiastic endorsement of many localities in the Commonwealth. T w o years a f t e r the Massachusetts

investigation

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poor relief was ended, a similar project was initiated in N e w Y o r k by the state legislature, commissioning Secretary of State Y a t e s to direct the inquiry and to prepare a report with a view toward legislative action. T h i s report, submitted in 1 8 2 4 , contains a thorough description of prevailing relief methods, a discussion of abuses, and recommendations f o r their correction. It is a document of great value. 8 N o t only does it present a comprehensive picture of poor relief as it was practiced in N e w Y o r k State more than a century ago, but it also contains interesting accounts of methods employed in other states. A m o n g its important features are the many communications f o r w a r d e d to the Secretary of State by local poor law officials, describing their methods of administering relief and presenting f r a n k comments on the subject. Documents such as this one, too often underestimated by historians, may shed more light on the social life of a particular period than thousands of generalizations. Since it embodies contemporary trends and views on poor relief generally, together with some direct accounts of the care of the insane, we shall examine this document in some detail. M a n y shocking practices were revealed in the report. Among these was the widespread custom of "passing o n " unsettled paupers, in health and in illness, from town to town and constable to constable, until they reached their supposed places of settlement. It was usually the policy of officials engaged in this passing-on to rid themselves of their unwelcome charges as quickly and as inexpensively as possible. In the process the least degree of humanity was exercised. T h e 1 8 2 4 report dolefully remarks that this barbaric procedure in vogue throughout the states often brought "untimely dissolution" to paupers subjected to it. T h e mentally ill in particular were victims of the passing-on system, since they could offer little or no defense against the abuses likely to be inflicted upon them by irresponsible individuals. Another cruel custom was that of "dumping" paupers on other towns by resorting to gangster methods of taking the victim " f o r a ride." T h i s practice was almost entirely confined to feebleminded and insane paupers. T h e latter were

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spirited away in the dead of night and l e f t in strange towns in the hope t h a t their inability to give coherent accounts of themselves would make it difficult, if not impossible, to trace them back to their original places of settlement. T h i s disgraceful method of relieving a town of its proper charge was resorted to with surprising frequency. O f t e n enough a town, itself imposed on through this practice, would show no compunction in repeating it on another, with no concern f o r the miserable central figure of the d r a m a . Such towns usually found balm f o r their conscience in the argument that they were justified in rejecting the role of scapegoats. Complaining bitterly of this practice, the overseer of the poor of Albany, in his communication to Secretary Yates, related the following incident: A poor unfortunate lunatic, of the age of eighteen or twenty years, was left in our streets in the winter, and in the night, whose feet were in consequence badly frozen : he could give no intelligible account of himself, but from all circumstances, there was too much reason to believe that this was one of the tricks frequently resorted to by towns, to free themselves of paupers. T h i s young man was of necessity sent to the almshouse, where he remained several months and by the mere accidental admission of a stranger, his residence was ascertained. 9

A still m o r e revolting example of the shameful custom is described in a letter f r o m a poor law official of Franklin, in Delaware County. Significantly enough, while the account shows the writer to be a humane person, dismayed by the barbarity entailed in " d u m p i n g " human stock, he nevertheless accepts the practice as an unavoidable m a t t e r of course. Several years previously, he states, an aged stranger traveling through Franklin fell sick and "was partially deranged." H e could give no coherent information about himself or his place of residence. Acting on inspiration, however, the officials decided that he might belong to the town of N e w Berlin, and he was f o r t h w i t h " d u m p e d " on that town. But New Berlin would have none of him, and litigation was started over the u n f o r t u n a t e lunatic.* A f t e r some costly court •Incidentally, these disputes over settlement often proved to be very expensive matters, and represented one of the most g l a r i n g evils of the poor relief

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procedure, the old man was returned to Franklin. But this failed to weaken the town f a t h e r s ' determination to lay the stranger at some other town's doorstep, by hook or crook. A f t e r another mysterious train of reasoning, the authorities arrived at the " t h o u g h t " that he might belong to the t o w n of W i l l i a m s t o w n , in Massachusetts, and their existing l a w s laying heavy penalties on any person bringing poor persons to that place, gave rise to the propriety of taking him there in a clandestine manner. H e w a s decoyed there in the night, and left, the L o r d k n o w s where, old, deranged and infirm! 1 0

In a communication to Yates f r o m the enterprising village of Danville, the authorities reported t h a t a " p a u p e r lunatic" was now ensconced in a small house erected in the public square " f o r the express purpose of containing the pauper aforesaid." One suspects that the idea of exhibiting the unf o r t u n a t e person to the gaze of the curious might have been uppermost in the minds of those who built the one-man institution right in the public square. H o w else can this strange selection of site be explained? One can almost see the village bucks whiling away an idle hour by "teasing the l o o n " so temptingly at hand. M o s t of the rural localities answering the Secretary of State's questionnaire on methods of poor relief stated t h a t they were auctioning their poor to the lowest bidder. T h e larger communities had already established poorhouses, which they declared with one voice to be f a r less expensive than the other relief methods. I t was also claimed that poorhouses afforded m o r e c o m f o r t to the paupers. A m o n g the smaller towns many f a v o r e d the abandonment of the old methods and the adoption of the poorhouse plan on a county scale. Both economic and charitable arguments in f a v o r of the plan were presented, with the f o r m e r motive predominating in most replies. T h e town of Fairfield f a v o r e d the establishment of a s y s t e m of the p e r i o d . O n e t o w n ( A n c r a m ) r e p o r t e d in 1 8 2 4 t h a t it h a d s p e n t $ 3 3 8 on a s i n g l e a p p e a l (sufficient to s u p p o r t a p a u p e r f o r ten y e a r s at c u r rent r a t e s ) , w h i l e a n o t h e r t o w n ( A u s t e r l i t z ) r e p o r t e d a n e x p e n d i t u r e of w e l l o v e r $ 3 0 0 on one l a w suit i n v o l v i n g settlement.

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poorhouse f o r these reasons, among others: " T h e infirm could be more readily healed—the idiot more humanly provided f o r — t h e lunatic more securely kept, and the youth better prepared f o r society." In this argument, more humane than most of the others, we nevertheless find expressed the all-too-common tendency of the day to consider the secure confinement of the insane to be the sole end of institutionalizing them. N o t all the towns looked with f a v o r upon the proposal to institute the almshouse system on a universal scale, however. Some were quite satisfied with the alternatives then in use. T h e town of C h a z y , f o r instance, stated that it had f o r f o u r years past "sold at public sale all the poor of the town; this mode of proceeding has been the means of lessening the expenses f o r the support of the poor, f r o m the year 1 8 1 7 , at least two-thirds. F o r none, except those that are objects of charity, will apply to the town f o r assistance, and be exposed f o r sale and liable to l a b o r . " Curiously enough, this very argument of deterrent relief was one of the most effective advanced by the advocates of the poorhouse system. T h e overseer of the poor at Coeymans also found the practice of bidding off the poor a satisfactory one, stating that " w e find no method of supporting our poor so easy as we now have adopted." A whole social philosophy is implicit in these simple w o r d s — a tenacious clinging to the line of least resistance. F r o m the town of Ghent, where paupers were disposed of under the contract system, came this pointed defense of rugged individualism: " W e are informed that the legislature have it in contemplation to pass an act to build a poorhouse in each county. T o this we are decidedly opposed, as the plan we have adopted to support our poor is the best we can devise. W e find that our poor tax is reduced annually . . . W e wish to retain our present privilege, that is to support our poor in our own way and not to be associated with any other towns, or the county." 1 1 Several towns reported that they had already experimented with poorhouses, but had returned to f o r m e r methods as being less expensive. Hampstead, f o r example, stated that "this town formerly

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had a poor-house, but o u r overseers of the p o o r f o u n d by experience that it cost the town more m o n e y than to sell the p o o r to the f r e e h o l d e r s of the said t o w n . " * W e h a v e dealt with the views of these r e p r e s e n t a t i v e communities at some length in the belief that they comprise a f a i r cross-section of the prevailing m e t h o d s and theories, and also a significant index to the mental a p p r o a c h e s of p o o r law officials to their problems. T o them w a s entrusted, in the final analysis, the f a t e , safe-keeping, c o m f o r t and perhaps cure of the g r e a t m a j o r i t y of the mentally ill throughout the country. W h a t e v e r the abstract theories f o r m u l a t e d during their time m a y h a v e been, in their hands rested the practical matters of providing f o r d e p e n d e n t s — t h e insane p o o r a m o n g them. In the opinions of these l o w l y officials a r e revealed actualities of existence that too o f t e n escape us in evaluating the social patterns of a given period. On the basis of the partial returns received in a n s w e r to his questionnaire, S e c r e t a r y Y a t e s estimated that there w e r e in N e w Y o r k S t a t e m o r e than 2 1 , 0 0 0 p a u p e r s , of w h o m 6,896 w e r e " p e r m a n e n t , " as distinguished f r o m "occasionata," or those w h o sought only t e m p o r a r y r e l i e f . O f the permanent paupers, 4 4 6 ( m o r e than 6%) w e r e classified as "idiots and lunatics." Y a t e s w a s emphatically of the opinion that the p r e v a i l i n g p o o r relief methods w e r e v e r y i m p e r f e c t , causing g r e a t hardship and involving much w a s t e . L i k e the Quincy committee in M a s s a c h u s e t t s , he s t r o n g l y u r g e d the introduction of a state-wide system of poorhouses as the best medium f o r administering r e l i e f . E a c h county, he f e l t , should h a v e at least one such institution, to be maintained at local expense. Requisite to the success of these poorhouses w a s an adequate provision f o r e m p l o y i n g all its • T h e general trend to the poorhouse w a s reversed in a number of localities, both in N e w Y o r k and other states. T h e town of D o v e r , Massachusetts, went through an interesting cycle within a short period. H a v i n g started by boarding out paupers with private families at fixed monthly allowances, it next adopted the poorhouse system. T h i s method proved unsatisfactory and the building w a s sold. D o v e r then turned to the auction system, which w a s also discarded, and the town returned to the old practice of boarding-out, completing the cycle. ( S e e : F r a n k Smith's History of Dover, Massachusetts. D o v e r , 1897. 354 pp., p. 245-46.)

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inmates able to do some work. " F r o m these general views," he said in summation, "it will be perceived that the adoption of the poorhouse plan in every county is recommended . . . and it may be safely affirmed, that wherever that plan has been fairly tried, the expense of supporting paupers has decreased 3 3 , and in many instances, 50 per cent." In support of this statement the Yates report cited the confirmatory opinions of many officials of other states. Acting upon the recommendations embodied in the reports of 1 8 2 1 and 1 8 2 4 , both Massachusetts and N e w Y o r k enacted laws encouraging the erection of poorhouses. A s a result of these acts, such institutions soon sprang up in many of the towns and counties of these two great states. In Massachusetts, f o r example, there were in 1800 only 35 almshouses throughout the state: by 1 8 3 0 there were more than three times that number, built f o r the most part in the decade following the Quincy report of 1 8 2 1 . 1 2 In N e w Y o r k the legislature passed a far-reaching law in 1 8 2 4 which made it mandatory f o r each county not already possessing at least one poorhouse to immediately set about establishing one. 13 Indigent persons applying f o r relief were to be sent to these poorhouses, where the authorities might demand of them any labor that lay within their capability. T h e law also provided that individuals convicted as "disorderly persons" might be committed to the poorhouse to serve out their sentences—a provision that clearly indicates the prevailing confusion concerning the proper purposes of a poorhouse. In the remaining states, too, the trend toward the poorhouses was strong and unmistakable. T h e events in Massachusetts and N e w Y o r k marked only the culmination of a general and gradual turn to the institutional ideal, the beginnings of which could be traced back to colonial times. In fact, the poorhouse system had become the dominant form of poor relief in several states even before the advent of the nineteenth century. A s f a r back as 1 7 9 1 Delaware had enacted a law providing f o r the establishment of almshouses in all its counties. By the terms of this act, support of the poor in any other manner than by confinement in these in-

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stitutions w a s proscribed.* B y 1 8 3 0 nearly every state had encouraged the erection of poorhouses, if not actually prescribing this move as mandatory. A t this time the poorhouse system w a s envisaged as a panacea, where paupers of all grades and classes could be made happy by honest toil ; where the more able could shoulder the support of the impotent; where the morale and health of all would soar to new heights—while the taxpayer could r e g a r d with satisfaction sharply reduced poor-rates. But, unfortunately f o r these f o n d hopes, the poorhouse system, as planned by its early nineteenth century advocates, proved a dismal failure. Designed as a receptacle f o r all paupers (and frequently petty offenders, t o o ) with no classification or differentiation, its inherent contradictions doomed it to f a i l u r e f r o m the very first. A n institution admitting all ages of paupers who ran the full gamut of physical and mental health ( o r more correctly, ill health) could scarcely minister successfully to the needs of any one class of inmates, let alone all of them. T h e I82O'S—that great decade of almshouse planning and building—had hardly passed into history b e f o r e these catchalls, which were also expected to serve as cure-alls, g a v e rise instead to even g r e a t e r evils than those they w e r e supposed to eliminate. F o r example, the Boston H o u s e of Industry, erected in 1 8 2 3 , and generally regarded as the perfect model of the new type of labor-providing poorhouse, was described just ten years later in these disillusioned terms, contained in a report to the Massachusetts legislature: When this establishment was commenced, it was intended for the reception and employment of the able-bodied poor, who should claim the charity of this city; hence it was called the House of Industry . . . Instead of being a House of Industry, the institution has become at once, a general Infirmary—an Asylum for the insane, and refuge for the deserted and most destitute children of the city. So great is the proportion of the aged and infirm, of the sick insane, idiots and helpless children in it, that nearly all the effective labor of the females, • O n e county ( S u s s e x ) , h o w e v e r , w a s g i v e n the p r i v i l e g e of contracting f o r the support of part of its paupers, p r o v i d e d that the latter recourse p r o v e d substantially cheaper than poorhouse care.

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and much of that of the males, is required for the care of those who cannot take care of themselves.1* T h e evils i n h e r e n t in the catch-all a l m s h o u s e a r e f u r t h e r r e v e a l e d in a r e p o r t , s u b m i t t e d to the N e w Y o r k l e g i s l a t u r e in 1 8 3 8 , w h i c h d e s c r i b e d c o n d i t i o n s in a typical county poorh o u s e w h e r e the s u p e r i n t e n d e n t o f the p o o r , f a r f r o m being m o r e cruel o r n a r r o w - m i n d e d than his f e l l o w s in o t h e r counties, a c t u a l l y d i s p l a y e d a d e g r e e o f intelligence a n d humaneness a b o v e the a v e r a g e . O f 1 7 4 i n m a t e s in this p o o r h o u s e , a c c o r d i n g to the r e p o r t , t h e r e w e r e ten lunatics and eight idiots. D i s t r i b u t i o n of the i n m a t e s p r o c e e d e d a l o n g the f o l l o w i n g l i n e s : in o n e u n h e a t e d g a r r e t r o o m twenty-five men a n d boys, t w o o f t h e m insane, s h a r e d eleven beds between t h e m . A n o t h e r g a r r e t r o o m , l i k e w i s e w i t h o u t protection a g a i n s t inclement w e a t h e r a n d n e i t h e r l a t h e d n o r s e a l e d , cont a i n e d t w e l v e w o m e n a n d c h i l d r e n , including " o n e f e m a l e lunatic w h o h a s sufficient sense of p r o p r i e t y to k e e p herself c l o t h e d . " A l l occupants o f this r o o m w e r e c r o w d e d into five b e d s . T e n w o m e n a n d c h i l d r e n w e r e c r a m m e d into t h r e e beds in o n e tiny r o o m ( 1 7 f e e t by 9 ) , w h i l e a n o t h e r c h a m b e r with ten beds w a s occupied by nineteen p e r s o n s o f all a g e s and conditions, n a m e l y : " t w o m a r r i e d men and their w i v e s , and o n e a g e d c o l o r e d w o m a n , t w o m a l e idiots, one v e r y o l d m a n , and eleven c h i l d r e n . " I n still a n o t h e r c h a m b e r t w o m e n t a l l y ill m e n l a y c h a i n e d t o the floor at o p p o s i t e c o r n e r s o f the r o o m . T h e institutional officials, in f o r w a r d i n g t h e i r r e p o r t , f r e e l y a d m i t t e d and d e p l o r e d the u n w h o l e s o m e and i n h u m a n conditions i n v o l v e d in the o p e r a t i o n o f the almshouse, p a r t i c u l a r l y the i m p r o p r i e t y o f p e r m i t t i n g " i d i o t s a n d lunatics to occupy the s a m e r o o m w i t h f e m a l e s a n d child r e n , " but a d d e d t h a t they w e r e p o w e r l e s s to e l i m i n a t e o r m i t i g a t e these evils. " T h e y [ t h e insane and the f e e b l e m i n d e d ] w e r e sent t o us, and the l a w c o m p e l l e d us to receive t h e m , but n e i t h e r the l a w n o r a n y a u t h o r i t y u n d e r it p r o v i d e d us the place to k e e p t h e m in a p r o p e r m a n n e r . " 1 5 " T h e y w e r e sent to u s . " T h e s e w o r d s w e r e f r a u g h t w i t h p r o f o u n d significance. T h e f a u l t w a s not that o f i n d i v i d u a l k e e p e r s o r officials o r of i n d i v i d u a l institutions, but of a

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society that, at best, was indifferent to such conditions, and at worst, actually put the seal of approval on them in the name of that fetich of government—Economy. Of course, we would get a distorted picture of the almshouse of this period if we were to use dark pigments exclusively in painting it. There were some institutions that overcame, in varying degrees, their initial handicaps by virtue of decent treatment and intelligent management. Many had infirmaries providing medical aid to the inmates suffering physical or mental illness. From almshouse infirmaries like these some of our greatest hospitals developed. Bellevue Hospital in New York, the Philadelphia General Hospital ("Old Blockley"), and the New Orleans Charity Hospital all trace their origin to early poorhouses in those cities. Here and there some system of segregation was attempted by placing the mentally ill in buildings separate from those housing other classes of paupers. But on the whole, the road that led over the hill to the poorhouse proved to be a Via Dolorosa for those unfortunate creatures driven along it. And of the congeries that made up the population of the average poorhouse, the group receiving the brunt of its manifold evils was the group at the very bottom—the mentally ill. Nor was their condition improved during the decades following the fateful '20's. On the contrary conditions grew progressively worse until, in the 1840's and *5o's, that remarkable woman, Dorothea Lynde Dix, brought them to the attention of a shocked nation, and then galvanized the nation into constructive action. What she saw in these poorhouses, and what she did about it, will be described in a later chapter.

CHAPTER

Vili

The Cult of Curability and the Rise of State Institutions ' I S H E second q u a r t e r of the nineteenth century witnessed a r e m a r k a b l e phenomenon in the theoretical approach to insanity. I r e f e r to the introduction and rise of a "cult of curability," involving an astonishing revolution in psychiatric theory in A m e r i c a , with tangible influences on the erection of state mental hospitals during the period of its ascendancy. U p to the third decade of the century the g e n e r a l attitude r e g a r d i n g the curability of mental disease w a s dominantly pessimistic. D e s p i t e the encouraging experiences of men like R u s h in this country, and the C h i a r u g i s , Pinels and T u k e s a b r o a d , it w a s widely believed that insanity w a s an incurable affliction. " O n c e insane, a l w a y s i n s a n e , " went the popular a d a g e . A b o u t 1 8 3 0 , h o w e v e r , the pendulum of opinion on this subject swung violently to the opposite extreme. T h e old notion that none, o r at best v e r y f e w , of the mentally ill could be cured w a s suddenly discarded. In its place, the conviction took root that all, or nearly all, were curable. W i l d claims on the probabilities of recovery in mental cases w e r e w i d e l y circulated and given f u l l credence. " I n s a n i t y is the most curable of all d i s e a s e s , " it was dogmatically declared. " A t least ninety per cent of all cases of insanity can be c u r e d , " it w a s solemnly asserted. E x t r a v a gant claims indeed, when c o m p a r e d with the cold statistics of our t i m e ! * T h e s e , r e g r e t t a b l y enough, indicate that even with our vastly i m p r o v e d methods of care and treatment, • O f course no i n f e r e n c e is i n t e n d e d h e r e t h a t 9 0 % c u r a b i l i t y in m e n t a l d i s e a s e is u n a t t a i n a b l e in the f u t u r e . T h e t e r m s " c u l t of c u r a b i l i t y , " a n d

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about 1 5 per cent of all cases admitted into State mental hospitals may be expected to recover, with an additional 25 per cent improved sufficiently to warrant discharge. Around the aforementioned over-optimistic notions there grew up a veritable cult of curability, numbering among its devotees not only laymen but most of the superintendents of institutions f o r the insane. Indeed, it was the latter who contributed the major stimuli to the spread of the fallacy of easy curability. It is a fact that many among the psychiatric fraternity were fully conscious of the error of the doctrine they were advancing, or at least supporting. It may be said in extenuation that some who knew better paid lip service to the idea of large-scale curability in the sincere belief that they were promulgating a "white lie." T h e y hoped thereby to hasten the establishment of more and better institutions f o r the mentally ill. Others deliberately doctored their statistics, crediting themselves with staggering recovery records, in order to stay abreast of their fellow practitioners who were doing the same thing. A vicious cycle of fallacies was thus kept in motion, f e d by the mutual desire, if not necessity, on the part of institutional heads to "keep up with the procession." F o r the origins of this significant phenomenon we must turn back to old England, the source of many practices and theories (not all equally commendable) adopted in America. L e t us go back to King George the T h i r d whose reign, in certain broader respects, was of great importance in the historical development of the American nation. G e o r g e the T h i r d , as we know, experienced periodic attacks of mental illness, the last of which ended in his death. In his early attacks he was attended by a remarkable person, D r . Francis Willis. T h e latter was a minister turned physician who specialized in mental disorders and maintained a private asylum, f r o m which he received very lucrative re"curability myth" used in this chapter refer strictly to the e x t r a v a g a n t claims and over-optimistic beliefs, as contrasted to extremely modest actual achievements, of the period under discussion. T h e figures on expectation of recovery and improvement are based on the United Slatti Census Report on Mental Patients in State Hospitals, ig^I and IÇ32. (U. S. Printing Office, Washington, D. C., 1934.)

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turns. T h e monarch reposed great confidence in him and made him chief attendant, over the protests of the regular staff of royal physicians. In the course of the famous parliamentary investigation into the King's illness in 1 7 8 9 D r . Willis advanced the startling claim that he cured nine out of every ten mental patients he treated. H i s assertion had a startling effect on a generation brought up in the belief that lunacy was, with f e w exceptions, incurable. When asked to furnish proof of his claim he could offer no definite figures on either the total number of patients he had treated or the number that had been cured. W h e n further pressed f o r specific data he replied that his claim was based mainly on the grounds that the first fifteen patients treated by him had recovered, and that subsequently as many as ten patients at a time had been discharged as cured f r o m his private asylum. H i s statement was ridiculed by most contemporary physicians, who suspected, not without reason, that D r . Willis was somewhat of a charlatan. But the boast had an element of dramatic force which left a deep impression. In 1 8 2 0 the question of high-percentage recoveries was again brought f o r w a r d by D r . George M a n Burrows of England in a pamphlet entitled An Inquiry into Certain Errors Relative to Insanity. It was one of the m a j o r theses of this little work that mental illness was f a r more amenable to therapeutic treatment than people supposed at the time. T o consider insanity incurable was a pernicious error, D r . Burrows declared. On the contrary, it was highly curable. A s p r o o f , he asserted that he himself had cured 81 per cent of all mental patients, including those in " a state of fatuity, idiocy and epilepsy," in his private asylum. Of "recent" cases (meaning cases of less than one year's duration) he claimed to have cured an average of 9 1 out of a hundred. D r . Burrows had treated 296 patients, a total which would hardly seem sufficient to draw any generalizations from even if the alleged percentage of recoveries in this particular instance were substantiated. D r . Burrows' book was widely read at home and abroad, and his contentions seem to have been uncritically accepted by many of his fellow practitioners.

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Another book written by an Englishman proved a strong stimulus to the spread of the idea of large-scale curability in America. Curiously enough, the author was a man whose interest lay f a r afield f r o m the subject of insanity, and the book was a tale of personal travels. In the years 1 8 2 7 - 2 8 Captain Basil H a l l , a retired officer of the R o y a l N a v y , made a tour through N o r t h America. U p o n his return to Great Britain he wrote a book on his travels which excited a great deal of interest and discussion. 1 In America he had visited a number of benevolent institutions, including the Retreat at H a r t f o r d , Connecticut, and had set down his impressions in his book. Both the Retreat and its superintendent, D r . E l i T o d d (then recognized as the foremost American superintendent of a mental hospital), received his unstinted praise. H e spoke of the "noble establishment" as " a model, I venture to say, f r o m which any country might take instruction." 2 In substantiation Captain H a l l quoted a startling passage f r o m the report of the Retreat f o r 1 8 2 7 , to the effect that "during the last year, there have been admitted twenty-three recent cases, of which twenty-one recovered, a number equivalent to 9 1 W per cent." T h i s phenomenal record was then compared with statistics of the "most ancient and celebrated institutions in Great B r i t a i n " which could boast of only 3 4 to 54 per cent cures of recent cases. Furthermore, the figures in two "highly respectable institutions" in America showed average recoveries in recent cases of only 25 and 3 1 per cent. T h e remarkable claims of the H a r t f o r d Retreat very likely would have been buried in the dust-gathering pages of the original report were it not f o r the adventitious visit of Captain H a l l and the remarks made in his widely read book. America had not yet thrown off the yoke of the "colonial complex" which bound her to Britain culturally: opinions of English visitors on American manners, customs and institutions, favorable or otherwise, were still given exaggerated respect. M o r e o v e r , in this instance, the commendation f r o m Captain H a l l was particularly impressive since his general notes on American life and institutions were so contemptuous as to arouse great indignation on this side of the Atlan-

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tic.* Hall's remarks on the H a r t f o r d Retreat were repeatedly quoted in the American newspapers and periodicals. Largely because of the publicity received in this roundabout manner the Retreat soon gained the reputation of being the most successfully operated institution for the mentally ill, not only in the United States, but in the whole world. Its unprecedented record of cures became a mark for the other institutions to aim at. A rivalry was thus set afoot which led to a fantastic race f o r high recovery rates. The immediate effect of the "curability craze" was beneficial in that it proved a potent impetus to the building of mental hospitals in the United States. But from the long-range point of view the fallacy proved to be decidedly injurious. It led to an unhealthy competition among heads of mental hospitals that lasted many years. Grotesque methods of compiling institutional statistics were resorted to in order to keep alive the fiction. Finally, as we shall see, the reaction following the exposure of the fallacy had a decidedly harmful effect on the cause of the mentally ill. The claims of Willis and Burrows and the impressive record of the H a r t f o r d Retreat, founded though they were on the treacherous sands of unscientific statistics, were accepted at face value by an uncritical generation. Skillfully exploited as major arguments for the erection of mental hospitals, they constituted indeed a powerful factor in the asylum-building movement during the 1830's and '40's. Of course there were other factors favoring this trend, some of which have already been described. Not the least among them were the really solid achievements of the early corporate hospitals (Frankford, McLean and Bloomingdale asylums, and the H a r t f o r d Retreat itself). These institutions afforded impressive demonstrations of the truth that a fair proportion of the mentally sick could be cured. Their existait is interesting to note that when Mrs. Frances Trollope's famous essay in derogation of the American people, Domestie Manners

of the

Americans,

was published several years later (1832), it was at first widely attributed to Captain Hall in the belief that he was the only foreigner unjust enough to cast such aspersions on the social life of the country. A saying of the time ran: "Either Captain Hall is Mrs. Trollope in breeches, or Mrs. T r o l lope is Captain Hall in petticoats."

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enee did much to dispel the hopeless atmosphere then surrounding the subject of care and treatment of the insane, and contributed to the optimism necessary to the advancement of the hospital idea. About 1 8 3 0 a vigorous movement having f o r its object the erection of suitable state hopitals f o r the insane manifested itself simultaneously in several states. T h i s movement found its first concrete expression in Massachusetts with the opening, in 1 8 3 3 , of the State Lunatic Hospital at Worcester. In 1 8 2 8 , following a stirring plea by H o r a c e M a n n in which he enunciated the principle that "the insane are the wards of the state," the Massachusetts legislature had appointed a committee to inquire into prevailing provisions f o r the insane throughout the state. In its report, submitted in 1 8 2 9 , the committee revealed that an intolerable state of affairs existed. M o s t of the mentally ill were still confined in jails, houses of correction, poorhouses and workhouses, suffering incredible cruelty and neglect. M a n y who were innocent of any crime had been incarcerated in prisons like common felons f o r periods ranging up to forty-five years, robbed of all opportunity f o r therapeutic treatment. T h i s situation, according to the committee, could be properly corrected only through the erection of a state hospital. T h e legislature, with unusual promptness, acted f a v o r a bly on the report. A site was selected at Worcester and a legislative commission was appointed to oversee the building and organization of the projected hospital. In 1 8 3 2 , the commissioners presented a report, drawn up by H o r a c e M a n n , which reflected the growing optimism regarding the curability of mental disease. " U n t i l a period comparatively recent," it stated, "insanity has been deemed as an incurable disease. T h e universal opinion has been that it was an a w f u l visitation from H e a v e n , and that no human agency could reverse the judgment by which it was inflicted. During the prevalence of this inauspicious belief, as all efforts to restore the insane would be deemed unavailing, they of course would be unattempted . . . It is now abundantly demonstrated that with appropriate medical and moral treatment

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insanity yields with more readiness than ordinary diseases."" T h i s cheering doctrine had passed beyond the realm of mere theory, the commissioners proclaimed. It was already "established by a series of experiments, instituted from holier motives, and crowned with happier results, than any ever recorded in the brilliant annals of science." W h e r e was their p r o o f ? T h e y triumphantly pointed to the claims advanced by Willis and Burrows, and to the records of the H a r t f o r d Retreat, indicating, cumulatively, that fully 90 per cent of recent cases of mental illness could be cured. N o t e the extreme to which the pendulum of opinion had swung, in its oscillations between pessimism and optimism! T h e Worcester State Hospital was opened in 1 8 3 3 , under the superintendency of D r . Samuel B . W o o d w a r d . In accordance with the recommendation of the M a n n Committee the first patients were drawn largely f r o m the correctional institutions of the state. Simultaneously with the agitation f o r a state hospital in Massachusetts, a similar drive was being pressed in N e w Y o r k . T h e movement in the latter state was initiated by the liberal governor, E n o s T . T h r o o p , in 1 8 3 0 when he recommended in his annual report the appointment of a legislative committee to study the conditions of the insane. T h e legislature complied and, a f t e r a year of investigation, a committee turned in a long and learned report, ending with an urgent plea f o r a state hospital such as the one established in Massachusetts that year. T h e argument of near-perfect curability was again effectively put f o r w a r d , in terms even bolder than in the Massachusetts commission report. Basing its claims on the statements of Willis, Burrows and the H a r t f o r d R e t r e a t — t h i s trinitarian authority was invoked in state a f t e r state by the proponents of mental hospitals— the committee sweepingly declared that every case of mental disease was curable, "unless there be some structural defect, some malcomformation of the cranium or the brain." Knowing the ways of legislators, and the arguments best calculated to sway their judgment, the committee brought f o r w a r d the argument of easy curability not only on humanitarian grounds, but on the even stronger basis of economy.

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A s long as custody rather than cure remained the uppermost purpose of institutionalizing the insane (it was argued) hundreds of mental cases were condemned to life confinement, with no opportunity f o r curative treatment, at the expense of the public treasury. N o w , if these persons were provided with hospital attention their stay in institutions, in a large number of cases, would be greatly shortened. In the long run such a situation would result in considerable savings f o r the state. M o r e o v e r , those discharged recovered f r o m a hospital could thenceforth take their places as producing members of society, with further economic benefits accruing to the state. Condemning the prevalent methods of selling the insane poor at public auction or incarcerating them in jails and in the strong rooms of county almshouses, the committee charged that "the whole system as to pauper lunatics and idiots is radically defective. It makes no provision f o r recovery. It does not effect the best mode of confinement. It does not sufficiently guard the public f r o m the consequences of furious madness. A n d it is the most expensive method of providing f o r them." 4 T h e legislature, however, was slow to respond to the eloquent plea of the committee, supplemented though it was by the repeated recommendations of Governor T h r o o p and his successor, G o v e r n o r M a r c y . Important material factors were involved in the delay, namely, the financial crisis of 1 8 3 4 and the severe economic depression of 1 8 3 7 , which turned the attention of the lawmakers to the problems of raising money rather than spending it on " n e w f a n g l e d projects." It was not until 1 8 4 3 that the first state hospital was finally opened at Utica, with D r . A m a r i a h B r i g h a m as the first superintendent.* In the decade between the opening of the hospitals at Worcester and Utica, nine new public hospitals f o r the mentally ill were opened in various parts of the United States. Seven of these were either state-owned or state-supported institutions. T h e Tennessee Lunatic Asylum at Nashville • " A n A c t to Authorize the Establishment of the N e w Y o r k State Lunatic A s y l u m " w a s passed M a r c h 30, 1836, but the ensuing depression of 1837 delayed its building, and it w a s not completed until 1843.

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w a s established in 1 8 3 2 and opened in 1 8 4 0 . T h e M a i n e Insane A s y l u m at A u g u s t a w a s established in 1 8 3 4 and opened in 1 8 4 0 . T h e V e r m o n t A s y l u m f o r the Insane at B r a t t l e b o r o w a s established in 1 8 3 5 and opened in 1 8 3 6 . T h e Ohio L u n a t i c A s y l u m at Columbus w a s established in 1 8 3 5 and opened in 1 8 3 8 . T h e G e o r g i a L u n a t i c A s y l u m at Milledgeville w a s established in 1 8 3 7 and opened in 1 8 4 2 . T h e N e w H a m p s h i r e A s y l u m f o r the Insane at Concord w a s established in 1 8 3 8 and opened in 1 8 4 2 . In Pennsylvania, the department f o r the insane in the first A m e r i c a n general hospital w a s removed to a site in W e s t Philadelphia in 1 8 4 1 as a separate institution, and w a s renamed the Pennsylvania H o s p i t a l f o r the Insane, with D r . T h o m a s S. Kirkbride appointed as its first superintendent. A l l of these institutions w e r e supported either in whole or in part by the several states, although they differed in important essentials in the matters of funding and administration. T h e state hospitals in Massachusetts, Ohio and N e w Y o r k were built entirely with state funds and administered by state officials. T h e V e r m o n t A s y l u m , the name of which w a s later changed to B r a t t l e b o r o R e t r e a t , w a s originally established through a $ 1 0 , 0 0 0 bequest of M r s . A n n a M a r s h , the state furnishing the additional funds necessary f o r the completion of the institution.* In pursuance of the terms • B e h i n d this bequest lies an interesting tale, s h o w i n g the late s u r v i v a l of the " w a t e r - c u r e " treatment of mental illness. T h e need f o r a mental hospital, it appears, w a s suggested by the death in 1 8 1 5 of R i c h a r d Whitney, a prominent citizen of Vermont w h o became "mentally d e r a n g e d " t o w a r d s the end of his life and w h o w a s attended by several physicians, including the husband of M r s . M a r s h . His treatment is thus described by Brattleboro's historian, Henry B u r n h a m : " A council of physicians . . . decided upon trying, f o r the recovery of M r . Whitney, a temporary suspension of his consciousness by keeping him completely immersed in w a t e r three or four minutes, or until he became insensible, and then resuscitate or a w a k e n him to a new life. Passing through this desperate ordeal, it w a s hoped, w o u l d divert his mind, break the chain of unhappy associations, and thus remove the cause of his disease. Upon trial, this system of regeneration p r o v e d of no a v a i l f o r , with the returning consciousness of the patient, came the knell of departed hopes, as he exclaimed, ' Y o u can't d r o w n l o v e ! ' " A c c o r d i n g to a f o r m e r version of the story, there w a s a second application of the d r o w n i n g process that terminated the l i f e of M r . Whitney. But M r . Hooker . . . lately informed us that M r . W h i t n e y did not pass through a second ordeal by w a t e r ; the physicians, upon mature deliberation, concluded

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of the M a r s h bequest it was at first operated as a corporate institution, but was reorganized in 1 8 4 5 as a state hospital. Georgia's first state hospital was founded through a g i f t of an anonymous "philanthropist f r o m the N o r t h . " In other states, funds were raised partly by private subscription, by state aid and, in some cases, by contributions f r o m localities chosen as sites f o r the proposed hospitals. In N e w Hampshire, f o r example, the state contributed 3 0 shares of N e w Hampshire bank stock, the town of Concord contributed $ 9 , 5 0 0 to secure the location of the asylum within its precincts, and the rest was raised by private donations. Incidentally, the widespread practice of having towns bid against one another f o r the privilege and economic advantages accruing f r o m the choice of site proved a serious impediment to the proper location and construction of mental hospitals built on such terms. It happened all too frequently (as in the case of the N e w H a m p s h i r e State A s y l u m ) that a mental hospital would be located in a certain town, not because it offered a salubrious or otherwise advantageous site f o r such an institution, but merely because it pledged a greater sum toward the erection of the hospital than any other town. A very unfortunate feature of most of the institutions reared during this period was their cheap and inferior construction. Usually, the building of state institutions was largely controlled by economic considerations. In the desire to keep expenses down to an absolute minimum, essential details of construction and equipment were disregarded. A t times the low quality of hospital buildings was attributable to overzealous friends of the insane who, in submitting appeals and plans f o r new hospitals, presented ridiculously low estimates of cost f o r f e a r that adequate estimates would deter the legislators f r o m taking f a v o r a b l e action. A poor institution f o r the insane, they believed, was they w e r e on the right track, but had not used the proper agent f o r the stupefaction of the l i f e forces. T h e next and last resort w a s opium, and M r . Whitney died under the treatment." ( H e n r y B u r n h a m , Brattleboro, Windham County, Vermont. Brattleboro, 1880. 1 9 1 pp., p. 78.)

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better than none at all. Furthermore, they often harbored the secret hope that once the ground was broken the state would not be backward in adding to the original appropriations a sum sufficient to assure adequate standards. These men sensed that when proposals f o r new institutions were being discussed by public officials and legislators the usual determining factor was not how well, but how cheaply, the job could be done.* Another reason underlying the generally poor construction of institutions f o r the insane was implicit in the prevalent opinion that, since most state hospitals were intended primarily f o r pauper and indigent patients, the poorest possible accommodations were quite good enough f o r them. T h e result was that buildings were often hastily reared, with important therapeutic aids overlooked, and resembled barracks or poorhouses rather than hospitals f o r the mentally ill. N o t that the zeal f o r economy was in itself a necessarily retrogressive f a c t o r : it was the extreme to which that zeal was carried that made poor construction inevitable.t T h i s overemphasis on economy was thus described by one of the foremost mid-century psychiatrists, D r . Isaac R a y : I t is regretted that the movement [ t o induce states to build mental hospitals] has been too much controlled by economical considerations . . . T o meet this spirit, estimates of cost have been too l o w , and, consequently, points have been sacrificed that w e r e absolutely necessary to the perfect attainment of the object. H e n c e ensued lame and unsatisfactory results calculated to discourage the benevolent and to fill the ignorant w i t h suspicion and distrust. O f course, in undertakings of this kind, economy is not to be disregarded, but w h e n allowed to frustrate or m a r an important end, it is no longer a virtue. 5 • I t is a significant commentary on this subject that the architect who planned and designed the Ohio State Insane Asylum (now the Columbus State Hospital) received f o r his labors the magnificent r e w a r d of $35. f O d d l y enough, this period of penny-pinching w a s followed a generation later by a swirl of wild extravagance, noticeable particularly in the northeastern states. Huge sums w e r e appropriated f o r mental hospitals. Unfortunately, the greater part of these outlays w a s used to line the pockets of politically wise contractors and to build ostentatious, heavily ornate façades in the Victorian tradition, with little thought given to suitable interiors or to utility in general. Such public hospitals came to be known as " p a u p e r palaces" and "lunacy cathedrals."

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Of the Worcester State H o s p i t a l , which was highly praised f o r its unusual distinction of having been erected within the limits of the original appropriation, and which was widely followed as a model f o r mental hospitals, D r . R a y r e m a r k e d : " B e i n g intended f o r the poorer classes, it was unwisely concluded that every subordinate object might be disregarded, provided the principal one—the custody of the patient—were secured. It was the first considerable example of cheap construction, and one, unfortunately, which building-committees have been too ready to imitate." Besides institutions built by the state, two municipal hospitals f o r the mentally ill—the first of their kind in America — w e r e built during this period, one at Boston and the other at N e w Y o r k . * T h e Boston Lunatic Hospital was established in 1 8 3 7 and opened two years later, in accordance with a legislative statute of 1 8 3 6 , directing the several counties in Massachusetts to maintain "within the precincts of the [county] H o u s e of Correction a suitable and convenient apartment or receptacle f o r idiots and lunatics, or persons not furiously m a d . " T h i s act grew out of the realization that the Worcester State Hospital could provide f o r only a small fraction of the mentally ill, and that some sort of provision must be quickly made f o r the growing numbers of insane poor who could not be admitted or maintained at the sole state institution. Only three counties—Middlesex, Suffolk and Essex—complied with the statute to the extent of building separate receptacles f o r the mentally ill. T h e county asylum at Middlesex was soon abandoned; the Suffolk County institution, located in South Boston, was turned over to the city, its name being changed to the Boston Lunatic H o s p i t a l ; the Essex County Receptacle f o r the Insane, at• B e f o r e this time, there had been municipal " a s y l u m s " connected with local poorhouses, as at Charleston, S. C., Baltimore, M d . , P h i l a d e l p h i a ( " O l d B l o c k l e y " ) , etc. T h e s e , h o w e v e r , w e r e merely extensions of the almshouse departments—sometimes separate buildings, more often only w a r d s of w i n g s p r o v i d i n g a minimum degree of classification between the mentally ill inmates and the others. T h e institutions opened in Boston and N e w Y o r k in 1839 w e r e the first of their kind to merit the distinction of mental hospitals, h a v i n g been built expressly f o r that purpose.

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tached to the local house of correction, remained for many years the only county institution of its kind. Like the Boston institution, the New York Lunatic Asylum was opened for the reception of patients in 1839. Its beginnings may be traced back to 1826, when separate wards for mentally ill paupers were provided by the city at Bellevue Hospital, then known as "the great pauper institution" of the metropolis. By 1835 the number of pauper insane in New York City had increased to such an extent that the accommodations at Bellevue proved hopelessly inadequate. It was found necessary to provide a structure for this class apart from the hospital. Blackwell's Island in the East River was chosen as a site, and the new city asylum was opened there in 1839. It may be remarked, in passing, that Charles Dickens, in his historic tour of the United States in 1842, visited both the Boston and New York asylums. His impressions are recorded in the American Notes, a book that set the American public aflame with resentment against what was considered "British snobbishness" on the part of its author. For the Boston institution he had naught but the highest praise; of its New York counterpart he painted a dismal and disheartening picture. Dickens, who made many a careless, and often amusing, slip in his notes, which were written as he ran, referred to the Boston Lunatic Hospital as "the State Hospital for the Insane." Comparing it with the best pauper asylums in England, he characterized the hospital as "admirably conducted on those enlightened principles of conciliation and kindness which twenty years ago would have been worse than heretical."® In view of his generally critical attitude towards American institutions, this praise from Dickens was considered praise indeed. But how differently he described the New York asylum! During his stay in the metropolis, he tells us, he "paid a visit to the different public institutions on Long Island or Rhode Island." A slight error may be noted here : the distinguished but geographically-confused visitor was of course referring

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to Blackwell's Island I H e r e is the Dickensian description of the newly opened lunatic asylum : I cannot say that I derived much comfort from the inspection of this charity . . . I s a w nothing of that salutary system which had impressed me so favorably elsewhere; and everything had a lounging, listless, madhouse air which w a s very painful. T h e moping idiot, cowering down with long, dishevelled hair; the gibbering maniac, with his hideous laugh and pointed finger ; the vacant eye, the fierce wild face, the gloomy picking of the hands and lips, with munching of the nails: there they were all, without disguise, in naked ugliness and horror. In the dining-room, a bare, dull, dreary place, with nothing for the eye to rest on but the empty walls, a woman w a s locked up alone. She was bent, they told me, on commiting suicide. If anything could have strengthened her in her resolution, it would certainly have been the insupportable monotony of such an existence. 7

T h e general confusion characterizing the construction and management of institutions f o r the mentally ill during this period was reflected in the methods of reporting statistics on recovery rates and other matters. T h e science of statistics was still in its infancy, and its application in the various fields of social phenomena was generally of a crude character. T h e excellent pioneering work of Esquirol (the worthy successor of Pinel at the Salpêtrière in P a r i s ) was particularly effective in demonstrating the value of tabulating mental hospital records. T h e r e was, at first, a great deal of stubborn opposition to the introduction of statistical reporting. M a n y asylum superintendents ridiculed the idea. It was utter nonsense to attempt any kind of "enumeration," they felt. Some authorities based their opposition to statistical reporting on the quite reasonable grounds that real knowledge concerning mental diseases—classification, causes, symptoms, cures, etc.—was still so meagre that no degree of accuracy could be attained through the use of statistical recording. In fact, they said, such reporting could only create misleading impressions. (This actually proved to be the case.) A heated controversy on this score was carried on throughout the 1 8 4 0 ' s , with Pliny E a r l e leading the statistical defenders. In an article published in 1 8 4 9 , D r · E a r l e

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v i g o r o u s l y championed the use of enumeration against the attacks of sceptics. A d m i t t i n g the p r e v a i l i n g weaknesses in statistical r e p o r t i n g on the p a r t of A m e r i c a n institutions, he wisely counseled that it w a s necessary not to abolish the practice, but to raise it to a really scientific level. 8 A glance at the records emanating f r o m mental hospitals during the p e r i o d under discussion explains much of the pessimism as to the utility of statistics in this field. Institutional tabulations w e r e g e n e r a l l y v a g u e , contradictory and w o e f u l l y lacking in either u n i f o r m i t y o r precision of d a t a . T a k e the tables of " C a u s e s " of mental cases, which naturally occupied a prominent place in c o n t e m p o r a r y case reports. In the tabul a t e d r e p o r t of a f a m o u s institution, the ailments of five different mental patients w e r e respectively attributed to " d o mestic t r o u b l e , " " j e a l o u s y , " "infidelity of w i f e , " "illtreatment of p a r e n t s , " and " a b u s e of h u s b a n d . " T h e s e blurred distinctions, it will be a g r e e d , w e r e h a r d l y calculated to t h r o w light on the individual cases. In some tables, the laconic etiological note, " d i s a p p o i n t m e n t , " w a s conveniently used to c o v e r a multitude of ills. O t h e r s , with a g r e a t e r attention to detail, but with hardly less confusion, laboriously enumerated the v a r i o u s types of " d i s a p p o i n t m e n t s " reg a r d e d as the determining causes in m a n y cases of mental illness: " d i s a p p o i n t e d l o v e , " " d i s a p p o i n t e d a f f e c t i o n , " " d i s appointed a m b i t i o n , " " d i s a p p o i n t m e n t in business," " f r u s t r a t e d e n t e r p r i s e , " etc. E v e n the term " d i s a p p o i n t e d expect a t i o n " was entered as a supposed cause. A m o n g other v a g u e " c a u s e s " listed in c o n t e m p o r a r y statistics w e r e : "ecclesiastical difficulties," " m e n t a l excitement," " m o r t i f i e d p r i d e , " " p e r p l e x i t y in investigating scriptural p r o p h e c i e s , " " n o v e l reading," "tobacco," "ill health," "repelled eruption," " b l a s t e d p r o s p e c t s , " " d r e a d of a f u t u r e s t a t e , " " c l o s e mental a p p l i c a t i o n , " and " M i l l e r i s m . " * • " M i l l e r i s m " w a s the popular name g i v e n to the doctrines of W i l l i a m M i l l e r , w h o founded the A d v e n t i s t sect in 1 8 3 1 . M i l l e r predicted, that the y e a r 1843 would witness the end of the world and the commencement of the millennium. His prediction gained a remarkably w i d e circulation and acceptance, and many suicides w e r e attributed to the terror induced by belief in its inevitable fulfillment. It undoubtedly w a s a precipitating factor in many cases of mental illness. In one y e a r , 1843 (the y e a r which M i l l e r had prophesied

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A n o t h e r interesting feature found in early mental hospital statistics is an exaggerated emphasis on quantitative data. In general, this insistence on the importance of quantitative analysis was to exert a healthy influence. But in some instances it was carried to strange extremes. F o r example, the first annual report ( 1 8 4 3 ) of the Utica State Asylum contains a table intended to serve as conclusive proof of the health-promoting effects of the institution, scrupulously measured in terms of masses. W e present a specimen item f r o m this table : Total weight on admission of 276 patients 34,856 lbs. " " of those discharged and remaining, December ist 351825 " Increase in weight of all received Total increase in weight of the 53 patients discharged cured

1,029 " 306

"

Still another indication of the prevailing looseness and confusion in statistical reporting may be mentioned. In 1 8 4 4 , D r . J . R . Allen, a desecvedly well-known superintendent of the Eastern Lunatic Asylum at Lexington, Kentucky, set himself the ambitious task of compiling the statistics of the institution f o r the first twenty years of its existence. A f t e r listing an impressive percentage of patients " c u r e d " during this period, D r . Allen naively remarked that a large proportion of these " c u r e s " were not actually so registered on the books, but that he had reported them " r e c o v e r e d " because there was no record of their condition at the time they were discharged! Shocking though this might be to modern statistical standards, it constitutes but a mild indication of the liberties taken with figures during the heyday of the curability cult. W e have traced, previously, the origin and early development of the cult of curability f r o m Willis to the 1 8 2 7 report w o u l d w i t n e s s the d e s t r u c t i o n of the u n i v e r s e ) , no less t h a n 3 2 p a t i e n t s a d m i t t e d into three d i f f e r e n t N o r t h e r n institutions w e r e o f f i c i a l l y r e c o r d e d a s v i c t i m s of " M i l l e r i s m . "

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of the H a r t f o r d Retreat, given wide publicity through the rather extraordinary medium of a light travel book written by a retired British naval officer. T h e pleasing belief in easy curability which consequently took hold of the popular imagination was strengthened with the years as statistical reports seemed to prove that other institutions f o r the insane were not only equalling but actually surpassing the H a r t f o r d Retreat record of 90 per cent cures. In fact, the climax was not reached until the claim of 1 0 0 per cent cures was finally advanced by at least two eminent superintendents of mental hospitals 1 T o what may we attribute these remarkable records, besides which our modest present-day claims of an average of about 15 per cent recoveries in institutionalized mental cases compare like candles to the sun? Is it because mental diseases were then of a less serious nature than they are today, and more amenable to treatment? Or was the system of therapeutics practiced in that period superior to present-day methods? H a r d l y . Where, then, may we properly seek an explanation of the phenomenal records of cures rolled up in the decades following 1 8 3 0 ? Mainly, I think, in these directions: ( 1 ) the irresponsible, artless manner in which statistics on the subject were compiled; ( 2 ) the peculiar set of circumstances which encouraged institutional officers to perpetuate a fallacy of which many were conscious; ( 3 ) the convenient use of the term "recent" cases (meaning cases of anywhere from three to twelve months duration), upon which most generalizations regarding curability were based; ( 4 ) the confused notions as to the meaning of the word "recovery." E v e n today, the latter term when applied to mental diseases, necessarily lacks the precision that it connotes in most physical diseases. In the middle decades of the nineteenth century, many superintendents of mental hospitals waited only f o r a temporary return to "sanity" on the part of a patient to discharge him as "cured," and to record him accordingly. L e t us pursue the interesting history of the cult of curability subsequent to the Basil H a l l incident. A s has been noted, the record of the H a r t f o r d Retreat was brought for-

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ward by the friends of the insane in many states as a major argument in f a v o r of establishing mental hospitals. T o the legislators it proved an impressive point: obviously, great savings would result in building a hospital where the mentally ill could be cured easily and rapidly, instead of placing them in non-curative institutions where they would most likely remain heavy burdens on the public purse f o r life. Once such a hospital was built, the superintendent was expected to emulate the achievements in high-recovery rates which had been so vociferously brought f o r w a r d b e f o r e its founding, or to face severe criticism and perhaps discharge. Such was the case with the Worcester State Hospital, the first to be erected in the 1 8 3 0 ' s . It was no accident that the Massachusetts authorities cast their eyes in the direction of the H a r t f o r d Retreat in seeking a suitable head f o r the new institution. T h e i r choice fell first on D r . E l i T o d d , superintendent of the Retreat, who was forced to decline the offer because of ill health. ( D r . T o d d died in 1 8 3 3 . ) D r . Samuel B . W o o d w a r d , active in the founding and management of the Retreat, was then appointed. T h i s proved to be a fortunate choice. F r o m his ascendancy to the head of the Worcester institution to his retirement in 1 8 4 6 , D r . W o o d ward was generally regarded, both at home and abroad, as the leading American authority on mental diseases. Statistically, however, the attempt to emulate the H a r t f o r d Retreat record of cures got off to a poor start in the first year. E v e n with some loose handling of statistical data, the institution's first annual report showed less than 50 per cent recoveries of recent cases in relation to admissions. T h e hospital authorities expressed their apologies f o r this supposedly low proportion of cures, explaining it on the grounds that many incurables had been transferred f r o m jails and poorhouses to the institution during the first year. In the second year, however, the officers found an ingenious device f o r stepping up the statistics of recovery to a respectable level. T h e y adopted the simple but quite effective expedient of calculating the percentage of cures, not on the basis of the total number of patients admitted during the year, but

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of the total discharged. Thus, they were able proudly to declare in their annual report to the legislature : D u r i n g the past year 1 1 9 patients have been received into the hospital ; of these, fifty-five were old cases, and sixty-four, recent ones. In the same period 1 1 5 have been discharged; of these, forty-nine were old cases and sixty-six recent ones. O f those discharged, sixtyfour were cured . . . T h e cures amount to 5 s f á per cent . . . O f the forty-nine old cases discharged during the year, ten have been cured, sixteen improved, fourteen are stationary, four have died, and one has eloped—the cures amounting to 2 0 ^ per cent. O f the sixty-six recent cases, fifty-four have been cured, six improved, two stationary, and four have died—the cures amounting to 8234 per cent.9 (Emphasis m i n e — A . D . )

This method of computing the percentage of cures on the basis of discharges instead of admissions naturally resulted in figures bound to impress. Average cures amounting to more than 55 per cent, and cures of recent cases to more than 82 per cent, compared very favorably even with the vaunted H a r t f o r d Retreat. They overshadowed by f a r the more cautiously compiled records of eminent European institutions, and the authorities were not backward in pointing out this element of apparent superiority in their report. Of course, they conveniently neglected to explain the different techniques employed in arriving at these ratios. The observant eye, to be sure, could apprehend the unorthodox tabulating devices of the Worcester Hospital, but to the untrained and casual general reader the proportion of cures claimed was accepted at its face value. During the next few years, the recovery percentages at Worcester mounted steadily until, in 1840, D r . Woodward announced that the cures in recent cases (in proportion to the total discharged) had reached the awe-inspiring point of 90 per cent. The belief, based on the reports of cures of recent cases, that insanity was easily curable if treated early enough, rapidly impressed itself on the public and professional mind and soon reached the plane of established, immutable dogma. But what of the psychiatric profession as a whole?

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Did it raise any objections to the spread of this fallacy? On the contrary : except for a very few instances, it not only subscribed wholeheartedly to the current misconceptions but stimulated and strengthened them as best it could. L e t us cite a few representative opinions from the most eminent medical superintendents of the day as an indication of the lengths which the delusion reached. A s early as 1 8 3 5 , D r . Woodward made this categorical statement, which was widely quoted for many years a f t e r : " I n recent cases of insanity, under judicious treatment, as large a proportion of recoveries will take place as from any other acute disease of equal severity."* T w o years later D r . Amariah Brigham, who soon after became the first superintendent of the Utica State Asylum, declared in an article appearing in the North American Review: " I t is gratifying to be able to state that no fact relating to insanity appears better established than the general certainty of curing it in its early stage." Quite as optimistic was the declaration of D r . Luther V . Bell, head of the McLean Asylum in Massachusetts, who, in his annual report for 1840, averred: " T h e records of this Asylum justify the declaration that all cases, certainly recent—that is, whose origin does not, either directly or obscurely, run back more than a year—recover under a fair trial. This is the general law; the occasional instances to the contrary are the exception." Even the famous superintendent of the Pennsylvania Hospital for the Insane, D r . Thomas S. Kirkbride fell victim to the infectious cult of curability. In his report for 1842 we find this grave assertion: " T h e general proposition that truly recent cases of insanity are commonly very curable, and that chronic ones are only occasionally so, may be considered as fully established." Dr. Pliny Earle, who later did more to explode the curability fallacy than any other individual, wrote in his report for • E i g h t years later, D r . W o o d w a r d ' s optimism r e g a r d i n g curability progressed sufficiently to permit him to go even beyond this comparison. In his annual report f o r the W o r c e s t e r Hospital in 1843, he states: " I think it not too much to assume that insanity, unless connected with such complications [epilepsy, paralysis, or g e n e r a l prostration of health], is more curable than any other disease of equal s e v e r i t y ; more likely to be cured than intermittent f e v e r , pneumonia, or rheumatism." ( E m p h a s i s m i n e — A . D . )

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1 8 4 5 as attending physician of the Bloomingdale Asylum in N e w Y o r k : " W h e n the insane are placed under proper curative treatment in the early stages of the disease, from 75 to 90 per cent recover."* T h e significance of these quotations is enhanced when we realize that all those we have cited were among the founders of the American Psychiatric Association, organized in 1 8 4 4 ; that they were all prominent in their profession; and that their views were substantially endorsed by all their contemporaries in America. In some of the general declarations of easy curability advanced by medical superintendents, cautious qualifications appeared, but even in such instances the qualifying words were lost on the general reader whose attention was usually focussed on the high-percentage recovery figures to the exclusion of all else. Meanwhile, institutions f o r the insane continued to engage in a fierce, if concealed, rivalry with one another in setting up impressive recovery tables. H i g h e r and higher rose the claims of cures, reaching fantastic heights, even dwarfing the claims of Willis and Burrows and the record of 1 8 2 7 which had suddenly catapulted the H a r t f o r d Retreat into world prominence. Well into the 90's soared the percentages of cures claimed in recent cases. It only waited f o r some enterprising superintendent to ring the bell at 100 per cent. In his 1842 report as head of the Eastern Asylum f o r the Insane at Williamsburg, Virginia, young D r . John M . Gait made a conditional claim to this ultimate result. Of thirteen cases of recent insanity which had been admitted to the institution during the preceding year, he declared, twelve, or 92.3 per cent of the total, had been discharged cured. T h e thirteenth patient had inconsiderately died, apparently causing the hospital to fall just one short of the perfect goal. But with the characteristic intrepidity of the time, our youth• I n his first report as medical head of the Bloomingdale A s y l u m ( 1 8 4 4 ) D r . E a r l e had w r i t t e n : " I t appears to be satisfactorily proved that, of cases in which there ¡9 no eccentricity or constitutional weakness of intellect, and when the proper remedial measures are adopted in the e a r l y stages of the disorder, no less than eighty of e v e r y hundred a r e cured. T h e r e are but f e w diseases f r o m which so l a r g e a percentage of the persons attacked a r e restored."

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ful superintendent was resolved not to let this factor stand as a serious obstacle in the way of the perfect score. With disarming naïveté, he dismissed the demise in this fashion : " I f we deduct this case from those under treatment, the recoveries will amount to 100 per cent!"* Carried away by the achievement thus obtained, he concluded: " F r o m such facts as the above, I am led to believe that there is no insane institution, either on the Continent of Europe, in Great Britain or in America, in which such success is met with as in our own." However, this remained a conditional record. The maximum unconditional claim was yet to be pronounced. It was not long in forthcoming. In the very next year, 1843, Dr. William M . Awl of the Ohio State Lunatic Hospital at Columbus announced the attainment of the ne plus ultra in a laconic finale to his statistical report: " P e r cent of recoveries on all recent cases discharged the present year, 100." Note the fact that here, as in the case of Woodward of Worcester, the ratios are based on discharged cases, and not on admissions. Howbeit, the record advanced by Dr. Awl, the distinguished head of the Ohio institution, gained him the sobriquet, among contemporary wits, of " D r . CureAwl." By this time, however, voices of protest were beginning to be raised against the excesses of the cult of curability. These voices were feeble and cautious at first, but gained strength and numbers with the passage of time. Dr. Isaac Ray, in his first report as superintendent of the Maine Insane Asylum in 1 8 4 1 , voiced his dissatisfaction with the misleading and wholly arbitrary practice of separating the mentally ill into "recent" and " o l d " cases, a practice which formed one of the main pillars in the structure of mathematical curability. " I have adopted this classification," he said, "in deference to the practice now somewhat common • D r . G a i t w a s b y no m e a n s l a c k i n g in p r e c e d e n t f o r m a k i n g this d e d u c t i o n f r o m h i s c o m p u t a t i o n s . I t w a s not u n u s u a l f o r i n s t i t u t i o n a l h e a d s to p u t a s i d e t h e d e a d in figuring the p r o p o r t i o n s of c u r e s , in o r d e r to g i v e t h e i r s t a t i s t i c s a m o r e i m p r e s s i v e d r e s s i n g . C a r r i e d to its u l t i m a t e c o n c l u s i o n , this p r a c t i c e w o u l d p e r m i t institutions l i s t i n g o n e r e c o v e r y a n d n i n e t y - n i n e d e a t h s out of 1 0 0 reccnt c a s e s to c l a i m 1 0 0 p e r cent c u r e !

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in N e w England hospitals ; but I must be allowed to express my conviction that the distinction is without any precise, well-marked difference, and had better be abandoned." In his next report he added: "Nothing can be made more deceptive than statistics; and I have yet to learn that those of insanity form any exception to the general rule." So strong, however, was the current of the curability mania that D r . R a y felt constrained to swim along with the tide as f a r as his statistical reports were concerned, employing under protest the methods of his contemporaries in achieving high recovery rates. About 1850, a number of critics of the prevailing statistical fallacies arose among asylum superintendents. Prominent among these early protestants were D r . J a m e s Bates, successor of R a y at the Maine Insane Asylum, D r . S. Hanbury Smith of the State Asylum at Columbus, Ohio, and D r . Andrew M c F a r l a n d of the N e w Hampshire Asylum at Concord. In 1845, D r . John Thurnam, resident medical superintendent of the Y o r k Retreat in England, published a book entitled Observations and Essays on Statistics of Insanity, wherein he came to rather gloomy conclusions regarding the curability of mental diseases. Basing his remarks on a study of case histories of 244 persons treated at the Y o r k Retreat, he formulated this generalization: I n round numbers, of ten persons attacked b y insanity, five recover and five die, sooner or later, d u r i n g the attack. O f the five w h o recover, not m o r e than t w o remain w e l l d u r i n g the rest of their l i v e s ; the other three sustain subsequent attacks, d u r i n g w h i c h at least t w o of them w i l l die.

T h i s conclusion, based on painstaking statistical research, had a chastening effect on institutional "enumeration" not only in Great Britain (where the tendency to exaggerate recovery rates also prevailed, though to a lesser extent) but in the United States as well. Superintendents began to tone down curability statistics, or to drop them f r o m their reports entirely. ( D r . Kirkbride of the Pennsylvania Hospital was among the first to adopt the latter course.) T h e cult of curability, which had reached its peak between 1 8 4 0

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and 1 8 5 0 , experienced a gradual deflating process. T h e pendulum began to swing back to the opposite extreme. So f a r backward did it swing, in fact, that D r . Luther Bell, whose confident belief in 90 per cent curability we have quoted, expressed this radically different point of view in 1 8 5 7 : " I have come to the conclusion that when a man once becomes insane, he is about used up f o r this w o r l d . " T h e curability cult lingered on f o r many years, however. T o D r . Pliny E a r l e , who was one of its early devotees, must be given the credit f o r dealing the fallacy its deathblow. Possessing an inquisitive and thoroughgoing turn of mind, D r . E a r l e began to question the validity of contemporary statistics on curability. H i s doubts deepened with time, and finally led him to enter upon a comprehensive study of the matter. H e spent years of intensive research, going f a r beyond the limits of D r . Thurnam's work. T h e complete records of many American institutions f o r the insane were carefully combed by the indefatigable E a r l e . T h e first results of his many years of investigation were published in the annual report of 1 8 7 5 f o r the Northampton State Hospital in Massachusetts, of which D r . E a r l e was then superintendent. Additional installments appeared in later reports, and were finally gathered together in a book, The Curability of Insanity, published in 1887. 1 0 T h e revelations contained in these studies had a profound and healthy influence on the subsequent course of statistical reporting in American mental hospitals. A major factor in the apparently high ratio of cures in institutions f o r the insane, D r . E a r l e found, lay in the abuse of the word " r e c o v e r e d , " and in the failure to distinguish properly between the words " c a s e , " "patient," and "person." In many instances, the same person was discharged " r e c o v e r e d " f r o m an institution a number of times within a f e w years, or even in the space of one year. In the statistical reports of the time, the reader was given no intimation that the same person might appear as several "recovered cases" in the record. Thus, E a r l e relates, one woman was discharged recovered six times at the Bloomingdale Asylum, and another seven times at the Worcester Hospital, each

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within the space of one year. Incidentally, the woman who contributed six " r e c o v e r i e s " to the record of Bloomingdale in one year was reported cured no less than fortysix times before her death—which took place in an insane asylum I D r . E a r l e also discovered that the obliging woman who recovered seven times in one year f o r the greater glory of Worcester had been discharged as cured nine times in the two preceding years, making sixteen recoveries in three years. T h e records of other institutions were replete with similar cases. In five asylums the records of which were examined by D r . E a r l e , forty persons were reported cured no less than 484 times, averaging more than twelve recoveries each. T h r e e women alone were admitted as patients into mental hospitals an aggregate of 1 1 8 times, and were discharged recovered, and placed in the records as such, 1 0 2 times. T w o of these finally died insane. In one institution, seven women were reported recovered a total of ninety-two times. Naturally, the uninitiated reader took it f o r granted that the number of cases was identical with the number of persons admitted, and since the statistics were very seldom accompanied by explanations pointing out this vital difference, he readily fell victim to the fallacy. N o wonder that the English medical superintendent, Sir J a m e s Coxe, in discussing institutional statistics on the insane, wrote of "that spirit of inflation which is a too prevalent characteristic of writers of this branch of medicine." N o wonder that the American, D r . J a m e s Bates, dryly noted that "they [statistical reports of cures] were received with wondrous admiration by that portion of the public who are better pleased with marvellous fiction than with homely truth." But the myth of easy curability lasted long and died hard. Its tenacious survival is indicated by the fact that, when D r . E a r l e began publishing his epochal studies on recovery statistics in 1 8 7 5 , most establishments f o r the mentally ill in America still subscribed to the hypothesis that insanity was easily curable. H i s findings were bitterly attacked (with more emotion than reason) by many of his contemporaries, including some leading medical superintendents. T h e wealth

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of evidence he brought forward, based on years of exhaustive research, created an impregnable wall of proof. But this fact did not save Dr. E a r l e from the calumnies of men who found offense in conclusions tending to destroy a convenient, comfortable and long-standing hypothesis, erroneous though it may have been. Once the cult of curability was dealt its death-blow, however, a period of reaction set in, the unfortunate effects of which are still observable today. Disillusioned, the public cast off the cloak of false optimism that had been woven with the warp of error and the woof of short-sighted opportunism. Instead, popular opinion respecting the curability of insanity became mantled in extreme pessimism. And long a f t e r a real basis for optimism was established with the firm materials of scientific knowledge, the ancient saying, temporarily discarded during the curability craze, once more echoed a dominant attitude: "Once insane, always insane 1"

CHAPTER

IX

Dorothea Lynde Dix—Militant Crusader A N A winter's day in the year 1841, a young theological ^ ^ student knocked hesitantly at the door of the home of Miss Dorothea Lynde Dix in Boston. H e was ushered in. Embarrassed, he stood in the presence of Miss Dix, quietly dominant, a retired school teacher nearing forty, her ravenblack hair combed back and knotted. T h e young man immediately plunged into the business that had brought him to her house. His class at the seminary had been assigned Sunday-school instruction at the East Cambridge jail, and he had been chosen to conduct a class among the women inmates. H e felt unsuited to the task, too self-conscious. His mother had advised him to solicit Miss Dix's counsel. A f t e r pondering for a few minutes, Miss Dix replied with quiet decisiveness: "I will take them myself." The bewildered theologue protested, but in vain. The next Sunday found Miss Dix at the East Cambridge jail. She was shocked by the filth and dirt, the evidences of negligence and brutality, that she saw all about her. Particularly did she notice the presence of insane persons locked up in cells. W h a t were they doing here, these innocents, in a place intended not for cure or even for care, but for punishment? It was the dead of winter, yet no warmth at all was provided for these insane inmates. They lay huddled in their unheated cells, the cold piercing them like knives. T o most others, the sight might bring a sigh of sympathy and a shrug of impotency: no more. But this woman was made of rarer stuff. She raged at the denial of elementary shelter to the insane. She approached the keeper and demanded that heat be immediately supplied to the helpless inmates. 158

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T h e answer was contemptuous: " T h e insane need no h e a t . " ( T h e myth that the insane are insensible to extremes of heat or cold was widespread.) With characteristic thoroughness, Miss D i x carried the issue to the E a s t Cambridge court. H e r petition was granted; the insane got heat. A rather trivial incident, this, but it marked the beginning of a long crusade without parallel in American annals. It transformed a retired N e w England school teacher, seemingly fated to go through life silently and unknown, into a fiery, world-famous standard bearer in a unique cause. F o r forty years thereafter she journeyed through the land, this apostle of the insane, spreading the gospel of humane treatment f o r the mentally ill. She built, instead of churches, hospitals where lost minds might find regeneration. A t the end of her unusual career she left more than thirty mental hospitals in her native land and abroad, founded or enlarged as a direct result of her personal efforts—majestic monuments to her crusading genius. World-renowned in her own time, it is surprising that this woman, one of the most remarkable America has produced, is hardly known to her countrymen of the present generation. Little is known of M i s s Dix's early years. T h e cloak of obscurity which she tried desperately to throw over this period of her life indicates its unhappy character more eloquently than the minutest detail could. " I have never known childhood 1 " she once exclaimed. A n d the f e w recorded facts concerning her child life give meaning to that bitter cry. She was born A p r i l 4, 1 8 0 2 , at Hampden, Maine, her parents removing to Worcester, Massachusetts, while she was yet an infant. H e r father seems to have been a ne'erdo-well—shiftless, poverty stricken and irresponsible. H e was fanatically religious, with a penchant f o r writing theological tracts in fits of "inspiration," pointing the way of salvation to an indifferent world. T h e dull, tiresome task of stitching and pasting these fanatical tracts was assigned to Dorothea and the other children, while father Dix waited f o r further messages f r o m God. T o a nature as intense, lifeloving and sensitive as Dorothea's, the stifling, joyless

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atmosphere in the Dix household became increasingly intolerable. At twelve, unable to endure it any longer, she ran away to her grandmother's home in Boston, where M a d a m Dix dwelt in fairly comfortable circumstances. H e r e she received none of that warm understanding and companionship her hungry soul craved, and f o r the want of which she had run away. Instead, during the next two character-forming years, Dorothea was subjected to a rigorous Spartan discipline that must have seared the soul of the sensitive girl, but proved invaluable in steeling her f o r her destined work. M a d a m Dix had stern ideas about one's diligence to duty. In her Puritan mind, all life was summed up in that one w o r d — D u t y . She regarded the least manifestation of emotion as an unmistakable sign of moral weakness, and did her utmost to stamp out every trace of it in her granddaughter. Besides, she saw in Dorothea one of Saturday's children, who was fated to work her own way through life. Let other girls indulge in time-wasting fancies and recreations: this one was marked f o r heavy burdens, and a sense of realism dictated that she be prepared to assume them as soon as possible. And so, scarcely had she come into her 'teens than maturity was precipitated upon her. If she had never known childhood, neither was she ever to know the glamor of adolescence except f o r a few stolen moments, hastily snatched. A t fourteen D o r o t h e a returned to Worcester, where she opened a school f o r little children. T o affect a grown-up appearance, the child-teacher took to wearing long skirts, long sleeves, and other outward signs of maturity. These trimmings proved superfluous, however. As her biographer Tiffany points o u t : "She bore the stamp of authority f r o m the start. Herself brought up in a stern school, she had at that date little idea of any government but the government of the will. Indeed, it is always characteristic of very young people, abruptly forced to play the role of maturity and experience, that they overdo things. . . . Thus, the impression left on the minds of the little girls and boys in Worcester by their fourteen-year old teacher, so f a r f r o m being that of a half-grown girl they could trifle with, was that of

Courtesy

of Houghton

DOROTHEA LYNDE DIX

Mifflin

Company

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1

one of whom they stood in f e a r . " H e r e was a nature born to rule—strong, imperious, assertive—revealing itself at this early date with perfect clarity. Unfortunately, the severe regimen she imposed proved unbearable to her pupils. One by one they dropped out: this first venture ended in dismal failure. U p o n the collapse of her enterprise, Dorothea returned to her grandmother's, where she continued her education under the same Spartan auspices as before. In a f e w years she felt prepared to resume her pedagogic career, and opened a school f o r older pupils in Boston. In this project she was markedly successful. Soon the Dix mansion itself was converted into a combined day and boarding school presided over by Dorothea. Although frail and sickly, she seemed to possess an unlimited supply of energy. She was an indefatigable worker—frequently up before dawn to commence her varied and arduous tasks, and keeping at them until the midnight hour. T o her combined duties of boarding-school administrator and teacher, head of a household, and mother to her two younger brothers (whom she had taken under her protective wing at the Dix mansion), she added a charity school, conducting classes f o r poor children in a converted barn.* M i s s D i x must have gained quite a reputation as an educator, f o r soon the leading families in Boston were sending their children to her school. In 1 8 2 7 D r . William E l l e r y Channing, one of the most influential figures in that cultural movement in N e w England which was featured by the rejection of narrow Puritanism and the introduction of a new humanism in American thought, invited her to tutor his children during the summer months. T h e offer was accepted and f o r several years she spent her summers in the stimulating atmosphere of the Channing household. D r . Channing was a noble and inspiring humanitarian, and f o r him M i s s D i x conceived an admiration and respect closely bordering on hero worship. H i s lofty ideals of service to his fellow men did much to awaken her own latent impulses, and helped • F r e e p u b l i c schools w e r e almost non-existent at that t i m e : p o o r c h i l d r e n w e r e w h o l l y d e p e n d e n t f o r e d u c a t i o n on p r i v a t e l y o p e r a t e d c h a r i t y schools.

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g i v e direction to the career she eventually f o l l o w e d . T h e influence of D r . C h a n n i n g ( a n d the movement with which he w a s identified) w a s undoubtedly g r e a t . U n t i l 1 8 3 6 M i s s D i x conducted a model day and boarding school with splendid success, and with an intensity that seemed to belie her f r a i l physical health. B u t finally the strain p r o v e d too g r e a t , and she suffered a severe physical b r e a k d o w n . D e a t h seemed perilously near at that moment. M a n y of her f r i e n d s shook their heads sadly and g a v e her up f o r lost. B u t she m a n a g e d to pull through. W h e n she w a s w e l l enough to m o v e about once more, her doctors ordered h e r to g i v e up teaching at once and to seek rest and recuperation a b r o a d . A trip to E n g l a n d f o l l o w e d , and in the ensuing eighteen months, spent at the home of kindly E n g l i s h f r i e n d s , she experienced f o r the first time in her life the bliss of complete r e l a x a t i o n . M i s s D i x returned home g r e a t l y r e f r e s h e d , though still w e a k . H e r strenuous l i f e seemed definitely behind her. A generous bequest f r o m her g r a n d m o t h e r ( w h o had died several y e a r s b e f o r e ) , t o g e t h e r with accumulated savings, g a v e assurance of a c o m f o r t a b l e income f o r l i f e . It a p p e a r e d logical f o r her, as a N e w E n g l a n d spinster of modest circumstances, delicate health and p e d a g o g i c background, to continue teaching on a g r e a t l y reduced s c a l e — a s a hobby r a t h e r than as a p r o f e s s i o n — a n d to indulge in little acts of personal charity so common to her kind. A n d that is exactly w h a t M i s s D i x proceeded to do on returning to her native land. Surely, it seemed, finis had been written to her period of intense a c t i v i t y : now this w o m a n would be content to live the r e m a i n d e r of her l i f e in a n a r r o w i n g orbit, and pass quietly t h r o u g h the y e a r s to the final obscurity of a N e w E n g l a n d spinster-teacher. T h e r e w a s up to this time nothing in her past l i f e to indicate the role that lay in store f o r her. She w a s nearing f o r t y . H o w could she sense that all her past w a s to be but the prelude to a new l i f e ? O r that she would yet break new trails in the service of humanity, trails that would carry her f a r beyond the confines of N e w E n g l a n d and w o u l d l e a d across two continents? T r u e , she m a y h a v e been a w a r e of

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the fire of r e f o r m that lay smoldering within her, awaiting only a spark to set it into blazing activity. But where was that spark, would it ever come? It did—and, as often happens in the careers of outstanding men and women, it came in the form of a quite inconspicuous event—at that jail in E a s t Cambridge. T o properly comprehend the course that Dorothea L y n d e Dix thereafter pursued, it is well to understand the social factors which conditioned it. M i s s D i x was not a " s p o r t " of history. She was the product of a particular environment that shaped both her personality and her ends. T h e famous feminist, Frances E . W i l l a r d , tells us that once, while gathering biographical material about D o r o t h e a Dix, an acquaintance remarked: " I t seems to me she was a N e w E n g l a n d w o m a n . " " T h a t goes without saying," was M i s s W i l l a r d ' s comment. " I n those early days no other woman would have dared attempt what she so gloriously p e r f o r m e d . " 2 Y e s , she could only have been a product of N e w England, at a particular stage of its cultural development. It was the time of a great cultural revival which found fullest expression during the thirty years preceding the Civil W a r , and produced such outstanding figures as Emerson, Channing, Thoreau, T h e o d o r e P a r k e r , Nathaniel H a w t h o r n e , J o h n G . Whittier, M a r g a r e t Fuller, William L l o y d Garrison and a host of others. It represented a sort of humanized Puritanism, a blending of the old rigid concepts with the rising liberalism and humanitarianism that was making itself manifest throughout E u r o p e — a movement strongly influencing the N e w England thought of the period. T h i s new Renaissance retained the old religious intensity of Puritanism, but substituted, in the concept of man's relationship with God, the ideal of love f o r that of f e a r . T h a t new ideal was extended into the field of man's relationship with his fellow men. In place of the old notion of man as a base, degraded creature f o r e v e r branded with the taint of original sin, it raised man to a high plane of dignity and nobility, with a firm belief in his innate perfectability. L i k e the eighteenth-century Enlightenment, with which it had much in common, the N e w E n g l a n d movement involved a new

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sense of duty towards humanity, particularly the weaker and more needy sections of it—a sense of duty that had been hitherto almost exclusively reserved for God. Although Dorothea Dix cannot be counted among the molders of the New England Renaissance, she most certainly was one of its representative products. Like her famous contemporary, M a r g a r e t Fuller, M i s s Dix cast off the hampering shackles of Puritan womanhood, and fought her w a y — i n her own field—to the top of a man's world. T h e y had in common, also, a degree of self-confidence that bordered closely on egotism. M a r g a r e t Fuller could calmly r e m a r k : "I know all the people worth knowing in America, and I find no intellect comparable to my own." M i s s Dix's consciousness of superiority was curiously tempered by a genuine modesty in all things unrelated to what she considered her divinely ordained duty—reform in the treatment of the mentally ill. She had an imperious bearing, and when she spoke it was as one with God-given authority. But here the points of resemblance end: in most other things these two eminent New England women were poles apart. In temperament, M a r g a r e t Fuller was of the speculative type, like Emerson, a thinker. For her, life was not so much physical movement as mental unfoldment. Dorothea Dix, on the other hand, was the practical reformer, the doer. Within her burned a crusading instinct that sent her f a r afield in the active service of her fellow men. She was to be to the insane what her great contemporary, Garrison, was to the slaves. She possessed, like him, an indomitable will-to-do, an impulse to ferret out evil and expose it to the eyes of a shamed society. T h e historic words which Garrison so feelingly inscribed in the first number of his Liberator might well have been uttered by her on the threshold of her own life-work. I will be as harsh as truth, and as uncompromising as justice. O n this subject, I do not wish to think, or speak, or write, w i t h moderation . . . urge me not to use moderation in a cause like the present. I am in earnest—I w i l l not equivocate—I w i l l not excuse—I w i l l not retreat a single inch—and I will be heard.*

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W e return now to our narrative. W i t h the E a s t Camb r i d g e incident, t r i v i a l t h o u g h it w a s in itself, M i s s D i x stumbled u p o n t h e r i g h t r o a d . She could n e v e r m o r e r e t r e a t t o t h e quietude of n o r m a l N e w E n g l a n d s p i n s t e r h o o d . She could n o t rest until an a n s w e r w a s f o u n d t o this q u e s t i o n : W e r e t h e conditions in the E a s t C a m b r i d g e jail exceptional, o r w e r e they t y p i c a l ? She set o u t t o find t h a t a n s w e r . H e r initial survey occupied t w o y e a r s , a n d t o o k h e r t h r o u g h t h e l e n g t h and b r e a d t h of M a s s a c h u s e t t s . I t entailed visits t o scores of almshouses and jails, m a n y of which o f f e r e d no m o r e hope t o their inmates, especially t h e insane p a u p e r s , t h a n t h e D a n t e s q u e legend o v e r t h e g a t e s of H e l l . H e r o b s e r v a t i o n s w e r e r e c o r d e d in a little n o t e b o o k she c a r r i e d with h e r . A t t h e end of t w o y e a r s she h a d collected an a m a z ing c a t a l o g u e of miseries a n d h o r r o r s . Miss Dix had found her a n s w e r : E a s t Cambridge was not an isolated instance of neglect of t h e indigent insane. I n d e e d , it w a s a m o d e l institution c o m p a r e d with m a n y of the o t h e r s . H a v i n g g a t h e r e d t h e facts, she p r o c e e d e d t o use t h e m . I n lesser h a n d s , t h e y m i g h t h a v e s e r v e d t o e v o k e a lurid nine days' s e n s a t i o n : t o prick t h e public conscience, d r a w a little blood a n d some explosive a n g e r , a n d t h e n t o give w a y t o a n o t h e r sensation. B u t in M i s s D i x ' s h a n d s , f a c t s became the f o u n d a t i o n stones on which t o build concrete p r o g r e s s . If h e r l a b o r s could n o t b r i n g a b o u t t h e bett e r m e n t of t h e conditions in M a s s a c h u s e t t s , she f e l t , t h e n t h e y w e r e in vain. C a r e f u l l y , step by step, she m a p p e d o u t a c a m p a i g n of action. F i r s t she e m b o d i e d h e r n o t e s in a m e m o rial t o the legislature, which b u r s t in its august halls with t h e f o r c e of a bombshell. I t b e g a n : I come to present the strong claims of suffering humanity. I come to place before the Legislature of Massachusetts the condition of the miserable, the desolate, the outcast. I come as the advocate of helpless, forgotten, insane and idiotic men and women . . . of beings wretched in our prisons, and more wretched in our Aims-Houses. I proceed, Gentlemen, briefly to call your attention to the state of Insane Persons confined within this Commonwealth, in cages, closets, cellars, stalls, pens: Chained, naked, beaten with rods, and lashed into obedience! 4

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H e r arsenal of facts was presented in a style t h a t startled by its very simplicity. In form, it had the bareness of a stock inventory; in content, the dramatic ring of terrible truth. T h e results of two years of investigation were summed up in this m a n n e r : Lincoln. Aledford. Concord.

Savoy. Lenox. Dedham.

Franklin. Taunton.

A woman caged. One idiotic subject chained, and one in a close stall for 17 years. A woman from the hospital in a cage in the almshouse. In the jail, several, decently cared for in general, but not properly placed in a prison. One man caged. T w o in jail; against whose unfit condition there, the jailor protests. T h e insane disadvantageously placed in the jail. In the almshouse, two females in stalls, situated in the main building; lie in wooden bunks filled with straw; always shut up. O n e of these subjects is supposed curable. T h e overseers of the poor have declined to give her a trial at the hospital [i.e., at Worcester], as I was informed. One man chained ; decent. O n e woman caged.

A n d so on. M a n y harmless idiots and insane persons were unjustly confined when they might be set to useful employment, or at least permitted the f r e e use of their limbs. In one almshouse she saw a perfectly harmless insane youth in close solitary confinement in a dark squalid cell, with straw serving as the only article of furniture. W h e n asked why this admittedly mild person was given no opportunity f o r fresh air or exercise, the matron replied : " Ó , my husband [the superintende n t ] is a f r a i d he'll run away, then the overseers won't like it; he'll get to W o r c e s t e r [ H o s p i t a l ] and then the town will have money to pay." She discovered another harmless creature, " c r a z y " f o r about twenty years, who, as a pauper, had annually been " s o l d " at the auction block to the lowest bidder. Several years before, he had been placed by his master-for-a-year in an unheated outhouse, and there had f r o z e n his feet, which

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were now reduced to shapeless stumps. Despite his inability to walk about, chains were nevertheless fastened about his stumps f o r fear that he might crawl f o r t h f r o m his present cell and do some damage ! In yet another town she learned of a young woman, in a complete state of nudity, confined in a stall in a barn, with no bed but straw. T h e r e she remained, alone and unprotected, the helpless prey of profligate men and idle boys who were permitted to visit the place at will. This scandalous situation, Miss Dix was told, had continued unchecked until the repeated remonstrances of an insane inmate of the town poorhouse forced the authorities to remove the girl to the presumably safe confines of the institution proper. W h e r e lay the remedies f o r such abuses and evils? Certainly not in the replacement of one set of superintendents and jail keepers by another. In many instances these very men had protested most bitterly against the conditions they were forced to tolerate under the law. Even the most shocking abuses were usually the result, not of the cruelty of some individual keeper, but rather of ignorance of better methods of treatment. It was still a widespread tendency, by no means confined to poor law and correctional authorities, to regard the insane as no more than brute beasts, to be treated accordingly. F o r example, in the course of a conversation with a man whose insane nephew was then confined in an almshouse cell, Miss Dix asked: " H a s he the comfort of a fire?" T h e man looked up incredulously: " F i r e ? Fire indeed! W h a t does a crazy man need of fire? Red-hot iron wants fire as much as he I"* • P e r h a p s the most shocking example of cruelty t h a t Miss Dix encountered in her extensive tour of America's infernos involved the treatment of a h a r m less lunatic at the home of his own sister, who g a v e as her reason for not sending him to an institution: " W e h a d r a t h e r take care of him, t h a n leave him to strangers, because we a r e kinder, and t r e a t him much better t h a n they would." And here a r e the comforts provided for this unoffending soul, as described in Miss Dix's memorial to the Legislature of Illinois (in which state the incident o c c u r r e d ) : " H e w a s confined in a roofed pen, which enclosed an area of about 8 feet by 8 . . . T h e interstices between the unhewn logs freely admitted the scorching rays of the sun then, as they now afford admission to the f r e q u e n t rains and d r i v i n g snow, and the pinching frost. H e was, said a neighbor, 'fed no better than the hogs.' His feet had been frozen, and had p e r i s h e d ; upon the

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N o , the solution did not lie in reprimanding individual persons and communities. State hospitals f o r the indigent insane—that was the answer ! " H o s p i t a l s are the only places where insane persons can be at once humanly and properly controlled. Poorhouses, converted into madhouses, cease to effect the purposes f o r which they were established, and instead of being asylums f o r the aged, the homeless, etc., are t r a n s f o r m e d into perpetual bedlams . . Massachusetts must build m o r e state hospitals, or must enlarge the only one existing at the time. T h e memorial raised a storm of opposition. Although it showed conclusive evidence of painstaking investigation and a constructive approach, the epithets "sensationalist," "distorter of t r u t h , " " m e d d l e r , " etc., were hurled at Miss Dix, especially by those who had felt the direct thrust of her lance. But f a r f r o m being deterred, she was only spurred on to greater efforts. She drew into the struggle such influential figures as Samuel G. H o w e ( w h o was N e w England's foremost leader in social w e l f a r e ) , R. C. W a t e r s t o n , Luther V. Bell, H o r a c e M a n n , and others.* T h e s e men formed effective rallying points f o r the mobilization of vitally needed public opinion. Before this formidable barrage, the opposition crumbled. shapeless stumps he could, aided by some motion of hie shoulders, raise his body partially up the side of the pen. T h i s wretched place w a s cleansed 'once in a week or fortnight' in mild w e a t h e r ; not so in the wet, cold, w i n t r y seasons. I w a s told that when the pen w a s opened f o r this purpose, the help of neighbors w a s requisite: ' W e h a v e men called, and they go in and tie him strongly with ropes, and lay him out on the ground, and then they clean the place and him, by throwing pails of w a t e r . ' Of course, no fire is here introhas been adopted, duced in the cold winter w e a t h e r ; but a singular expedient as horrible as it is singular. Beneath the pen is excavated a pit about six feet deep and six on either side. This dreary, ghastly place is entered through a trap-door; neither light, heat, nor ventilation are there; but there is to be found a pining desolate, suffering maniac, vihose piteous groans, and frantic cries, tvould move to pity the hardest heart." ( D . L. Dix. Memorial to the Legislature of Illinois. J a n . 1847.) • D r . H o w e published in 1843 a much discussed article supporting M i s s Dix's findings and c a l l i n g f o r legislative action in the North American Review, 1843. v . 56, pp. 1 7 1 - 9 1 . Simultaneously, R . C. Waterston p r e p a r e d a pamphlet on the same theme: The Condition of the Insane in Massachusetts. (Boston, 1843, 23 pp.) D r . H o w e , w h o w a s then a member of the State Legislature, brought M i s s D i x ' s memorial before the House.

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T h e legislature, by a large majority, passed a bill calling f o r a generous enlargement of the Worcester State Hospital f o r the reception of indigent insane. H a v i n g achieved this signal triumph, M i s s D i x was now prepared to carry the cause of the mentally ill beyond the borders of Massachusetts. Rhode Island was next to feel the galvanizing effect of her presence. H a v i n g made a preliminary investigation, she fired her opening gun in the f o r m of an article in a Providence paper, ironically entitled, "Astonishing Tenacity of L i f e . " It describes the remarkable case of A b r a m Simmons, an insane pauper who had suffered f o r several years a living entombment in a small Rhode Island town. H e had been incarcerated in a vault, six or eight feet square, built entirely of stone except f o r a door of iron, heavily-bolted. N o t a ray of light nor a breath of fresh air could force its way into this miserable tomb. T h e interior walls were covered with f r o s t a half-inch thick in some places; the straw thrown across an iron f r a m e serving as a bed was thoroughly soaked; the outer of two comforters calculated to save him f r o m freezing was so wet and hoary with frost as to present the appearance of a sheet of ice. " T h u s , in utter darkness, encased on every side by walls of frost . . . has this most dreadfully abused man existed through the past inclement winter."® H e r e was a case that could be compared only to the worst brutalities of the dark ages. T h e story of poor Simmons would have been incredible to the inhabitants of the state founded by R o g e r Williams, were it not f o r the fact that it was fully corroborated by eye-witnesses, including the state's leading humanitarian, T h o m a s G. H a z a r d . * M i s s Dix's opening shot had its desired effect: the public was aroused to renewed interest in the plight of the mentally ill. Rhode Island had no mental hospital as yet, although a subscription had been started toward building one, and some funds raised. M i s s D i x felt that it might be best *In 1851 Hazard served as a commissioner appointed to make a state-wide survey of pauperism, with particular regard for the insane poor. His report on poor relief conditions in Rhode Island was a model of its kind. (See: Hazard, Thomas G. Report on the Poor and Imane in Rhode Island. Made to the General Assembly, 1851. 1 1 9 pp.)

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f o r her, under these circumstances, to apply pressure on wealthy individuals so that the subscription campaign already under way could be brought to a successful conclusion. First on her list of prospects she placed the name of Cyrus Butler, reputedly the wealthiest man in the state and also the most niggardly one: he had never been known to contribute a cent toward charity. Friends warned her that she had better save her time and energy f o r more hopeful possibilities; that it was easier to draw blood f r o m stone than money f r o m this person. Undaunted, M i s s D i x sallied forth to beard M r . Butler in his own den. Accompanied by a skeptical f r i e n d — a minister—she sought him out. She was greeted gruffly and suspiciously by her host. Losing no time in the exchange of empty pleasantries, she immediately plunged into the heart of her subject. So impressed was M r . Butler by the eloquent appeal poured forth in Miss Dix's remarkable low, musical voice that when the short interview terminated, he had pledged the $ 4 0 , 0 0 0 needed to build the hospital. When the Rhode Islanders learned the good news, it seemed to them as if Moses, in smiting the rock and drawing forth water f o r the Israelites to drink, had wrought no greater miracle than this I So was born the Butler Hospital, named a f t e r its principal benefactor, which was to become one of the finest institutions of its kind in America. If there had been any lingering doubts in Dorothea Dix's mind as to her future course, they were by now completely dispelled. She saw eye to eye with destiny, and it pointed clearly along the path she had stumbled upon in that little E a s t Cambridge jail. F o r f o r t y years a f t e r she was to follow that path, winding through the darkest areas of the land where lay, in hidden misery, society's lowliest pariahs — t h e pauper insane. She threw her whole soul into her new w o r k ; all her hitherto dormant powers awakened to the Herculean tasks she set herself. T h e r e was in her a firm strength of purpose, fed by a seemingly inexhaustible supply of energy, and driven by a passionate devotion to a cause. T h i s moral and mental stamina stood out in sharp contrast to her f r a i l physical health, seeming like a Diesel engine operating in a canoe.

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H e r work now became national in scope. In Massachusetts and Rhode Island, Miss Dix had proved the m a j o r instrument in enlarging and improving mental hospitals already established or projected. In the next state she marched o n — N e w Jersey—she was to win a newer and more significant triumph. H e r e the opposition of parsimonious taxpayers had effectively blocked all efforts to establish a state asylum f o r the insane, despite the urgent need f o r one. Aligned against progressive legislation, too, were the ever-present watchdogs of the public purse, and the reactionaries generally. But calmly she went through what was to become f o r her a fixed routine : state-wide investigation of provision f o r the mentally ill, the preparation of a memorial and bill, the introduction of the latter in the state legislature, and the rallying of public opinion and the press behind her cause. All this involved bitter struggle, during which she was subjected to the sting of direct attacks and the even more poisonous indirect ones. F o r a time it seemed as though her efforts were futile. But finally she triumphed; her bill providing f o r the establishment of a state hospital was passed. T h a t hospital at T r e n t o n was remembered ever after by its founder as "my first-born child." She was to prove a prolific mother of such children as this: during her long period of service she was to bring into being more state hospitals than had existed in all the United States up to the time she embarked on her singular enterprise. T h e decade following the N e w Jersey exploit found this American counterpart of Elizabeth F r y carrying her cause personally to every state east of the Rockies. H e r plan of action had been perfected to a high degree of effectiveness. I t consisted not only in collecting facts and presenting them to the legislature; it involved their interpretation in the light of progressive action. It was not enough to point out degrading conditions; it was necessary to show how they might be changed. New and better state hospitals! T h i s was her invariable solution f o r the miserable conditions of the pauper insane in the hundreds of almshouses and jails she visited. ( T h e majority of mentally ill dependents were still confined in these institutions.)

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F r o m state to state the crusader journeyed, spreading the seeds o f justice f o r the mentally ill and watching them take r o o t . N o sooner was her mission in one state accomplished, than she shifted the scene o f her activity to another. N e a r l y all her memorials included practical suggestions on the selection o f proper sites, the most suitable administration o f proposed institutions, etc. T h e s e suggestions were based on her truly amazing knowledge o f the latest advances in psychiatric practice, with which she maintained constant contact through her personal acquaintance with the f o r e m o s t medical superintendents in A m e r i c a and E n g l a n d , and her broad reading in the subject. A keen student o f politics and politicians, she sensed that the most eloquent appeals to humanity set f o r t h in her memorials would be unavailing without the all-important argument o f economy. T h e r e f o r e she always included in her memorials facts and figures proving the ultimate savings o f expenditures involved in the creation o f state hospitals. " N o f a c t , " she would conclude, " i s b e t t e r established in all hospital annals than t h i s : that it is cheaper to take charge o f the insane in a curative institution than to support them elsewhere f o r life." I n nearly every instance her memorial was followed by the erection o f a State hospital, or the enlargement and improvement o f an existing one. N o t in every case, o f course, was this happy culmination due solely to her efforts. In some states agitation f o r legislative provision had been carried on f o r years b e f o r e her appearance on the s c e n e — a s in Pennsylvania, f o r example. H e r role in such instances was not so much that o f a c r e a t o r as o f a catalytic agent, precipitating an action that otherwise might have been delayed f o r many years. W h e n we read o f the many thousands o f miles covered by this ever-sickly frail woman on her missions o f mercy, in t h a t day o f backbreaking stage coach travel o v e r the rough, muddy roads o f young A m e r i c a , we cannot help but marvel at the sheer power o f will t h a t could overcome the terrible hardships encountered. T h e extent o f her labors, and the breathless pace she set f o r herself, is indicated in this

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characteristically telegraphic summary of her first three years of r e f o r m work, in a letter to a friend : I have traveled more than ten thousand miles in the last three years. H a v e visited eighteen state penitentiaries, three hundred county jails, more than

five

hundred almshouses and other institutions,

besides

hospitals and houses of refuge. I have been so happy as to promote and secure the establishment of six hospitals f o r the insane, several county poorhouses, and several jails on a reformed plan.*

W h a t a wealth of drama is hidden behind those w o r d s ! Picture this lone crusader doggedly pursuing her circuit of Inferno, without even having a Vergil to guide her through all-too-real circles of hell as Dante had in his imaginary ones. Remember, too, that despite her progressive ideals in her special field, here was one who still clung tenaciously to the conservative sex prejudices of the Victorian age, deeply sensitive to her station as a woman. " I am naturally diffident and timid, like all my sex," she once wrote. So extreme were her notions of lady-like propriety that when the sleepingcar was introduced, with all its promise of easing the hardships of long journeys, she denounced the innovation as " i m m o r a l " and a device of the devil a f t e r her very first trial, and vowed that she'd never travel in a sleeping-car again ! But compared with the obstructions placed in her path by her opponents, the physical hardships of travel were as nothing. H e r s was no path strewn with roses, leading to easy triumphs. E v e r y inch of the way had to be fought f o r . E v e r y w h e r e she was faced with a disheartening apathy, and the active antagonism of narrow-minded, selfish taxpayers and petty politicians who did not scruple to make her the * I t will be noted that Miss Dix's interest in reform extended to correctional and poor law institutions generally. Her eminent role in the history of penal reform in the United States has been all but obscured by the glory of her work f o r the mentally ill. She conducted many investigations of prison conditions, and her memorials to state legislatures on this subject were instrumental in effecting important progressive changes. Her Remarks on Prisons and Prison Discipline in the United States (Boston, 1845, 104 pp.), embodying the results of personal researches throughout America, is considered one of the great milestones in the history of prison reform in this country. Horace M a n n , who followed the career of Miss D i x v e r y closely, once said of this aspect of her w o r k : "It would make as wonderful a record as her more especial work in behalf of the insane."

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object of unjust attacks. She had to meet the opposition of town and county officials who greedily f o u g h t among themselves f o r the location of proposed institutions within their own borders because of the financial advantages accruing t h e r e f r o m , regardless of the suitability of their favorite locations. She h a d to meet the attacks of rich landed proprietors who desired no " m a d h o u s e s " to blemish the beauty of the scenery surrounding their estates. She had to contend with the enmity of parsimonious public officials who watched the treasury with eagle eye, and who raised heartrending cries whenever it was dipped into f o r humanitarian, non-profitmaking purposes. H e r reception by institutional officials on her rounds of inspection was by no means always a cordial one. Certain of these gentry f e a r e d and disliked her because the condition of their institutions gave them good reason to expect criticism. T h e r e were others, honest and high-minded persons, who deeply resented the intrusion of one whom they termed " a self-appointed Lunacy Commissioner," a lay person with no professional training f o r the position she had assumed. T h i s resentment, in many cases, was heightened by the naturally imperious bearing she always maintained in her dealings with o t h e r s — a p a r t of her personality which was vitally needed f o r the nature of her task, but which unfortunately led to many misunderstandings. I t was not always possible f o r this single-handed crusader to beat back the imposing a r r a y of antagonists aligned against her and the cause she stood for. Along with the wine of victory she was sometimes forced to taste the dregs of defeat. But like most great social reformers, she thrived on struggle. U n t i r e d by the struggles in behalf of the mentally ill in her own country, she found time and energy to carry the cause to neighboring C a n a d a . T h e r e she was instrumental in securing the creation of mental hospitals in N o v a Scotia and N e w f o u n d l a n d . Received with mingled suspicion and respect by the Canadian public when she launched on her labors, she retired f r o m that country amid a shower of honors f o r her noble work in gaining the establishment of

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two badly needed hospitals, one at H a l i f a x and the other at St. John's. A select committee, reporting f a v o r a b l y on her memorial to the N o v a Scotia Legislature, took occasion to express their unstinted praise of M i s s Dix, " w h o , endowed with every quality calculated to advance society, dedicates her time and thoughts solely to the cause of those who cannot appreciate her efforts." 9 Similar tributes were heaped upon her by a number of other g r a t e f u l legislative bodies, particularly in the Southern states, where Miss Dix scored some of her most important victories. It was quite customary f o r the Southern legislatures, following each successive D i x conquest, to tender a vote of thanks to that "chosen daughter of the Republic," that "angel of mercy," "that crown of human nature," as she was variously called. A typical tribute was that proffered by the Tennessee legislature, declaring that " h e r disinterested benevolence, sublime charity, and unmixed philanthropy challenge alike the gratitude and admiration of our state." 7 Several of the states that responded to her appeals f o r mental hospitals desired to name these institutions a f t e r her, but in line with her aversion f o r personal glory, she consistently refused to accept such honors. Only in one instance — t h e Dixmont Hospital in Pennsylvania, established in 1 8 4 7 — d i d she permit her name to be associated with an institution she founded. N o r t h Carolina, however, would not be deterred f r o m giving the name D i x H i l l to the site of the hospital at Raleigh established through her efforts. Dorothea Dix was cast in a truly heroic mold. In her was that rare combination of endowments that serve to set off great personalities f r o m the ordinary run of men—an imagination capable of conceiving the "impossible," and the will and courage to achieve it. She stormed the citadels of State—and captured them—when wise men shook their heads and termed her a female Don Quixote fighting a hopeless cause. A s her brilliant victories over the obstructionists of progress steadily mounted, her contemporaries stared in wide-eyed astonishment as though they were beholding miracles. Y e t , if we were to choose the one event of her career that

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captures our admiration above all others, we must turn to a project that ended in defeat, a defeat doubly bitter because it came when victory seemed certain. W e refer to the famous " 1 2 , 2 2 5 , 0 0 0 A c r e B i l l " — t h e most ambitious project in behalf of the mentally ill conceived up to the twentieth century. It involved a gruelling six-year struggle : the stakes were the highest played f o r in M i s s Dix's career. H a d that bill become law it would have written a new chapter, not only in the history of the insane, but in the history of social w e l f a r e generally in the United States. F o r it contained a new concept of the duty of the nation toward dependent classes, a concept that has been recognized, officially, only in recent years. H a v i n g besieged state a f t e r state and won them to her cause in varying degrees, M i s s D i x in 1848 felt prepared to train her guns on the national capital itself. She had noted that Congress was then making generous grants of choice public land to the several states f o r use in advancing public education and public works. M o r e than 100,000,000 acres of government land had already been apportioned to the states to aid them in raising funds f o r educational purposes alone. T h e r e still remained many more millions in the hands of the federal government. W h y not grant some of these acres f o r charitable purposes? W h y not f o r the benefit of America's mentally ill? N o sooner did she conceive the idea than she acted upon it. A petition to Congress was forthwith drawn up, urging that body to grant to the states, on the basis of population, 5,000,000 acres of land, the proceeds of the sales of which were to be used exclusively f o r bettering the condition of the indigent insane. H e r memorial was one of the ablest she ever prepared, containing a detailed and vivid record, compiled state by state, of man's inhumanity toward the mentally ill. N o t only did it describe existing evils and inadequacies; it pointed clearly to the remedies, offering in illustration alreadyexisting model state hospitals where curable cases might find cure, and the others at least comfort. T h e petition was received with mixed feelings, with doubt dominating. Granted, said the sceptics, that the treatment of

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the indigent insane was f a r f r o m being what it could and should b e — w h a t h a d the federal government to do with this or any o t h e r dependent class? H e r e Miss Dix essayed her boldest stroke. Exactly twenty years before, her friend H o r a c e M a n n had startled his contemporaries by enunciating the doctrine that " t h e insane are the w a r d s of the State." T h a t doctrine was still f a r f r o m being generally accepted. Imagine, then, the staggering effect of the unequivocal declaration which ended Miss Dix's m e m o r i a l : I confide to you the cause and the claims of the destitute and of the desolate, without fear or distrust. I ask, for the thirty states of the Union, 5,000,000 acres of land, of the many hundreds of millions of public lands, appropriated in such manner as shall assure the greatest benefits to all who are in circumstances of extreme necessity, and who, through the providence of God, are wards of the nation, claimants on the sympathy and care of the public, through the miseries and disqualifications brought upon them by the sorest afflictions with which humanity can be visited. 8

W a r d s of the nation I H e r e was a brand-new concept of governmental responsibility f o r mentally ill dependents. M a n y greeted her proposal with ridicule. T h e plan she proposed was wildly visionary, impossible of attainment. O t h e r s frankly wondered whether it would not be best f o r the memorialist to retire to the confinement of one of the institutions she had founded. A mountain of opposition arose at once. But characters like D o r o t h e a Dix thrill to the "tonic of opposition." T o the epithets of "impractical idealist" and "spinner of d r e a m s " Miss Dix paid no heed : she went about her campaign with the usual military precision—enlisting the aid of the press and of influential public figures, and marshalling mass opinion behind her plan, f o r she was well aware of the sensitiveness of legislators to the pressure of public opinion. T h e bill f o r m u l a t e d around her memorial failed of passage t h a t year. Did Miss Dix give u p ? D i d she lessen her d e m a n d s ? N o t at all. W i t h the audacity t h a t knows no retreat, she modified her bill upward, asking f o r a g r a n t of / 0 , 0 0 0 , 0 0 0 acres f o r the insane—double the amount in the original a c t — a n d added, to boot, a request

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f o r 2 , 2 2 5 , 0 0 0 acres f o r deaf mutes, making 1 2 , 2 2 5 , 0 0 0 acres in all. T h e ensuing years were fraught with harrowing suspense f o r the friends of the cause. Delay followed delay. In one session, the House of Representatives passed the bill, but the Senate did not. In another, the tables were turned, the bill failing in the House a f t e r passing the Senate. ( T o become a law, a bill has to pass both houses in the same session.) In 1 8 5 4 the time was propitious f o r passage of the bill through both houses—and pass them it did, with comfortable majorities. T h e impossible seemed accomplished. A l l that was lacking was the President's signature, and vetoes were very rare in those days. Only one man stood between the cause and victory. It appeared incredible that the bill would be vetoed in the face of the overwhelming public support M i s s D i x had rallied behind her. But the incredible happened. With one stroke of the pen, President Franklin Pierce nullified the results of years of arduous labor. H e seemed to sense that his action was somehow indefensible, f o r he took the unusual recourse of preparing a lengthy pamphlet to " e x p l a i n " his veto. 9 Its very length betrayed its weakness of argument. T h e government, maintained the President, could not become involved in granting aid f o r any humanitarian cause whatever. " I f Congress have p o w e r , " he wrote, " t o make provision f o r the indigent insane without the limits of this district [District of Columbia], it has the same power to provide f o r the indigent who are not insane, and thus to transfer to the federal government the charge of all the poor in all the States." W h a t a non sequitur! Boiled down to its essentials his argument meant only this : N o power that may be abused should ever be permitted to exist. Pierce tried to defend his veto on constitutional grounds, too, although Miss D i x in her memorial had cited two precedents when Congress had made land grants f o r humanitarian purposes—both times in behalf of deaf-mutes. A grant of land in aid of the Connecticut asylum f o r the education of the deaf and dumb had been made in 1 8 1 9 ,

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and again f o r a similar institution in K e n t u c k y in 1 8 2 6 . T h e constitutionality of these acts had n e v e r been contested. A n other argument a d v a n c e d by P i e r c e f o r his v e t o was that of " S t a t e ' s R i g h t s , " a point evidently intended to win the s y m p a t h y of the Southern states to his stand. ( H e had been elected as " A N o r t h e r n e r w i t h Southern p r i n c i p l e s . " ) I n p e r f o r m i n g a humanitarian service to the poor, he claimed, the f e d e r a l g o v e r n m e n t w o u l d be usurping the p o w e r s of the individual states ! So w a s the g r e a t 1 2 , 2 2 5 , 0 0 0 A c r e B i l l finally d e f e a t e d by the penstroke of one man. M i s s D i x h a d t h r o w n all her e n e r g y into this fight; the end f o u n d her completely exhausted and w e i g h e d down with disappointment. In the f a l l of 1 8 5 4 she set sail f o r E n g l a n d f o r much-needed rest and recuperation. B u t to a nature like hers there is no contradiction between rest and w o r k . H a r d l y had she set f o o t on E n g l i s h soil than she w r o t e to a f r i e n d back h o m e : I a m still here w i t h dear friends, m u c h occupied w i t h

charitable

institutions and the meetings of the British Scientific Association. A l l this tires me sadly, but I shall take things easier in a w e e k . I t is m y purpose to go to S c o t l a n d to see the hospitals in ten d a y s . 1 0

L i t t l e did she d r e a m at the m o m e n t that this casually mentioned visit to Scotland w o u l d d e v e l o p into one of the m a j o r struggles of her career, the outcome of which w a s to change completely that country's lunacy system. A short time a f t e r , she w a s w r i t i n g to the same f r i e n d ( M i s s A n n e H e a t h ) f r o m E d i n b u r g h , r e f e r r i n g to the s a d state of the institutions f o r the insane: " O f these none a r e so much needing quick r e f o r m as the p r i v a t e establishments f o r the insane. I am confident that this m o v e is to rest with me, a n d that the sooner I address myself to this w o r k of humanity, the sooner will my conscience cease to suggest effort, o r rebuke inaction. It is true I came here f o r pleasure, but that is no reason w h y I should close my eyes to the condition of these most helpless of all G o d ' s c r e a t u r e s . ' " 1 H u m a n i t a r i a n i s m knows no national boundaries. W h e r e m i s e r y is, there duty calls. A n d to M i s s D i x , that call w a s inexorable. She set about her w o r k , f e r r e t i n g out abuses and

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evils, and f o r c i n g them b e f o r e the public eye. N o sooner h a d she begun than the w o l f - p a c k of reaction w a s at her heels. H e r e w a s an alien meddler, they cried, betraying a country's hospitality by i n t e r f e r i n g in its internal a f f a i r s . " T h e A m e r i c a n I n v a d e r , " one of her opponents labeled her with contempt, and the epithet w o n the a p p r o v a l of many others. B u t M i s s D i x cared not how m a n y antagonists w e r e a r r a y e d against her, so long as she f e l t truth and justice at h e r side. T h e n , too, she h a d the full-hearted support of m a n y individuals w h o had themselves been trying unsuccessf u l l y f o r y e a r s to institute requisite r e f o r m s , and who now welcomed the dynamic presence of this new leader. A survey of a f f a i r s in Scotland convinced M i s s D i x that an appeal to the native officialdom w o u l d be fruitless. She announced her intention to take the cause of Scotland's insane to the B r i t i s h H o m e S e c r e t a r y h i m s e l f . A p p r e h e n d i n g trouble and a w a r e of the a d v a n t a g e of h a v i n g M i s s D i x discredited b e f o r e h e r a r r i v a l at the H o m e Office, the L o r d P r o v o s t of E d i n b u r g h , one of her principal opponents, packed his trunk that v e r y night in readiness to depart f o r L o n d o n the next d a y . M i s s D i x , h o w e v e r , w a s not to be outgeneralled by the canny Scot. A n t i c i p a t i n g the L o r d P r o v o s t ' s s t r a t a g e m , M i s s D i x hurriedly threw her cffects into a little h a n d b a g , swung on the night mail train f o r L o n d o n , and reached her destination a f t e r a sleepless, unc o m f o r t a b l e ride. B e f o r e the leisurely Scotch official a r r i v e d in L o n d o n , she h a d g a i n e d an interview with the Secretary of the H o m e Office, and impressed the latter with her presentation of f a c t s and the necessity f o r an immediate inquiry. So conclusive w a s her evidence that on A p r i l 3 , 1 8 5 5 , Queen V i c t o r i a appointed a R o y a l C o m m i s s i o n to inquire into the condition of the lunatic asylums in Scotland, and the state of the lunacy l a w s of that country. T h e report of that R o y a l C o m m i s s i o n ' s inquiries and recommendations, which revolutionized the lunacy system of Scotland and m a d e it one of the most e x e m p l a r y in the w o r l d , marks a notable milestone in the history of provision f o r the mentally ill. F o r h e r g r e a t f e a t , M i s s D i x received the unreserved praise of all p r o g r e s s i v e s in G r e a t B r i t a i n . A member of

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Parliament, stating that "the Commission was entirely due to Miss Dix's exertion," added that "no one could read the report of the Commission without feeling g r a t e f u l to that lady f o r having been instrumental in exposing proceedings which were disgraceful to this or to any other civilized country." T h e H o m e Secretary, Sir G e o r g e G r a y , voiced similar sentiment on the floor of the House of Commons, regretting only that the materialization of this long-needed reform should have been achieved by " a foreigner, and that foreigner a woman, and that woman a dissenter I " 1 2 H e r labors in E u r o p e were not yet over. While recuperating in the home of D r . D . H a c k T u k e at the f a m e d Retreat at Y o r k , Miss Dix's attention was called by her host to a pamphlet by a D r . V a n Leuven, describing the deplorable condition of the insane in the Channel Islands, due largely to the location there of private asylums by unscrupulous owners who had been driven f r o m England. M i s s Dix lost no time establishing correspondence with the Dutch doctor : before long she was on the spot. Within a month, she had made it so hot f o r the racketeers who preyed on the misfortune of others that they left the island in precipitate haste. She secured the formation of a constructive commission, and was instrumental in getting a public mental hospital established on the Island of J e r s e y . H e r mission accomplished, M i s s D i x journeyed to the Continent, where she spent many months in a tour of inspection of mental hospitals and other types of humanitarian institutions, covering nearly every European country. E v e r y w h e r e her name and f a m e preceded h e r : she invariably was given carte blanche to visit and inspect at will. H e r most notable work was p e r f o r m e d in Rome, where she brought to the Pope's attention the terrible mistreatment of the insane at his very doorstep, and elicited f r o m him the promise that a new institution f o r the insane would be erected at once. T w o years had been spent in pursuing the ever elusive " r e s t " abroad; her thoughts now turned toward home. In September, 1 8 5 6 , she set sail f r o m Liverpool f o r N e w York.

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T h e outbreak of the Civil W a r found her in Baltimore. N o sooner had the first gun been fired, than she presented herself before the administration in Washington for any service she might fit into. She was promptly appointed to the post of Superintendent of W o m e n N u r s e s — t h e highest office held by a woman during the W a r — w i t h power to "select and assign women nurses to general or permanent military hospitals, they not to be employed in such hospitals without her sanction and approval, except in cases of urgent need." M i s s Dix entered upon her new task with characteristic intensity. Mobilizing a nursing force at t h a t time, with little or no preliminary preparations, might well be compared to the twelve labors of Hercules. But under her skillful hand, iron will, and infinite supply of energy, the work of organization went on admirably. In the field of administration, however, the results were not quite so happy. She soon found herself embroiled in an endless conflict with the medical and technical men in the hospital service, a conflict that continued unabated to the end of the W a r . Miss Dix was used to giving commands, and having them obeyed. T h e professional men who worked beside her, on the other hand, deeply resented w h a t they considered the officiousness of an untrained lay person. I t was charged also that Miss Dix, in selecting nurses, placed too much emphasis on the moral background of applicants, and too little on their efficiency. She o f t e n showed an overzealousness in her duties that brought on clashes with fellow workers. She herself realized the difficulties of her project, and exclaimed once: " T h i s is not the work I would have my life judged by !" Howbeit, Lossing, in his Pictorial History of the Civil fVar, says of h e r : "Like an angel of mercy, this self-sacrificing woman labored day and night throughout the entire war for the relief of suffering soldiers . . . T h e amount of happiness that resulted f r o m the services of this woman can never be estimated." 1 3 T h e W a r ended, and the nursing service demobilized, Secretary of W a r Stanton sent her a letter of high commendation, inviting her to choose a suitable official reward

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in recognition of her work. W h e n she asked for nothing more, he presented her with a stand of arms of the nation's colors. Miss Dix now turned once more to her special labor of love. She was already sixty-five years of age when she resumed her ministrations to the mentally ill, but she continued her rounds of investigation through the states, and agitated f o r progressive lunacy legislation f o r fifteen years longer. H e r inspection tours brought her many crushing disappointments, as reflected in the despair frequently voiced in her letters of this period. In state a f t e r state she found the very abuses and evils she had set out so hopefully to eliminate years ago again rearing their ugly heads. H a d all her work, then, been in vain, she asked herself? M o s t saddening of all was the discovery that many of her "children"—hospitals founded directly through her labors—exhibited scenes of suffering and neglect little better than those she had so bitterly condemned long before in her reports on jails and almshouses. As Franklin B. Sanborn points out in his Memoirs of Pliny Karle: Through her it was, campaigning for the neglected insane from State to State and from country to country, that so many new asylums had been built, so many old ones enlarged ; but they had in too many instances become centres of intellectual indolence or of semi-political intrigue; to whose busy and well-paid medical men new ideas were irksome, and any forward step in the care of their patients or the guidance of public opinion was a kind of reproach to their imbibed complacency of attained perfection. It was the familiar story of goodness gone to seed and planting the surrounding fields with a growth which was not goodness. . . . Miss Dix had done her work. T h e fame of it remained and will not be forgotten. It was, however, a work for a time of ignorance and developing civilization, and by no means a permanent model for all coming time. T h i s fact she hardly recognized, nor was it natural she should. Like all strong natures of her type, she saw what she was appointed to see, wrought her task therein with zeal and swift accomplishment, but she saw little beyond. 14

Miss Dix had throughout her career played the role of the lone eagle, partly because the stage of humanitarian re-

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f o r m in her time gave rise to the individual crusader of the type she represented, partly through the dictates of her own peculiar temperament. By the sheer force of her personality she had awakened public opinion to the sufferings and needs of the mentally ill to a degree unparalleled by any other individual before her time or f o r many years after. She had succeeded in forcing on recalcitrant public authorities the acceptance of definite standards of care and treatment. H o w ever, to organize that enlightened opinion on a permanent basis so as to safeguard adequate standards, in addition to obtaining immediate gains, was beyond the capacity of any individual at that time, even of such a rare person as she was. Consider, too, that her activities belonged to a period when social customs made it virtually impossible f o r a woman to rise above obscurity, and her success becomes all the more amazing. W h a t a record she could point back to at the end of her long career! T w e n t y states had responded directly to her appeals by establishing or enlarging mental hospitals. In several states more than one institution was credited to her personal efforts. She had played an important role in the founding of the Government Hospital f o r the Insane, at Washington, D . C . * A s f o r her work in other lands— Canada, the British Isles, and the Continent—that phase of her career alone would have been sufficient to secure her a prominent niche among humanitarian reformers. In all, she was directly responsible f o r the founding or enlarging of thirty-two mental hospitals in the United States and abroad. • T h i s institution, n o w k n o w n as St. E l i z a b e t h s H o s p i t a l , w a s f o u n d e d in 1 8 5 2 a n d opened t h r e e y e a r s l a t e r . It is u n d e r t h e d i r e c t c h a r g e of the U . S. D e p a r t m e n t of the I n t e r i o r , a n d r e c e i v e s p a t i e n t s f r o m the m i l i t a r y o r g a n i z a tions stationed in the U n i t e d States, f r o m the D i s t r i c t of C o l u m b i a , a n d f r o m o u r i s l a n d possessions. M i s s D i x d r a f t e d the bill o r g a n i z i n g the hospital, a n d a l s o o b t a i n e d its p r e s e n t b e a u t i f u l location. A n o t a b l e f e a t u r e in the history of this h o s p i t a l is that t h r e e men h a v e s e r v e d as its h e a d f o r a total of e i g h t y - o n e out of its e i g h t y - f i v e y e a r s of e x i s t e n c e . Its first s u p e r i n t e n d e n t , D r . C h a r l e s H . N i c h o l s ( a l i f e - l o n g f r i e n d of M i s s D i x ) , w a s a p p o i n t e d in 1 8 5 2 a n d s e r v e d until 1 8 7 7 . H i s successor, D r . W . W . G o d d i n g , w a s superintendent f o r twenty-two years, 1877-99. Dr. W i l l i a m A . W h i t e held the post f r o m 1 9 0 3 , until h i s d e a t h in 1 9 3 7 .

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In this connection, we may mention the little realized, but vastly important role of M i s s Dix in the development of psychiatric training in this country. T h e many institutions created through her efforts later became valuable training schools f o r specialists in mental disease. A s T i f f a n y states, in reference to the "rapid, Napoleonic victories" of her first ten years of crusading, "there had existed—except in a f e w scattered places—neither the call nor the opportunity f o r practically enlisting and employing this special [psychiatric] order of medical talent. N o w fast grew up a wide demand f o r it, a great school of practice in which to acquire and exercise the requisite knowledge and skill." 1 5 She had effected a revolution in the care of the mentally ill in a foreign country where native reformers had almost despaired of progressive reform. H e r greatest battle—the fight f o r the 1 2 , 2 2 5 , 0 0 0 Acre B i l l — w a s lost a f t e r coming within a hair's breadth of victory. If that fight had been won, the principle of federal grants to states in aid of the indigent would have been established fully three-quarters of a century sooner than actually happened. On this score, posterity vindicated Dorothea Dix and not Franklin Pierce. In 1 8 8 1 , when nearly eighty, Miss Dix retired from active work. Broken in physical health (though her mental vigor remained unimpaired to the end) she sought asylum in the bosom of her "first-born child," the N e w J e r s e y State H o s pital at Trenton, where she spent the remaining years of her life. She died on J u l y 1 7 , 1 8 8 7 , and was buried in M o u n t Auburn Cemetery near Boston, Massachusetts, in the presence of a small circle of friends. Among them was D r . Charles H . Nichols of Bloomingdale Hospital who, apprising M i s s Dix's English friends of the event, w r o t e : T h u s has died and been laid to rest, in the most quiet, unostentatious w a y , the most useful and distinguished woman America has yet produced.

" T h e most useful and distinguished woman America has yet produced." Superlative words, these, but, in large measure, true ones.

CHAPTER

Χ

Mid-Century Psychiatrists T \ O R O T H E A L Y N D E D I X w a s m o r e than a unique p e r s o n a l i t y ; she w a s the symbol of an epoch. J u s t as we might characterize the age of C h i a r u g i , Pinel, T u k e and R u s h as one of " r a t i o n a l r e f o r m " so w e might characterize hers as one of " m o r a l r e f o r m . " R e f o r m moved f o r w a r d on the wheels of philanthropy, but it w a s a r e f o r m which f o u n d its f u n d a m e n t a l impetus not so much in a search f o r scientific k n o w l e d g e , as in a v a g u e , sentimental attitude t o w a r d mankind, heavily tinged with an impersonal, religious sense of duty.* A l l too o f t e n sentimental humanitarianism, lacking the vital attributes of science, leads a l o n g deceptive r o a d s and into blind alleys f r o m which society later extricates itself only with g r e a t pain and difficulty. T h i s truth is well exemplified in certain historical phases in the care and treatment of the mentally sick. T h e ideal of institutionalization, as w e h a v e previously noted, w a s peculiarly a product of the nineteenth century. I t o w e d its rise mainly to the industrial revolution, with concomitant changes in the social o r d e r , rapidly e v o l v i n g complexities in social relationships, tremendous expansion of population, and closer g r o u p i n g of that population in l a r g e towns and cities. T h e simple m a k e s h i f t s of a simple community living under a simple economy w e r e no l o n g e r possible in this increasingly complex w o r l d . T h e first and most logical solution that presented itself in dealing with • I n at least this respect, E. Douglas Branch is correct in entitling his historical account of the period 1836-1860, The Sentimental Years. (New York, 1934.) 186

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the mentally, physically and economically disabled was to gather them together into centers of custody, care and treatment. T h i s was all very well in so f a r as the building of institutions represented a radical improvement over the f o r m e r anarchy and indifference and neglect. But in social processes, w h a t originates as a progressive idea may become rigid, inflexible and anachronistic with the passing of time. It fixes itself on the body of r e f o r m like an incubus. W h i l e the once progressive idea remains static, changing social forces leap ahead of it; what was once a f o r w a r d tendency degenerates into retrogressive channels. During the dominance of the custodial ideal, institutionalization was conceived of as an end in itself. Curiously enough, this conception persisted f a r into the period when cure superseded mere care as an institutional objective. T h e asylum or hospital had become a fetish, as it were, with nearmagic powers unconsciously attributed to it. It seemed to matter not how ill-equipped it might be f o r curative treatment; any institution labeled " H o s p i t a l f o r the Insane," was expected to restore the sick mind by simply enveloping that mind within its healing walls. H e r e we meet with one of those interesting recurrences found o f t e n enough in the pages of history. F o r what was this exaggerated concept of a mental hospital per se—what was it but a throw-back to the healing temples of the ancient Egyptians and Greeks, where, it was thought, the sick body and mind could be made whole again by the operation of a mystic power inherent in the temple itself? T h e prevailing approach to the therapeutic problems of mental illness was a simple one; all the insane, or nearly all, could be cured in institutions; none, except a very few, could be cured outside. Even in the minds of the most eminent practitioners in the field of mental diseases, this over-simplified doctrine received credence over a long period of years. It is not surprising, therefore, that the main emphasis in treating the insane during this period was placed on the mechanics of institutional arrangement. T h e problems of organization, administration and methods of therapy were, as a rule, considered to be of relatively small consequence

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in mental hospitals; the important thing was to build them. It didn't matter that some of the special hospitals and asylums were hardly better than the almshouses and jails where the insane had formerly been confined—the very change in nomenclature seemed to possess a magic potency in itself. T h e r e were, of course, other factors tending to emphasize the construction of hospitals rather than their operation along scientific principles. A s D r . Walter Channing said f o r t y years ago in defense of his forerunners: " I t was not a question of knee-jerk, or ankle-clonus or reaction-time which confronted them, but how to house the then already large numbers of insane, who, as shown by Miss Dix, were suffering the tortures of the damned in almshouses and in their own homes; and f r o m that day to this the pressure has never relaxed f o r more accommodations. T h e r e are still [ 1 8 9 4 ] thousands scattered through the country, kept in the vilest of almshouses, still suffering tortures." 1 T h e paramount question to the early psychiatrists, then, was to provide state institutions built especially f o r the insane. It remained f o r later generations to concentrate on the problems of therapeutic treatment within these hospitals. It goes without saying that in general the mental hospitals erected in this period were really f a r superior to the old receptacles where the mentally ill were herded indiscriminately with all classes of sufferers, and made possible many recoveries that might never have taken place in the old days of indifference. In the examination of history one must always be careful to distinguish between theory and actual practice at any given time. L e t us not forget that most of the humane theories that rallied the forces of reform in the late eighteenth and nineteenth centuries (and that are still considered sound today) had been clearly enunciated by Greek practitioners like Asclepiades and Aretaeus many hundreds of years before. It was the gradual development of certain social forces that made possible the materialization of some of these ideals a f t e r a lapse of many centuries. I say "some of them" advisedly, because many of the barbaric practices

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that had their origin in the days of demoniacal possession and other superstitious beliefs continued to exist well into the humanitarian period. Kindness is a relative term, depending f o r its interpretation upon the elements of time and place. U n d e r a kindly impulse, the Q u a k e r s of Pennsylvania, while taking an historic step f o r w a r d by founding the first state prison, inaugurated therein the system of solitary confinement which, in effect, was f a r m o r e soul-racking than the types of corporal punishment t h a t h a d been abolished. W e have seen how the great pioneer, Benjamin Rush, in the belief t h a t he was aiding the cause of the insane, invented that instrument of torture, the tranquilizing chair, which continued in use f o r decades a f t e r his time. Likewise, his successors, who were also motivated by the kindliest of impulses and looked with h o r r o r upon chains and irons, nevertheless sanctioned the liberal use of other types of restraining devices which, though mild enough in appearance, when applied continuously f o r long periods (as frequently happened) were even more agonizing than the clanking chains and the whips of yore. W a s it because the men of those days were less humane than we are t o d a y ? N o t at all. T h e difference lay mainly in this: they were just as kind, but their kindness was not implemented by adequate knowledge. T o d a y we benefit by the greater knowledge accumulated slowly and painfully in the intervening years. O u r knowledge of mental illness, its causes and treatment, is still very, very f a r f r o m being complete, but it is ever so much richer than that of our nineteenth century ancestors. Humanitarianism, groping its way forw a r d along the dark corridors of ignorance, can accomplish but little by itself. It becomes truly effective only when its path is lighted by the beacon of science. I t is significant t h a t the greatest reforms in the care and treatment of the insane in the first half of the nineteenth century lay rather in the substitution of kind for cruel treatment than in scientific therapy. Even the most advanced hospitals of the day resembled well-conducted boarding houses rather than hospitals. They had little more to offer

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the mentally ill than food, clothing, pleasant surroundings, neat apartments, and perhaps some means of employment and exercise. N o t that these factors were u n i m p o r t a n t : the environment afforded in these institutions was certainly f a r more conducive to recovery than t h a t of the almshouse, jail or home-made cage. It was a great step ahead. T h e pity was t h a t too many felt that the end had been reached once a pleasantly located building was reared. T h e heads of institutions were pleased to call themselves "medical superintendents," a term that aptly described their functions. In the mid-nineteenth century they actually differed little f r o m their predecessors, the lay superintendents. Except f o r a few outstanding leaders, most of them were not so much psychiatric specialists as physicians with executive and business ability. 2 About the time that D o r o t h e a Dix stumbled upon her great life-work, the care and treatment of the mentally ill was in a more or less chaotic state. Medical care in hospitals f o r the insane had advanced but little since the days of the venerable Rush. A case in point was the still widespread use of bloodletting as a remedy f o r mental disorders. Progress in this respect took the negative f o r m of discarding therapeutics shown by experience to be unavailing or even injurious, rather than of discovering better methods of treatment. T h e construction, organization, and administration of hospitals differed widely and were patterned upon a rather h a p h a z a r d , unscientific selection. In other aspects of institutional treatment and care a similar anarchy was evidenced. State hospitals were everywhere springing up. But they were heavily handicapped at the very outset by haste in building and lack of adequate planning, general ignorance as to what the true functions of a hospital should be, and the confusion a m o n g experts on the whole subject of hospital building and administration. M a n y of the new institutions were headed by men who were willing and energetic enough, but who had h a d little or no previous experience in treating the mentally ill. ( T h i s situation is unfortunately true even today in certain p a r t s of the country.) Structures that were launched with high hopes and noble aspirations soon degenerated into

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m e r e places of custody instead of cure, to the despair of those w h o had labored and f o u g h t to bring them into being. T h e m o r e advanced a m o n g the medical superintendents of the time w e r e keenly a w a r e of the chaotic situation t h a t c o n f r o n t e d them. T h e time w a s ripe f o r f o r m i n g a body to advance the interests of the mentally ill, to o r g a n i z e the k n o w l e d g e of psychiatry then available, and to build solidly upon it. E a r l y in 1 8 4 4 the question of an o r g a n i z a t i o n of medical superintendents w a s discussed by D r . Samuel B . W o o d w a r d , of the W o r c e s t e r State H o s p i t a l in M a s s a c h u setts, and D r . F r a n c i s T . Stribling of the W e s t e r n State H o s p i t a l at Staunton, V i r g i n i a . B o t h men were convinced of the timeliness of such a society, and m a d e contact with a number of their c o n f r e r e s to bring it about. T h e i r conversation resulted in a founding meeting held at J o n e s ' H o t e l in P h i l a d e l p h i a on October 1 6 , 1 8 4 4 , which w a s attended by thirteen medical superintendents, t h e r e a f t e r reverently ref e r r e d to in A m e r i c a n psychiatric annals as " T h e O r i g i n a l T h i r t e e n . " Out of that meeting w a s born the Association o f M e d i c a l Superintendents of A m e r i c a n Institutions f o r the Insane. E v e n t u a l l y , that ponderous title w a s c h a n g e d : the o r g a n i z a t i o n f o u n d e d in that Philadelphia hotel w a s k n o w n f r o m 1 8 9 3 to 1 9 2 1 as the A m e r i c a n M e d i c o - P s y c h o l o g i c a l Association, and it now bears the title of the A m e r i can Psychiatric Association. I t w a s the first national society of medical men in the U n i t e d States. In its special field it w a s not without precedent a b r o a d , since three y e a r s earlier, the first national psychiatric body in the w o r l d had been f o r m e d in E n g l a n d as the A s s o c i a t i o n of M e d i c a l Officers of A s y l u m s and H o s p i t a l s f o r the Insane. Its objects, as set f o r t h in the circular letter of organization, w e r e a l m o s t identical with those of the A m e r i c a n society: " t h e medical gentlemen connected with lunatic asylums should be better k n o w n to each other, should communicate m o r e f r e e l y the results of their individual experience; should cooperate in collecting statistical i n f o r m a t i o n relating to insanity, and above all, should assist each other in improving the treatment of the insane." 3 T h e names of the T h i r t e e n who sat at the founding meet-

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ing in Philadelphia loom large in the pages of American psychiatric history. T h e y were Samuel B. W o o d w a r d of the Worcester State Hospital, Isaac R a y of the Maine State A s y l u m at Augusta, Luther V . Bell of the M c L e a n Asylum, Charles E . Stedman of the Boston Lunatic Asylum, Nehemiah Cutter of the Pepperell Private Asylum ( M a s s a chusetts), John S. Butler of the H a r t f o r d Retreat, Amariah B r i g h a m of the N e w Y o r k State Lunatic Asylum at Utica, Samuel White of the Hudson Lunatic Asylum (private) at Hudson, N e w Y o r k , Pliny E a r l e of the Bloomingdale Asylum, T h o m a s S. Kirkbride of the Pennsylvania Hospital f o r the Insane, William M . A w l of the Ohio Lunatic Asylum at Columbus, Francis T . Stribling of the Western Lunatic Asylum of Virginia at Staunton, and J o h n M . Gait of the E a s t e r n Lunatic Asylum at Williamsburg, Virginia. H e r e were names to conjure with. T h e r e was hardly a man among them who did not make some outstanding contribution to his field. T h e original Thirteen represented a f a i r cross-section of every type of mental hospital in the country: state-owned, municipal, corporate and private. N o t the least striking feature about them was their youth; nearly all had been appointed to superintendencies (or the equivalent) at a very early age. Gait was but twenty-two when he became an institutional head ( 1 8 4 1 ) ; Stribling was twenty-six ( 1 8 3 6 ) ; Bell received his appointment at thirty ( 1 8 3 6 ) ; Kirkbride at thirty-one ( 1 8 4 0 ) ; R a y at thirty-four ( 1 8 4 1 ) ; E a r l e at thirty-five ( 1 8 4 4 ) ; Butler at thirtysix ( 1 8 3 9 ) ; Stedman at thirty-seven ( 1 8 4 2 ) ; A w l at thirtynine ( 1 8 3 8 ) ; and Brigham at forty-one ( 1 8 4 0 ) . Of the Thirteen, only White, W o o d w a r d and Cutter were above forty-five years of age at the time of organization. A compact group they formed, alive with energy. T h e y were f o r the most part men of great vitality, forceful will and abounding humanity. Naturally they were not without faults and shortcomings, but their defects originated not so much f r o m a lack of fine aims and ability as f r o m the prevailing scarcity of knowledge. T h e y had at their disposal but f e w scientific data concerning the needs of the mentally sick and methods of meeting those needs. Despite all that

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had been done in the humanizing of care and treatment, the scientific side of psychiatric practice had advanced hardly at all. Franklin B. Sanborn, in his biography of one of the most eminent of the Thirteen, succinctly describes the situation in these terms : None

of

these

alienists . . . had

comprehended

the

statistical,

economic, or even sanatory relations of the public care of the insane. I t w a s still a n e w matter. E x p e r i e n c e w a s w a n t i n g . . . T h e asylums w e r e f e w and small, receiving but a portion of the insane, and had no means of determining the exact physical condition of the patients they treated. T h e microscope had h a r d l y begun to do its w o r k in revolutionizing medicine. T h e localization of function in the brain w a s in its rudiments, and w a s obscured by the c h a r l a t a n r y of

phrenology.

T h e classification of insanity by its external manifestations w a s v e r y little advanced, and had to be the study of each alienist in his o w n n a r r o w field of observation. T h e y experimented w i t h medical and m o r a l t r e a t m e n t ; and, like D r . R u s h , they f o r m e d singular notions of w h a t treatment w a s applicable to the mass of the insane. Still, k n o w l e d g e advanced under their isolated experiences. T h e y communicated f a c t s to each other and to the p u b l i c /

N o r was America alone in this backwardness. T a k e Germany, f o r instance, which was destined soon to gain the foremost place in psychiatric knowledge and experimentation. A s late as 1 8 4 0 there were many German medical men who still accepted as true Heinroth's theory that insanity and sin were identical, that mental illness was merely the manifestation of demoniacal possession, and that treatment should be based on theological doctrines rather than on science. It was not until William Griesinger published his monumental Die Pathologie und Therapie der psychischen Krankheiten in 1 8 4 5 (the year a f t e r the Association of Medical Superintendents was founded in America) that the metaphysical concepts of Heinroth were finally swept into the discard. Incidentally it was Griesinger who, more than any other individual of his century, placed psychiatry on a scientific footing, defining its position in relation to kindred sciences. H e was only twenty-eight when his revolutionizing book was published, another indication that his was a period when youth led the way in scientific advancement.

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I n A m e r i c a , as elsewhere, psychiatry w a s still in its i n f a n c y . T h e thirteen w h o met in 1 8 4 4 w e r e alive to the momentous problems f a c i n g them. T h e y wisely sensed that their m a j o r task of the moment w a s to g a t h e r the loose, disconnected threads of k n o w l e d g e pertaining to their c r a f t , and to knit these threads into a unified pattern. It w a s their j o b to get their bearings and to direct their course accordingly. I t w a s a gigantic task they undertook, but they attacked it with characteristic v i g o r . U n d e t e r r e d by their small number, the g r o u p of enthusiasts appointed no less than sixteen committees, embracing well-nigh e v e r y phase of their specialty, with instruction to submit reports at the next meeting. T h e names of these committees a f f o r d an interesting index to the topics uppermost in the minds of these men. T h e y included a committee on the m o r a l treatment of insanity, another on medical treatment, a committee on restraint and restraining apparatus, on the construction and o r g a n i z a t i o n of mental hospitals, on the jurisprudence of insanity, on the prevention of suicide, on a manual f o r attendants, on statistics, on support of the pauper insane, on asylums f o r idiots and the demented, on post-mortem examinations, on the c o m p a r a t i v e a d v a n t a g e s of hospitals and p r i v a t e practice, on asylums f o r colored persons, on p r o p e r provision f o r insane prisoners, and on the causes and prevention of insanity. 5 D r . W o o d w a r d w a s elected first president of the Association, D r . W h i t e vice-president, and D r . K i r k b r i d e secretary. R e f e r r i n g to that founding g r o u p a half-century later, D r . W . W . G o d d i n g invoked the Biblical text : " T h e r e w e r e giants in the earth in those d a y s . " A n d we m a y well concur in that characterization. W h e n w e consider how little they h a d to start with, and w h a t difficulties they f a c e d in the triple threat of apathy, ignorance and niggardliness, their achievements cannot but win our respect and admiration. T o gether, they tried to f o r m u l a t e their specialty into an integrated whole, and they w o r k e d continuously f o r its advancement. T h e y e a g e r l y strove to collect the f a c t s and to use them to benefit their stricken f e l l o w men. A n d more : they endeavored to impart their findings not only to their

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confreres in the field, but to the public at large, knowing that their progressive efforts would come to naught without the backing of an alert public opinion. T h e y were propagandists in the best sense of the term. If they failed in some of the tasks they set themselves, it was not so much their fault, as individuals or as a group, as it was the restricted social frame in which they were compelled to operate. N o generation in any profession pulls itself up f r o m its milieu by the bootstraps. A s has been noted, their duties demanded of them a great degree of versatility. Y e t , almost without exception, each of the founding fathers was able to gain a marked distinction in some particular branch of his profession to which he directed his special attention. T h e i r individual accomplishments are inseparably bound up with the general progress of the care and treatment of the mentally ill during their lifetime. L e t us briefly examine them, one by one. Samuel B. W o o d w a r d ( 1 7 8 7 - 1 8 5 0 ) was a pioneer in his profession in a very real sense. H e was most active in founding the Retreat at H a r t f o r d , Connecticut, in 1 8 2 4 , and afterwards served as one of its visiting physicians. W h e n the Worcester State Hospital was organized in 1 8 3 2 , he was named its first superintendent. H i s reports as head of that institution were probably the most widely read in America, being circulated in editions averaging three thousand each. T h e y also evoked much favorable comment in Europe. During the movement toward state-asylum building that may be said to have begun with the establishment of the Worcester Hospital, he was probably the most quoted authority on the subject. H i s optimistic descriptions of results obtained at Worcester did a great deal to stimulate the movement in other states. H e paid particular attention to the question of asylum statistics, as the laboriously prepared tabulations in his own reports show. Although his own methods were seriously erroneous in some respects (such as his computing recovery percentages on the basis of discharges instead of admissions) he succeeded in attracting the attention of his contemporaries to the values inherent in the comparatively new science of statistics. A n enthusiastic

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student of Pinel and Esquirol in the treatment of mental illness, he did much to popularize their methods in America. Samuel White ( 1 7 7 7 - 1 8 4 5 ) conducted a private asylum f o r the insane at Hudson, N e w Y o r k . Opened in 1 8 3 0 , it gained a wide reputation as the most successful private institution in the country. D r . White was looked upon as New Y o r k State's foremost specialist during the '30's. H e was frequently consulted by legislative committees in the steps that led to the establishment of the Utica State Asylum, and was the recipient of high praise in several official reports. H e died shortly after the founding of the Association. T h e one other among the original Thirteen who operated a private establishment was Nehemiah Cutter ( 1787— 1 8 5 9 ) . H i s hospital was located at Pepperell, Massachusetts, where it had developed out of the occasional treatment of mental patients at D r . Cutter's own home while he was engaged in general practice. H i s reputation as a healer spread rapidly, with a corresponding increase in patients, so that in a short time he was compelled to add new wings to his home in order to accommodate them all, and finally to erect a large hospital building on the premises. This institution burned down in 1 8 5 3 , and was never rebuilt. T h e Virginians, John M . Gait ( 1 8 1 9 - 1 8 6 2 ) and Francis Stribling ( 1 8 1 0 - 1 8 7 4 ) , heads of the Eastern and Western Lunatic Hospitals of Virginia, respectively, were the youngest founding members of the Association. Quiet and unassuming, D r . Stribling was consistently a staunch advocate of humane reforms in the care and treatment of the mentally ill, and presided over his own institution with consummate skill. D r . Gait, who was appointed medical superintendent of the Eastern Lunatic Asylum in 1 8 4 1 , was the third member of the Gait dynasty to head that historic institution in succession. T h e family ruled over the destinies of the hospital without interruption f o r nearly a century, f r o m its opening in 1 7 7 3 until 1 8 6 1 — a record unequalled even by the famous T u k e family's connection with the Retreat at Y o r k , England. Getting his appointment at twentytwo (only a few months a f t e r receiving his medical deg r e e ) , D r . Gait soon rose to a leading position in his

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specialty. Of a brilliant temperament and studious frame of mind, his commentaries on insanity, particularly those embodied in his principal treatise, Treatment of Insanity ( 1 8 4 6 ) , attracted wide attention. H e was a frequent contributor to scientific and learned journals on the subject of insanity, and undoubtedly would have achieved greater renown had not his career been cut short at a comparatively early age. Luther V . Bell ( 1 8 0 6 — 1 8 6 2 ) was a man of varied pursuits, equally active in political life and professional work. While in his late twenties, he served as a member of the New Hampshire legislature. ( H i s father had served as governor of that state.) His able reports to the legislature were mainly instrumental in establishing the state hospital at Concord. In later life, D r . Bell was several times a candidate f o r high public office in Massachusetts. In 1826 he was appointed physician and superintendent of the M c L e a n Asylum, where he presided f o r the next twenty years. A w a r e of the importance of structural details in hospitals he closely followed developments in this field and was quick to embody the latest improvements at the institution he headed. T h e M c L e a n Asylum, under his superintendency, was the first institution in America to employ successfully a circulating hot water system f o r warming a large, inflowing current of air. In 1 8 4 5 he made a round of inspection of mental hospitals in Europe at the solicitation of the trustees of the newly established Butler Asylum in Providence. H i s recommendations, together with those of D r . Isaac R a y (who had been sent on a similar mission) formed the basis of the plans f o r the proposed asylum. When completed, this hospital was conceded to be one of the finest in America. D r . Bell's excellent reports, like those of his leading confreres, teemed with propaganda aimed at the erection of more and better built institutions f o r the insane. T h e y were frequently and effectively quoted by his close friend, Dorothea Dix, in her petitions to various state legislatures. An acute observer and clinician, he made many valuable contributions to the then meagre knowledge of diagnosis in mental diseases. H e wrote the first description of a form of

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acute mania thereafter known as Bell's Disease. In 1 8 5 6 , he resigned his post at the M c L e a n Asylum due to failing health. But when the Civil W a r broke out he immediately volunteered in the Union forces, and was brigade surgeon to General Hooker's Division when he died in camp on February 1 1 , 1862. Amariah Brigham ( 1798—1849) was occupying a professorship of anatomy and surgery at the College of Physicians and Surgeons in N e w York City in 1 8 4 0 when he was called to the H a r t f o r d Retreat to serve as medical superintendent. H e resigned two years later to accept the superintendency of the newly organized Utica State Asylum in N e w Y o r k , built at a higher cost than any other mental hospital up to that time. Dr. Brigham began his regime under great difficulties. Before the asylum buildings had been completed the doors were thrown wide open f o r the reception of patients, causing no little confusion. Within a year a f t e r opening, it was obvious that the original plans were inadequate to meet the pressure of the increasing stream of patients, and enlargements were begun at once. T h e entire task of overseeing the structural changes, organizing the asylum staff, caring for and classifying the patients, etc., was borne by D r . Brigham. N o t content with conducting a mere boarding house f o r the insane, as was then the vogue, he did all in his power to have his institution function as a real hospital, with cure the ever-present and dominant ideal. H e was a firm believer in the efficacy of occupational therapy, and instituted a thorough system of indoor and outdoor labor, to suit the varied needs and backgrounds of the patients. In 1844, Brigham founded the American Journal of Insanity, which represented his most important contribution to American psychiatry. It was published at his own expense, edited by himself and his fellow-officers at the Utica State Asylum, and printed with the help of patients at the asylum print shop. This was the first journal in the English language devoted to mental medicine. ( A French publication, the Annales Medico-Psychologiques had been established a year earlier in Paris, and the Allgemeine Zeitschrift für

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Psychiatrie was launched in 1844. T h e first journal devoted to psychiatric problems had been founded in Germany in 1805 by Johann C. Reil.) In his introductory prospectus to the journal, setting forth its raison d'être and its objects, D r . Brigham wrote : T h e object of this Journal is to popularize the study of insanity—to acquaint the general reader with the nature and varieties of this disease, methods of prevention and cure. W e also hope to make it interesting to members of the medical and legal profession, and to all those engaged in the study of the phenomena of mind. Mental philosophy, or metaphysics [ ! ] , is but a portion of the physiology of the brain ; and the small amount of good accomplished by psychological writers may perhaps be attributed to the neglect of studying the mind, in connection with that material medium which influences, by its varying states of health and disease, all mental operations. W e regard the human brain as the chef d'oeuvre or masterpiece of creation. T h e r e is nothing that should be so carefully guarded through all the periods of life. U p o n its proper development, exercise and cultivation, depend the happiness and higher interests of man. Insanity is but a disease of that organ, and when so regarded, it will often be prevented, and generally cured by the early adoption of proper methods of treatment. 0

Obviously, its founder intended the journal to reach the general public quite as much as those engaged in the specialty. H e burned with the evangelistic zeal that so sharply characterized his generation. This enthusiasm is also reflected in his institutional reports, a generous part of which was always devoted to impressing upon the general reader the necessity of increasing existing facilities f o r the care and treatment of the insane. H e was also alive to the importance of removing from the subject of insanity the mantle of mingled horror and mystery that popular fancy wrapped about it, and to strike down the surviving superstitions standing in the way of progress. This must have been one of his principal considerations in desiring to keep in close contact with the public. It is interesting to note in D r . Brigham's prospectus reflected a significant turn in the professional theory of in-

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sanity: in contrast to the f o r m e r belief that mental disease was wholly psychic in origin, it was at this time generally held to be purely physical, with the seat of mental disorders rooted in the brain. A later age was to effect a compromise between the two extremes. A s f a r as the budding psychiatric profession of the time was concerned, the journal could hardly have appeared at a more opportune moment. A s D r . G . Alder Blumer once said: " T h i s journal . . . soon becoming the organ of the whole specialty in this country, and reporting the papers and discussions of our Association, served to concentrate and strengthen the scientific spirit of investigation and to give it purpose and consistency; f o r the science itself, in which so much still remains to be done, was then really at a stage almost elementary and inchoate." 7 A f t e r D r . Brigham's death in 1849, the journal passed into the hands of the managers of the Utica State Asylum. T o w a r d s the end of the century it was taken over by the Association, becoming its official organ, and its place of publication was transferred to Baltimore. In 1 9 2 1 it underwent a change of title to the American Journal of Psychiatry. Another interesting literary experiment was introduced at Utica with the founding in 1 8 5 0 of an intramural periodical, The Opal, edited and published by the patients themselves at the institutional print shop. It was not the first intramural publication prepared by and f o r mental patients, but it represented by f a r the best up to that time, and gained the widest recognition. A s early as 1 8 3 7 a newspaper, the Retreat Gazette, probably the first of its kind in America, had been published at the H a r t f o r d Retreat. It was edited by a patient who had been a newspaperman before entering the Retreat. Unfortunately, the Gazette was a one-man affair and ceased to function a f t e r the editor's recovery and discharge from the hospital. T h e second intramural publication in the United States ( T h e Asylum Journal) was founded in 1 8 4 2 at the Vermont Asylum at Brattleboro. It was issued first as a weekly, then as a monthly. 8 It was established by an enterprising young patient—a seventeenyear-old printer—and discontinued publication a f t e r four

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years due to the discharge of the founder and several other editor-patients from the hospital. The third institutional periodical, The Opal at Utica, went out of existence in 1861 for similar reasons. John S. Butler ( 1 8 0 3 - 1 8 9 0 ) and Charles Harrison Stedman (1805—1866) served as first and second superintendents, respectively, of the Boston Lunatic Hospital, the first municipal institution of its kind to be established in the United States. Dr. Butler, who received his earliest training in the care of the mentally ill from Woodward of Worcester, occupied the post of superintendent from its opening in 1839 until 1842. The following year he became head of the Hartford Retreat, where he remained for the next thirty years. Throughout his active career, Dr. Butler exercised a powerful influence in the Association he had helped organize. He made a particular study of the legal aspects of insanity and was frequently called upon to give expert testimony in important cases involving the plea of insanity. In 1873 he resigned as superintendent of the Hartford Retreat, and retired to private practice. Five years later he was named the first president of the newly created Connecticut State Board of Health, retaining his membership on that Board until his death at the advanced age of eighty-seven. Dr. Stedman was the recipient of glowing praise from the pen of Charles Dickens, who visited the Boston Hospital for the Insane in 1842 (soon after Stedman became the executive officer there) and recorded his impressions of both the institution and its head in his American Notes. Besides his duties at the Hospital, Dr. Stedman was called upon to function as physician and surgeon to the city's various charitable and correctional institutions. H e resigned in 1 8 5 1 , and thereafter pursued a dual career as practicing physician and politician. He was subsequently appointed Massachusetts' first medical coroner, served in the State Senate and on the Governor's Council, and was senior surgeon at the Boston City Hospital (established 1864) at the time of his death. William M . Awl ( 1 7 9 9 - 1 8 7 6 ) helped found the Ohio

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S t a t e A s y l u m f o r the Insane at Columbus, and became its first superintendent when it opened in 1 8 3 8 . H e continued in that office t w e l v e y e a r s , when he w a s turned out by the p r e v a i l i n g system of political appointment. Subsequently he became physician at the Ohio Institution f o r the B l i n d , having played a prominent role in its establishment, also. Pliny E a r l e ( 1 8 0 9 - 1 8 9 2 ) brought to the specialty a temp e r a t e , clear-thinking personality. Possessing a keen-edged mind, he w a s able to cut through many of the l a y e r s of ignorance and pretension that lay h e a v y on the y o u n g body of psychiatry. H e w a s not so much an original thinker as a critical one, and his outstanding contributions w e r e born of his critical ability. A f t e r f a l l i n g a victim to the "curability c r a z e " in his early d a y s of practice, he saw through the delusion and set out courageously to destroy it. H e m a n a g e d to expose many other current fallacies, accumulating a f o r m i d a b l e a r r a y of enemies in the process, as is the f a t e of e v e r y iconoclast. H i s critiques of the slipshod, archaic methods of compiling hospital statistics in his time p r o v e d of g r e a t value in rescuing the reporting of institutional statistics f r o m its l o w estate. T h o u g h he was no innovator h i m s e l f , he was ever r e a d y to adopt new methods that, in his opinion, had been adequately tested by others. L i k e K i r k b r i d e and R a y , he w a s a man of strong convictions and stubbornness of purpose. Once convinced a course w a s right, nothing could deter him f r o m putting it into practice and seeing it through. E a r l e began his p r o f e s s i o n a l career in 1 8 4 0 as resident physician at the F r i e n d s ' A s y l u m at F r a n k f o r d , a f t e r he h a d returned f r o m a two-year study of mental hospitals in E u r o p e . In 1 8 4 4 he w a s appointed attending physician to the B l o o m i n g d a l e A s y l u m in N e w Y o r k . H e r e he instituted a strong regimen of manual w o r k , believing it to be a m a j o r therapeutic agent in the cure of mental diseases. H e never hesitated to f o r c e l a b o r on patients w h o , he f e l t , w o u l d benefit by it, r e g a r d l e s s of w h a t protests might be m a d e by the patient o r his f r i e n d s on the basis of social status, etc. D r . E a r l e retained his post at B l o o m i n g d a l e f o r five y e a r s . T h e n f o l l o w e d a second tour through E u r o p e , with visits to

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hospitals along the way. His observations were recorded in a work entitled Institutions for the Insane in Prussia, Austria and Germany (published 1 8 5 3 ) . This brochure did much to familiarize medical men in the United States with the progress in these countries, where psychiatrists were throwing off the metaphysical shackles that bound their predecessors. Previously, American and English observers of continental institutions had seldom penetrated beyond the borders of France. Americans were still prone to think of all German "alienists" (the term adapted from the French, designating specialists in mental diseases) as speculative metaphysicians, still following Heinroth slavishly. Significantly enough, English and American medical men were f o r many years reluctant to accept the term "psychiatry," which originated in Germany, because of their distrust of its metaphysical associations. They clung to the less definite term, alienism, until very recent years. E a r l e ' s contemporaries could hardly believe his statement that he had found in the German-speaking countries "a long list of men eminent in the specialty, who had produced a surprisingly large amount of published matter, both of speculative research into the origin and essential nature of insanity, and of treatises on its practical care and recovery."" A f t e r his return to America D r . E a r l e resumed the practice of his profession, serving f o r some time as visiting physician in the N e w Y o r k Lunatic Asylum at Ward's Island, and lecturing on mental diseases at the College of Physicians and Surgeons. In 1864 he was named superintendent of the Northampton Lunatic Asylum, which had opened in 1 8 5 8 as the third state hospital in Massachusetts. Here he remained until his death, although he resigned from active service in 1885 at the age of seventy-six. T h e curability myth, against which he waged a long and strenuous fight, was dealt its coup de grâce in his chief work, The Curability of Insanity ( 1 8 8 6 ) , based on painstaking research into the reports and statistical records of scores of American and British hospitals over a period of some fifty years. Isaac Ray ( 1 8 0 7 - 1 8 8 1 ) ranks among the foremost leaders of his period. Like many others in the specialty, he be-

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gan his professional career as a general practitioner a f t e r completing his medical education. W h i l e practicing at Eastport, Maine, his attention was attracted to the study of insanity, particularly in its legal aspects. T h i s important juridical area was as yet almost totally unexplored in America. T h e r e was a crying need f o r clarification. T h e need was supplied in 1 8 3 7 with the publication of Ray's Treatise on the Medical Jurisprudence of Insanity, a work that received wide and well merited attention. It is still quoted and accepted as an authority on many phases of medico-legal practice in the United States and abroad. In 1 8 4 1 D r . R a y was appointed medical superintendent of the State Hospital f o r the Insane at Augusta, Maine. H e continued there until 1 8 4 5 , when he was invited to become head of the Butler Asylum at Providence, then in the process of organization. T o g e t h e r with D r . Bell, he was solicited by the trustees to make an inspection tour of European institutions f o r the insane, so that the best features abroad might be synthesized in the contemplated hospital. A f t e r his return, he spent two years in supervising its erection. When the Butler Asylum opened in 1 8 4 7 he assumed charge of its administration and, during his ensuing twenty years of service, raised it to a position of high renown. In 1867 he resigned f o r reasons of health and thereafter made his residence in Philadelphia, where he carried on a lucrative private practice until his death in 1 8 8 1 . R a y was a man of wide interests, constantly keeping abreast of developments in the social sciences outside the orbit of his own specialty. H i s published writings, comprising more than one hundred items, display an excellent literary skill, marked by lucidity of thought and grace of style. In 1 8 6 3 he published a work entitled Mental Hygiene, an admirable exposition within the limits of knowledge then prevailing, of the origins and nature of insanity. It was one of the first treatises in America to present a detailed program f o r the prevention of mental disorders. H i s third important work was Contributions to Mental Pathology ( 1 8 7 3 ) consisting of a collection of papers and essays touching on nearly every phase of the subject.

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H e possessed an imposing f o r e n s i c ability, and used it with d e v a s t a t i n g effect in pointed attacks on the e r r o r s and abuses of his d a y . L i k e most of his leading contemporaries he w a s r a t h e r inclined to d o g m a t i s m , clinging tenaciously to w h a t e v e r doctrines he believed in. A l t h o u g h l a t e r experience did not confirm the correctness o f all his policies and theories, he w a s usually to be f o u n d on the side of p r o g r e s s in his p r o f e s s i o n . T h e r e w a s h a r d l y a m a j o r issue in psychiatry t h a t did not find him in the f o r e f r o n t of the battle, and m a n y a f a l s e doctrine w a s utterly demolished under the pitiless blows of his logic. W i t h Pliny E a r l e and E d w a r d J a r v i s , he led the fight f o r honest and efficient tabulating in mental hospitals. "Statistics which are not really statistics," he w r o t e , " a r e w o r s e than useless; and the reason is that they beguile the student with a show of k n o w l e d g e , and thus take a w a y the main inducement to f u r t h e r inquiry. W h y should he l o o k f a r t h e r f o r truth when it a l r e a d y lies b e f o r e h i m ? S o m e of the p r e v a l e n t e r r o r s respecting insanity and the insane a r e f a i r l y attributable to these vicious statistics, f o r figures m a k e a deeper impression on the mind than the most cogent a r g u m e n t s . " 1 0 D r . R a y w a g e d a continuous and courageous struggle f o r adequate a p p r o p r i a t i o n s f o r mental hospitals. A t a time when most f r i e n d s of the mentally ill deemed it sufficient to obtain f r o m the legislatures f u n d s b a r e l y enough to build institutions, with no thought f o r their maintenance, and when many medical superintendents felt it impolitic or dangerous to protest a g a i n s t legislative niggardliness, he repeatedly pointed out the absurd w a s t e f u l n e s s — i n the long r u n — o f short-sighted, pinch-penny policies tending to hamper, o r even to prevent, sound therapeutic practices in public hospitals. N o t the least of his achievements w a s the conspicuous role he p l a y e d in creating a sounder and m o r e sympathetic understanding of the mentally ill in both the public and prof e s s i o n a l mind. H i s d e l i g h t f u l little pamphlet, " I d e a l C h a r acters of the Officers of a H o s p i t a l f o r the I n s a n e , " written in 1 8 7 3 , might well serve t o d a y as a handbook in hospital service, as f a r as the sympathetic treatment of patients is concerned.

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R a y w a s generally considered the f o r e m o s t authority of his time on insanity in its relation to the law, and his service as an expert w a s in constant demand in important criminal cases. T h e l e a d i n g figure in the first f o u r decades of the Association and the most prominent A m e r i c a n psychiatrist of his time w a s T h o m a s Story K i r k b r i d e ( 1 8 0 9 — 1 8 8 3 ) . B o r n of Q u a k e r parents, his psychiatric career w a s begun as a resident physician at the F r i e n d s ' A s y l u m at F r a n k f o r d . L a t e r he joined the staff of the Pennsylvania H o s p i t a l as a surgeon, maintaining a flourishing p r i v a t e practice at the same time. W h e n the new D e p a r t m e n t f o r the Insane of the Pennsylvania H o s p i t a l w a s opened as a separate building in W e s t P h i l a d e l p h i a in 1 8 4 1 , he accepted a call to become its first superintendent and physician-in-chief. T h i s post he held f o r n e a r l y f o r t y - t h r e e y e a r s — p r o b a b l y a record tenure of its kind. So g r e a t w a s the impress of his personality on the institution he h e a d e d that it became popularly known as " K i r k b r i d e ' s . " A prominent British psychiatrist, D r . T . S. Clouston, recalling a visit he once m a d e in Philadelphia, r e m a r k e d t h a t a street car conductor w h o m he a p p r o a c h e d could not tell him w h e r e the Pennsylvania H o s p i t a l f o r the Insane w a s , but readily directed him to " K i r k b r i d e ' s . " 1 1 F r o m the v e r y first D r . K i r k b r i d e stood out as one of the leading medical superintendents. E v e n his earliest reports r e v e a l a m a n w h o h a d acquired a splendid g r a s p of his profession, w h o saw clearly the requirements of his charges and w a s determined to meet them. Gentle, kind and considerate in manner, he yet possessed a firmness of conviction that, though sometimes indistinguishable f r o m obstinacy, served as a t o w e r of strength to his f e l l o w s in those unsteady days of the specialty. W e h a v e a l r e a d y alluded to the pronounced tendency of the time to use mental hospital reports as mediums of beneficial p r o p a g a n d a , addressed to the public in the hope of creating mass backing behind the cause of the insane. T h e reports of no other medical officer, perhaps, showed this proclivity as m a r k e d l y as K i r k b r i d e ' s . H i s rep o r t s f a i r l y teem with g e n e r a l i n f o r m a t i o n on the subject of mental diseases, and display a knack f o r dealing with

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those phases which were uppermost in public discussion at the m o m e n t . D r . Kirkbride boldly combatted the popular inclination to regard mental diseases as mysterious afflictions, entirely remote in origin and nature f r o m all other diseases. D e p e n d ing f o r ammunition upon his arsenal of hard facts, he constantly b o m b a r d e d t h e citadels of superstition and delusion and strove to inculcate in the public mind a rational approach toward the subject o f insanity. H e r e are some representative statements culled f r o m his earliest reports : Insanity should be classed with other diseases . . . It should never be forgotten that every individual who has a brain is liable to insanity, precisely as every one who has lungs is liable to pneumonia, or as every one with a stomach runs the risk at some period of being a martyr to dyspepsia . . . It has been too much the custom to say, without any qualification, that "insanity is the greatest infliction that can befall humanity," and many patients have had their wretchedness vastly increased by this common assertion . . . T h e proposition just referred to has originated from taking, as a type of the disease, some incurable case, laboring under the most violent and repulsive symptoms, and made hopeless, perhaps, by want of proper care, or by a course of management tending only to prevent recovery. In a comparison of insanity with other diseases, it must be borne in mind that it presents the greatest diversity of aspect, and that the symptoms are in almost endless variety ; that many cases are attended with very little suffering, require but little restraint of any kind, are not disabled from appreciating books, or the society around them, or from enjoying many intellectual and physical comforts. 12 T h e s e w e r e sane w o r d s f o r those days, when even m a n y of the m o s t enlightened benefactors of the mentally ill believed that they could most effectively gain their ends by arousing terror and pity through citing the worst aspects o f insanity, thus unconsciously tending to perpetuate distorted v i e w s on the subject. I n the matter o f hospital organization, D r . Kirkbride w a s one o f the m o s t vigorous advocates of trained nursing staffs, carefully selected and well paid, and one o f the first to issue a printed manual to guide hospital e m p l o y e e s in

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their duties. L o n g b e f o r e the idea of training schools became accepted, he announced his intention of personally conducting a training course f o r attendants under his c h a r g e ( 1 8 4 3 ) . I t a p p e a r s , u n f o r t u n a t e l y , that the pressure of his v a r i e d l a b o r s p r e v e n t e d him f r o m carrying out his design. K i r k b r i d e ' s most distinctive contribution to the care and t r e a t m e n t o f the insane lay in the field of construction o f mental hospitals. F o r an entire generation his w o r d on hospital building w a s accepted as l a w in A m e r i c a . B e t w e e n the y e a r s 1 8 5 1 and 1 8 8 0 , at least thirty mental hospitals in this country w e r e designed and built on the " K i r k b r i d e p l a n . " U n t i l K i r k b r i d e ' s time there h a d been no u n i f o r m system of hospital construction. M a n y of the earlier institutions, as we h a v e seen, h a d been merely reconstructed p r i v a t e dwellings, o r else public institutions originally built f o r purposes o t h e r than the reception of the insane. Still others w e r e built f o r this specific p u r p o s e , but w e r e designed without any thought being g i v e n to the special needs of the mentally ill, and d i f f e r e d but little f r o m o r d i n a r y prisons or almshouses. D u r i n g the custodial period, when institutions f o r the insane w e r e r e g a r d e d as places f o r the secure keeping of lunatics with the s a f e t y of the general public in mind, asylums w e r e built accordingly. E v e n in the early period o f the curative ideal, " i n s a n i t y " w a s l o o k e d upon as " a d i s e a s e , " a single entity, r a t h e r than a g e n e r a l term comprehending a l a r g e and v a r i e d number of mental diseases. T h e resultant c o r o l l a r y w a s that, since all the insane w e r e alike, they required the s a m e t r e a t m e n t and the same surroundings. H e n c e all w e r e c o n g r e g a t e d t o g e t h e r indiscriminately, with little o r no classification in treatment, and usually none in structural a r r a n g e m e n t s . In the 1 8 4 0 ' s m o r e and m o r e thought w a s being devoted to the special requirements of the mentally ill, and this in turn led to serious consideration of structures of special design. A m o n g those w h o concentrated on this particular aspect of the care and t r e a t m e n t of the mentally ill, K i r k bride soon assumed a position of leadership and authority. A t the time the A s s o c i a t i o n of M e d i c a l Superintendents w a s f o r m e d , the question of construction occupied a para-

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mount place in the minds of its members, as their early discussions p r o v e . * T h e y f e l t keenly the need o f definition a n d clarification, and it w a s in this direction that their earliest attention w a s turned. T h e A s s o c i a t i o n h a d been in existence but a f e w y e a r s when D r . K i r k b r i d e , recognized as the ablest a m o n g them in building m a t t e r s , w a s d e l e g a t e d to d r a w up a set of " p r o p o s i t i o n s " o r rules embodying, as f a r as possible, the m a j o r structural considerations in a model hospital f o r the insane. In 1 8 5 1 , a f t e r a f u l l and f r e e discussion, the P r o p o s i t i o n s d r a w n up by K i r k b r i d e w e r e unanimously a d o p t e d by the A s s o c i a t i o n as a permanent guide. A m o n g the twenty-six rules w e r e these : E a c h hospital f o r the insane should be located in the country, not less than t w o miles f r o m a l a r g e town, and easily accessible at all s e a s o n s ; it should have not less than fifty acres of land, d e v o t e d to g a r d e n s and pleasure g r o u n d s f o r the p a t i e n t s ; e v e r y state hospital should have at least one hundred a c r e s ; no hospital should be built without the plans first h a v i n g been submitted to experienced medical men f o r a p p r o v a l ; the highest number that can with p r o p r i e t y be t r e a t e d in one building is 2 5 0 patients, while 2 0 0 is a p r e f e r a b l e m a x i m u m ; buildings should be constructed of stone o r brick and, as f a r as possible, m a d e fireproof; e v e r y hospital with p r o v i s i o n s f o r t w o hundred o r more patients should contain at least eight distinct w a r d s f o r each sex, m a k i n g sixteen classes in the entire building; no u n d e r g r o u n d a p a r t m e n t s should e v e r be p r o v i d e d f o r the confinement of patients, o r as their lodgingr o o m s ; the hospital pleasure grounds should be surrounded by a substantial w a l l ; all r o o m s should be p r o v i d e d with w i n d o w s ; a l a r g e hospital should consist of a main central building with wings, the central building to contain the ad• A s a m a t t e r of f a c t , it c o n t i n u e d to hold its s u p r e m a c y o v e r o t h e r q u e s tions r i g h t up to t h e last d e c a d e of the 19th c e n t u r y . T h e c h a n g e in n a m e of the o r g a n i z a t i o n in 1 8 9 3 to the A m e r i c a n M e d i c o - P s y c h o l o g i c a l A s s o c i a t i o n r e p r e s e n t e d in l a r g e m e a s u r e a r e v o l t a m o n g the y o u n g e r m e m b e r s a g a i n s t the e m p h a s i s p l a c e d on the b u i l d i n g s i d e of h o s p i t a l o r g a n i z a t i o n , a s s y m b o l i z e d b y the inclusion of the t e r m " S u p e r i n t e n d e n t s " in the old n a m e . T h e y w i s h e d m o r e time d e v o t e d to c l i n i c a l d i s c u s s i o n s , a n d less to s t r u c t u r a l ones. T h u s the c h a n g e in n a m e a c t u a l l y s y m b o l i z e d a p r o f o u n d r e o r i e n t a t i o n i n A m e r i c a n p s y c h i a t r y — i n its l a r g e r i m p l i c a t i o n s , a m o v e m e n t a w a y f r o m i n s t i t u t i o n a l i z a t i o n a s an i d e a l .

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ministrative office and living quarters of the medical superintendent. Other propositions dealt with proper drainage, adequate and pure water supply, a complete system of forced ventilation and heating, etc. 13 In 1 8 5 4 , D r . Kirkbride elaborated these original propositions to f o r m the basis of his famous work, On the Construction and Organization of Hospitals for the Insane, which became the standard textbook on the subject in America. T h e individual features of the Kirkbride plan of mental hospital architecture were not original with Kirkbride. Separately, they had been used b e f o r e in building. It was he, however, who first united them in the closely integrated system known by his name. Perhaps the major feature of the Kirkbride plan, partly incorporated in the twenty-six Propositions, was the linear projection of wings f r o m a central administration building (Proposition X I V ) , in place of the quadrangular construction that had dominated hospital buildings up to that time. Another main feature was the limiting of the number of patients in any mental hospital to a maximum of 2 5 0 (Proposition V ) . Around this latter point there gathered a storm of controversy that gained in intensity with the years and finally grew so fierce as to threaten to break the Association apart on the rocks of dissension. T h e Propositions were formulated and adopted at a time when highly exaggerated ideas of curability still prevailed. It was thought that recent cases could be quickly cured and that cases discharged recovered would perpetually balance newly admitted ones. A g a i n , at the time, it was considered the duty of executive medical officers personally to supervise the treatment of each individual case in the institution — m a k i n g the rounds every day if possible. T h i s intensive personal supervision was considered to be impossible in institutions housing more than 2 5 0 patients. A s time went on, the older members of the Association came to regard the Propositions with increasing awe and reverence, and finally very much as if they were as immutable and sacrosanct as the ten commandments. A bitter tug of w a r took place between the " o l d g u a r d " and the

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younger members, the former defending the original Propositions as fundamentalists do the Bible. T h e y refused to permit the change of a single line, a phrase, or even a syllable. Arrayed against them were men who agreed that most of the Propositions remained sound, but that several—particularly the one setting the maximum, and the one that prescribed wings extending f r o m a central building—would have to be modified to keep pace with changing social needs.* Necessity at last solved the controversy, and brought about the downfall of the Propositions. Undoubtedly, when they had been formulated and adopted, they represented a marked step in advance over previous methods of construction. What the founders failed to realize, however, was the truth of the maxim that the only immutable law is the law of change; it was historical blindness to believe that the whole future could be fitted into the rigid framework of their twenty-six rules. Desirable as most of the features were, they could not withstand the imperious demands of necessity. T h e most important factor in the breakdown of the 250maximum rule was the tremendous growth in population and the concomitant increase in the number of insane, necessitating larger hospitals f o r their care and treatment. Another factor, of course, was the accumulation of uncured cases in hospitals, an eventuality overlooked by the fathers in their over-optimistic views on curability. * F o r example, the l i n e a r plan, a d m i r a b l y suited to small institutions, could not meet the requirements of the l a r g e r mental hospitals, with capacities of 1,000 beds and more. Its limitations w e r e well illustrated in the B u f f a l o State Hospital w h e r e the medical officers had to w a l k a distance of half a mile f r o m the administration building to reach the f a r t h e s t w a r d on either side. It must be said, h o w e v e r , that some serious defects and shortcomings of asylum architecture d u r i n g the latter half of the century w e r e unjustly attributed to the K i r k b r i d e plan simply because they occurred in institutions ostensibly built according to the lines laid d o w n in that plan. T h u s , many of the so-called " p a u p e r p a l a c e s " that s p r a n g up during the 1870's and '8o's (of which the D a n v e r s State Hospital in Massachusetts w a s a notable e x a m p l e ) , i n v o l v i n g e x t r a v a g a n t outlays f o r imposing fronts, ornate roofs, etc., at the expense of essential internal items, w e r e w r o n g l y laid to K i r k bride's influence, w h e r e a s they w e r e really children of the Victorian v o g u e which w a s then blighting all architectural developments. A s a matter of fact, simplicity in design w a s an outstanding f e a t u r e of the plan formulated by K i r k b r i d e .

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H e n c e , while the A s s o c i a t i o n affirmed and reaffirmed its abiding f a i t h in the P r o p o s i t i o n s , the exigencies of reality w e r e p l a y i n g h a v o c with them. D r i v e n by the inexorable pressure of necessity, state hospitals increased their capacities to 5 0 0 , 1 , 0 0 0 , and even 1 , 5 0 0 beds. Ironically enough, the P e n n s y l v a n i a H o s p i t a l f o r the Insane, presided o v e r by the v e n e r a b l e f r a m e r of the P r o p o s i t i o n s , w a s soon f o r c e d to e x p a n d beyond the 2 5 0 - m a x i m u m o r i g i n a l l y set. In χ 866, the A s s o c i a t i o n w a s reluctantly constrained to m o d i f y P r o p o sition V to p e r m i t a m a x i m u m of 6 0 0 beds in mental institutions. W i t h this modification, the w h o l e set of Propositions p r o v e d unwieldy, since m a n y of them had been premised on the small-hospital idea. F i n a l l y , in 1 8 8 8 , at a meeting of the A s s o c i a t i o n at O l d P o i n t C o m f o r t , the Propositions w e r e scrapped in toto a f t e r a bitter debate, and none w a s substituted t h e r e a f t e r . B y that time the trend t o w a r d the so-called " c o t t a g e syst e m , " based on the g r o u p i n g of small detached buildings around a central administration building, w a s already gaining strength, a trend that continues to this d a y . T h e cottage system permitted a f a r better classification of patients, a g r e a t e r d e g r e e of p r i v a c y , and elimination of much of the old monotony and other unpleasant aspects of institutionalization, and f a c i l i t a t e d administrative control and supervision. W h i l e the c o t t a g e system is universally accepted as the ideal one in the hospital treatment of mental patients, it has f a i l e d to achieve universal adoption l a r g e l y because of economic pressure. T o o many of our legislators, executives and " l e a d i n g t a x p a y e r s " a r e unwilling to sanction the building of hospitals along the best lines of curative principles while outmoded, inadequate designs are available at less expense.

CHAPTER

XI

Conflict of Theories : Restraint or NonRestraint? Λ

Ι λ Η Ε rise of psychiatric knowledge, with analysis and synthesis evolving f r o m simple into complex processes, inevitably brought in its wake numerous theoretical controversies. In so f a r as debate reflected a lively interest in a g r o w i n g science, these controversies constituted an encouraging sign of progress. In some respects, however, they indicated all too clearly the stubborn resistance of old and outworn practices against the advance of new and better ones, and a growing confusion as to aims and methods. Of the many questions that stirred American asylum superintendents during the half-century following the organization of the Association, one of the most discussed and heated—and probably the least understood—centered around the doctrine of "non-restraint." Although it seemed on the surface a very simple doctrine, apparently involving merely the abolition of mechanical restraint* in the care and treatment of mental patients, it really was quite complicated, and caused no end of confusion and acrimonious dispute on this side of the Atlantic. T h e theory and practice of non-restraint is intimately associated with the name of D r . J o h n Conolly ( 1 7 9 4 — 1 8 6 7 ) , who first formulated it into a system, although he was not the first to practice it. Of course, it did not come upon the world full-blown: it experienced a gradual development • M e c h a n i c a l restraint may be simply defined as consisting of " a n y app a r a t u s that interferes with the f r e e movement of the patient, and which he is unable to remove easily." (Handbook of the Nevi York State Department of Mental Hygiene, 1933, p. 356.) 213

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dating f r o m the first removal of chains and fetters by Chiarugi, Pinel and T u k e toward the end of the eighteenth century. Also in the line of evolution was the celebrated British parliamentary investigation of 1 8 1 5 , which revealed horribly cruel treatment of patients in public and private asylums. It had the effect of arousing public sentiment against coercive methods, and led progressive leaders to seek ways and means of bringing restraints down to a minimum. In 1 8 2 9 , further impetus to reform was afforded by the tragic death at Lincoln Asylum, England, of a patient in consequence of his being strapped in bed in a strait-jacket during the night. A s a result of this incident, the asylum adopted a rule that whenever mechanical restraints were used at night, an attendant should remain with the patient. (Night attendant service in institutions throughout the nineteenth century was very rare, it being the custom to simply lock up the patient in his room or cell until morning.) Much to the surprise of the asylum officials, it was observed that mechanical restraints were seldom needed at night f o r the pacification of patients. Further experiments proved that they could be dispensed with by day as well as by night with no harmful effects ensuing. Finally, in 1 8 3 7 , under the direction of D r . Charlesworth and M r . Gardiner Hill, mechanical restrains were entirely abolished at Lincoln Asylum. T h e non-restraint methods introduced by Charlesworth and Hill at Lincoln were closely studied by D r . John Conolly, who was profoundly impressed by them. In 1 8 3 9 Conolly was appointed medical superintendent of the Middlesex Asylum located at Hanwell, England, where he proceeded to establish the principles of non-restraint. H e extended these new principles and finally formulated them into a complete pattern of mental hospital management. This system he presented to the world in his famous book, The Treatment of the Insane Without Mechanical Restraints (1856). T h e completeness of the reform effected by D r . Conolly at Hanwell is most impressively shown in his own descrip-

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tion of what he found there upon first assuming direction of the institution: "Instruments of mechanical restraint, of one kind or another, were so abundant in the wards as to amount, when collected together, to about six hundred—half of these being handcuffs and leg-locks." 1 In his first annual report ( 1 8 4 0 ) he was able to inform the managers that within four months after his taking charge, all mechanical restraint had been abolished. " N o form of strait-waistcoat, no handstraps, no leg-locks, nor any contrivance confining the trunk or limbs, or any of the muscles, is now in use. T h e coercion chairs, about forty in number, have been altogether removed from the wards." 2 T h e non-restraint system, which involved a great deal more than the mere removal of mechanical restraint, as many willing but unknowing hospital heads were to learn through bitter experience, was widely adopted in England after its successful introduction at Hanwell. But in America it met with an antagonism remarkable f o r its extreme bitterness. T h e opposition evinced by most American superintendents of mental hospitals undoubtedly originated from serious misconceptions as to the methods and aims of nonrestraint. But the antagonism continued long after the misconceptions were cleared up. T h e fact that the subject of mechanical restraint was discussed in nearly every meeting of the Association during its first fifty years of existence indicates the lingering doubts in the minds of its advocates as to the validity of their position, and their constant need f o r reaffirmation. Through the years every possible argument against non-restraint was desperately put forward, some of them appearing pitifully ludicrous in the light of our present perspective, others meriting more serious consideration. A t the founding meeting in 1844, the Association of Medical Superintendents adopted as its very first rule, or "proposition," the following: "Resolved, that it is the unanimous sense of this convention that the attempt to abandon entirely the use of all means of personal restraint is not sanctioned by the true interests of the insane." One of the thirteen there assembled, D r . Isaac Ray, was to stand out

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during the next t w o decades as the f o r e m o s t opponent of non-restraint on the A m e r i c a n scene.* In that v e r y year ( 1 8 4 4 ) , D r . R a y had presented an extended criticism of the system in his annual report f o r the M a i n e Insane H o s p i t a l . T h i s critique, which indicated that even at that early date the w r i t e r had devoted much attention to the subject, remained the m a j o r basis f o r A m e r i c a n assaults on the nonrestraint system f o r y e a r s to come. T h e arguments originally brought f o r w a r d by R a y in 1844, and later expanded by others, may be summarized as follows : ι . In the final analysis, the ideal of non-restraint could never be completely realized. H e n c e , it w a s idle to even consider p u t t i n g such a system into operation. S o m e f o r m s of forcible restraint w o u l d a l w a y s be necessary to the proper discipline of a mental hospital. T h e v e r y w a l l s and gates w e r e coercive. Institutionalization of the insane per se implied coercion, as it w a s o f t e n effected against the w i l l and wish of the patient. A s f o r mechanical restraint p r o p e r — t h a t is, limitation on the bodily m o v e m e n t s of the patient by means of e x t e r n a l devices — i t w o u l d continue to be required in v e r y special instances, as most " C o n o l l y i s t s " f r e e l y a d m i t t e d . T h i s being the case, it w a s m o r e honest to champion restraint in principle, rather than non-restraint. 2. T h e abolition of mechanical restraint meant merely the substitution of another f o r m of c o e r c i o n — " m a n u a l r e s t r a i n t , " o r force exercised at the hands of a t t e n d a n t s — w h i c h w a s hardly more desirable. 3. T o supplant mechanical restraint by attendants w o u l d tate l a r g e r staffs and consequently greater expense.

necessi-

4. Suicidal, d e s t r u c t i v e and u n m a n a g e a b l e patients required some f o r m of personal restraints, of w h i c h mechanical appliances w e r e least onerous and most effective. 5. M e c h a n i c a l restraints w e r e also required f o r patients w h o w e r e prone to exhaust their energy and to l o w e r their vitality b y excessive physical excitement. 6. T h e patients in E u r o p e a n institutions, accustomed as they w e r e to unquestioned acceptance of a u t h o r i t y , m i g h t w i l l i n g l y submit to " m o r a l " restraint, but not your l i b e r t y - l o v i n g A m e r i c a n w h o , sane • H i s p l a c e a s l e a d e r w a s l a t e r o c c u p i e d by D r . J o h n P . G r a y , s u p e r i n t e n d e n t of t h e U t i c a State A s y l u m , w h o w a s f o r y e a r s e d i t o r o f the American Journal of Insanity, and w a s one o f t h e most i n f l u e n t i a l men in his p r o f e s s i o n .

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or insane, would never agree placidly to the imposition of authority by an individual, and hence could be restrained only by mechanical means. 7. In certain institutions where the abolition of mechanical restraint had been tried, it had resulted in dismal failure, and the old restraints had been resumed.

T h e s e arguments, together with others of less consequence (conjured up f r o m time to time to bolster the opposition), seemed well-nigh irrefutable to the m a j o r i t y of American superintendents f o r many years. It must be said, in all frankness, that not many of them sought very diligently to examine the claims of the other side. U n t i l the closing years of the past century, non-restraint remained the bete noire of American psychiatry—grossly condemned because its practical applications were little understood. Perhaps in no other aspect of the care and treatment of mental illness were American institutions so backward as in this. H a d the opponents of non-restraint sought earnestly enough f o r answers to the arguments we have just enumerated, they might have found them summarized thus, in their respective order : ι. T h e r e are certain exceptions implicit in every rule of human conduct t h a t may be laid down as a principle. Rejection of a principle, because it admits of such exceptions, invariably leaves room f o r the encroachment of all sorts of abuses that are effectively checked when the principle is stated in positive terms and enforced. Strangely enough, many medical superintendents in the United States were themselves reducing the use of mechanical coercion to an insignificant minimum while they went about belaboring non-restraint in principle. T h u s , D r . Kirkbride, who consistently opposed the doctrine laid down by Conolly, was nevertheless characterized by one of its most prominent defenders as "one who advocated restraint but never used it." 3 Kirkbride himself wrote in one of his early reports : Had I felt anxious to make such a declaration, it would have been in my power to have stated that during the past year, no restraining apparatus of any kind had been upon the person of a single patient of

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this hospital—but believing as I do that its occasional employment may be conferring a favor on the patient, it has always been resorted to where there existed a proper indication for its use. T h e only indication for its use that is recognized in this Hospital, is the positive benefit or safety of the patient—never the trouble of those to whose care he is entrusted—and the direct order of the physician or his assistant, the only authority under which it can be applied. 4 A s a matter of sober fact, Conolly himself never conceived of, or tried to practice, absolute non-restraint, although several of his more enthusiastic disciples, like D r . Batty Tuke, advanced it to the extreme lengths of doing away not only with all bodily coercion, but even with locked doors and protected windows in all cases. Conolly held that restraint might not only be useful but necessary in exceptional instances, such as in surgical operations. His biographer and friend, Sir J a m e s Clark, states in clarification of this point: " . . . it should be understood that there is no such thing as an absolute repudiation of restraint in the treatment of the insane. T h e warmest advocates of nonrestraint admit that cases may occur in which it is proper to resort to mechanical restraint, and by this admission we do not think that we invalidate the principle." 11 T h e boundaries of the abolition of mechanical restraint, as first defined by Conolly, might best be illustrated by referring to the rules promulgated by the N e w Y o r k State Department of Mental Hygiene in 1 9 3 3 , covering all state hospitals, which read in part: Mechanical restraint or seclusion is to be employed only for satisfactory surgical or medical reasons, or to prevent a patient from injuring himself or others. Mechanical restraint or seclusion shall be employed only on the signed order of a physician, setting forth the reasons for its use; and a physician shall always be present at the first application of restraint. A full record of restraint shall be kept from day to day and shall be subject to inspection by authorized persons. Mechanical restraint consists of any apparatus that interferes with the free movement of the patient, and which he is unable to remove easily. T h e only forms of mechanical restraint permissible are the camisole and restraining sheet.

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219

T h e maximum period in the day time during which a patient may be kept continuously in restraint shall be two hours and such patients shall be visited at least every hour. A patient shall be considered in seclusion, either in the day time or at night, when in a room alone with closed door which it is not possible for the patient to open from the inside. T h e maximum period of continuous seclusion shall not exceed three hours in the day time and the patient shall be visited every hour.®

It may readily be seen that the establishment of principles in this positive and precise manner admits of relatively f e w abuses. 2. T h e picture drawn by those who held that " m a n u a l " restraint was the only effective substitute f o r mechanical appliances was so overdrawn as to sink to poor caricature. T h e y envisaged, in hospitals operated under the non-restraint system, giant bullies hovering constantly about the hapless patient, ready to pounce upon him and to pummel him into subjection at the slightest manifestation of boisterousness or violent behavior. Rather than resort to this alternative, American superintendents, notably Isaac R a y , f a v o r e d mechanical restraints. A s R a y put it: " I have no hesitation in saying that they [mechanical restraints] are f a r preferable to the vigilance or force of attendants. T h e object is gained more surely, more effectually, and with f a r less annoyance to the patient. A mechanical device p e r f o r m s its office more steadily, uniformly and thoroughly, and is submitted to as something inevitable. T h e will and strength of an attendant are capricious and variable in their operation." 7 D r . R a y was wrong in regarding the physical force of an attendant as the only alternative to mechanical restraints. A s we shall see, the system advanced by Conolly and his disciples included carefully designed provisions permitting peaceful and healthful safety-valves in congenial occupations and recreation f o r the pent-up energies of patients. Furthermore, instead of breeding antagonisms between patient and attendant the non-restraint system, when faithfully followed, expressly provided means f o r obtaining a maximum amount of friendliness between the two. 3 . Although many opponents of the non-restraint system

220

THE

MENTALLY

ILL IN

AMERICA

publicly minimized the importance o f the economy factor, it undoubtedly exerted no small influence in determining their attitude. Feeling, as they did, that manual restraint w a s the only alternative to mechanical means, they concluded that the increased expenditures necessitated by corresponding enlargement of staff would be too burdensome to be borne by most institutions. A s early as 1844, D r . Ray had written : W h e n mechanical restraints are entirely disused, the first consideration that presents itself is, that the number of attendants must be much larger than when they are used even in a very limited degree, and thus the expense of the establishment is swelled to a very onerous amount. In many parts of our country, the only alternative is between a cheap establishment and none at all ; and certainly, nothing but the clearest and weightiest reasons should be suffered to have the effect of debarring a large number of the insane from receiving the benefit of hospital treatment. 8

T h i s statement stands in surprising contradiction to others m a d e repeatedly by D r . R a y throughout his career. H e invariably stressed the principles of humaneness and generosity above those of expediency and economy. T i m e and time again he t o o k sharp issue with those w h o deemed it sufficient to build institutions f o r mere custody. T h e fact that this progressive psychiatrist w a s forced into such a contradiction in his attack on non-restraint indicates, perhaps, the paucity o f real arguments against the system laid down by Conolly. 4. T h e non-restraint system, as w e h a v e seen, made due allowance f o r the use o f mechanical restraint in exceptional and extreme cases w h e r e patients were dangerous either to themselves or to others. It did, h o w e v e r (as do the bestconducted institutions t o d a y ) , strictly define the limits, both in type of appliances used and maximum time of duration, within which mechanical coercion might be applied. W h e r e ever possible it substituted the milder, less painful and less humiliating method o f seclusion as a means of restraint. O n the other hand, w h e r e mechanical restraint was adhered to

RESTRAINT OR NON-RESTRAINT?

221

as a principle, there was a strong tendency to resort to it at t h e least manifestation of suicidal or destructive ( o r merely annoying) dispositions in patients, and to keep them confined until "they got over it." In those days, few recognized the fact t h a t mechanical restraints invariably stimulated and encouraged the very conditions they were supposed to eliminate or to mitigate. "Violence begets violence." If the excitement of the normal individual is increased by a display of needless repression, the excited mental patient, forcibly restrained in a humiliating and o f t e n painful manner, is apt to become even more agitated. Violent or noisy outbursts t h a t might, under tactful treatment, be overcome in a few minutes, are frequently protracted indefinitely. Suicidal tendencies are likely to become more pronounced, r a t h e r than lessened, t h r o u g h the use of mechanical force, which serves to confirm the patient's feeling that he moves about in a hostile environment. In institutions where non-restraint was rejected as a principle it was too o f t e n the custom to confine the patient in strait-jackets, muffs, handcuffs, etc., over long periods of time, not because of a present emergency, but because of some violent outburst in the remote past, or, perhaps, to forestall one anticipated in the f u t u r e . O f t e n enough, officials were in the habit of placing patients in mechanical restraints on Sundays and holidays f o r no other reason than t h a t they found themselves " s h o r t - h a n d e d " of attendants on such occasions.* In still another sense, economy was an important factor in determining the frequency of restraining "destructive" patients; f o r example, the desire to save clothes and furniture f r o m being torn or broken. T h e "nonrestrainters" resorted to a more humane, though less simple, method of achieving the same end. Instead of shackling patients who destroyed their clothing, or just letting them run about naked, they recommended the expedient of garbing such persons in clothes that could neither be t o r n nor cast off. • W i t h much truth Conolly had w r i t t e n : "Restraints and neglect m a y be considered synonymous ; for restraints are merely a general substitute f o r the thousand attentions required by troublesome patients."

222

THE MENTALLY ILL IN AMERICA

It w a s maintained by m a n y superintendents that mechanical restraint not only prevented patients f r o m indulging in destructive inclinations, but had the positive effect of building up their p o w e r of self-control, thereby advancing their r e c o v e r y . T h i s a r g u m e n t w a s s o m e w h a t specious. T h e humiliation, loss of self-respect, untidiness and pain occasioned by most f o r m s of mechanical restraint actually intensified the v e r y t r a i t s — s e l f - p i t y , moroseness, desire f o r revenge, r e s e n t m e n t — b e s t calculated to r e t a r d either self-control o r r e c o v e r y . O b v i o u s l y , too, the liberal use of forcible restraints h a d a n e g a t i v e effect on the attitude of attendants t o w a r d s patients, serving to brutalize them, and to g e n e r a t e a contempt t o w a r d patients. In m a r k e d contrast, hospitals which reduced restraints to an absolute minimum and substituted well planned " s a f e t y - v a l v e s " generally presented a picture of m o r e contentment, f r e e d o m and c o m f o r t , and w e r e troubled with f a r f e w e r outbursts of violent beh a v i o r on the p a r t of patients. F u r t h e r m o r e , institutional tension diminished when p s y c h i a t r y a d v a n c e d to the point w h e r e it b e g a n to p r o b e into the causes of violent and destructive b e h a v i o r and tried to check them at the root, instead of merely dealing with their consequences. 5. I t is indeed true that some types of mental illness require continued rest as a m a j o r therapeutic measure. B u t mechanical restraints w e r e h a r d l y calculated to effect this a i m ; on the c o n t r a r y , they i n v a r i a b l y tended to d e f e a t it. F o r instance, s t r a p p i n g a patient in bed w a s once a p o p u l a r method of e n f o r c i n g rest. T h e most widely used mechanical device f o r this purpose up to about a half-century a g o w a s the " U t i c a c r i b , " so n a m e d because it was first introduced in A m e r i c a at the U t i c a State A s y l u m , and there developed. T h e crib-bed, of which it w a s a modification, h a d been invented by D r . A u b a n e l of M a r s e i l l e s , F r a n c e , in 1 8 4 5 , and w a s adopted by D r . B r i g h a m at U t i c a the f o l l o w ing y e a r . I t w a s shaped like an o r d i n a r y baby's crib, except that it had attached on its top a hinged lid, like that on a trunk. T h i s could be f a s t e n e d o v e r the patient at night, thus restricting his f r e e d o m of movement. T h e champions of the U t i c a crib and similar devices o v e r l o o k e d the f a c t

RESTRAINT

OR

NON-RESTRAINT?

223

that the patient usually expended as much energy, and m o r e , in struggling to f r e e h i m s e l f , as he m i g h t if his m o v e m e n t s w e r e unrestrained. In addition there w a s the extreme disc o m f o r t occasioned by this m o d e of confinement. On the w h o l e it created a situation h a r d l y conducive to sleep and restfulness. T h e abolition of the crib p r o v e d that patients could rest as easily in " f r e e " beds. T h e development of modern h y d r o t h e r a p y ( h o t baths, etc.) and " c h e m i c a l res t r a i n t s " ( s e d a t i v e s ) also p r o v e d m o r e effective means o f ensuring rest. 6. Inasmuch as e v e r y conceivable type of argument w a s conjured up by opponents of non-restraint, it is h a r d l y surprising that they sometimes b r a n d e d it as a " f o r e i g n " system, and d e f e n d e d mechanical coercion on purely patriotic grounds. M a n y A m e r i c a n officers of institutions f o r the insane w e r e perplexed to discover, on visiting E n g l i s h hospitals o p e r a t e d under the non-restraint system, that, despite the g r e a t e r amount of liberty permitted in the latter, the patients w e r e invariably m o r e p e a c e f u l , better b e h a v e d and neater than in the f o r m e r . A t first they w e r e at a loss to explain this p a r a d o x . B u t possessing true Y a n k e e ingenuity, they did not permit themselves to remain nonplussed f o r long. A convenient theory w a s e v o l v e d : non-restraint might do f o r E n g l i s h m e n , but it w o u l d n e v e r be t o l e r a t e d by redblooded A m e r i c a n s ! D r . C l e m e n t W a l k e r , h e a d of the B o s ton L u n a t i c A s y l u m and a prominent psychiatrist of his d a y , in an address delivered b e f o r e the A s s o c i a t i o n of M e d i c a l Superintendents in 1 8 7 4 , d e c l a r e d : I suppose if a n y t h i n g has been settled to t h e satisfaction of t h e m e m b e r s of this Association it is that, in this c o u n t r y , o u r patients, by original temperament, or by some i n h e r e n t q u a l i t y in the universal Yankee, w i l l n o t submit to the c o n t r o l of a n y person they consider their equal o r i n f e r i o r as r e a d i l y as t h a t of mechanical appliances. 9

Commenting on this belief held by some A m e r i c a n medical men, the noted B r i t i s h psychiatrist, J o h n C . Bucknill, r e m a r k e d : " T h e essence of the non-restraint system is to lead the lunatic by such remains of mental p o w e r and coherence as the physician can l a y hold upon, and w h e r e there has

224

T H E MENTALLY ILL IN AMERICA

been the least mind, there would be the slightest means of moral guidance; but to make the men of the United States an exception because they, m o r e than others, have learned how to rule themselves, is a blundering censure upon their culture and their virtues." 1 0 T h e defense of mechanical restraint as being "peculiarly" necessary in America because of the singular nature of its inhabitants was most ingenious, to say the least. I t represented an amusing oversimplification of a general t r u t h — namely, t h a t social mores, traditions and institutions are bound to influence individual behavior—employed to cover a situation in which t h a t t r u t h h a d very little, if any, application.* Allied to the patriotic defense of mechanical restraint in the U n i t e d States, was the contention t h a t it was needed in this country because of peculiar climatic and geographic factors. I t was a common notion t h a t the relatively equable climate of G r e a t Britain bred a mild and complacent people, while the violent changes t h a t characterize meteorological conditions in America ( particularly in the N o r t h e r n states) developed a correspondingly violent race. T h i s violence was especially manifest in the insane, and hence the frequent recourse to mechanical restraint to subdue them. T h i s outlandish theory requires no comment. Several American institutions f o r the insane did indeed make an honest effort to introduce the non-restraint system, only to abandon the experiment a f t e r a brief trial, and to revert to the f r e e use of mechanical restraint. Invariably, the failure in these hospitals was attributable to a lack of proper understanding of the system, and of its comprehensive scope. Some superintendents merely removed the mechanical appliances f r o m confined patients and then waited •Significantly enough, this v e r y same "liberty-loving, authority-hating" theory n a i utilized by G e r m a n medical superintendents of that time to explain the necessity for mechanical r e s t r a i n t in their o w n country. They, too, argued that non-restraint succeeded in English hospitals precisely because the Englishman, sane or insane, instinctively f e a r e d and obeyed personal authority! In Scotland, it w a s g r a v e l y held by some that the native insane h a d to be treated like wild beasts because of the wild, u n t a m a b l e nature of the Scots I

OLD METHODS OF R E S T R A I N T AND A SUBSTITUTE

MODERN

A. Benjamin Rush's Tranquilizer (See p. 79). B. Norris in Chains, 1 8 1 5 (See p. 100 n.). C. Recreational therapy in a modern state hospital, a positive factor in curative treatment.

R E S T R A I N T OR N O N - R E S T R A I N T ?

225

idly by to see a miracle happen. T h e y heeded not the warning of Conolly, who, in formulating his principle, w r o t e : It is, above all, important to remember . . . that the mere abolition of fetters and restraints constitutes only a part of what is properly called the non-restraint system. Accepted in its full and true sense, it is a complete system of management of insane patients, of which the operation begins the moment a patient is admitted over the threshold of an asylum. 11

Besides the rejection of mechanical coercion, the system included those intangibles that had first been formulated by the T u k e s and Pinels under the name of " m o r a l " t r e a t m e n t . I t meant nothing less than the complete humanizing of the institution in its entirety. It required kindness, patience, understanding and truthfulness on the p a r t of the hospital staff. It required the careful inculcation and development of confidence, trust, self-respect and hope in the patients, as f a r as possible. I t required the elimination of heavy-walled, n a r r o w "airing courts" and o t h e r prison-like aspects t h a t cast oppressive shadows over so many institutions, causing some patients to feel that they were being punished f o r misdeeds r a t h e r than being treated f o r ailments. It required the planning of healthful recreations and congenial occupations to d r a w the ill mind f r o m morbid fancies and to help build up a sound body to house a sound mind. In short, the system of non-restraint did not end with the mere removal of bodily coercion. It involved a complex and all-embracing method of hospital administration and treatment. H o w e v e r g r e a t was the obloquy heaped upon the principle of non-restraint in America up to the end of the century, this principle nevertheless exerted a decided and healthy influence here f r o m the first. I t had the effect of gradually mobilizing public opinion to the point of forcing the reduction of mechanical restraint, in varying degrees, in institutions f o r the insane throughout the country. T h i s was true even in asylums the officers of which disagreed most violently with the principle of non-restraint. In several asylums non-restraint was actually practiced within the limits originally defined by Conolly, although f o r one reason or

226

T H E M E N T A L L Y ILL IN AMERICA

another, the superintendents clung tenaciously to the negatively stated theory of "mechanical restraint at discretion." In taking this course, they unwittingly left a wide loop-hole f o r all sorts of abuses in institutions run by men of lesser intelligence and, perhaps, looser conscience, than they. A s early as 1 8 5 7 , Pliny E a r l e had pointed out the danger, saying: "While it is occasionally necessary to employ mechanical restraint, yet I believe that this admission is calculated to favor a tendency to its excessive use." It is difficult to explain adequately the hostile, often acrimonious, reaction of American hospital superintendents to non-restraint during the third quarter of the nineteenth century. Their attitude was in no small measure due to their undeviating insistence that supreme authority in each institution should be wielded by the superintendent without "outside" interference. Rugged individualists all, they felt that non-restraint, legislated on the statute books, might place the executive officer constantly under the thumb of investigating committees, and deprive him of his jealously guarded authority. I might mention another factor, less direct perhaps, but just as potent in keeping alive the resentment of many American superintendents to the British-born system of non-restraint. I refer to the unbearably patronizing attitude of certain English medical men towards their American cousins in the psychiatric specialty. It was not unusual f o r English physicians to make a casual and very limited inspection of American asylums f o r the insane, and, upon their return home, to apply some sweeping derogatory generalization covering all such institutions in the United States. ( I t was then quite the custom f o r English literary and professional men to cross the Atlantic with the preconception that they were about to visit a savage people, and they usually managed to return with their prejudgments confirmed.) T h e most notorious of the blanket attacks on American mental hospitals appeared in the London Lancet of 1 8 7 5 . Referring, in a leading article, to the "ignorance and misconceptions of our brethren in America," the writer categorically declared that the American " M a d Doctors" remained f o r the most part "in that stage in which the lunatic

RESTRAINT OR N O N - R E S T R A I N T ?

227

Is simply regarded as a wild and dangerous animal, f r o m which society needed protection, and which might be kept in chains, tamed or destroyed, as convenience should dictate." Then followed these choice characterizations: O u r friends across the Atlantic have not yet mastered the fundamental principles of the remedial system. T h e y adhere to the old terrorism tempered by petty tyranny. T h e y resort to contrivances of compulsion ; they use, at least, the hideous torture of the shower-bath as a punishment in their asylums, although it has been eliminated from the discipline of their gaols. And worse than all, if reports that reach us may be trusted, their medical superintendents leave the care of patients, practically, to mere attendants, while devoting their energies principally to the beautifying of their colossal establishments. 1 2

While it is undoubtedly true that this biting criticism was applicable to many institutions f o r the mentally ill in America, it was grossly unfair to men like Butler, E a r l e , Nichols and Kirkbride who, despite individual shortcomings, were putting into practice the most progressive principles of the time. Such indiscriminate attacks could not but stir up deep resentment on this side of the Atlantic. U n f o r t u nately, but quite inevitably, the counter attack loosed on the self-appointed champions of non-restraint who were guilty of the aforementioned injustice, fell in part on the principle itself. It should be noted in passing that the particular Lancet article in question was vehemently condemned by the two leading British psychiatrists, J o h n C . Bucknill and D . H a c k T u k e , who were best fitted to judge the American scene, and who forced a partial retraction f r o m the editors. A m o n g the early advocates of the non-restraint system in America were D r s . E d w a r d J a r v i s , Joseph L . Bodine, Alice Bennett, E . C. Seguin, William A . H a m m o n d , Nathan Allen and Charles W . Page. T o d a y , the non-restraint system is written into law on the statute books of several states (notably Massachusetts, which passed the pioneer non-restraint law, f r a m e d by D r . L . Vernon Briggs, in 1 9 1 1 ) , and is also prescribed in the rules and regulations in many other states (e.g., the N e w Y o r k State rules referred to earlier in the chaDter). Some

228

T H E M E N T A L L Y ILL IN AMERICA

backward states still lack adequate s a f e g u a r d s against the abuses of mechanical restraint, but it is to be hoped t h a t professional leadership and public opinion will, in the near future, eradicate these relics of a barbaric age. It will be a red-letter day indeed when the last appliance of mechanical restraint passes out of service and takes its place beside the tranquilizing chair and the ball and chain as a museum piece, a memento of a bygone age in the care and treatment of the mentally ill.

CHAPTER

XII

The Trend Toward State Care

T

I M E alters many things, including the meaning of terms.* When, f o r example, young H o r a c e M a n n stood on the floor of the Massachusetts legislature and enunciated the principle that " t h e insane are the wards of the state," his thought was quite removed f r o m the present-day conception of his words. In M a n n ' s time "state c a r e , " as construed even by the progressive elements, implied no more than the duty of the state to see that all the insane requiring institutionalization received it in special asylums. T h e latter did not necessarily have to be built, maintained or supervised by the state itself. A later generation defined the principle as establishing the state's duty to supervise the care of all the insane within its borders, though contributing to the support of this class only to a limited degree. T o d a y , in such states as N e w Y o r k and Massachusetts, state care includes provision in state-owned hospitals, administered and maintained by the state, f o r all mentally ill persons in need of public care and treatment. T h e evolution of state care followed a long and winding trail before reaching its most significant expression with the passage of the N e w Y o r k State C a r e Act of 1890. Its beginnings in the United States may be traced back to 1 7 5 1 , when the provincial legislature of Pennsylvania appropri-

*As interesting illustrations of this truism, vre might point to the etymological origini of such psychiatric terms as melancholia (literally, "black bile"), reflecting the humoral pathology of Hippocrates; hysteria (derived from the Greek for uterus), which stems from the ancient notion that this disorder was caused by the movement of the uterus, conceived of as a living, independent animal roving at will through the body; and lunacy, the derivation of which is obvious. 229

230

T H E MENTALLY ILL IN AMERICA

ated s e v e r a l thousand pounds t o w a r d the erection of the P e n n s y l v a n i a H o s p i t a l at P h i l a d e l p h i a . T h e next step came in 1 7 6 9 with the f o u n d i n g of A m e r i c a ' s first institution exclusively f o r the i n s a n e — t h e L u n a t i c H o s p i t a l at Williamsb u r g , V i r g i n i a . T h i s institution m a r k e d a tremendous advance t o w a r d the ideal of state care. It was built entirely at state expense, and the indigent patients therein w e r e wholly supported by state f u n d s . I t s administration and control, h o w e v e r , w e r e l e f t in the hands of a self-perpetuating b o a r d of directors acting as a c o r p o r a t e body. T h e E a s t e r n Kentucky L u n a t i c A s y l u m at L e x i n g t o n , established in 1 8 2 2 , seems to h a v e been the first built primarily f o r the reception of p a u p e r and indigent insane,* although pay patients w e r e also received. H e r e , too, the cost of caring f o r dependent patients w a s borne by the state alone. 1 D i f f e r i n g f r o m this w a s the policy pursued in most of the mental hospitals established during the ' 3 0 ' s and ' 4 o ' s , such as the W o r c e s t e r L u n a tic H o s p i t a l in M a s s a c h u s e t t s and the U t i c a A s y l u m in N e w Y o r k , w h e r e the maintenance of dependent patients w a s c h a r g e d to the localities in which these persons had settlement, the state p a y i n g only f o r non-resident and alien insane. t T h e opening of the W o r c e s t e r State H o s p i t a l in 1 8 3 3 m a r k e d the beginning of an extensive asylum-building movement t h r o u g h o u t the country. A t first, in accordance with the p r e v a i l i n g belief that f u l l y 9 0 per cent of mental cases could be cured, it w a s expected that one centrally located hospital in each state w o u l d a f f o r d sufficient provision f o r all the insane. In s e v e r a l of the sparsely settled states in the W e s t , of course, one asylum w a s f o r a long time all that w a s necessary. B u t in most states this expectation w a s soon • W e might do well to c l a r i f y here the distinction between the terms " p a u p e r " and " i n d i g e n t . " A pauper does not possess any property, and is wholly dependent on public support. A n indigent person is one not possessing sufficient property or sufficient income to support himself or bis f a m i l y d u r i n g illness or disability. t i n Massachusetts, w h e r e the local poor relief system prevailed, the dependent insane w e r e c h a r g e d to the towns and cities; in N e w Y o r k , where the county w a s the poor relief unit, the insane w e r e charged to the counties of settlement.

THE TREND TOWARD STATE CARE

231

dispelled. H a r d l y w e r e hospitals opened than their capacities became o v e r t a x e d by the never-ceasing flow of patients. O v e r c r o w d i n g soon f o r c e d upon authorities the problem of selection. F a c e d with the necessity of admitting a certain number of applicants and excluding others, authorities naturally f a v o r e d the admission of recent cases o v e r chronic and incurable cases. G r a d u a l l y , then, there d e v e l o p e d the c u s t o m — i n some states amounting to an " u n w r i t t e n l a w , " in o t h e r s explicitly stated in s t a t u t e s — o f sending only acute cases to institutions f o r the insane, while the chronics (sometimes euphemistically called the " s u r p l u s i n s a n e " ) w e r e confined in poorhouses and j a i l s o r else supported in the homes of f r i e n d s or relatives. G e n e r a l l y , if a dependent patient in a hospital was not discharged r e c o v e r e d within a stipulated period (say, t w e l v e m o n t h s ) , he w a s returned f r o m the hospital to his place of settlement as incurable and w a s thencef o r t h maintained at a local institution, usually the p o o r h o u s e or j a i l . T h u s there d e v e l o p e d a division between recent and chronic cases in relation to institutional treatment, not so much as the result of a definitely f o r m u l a t e d plan as of a m o r e o r less h a p h a z a r d development. F o r practical purposes, state hospitals maintained only acute and d a n g e r o u s cases, while all others w e r e r e l e g a t e d to local care. F a r f r o m solving the p r o b l e m of p r o p e r disposition of the insane, this situation c r e a t e d new and m o r e c o m p l e x problems. F o r one thing, so r a p i d w a s the increase in the number of mental patients that accommodations in m a n y states soon p r o v e d insufficient even f o r the acute cases alone. A s a result the p r o p o r t i o n of insane persons d e p r i v e d o f p r o p e r treatment o r care g r e w a l a r m i n g l y . T h e f o l l o w i n g table indicates the increase in insanity in relation to the increase in the general population of the U n i t e d States, during the latter half of the 1 9 t h c e n t u r y : * • B e c a u s e of f a u l t y c e n s u s - t a k i n g m e t h o d s a n d the r e i g n i n g c o n f u s i o n o v e r the t e r m s " i n s a n e " a n d " i n s a n i t y , " the figures on the i n s a n e f r o m 1 8 4 0 - 1 8 7 0 , i n c l u s i v e , a p p r o a c h e d n e i t h e r a c c u r a c y n o r r e l i a b i l i t y . I n d e e d , D r . J o h n S. B i l l i n g s , w h o c o m p i l e d the r e p o r t on the i n s a n e a n d f e e b l e m i n d e d f o r the ι i t h c e n s u s ( 1 8 9 0 ) , stated b l u n t l y : " T h e figures f o r the U n i t e d S t a t e s C e n s u s e s p r e v i o u s to ï 8 8 o a r e e n t i r e l y w o r t h l e s s so f a r a s the c a l c u l a t i o n of

232

THE MENTALLY ILL IN AMERICA Total

Year

Population

United

Estimated

Ν umber

Insane and

in

Hospitals

States

of Insane

Asylums

1840

i7>o69,453

17,457*

2,561

1850

23,191,876

15,610

4,730

i860

31,443,322

24,042

8,500

1870

38,555,983

37,432

17,735

1880

50,155,783

91,959

38,047

1890

62,947,714

106,485

74,028

Remarkable though the growth of the general population was during this half century, the rate of increase in insanity appears by the figures to have been f a r greater. H o w much of this apparent acceleration in the rate of insanity is attributable to the actual spread of mental illness, and how much to such factors as more efficient methods of censustaking, greater accuracy in diagnosis and classification, and the steady widening of the concept of mental disease, is a speculative question that defies solution at the present time. Be that as it may, the rise in the known cases of mental illness necessitated continual building of new institutions, and enlargement of existing ones. But these institutions could never quite catch up with the total need. B y 1 8 5 0 , when the curability bubble was beginning to burst, it became apparent that (except f o r a f e w thinly populated Western states) a single state hospital could not meet the requirements of a growing population. State hospitals were enlarged; new ones were erected. But still the number of insane deprived of hospital care continued to keep pace with the number who found refuge (in varying degrees) in ratios of the number of insane to the population is concerned, since the number of insane returned in these censuses w a s certainly less than half the number actually present." T h e tremendous leap in the number of insane in 1880 as compared with 1870 is largely attributable to the fact that in this census, f o r the first time, the cooperation of the physicians throughout the country w a s obtained in reporting cases of insanity. Conversely, the apparent drop in the ratio of insane persons in 1890 does not represent a real decrease, but is explained by the fact that in this census the physicians did not supplement the reports of the enumerators. • T h i s figure includes both the insane and the feebleminded, since census takers at that time made no distinction between the two groups.

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hospitals and asylums.* In 1 8 5 4 a lunacy commission authorized by the Massachusetts legislature to m a k e a survey of insanity and feeblemindedness, under the able direction of D r . E d w a r d J a r v i s , f o u n d that there w e r e then in the state a total of 2 , 6 3 2 insane persons. O f these only 1 , 1 4 1 — l e s s than h a l f — w e r e being maintained in special establishments f o r the mentally ill. T h e f o l l o w i n g y e a r a report submitted to the N e w Y o r k legislature revealed that, of an estimated total of 2 , 1 2 3 dependent insane persons within the state, only 296 w e r e being treated in the U t i c a State A s y l u m . M o s t of the remainder w e r e confined in houses of correction, almshouses and jails. M e a n w h i l e the nation was being stirred by the horrible conditions uncovered by D o r o t h e a D i x in her travels through A m e r i c a . Other investigators, too, w e r e constantly bringing f o r t h new evidences of the terrible treatment of the insane in local poorhouses. Still, the m a j o r i t y of the mentally ill continued to be thrust into these receptacles. W h a t w a s to be done? A l t h o u g h enlightened opinion w a s quite unanimous as to the desirability of removing insane persons f r o m the poorhouses, there was no such unanimity on the question as to how to effect this end. V a r i o u s solutions were offered, the principal ones f a l l i n g within these c a t e g o r i e s : 1. T h e state should provide for all recent cases of insanity, while counties should erect asylums for all chronic cases. 2. T h e state should provide for all the insane in state hospitals. 3. Recent and chronic cases should be maintained in separate institutions, the former in hospitals, the latter in asylums. Chronics, being for the most part beyond cure, require only custodial care and could be accommodated much more cheaply in asylums. 4. Chronic and acute cases should be accommodated in "mixed" hospitals, and all subjected to therapeutic treatment. * T h e difference between a hospital and an asylum might be stated thus: the f o r m e r is an institution intended p r i m a r i l y f o r curative treatment, w h i l e the latter is p r i m a r i l y a place of custody. It must be remembered, h o w e v e r , that the terms h a v e been used interchangeably and indiscriminately: asylums h a v e been called hospitals, and vice v e r s a . A n interesting case in point is the first special institution f o r the insane in A m e r i c a , at W i l l i a m s b u r g , V a . ,

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T h e s e p r o p o s a l s f e l l into t w o distinct patterns, which finally d e v e l o p e d into the systems that characterize public p r o v i s i o n f o r the insane t o d a y : state c a r e and county care. T h e principle of state care is identified with the plan ultim a t e l y a d o p t e d by N e w Y o r k ; the county care system is associated with Wisconsin. T h e s e w e r e the pioneer states in the f o r m u l a t i o n of the r i v a l plans which w e r e adopted, with slight modifications, by most of the other states. In the f o l l o w i n g p a g e s the historical d e v e l o p m e n t of state care in N e w Y o r k will be e m p h a s i z e d , since it w a s there that the principle experienced its classic evolution. T h e earliest o r g a n i z e d m o v e m e n t t o w a r d complete state care in N e w Y o r k came f r o m a r a t h e r unexpected source. In 1 8 5 5 the county superintendents of the p o o r in the state held a convention at U t i c a , p r i m a r i l y f o r the purpose of f o r m u l a t i n g a definite policy of public provision f o r the dependent insane. T h e situation must h a v e been v e r y serious to h a v e necessitated such a meeting, the first of its kind in the state and p r o b a b l y in the c o u n t r y . * T h e question of r e m o v ing the mentally sick f r o m poorhouses to state hospitals received the g r e a t e s t attention. A t the end of the convention, a series of resolutions on the subject w e r e adopted, including the f o l l o w i n g : W h e r e a s , it is a l r e a d y conceded, and has been adopted as the policy of this S t a t e , that insanity is a disease requiring, in all its f o r m s and stages, special means f o r treatment and c a r e ; therefore, R e s o l v e d , T h a t the S t a t e should make ample and suitable provision f o r all its insane not in a condition to reside in private families. R e s o l v e d , T h a t no insane person should be treated, or in any w a y taken care o f , in a n y c o u n t y poorhouse or almshouse, or other receptacle provided f o r , and in w h i c h , paupers are maintained or supported. Resolved, T h a t

insane persons considered curable and those sup-

posed incurable should not be provided f o r in separate establishments. 2 which w a s called a " h o s p i t a l " in its early y e a r s w h e n its standard of treatment did not rate it above an asylum, and which a f t e r w a r d s underwent an inexplicable change in title to " a s y l u m " at a time when it had a l r e a d y developed hospital s t a n d a r d s ! • I n 1874 the county superintendents of the poor w e r e organized into a permanent body, and held conventions annually t h e r e a f t e r f o r the purpose of discussing g e n e r a l public w e l f a r e problems.

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T o this set of resolutions, another was added a month a f t e r the Utica meeting, reading as f o l l o w s : " R e s o l v e d , First that the present provision f o r the insane of the state is defective and inadequate. Second, T h a t their present condition demands immediate attention and relief. T h i r d , T h a t the relief should be commensurate with the demand." T h e passage of these resolutions by the county superintendents of the poor stands in remarkable contrast to the subsequent role of these officials. In later years they were to offer the strongest and most inflexible resistance to the state care system. Nevertheless, in this historic instance a state care movement was not only supported, but actually initiated, by its traditional foes. T o implement their resolutions, a memorial to the legislature was prepared, setting forth the inadequate provisions f o r the insane in county poorhouses and recommending "the immediate erection of two State lunatic hospitals, so located that they may accommodate the largest number of insane at present unprovided for, and so relinquish the undersigned the pain of longer continuing a system fraught with injustice and inhumanity." 3 Acting upon this petition, the state Senate in 1 8 5 6 appointed a select committee to visit charitable institutions, particularly almshouses, throughout the state, to ascertain the condition of the dependent insane and to make recommendations based on the survey. A f t e r a thorough investigation the committee submitted its report, revealing among other things the disheartening spectacle of lunatics chained in cells and dungeons under conditions as dismal as those observed by Dorothea D i x twelve years before. 4 T h e committee endorsed the recommendations made by the county superintendents f o r immediate establishment of two or more state asylums. A s a result of this investigation, an act was introduced into the legislature providing f o r two new hospitals to supplement the one at Utica. T h i s bill passed the Senate but the Assembly adjourned before it could be voted upon by that body. It was subsequently laid aside and forgotten. Nothing further was accomplished until 1 8 6 4 , when the legislature ordered a state-wide inquiry into the care of the

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insane in local poorhouses. D r . Sylvester D . Willard, secretary of the N e w Y o r k Medical Society, was appointed special commissioner to direct the investigation. With the cooperation of physicians throughout the state, Dr. Willard was able to collect comprehensive data on prevailing conditions, which he embodied in a report submitted to the Legislature in January, 1865. 5 Once more the old and oftrepeated tale of misery, neglect and cruelty was unfolded. T h e disheartening truth, as abundantly illustrated in the report, was that the plight of the insane remained as desperate as it had been in 1 8 5 7 , and even in 1 8 4 5 when Miss Dix made her tour of inspection of the institutions of N e w Y o r k . T h e r e were 1 , 3 4 5 insane persons confined in almshouses. M o s t of these were chronics, although a number of instances were adduced in which recent cases had been sent directly to poorhouses instead of to Utica, because it was cheaper to maintain them there than at the state hospital. " L e t an institution f o r incurables be established," D r . Willard recommended. " L e t the incurables be there colonized. T a k e the insane from the counties where they are ill provided f o r first, and change the law relative to the insane poor, so that counties shall not have the management of them, nor any authority over them." 6 Behind the drive to get the insane poor out of the almshouses was the pressure of public opinion that had been mounting steadily as inquiry after inquiry brought forth additional evidence of the inhuman treatment of the insane. This public pressure must have been formidable indeed, since it forced legislative action at a time when civil strife was consuming the energy and attention of the war-torn nation almost to the exclusion of everything else. In April, 1 8 6 5 , an act was passed creating a state asylum for the chronic insane. It was named after D r . Willard, who had died shortly before. T h e Willard Act provided f o r the removal to the Willard Asylum of all chronic insane persons from the county poorhouses. All those discharged as chronic cases from the Utica hospital were also to be sent to Willard. Defining chronic lunatics by inference, the act required local authorities to

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send to Utica all indigent and pauper insane coming under their jurisdiction " w h o shall have been insane less than one y e a r . " A l l others were to be admitted and maintained at Willard. T h e act provided f o r 1 , 5 0 0 beds, making the asylum by f a r the largest institution f o r the insane erected up to that time in the United States. T h i s was a radical departure f r o m the time-honored limits of 2 5 0 beds per institution, set by the Association of Medical Superintendents in its Propositions of 1 8 5 1 . In 1 8 6 6 , largely through the pressure exerted by the establishment of the W i l l a r d Asylum, the Association modified its proposition upward to permit a maxi· mum capacity of 600 beds in institutions f o r the insane. T h e founding of W i l l a r d marked the introduction of a new principle, explicitly stated, in the care and treatment of the mentally ill in the United States; namely, the creation of two distinct types of state institutions—hospitals f o r the acute insane and asylums f o r the chronic cases.* A flood of discussion within the psychiatric specialty was precipitated by the passage of the W i l l a r d Act. T h e debate, often reaching acrimonious proportions, found its peak at the annual convention of the Association of 1 8 6 6 . T h i s session was probably the most exciting in the history of the Association. It certainly witnessed more heated argument and mutual recrimination than any other. T h e opening shot at this conference was fired by D r . G e o r g e Cook of Brigham H a l l Asylum at Canandaigua, N e w Y o r k , in a paper entitled, " P r o v i s i o n f o r the Insane P o o r in the State of N e w Y o r k . " It constituted a vigorous defense of the W i l l a r d Act, defying the great majority of the Association membership who opposed separate institutions f o r chronics and acutes. T h e m a j o r significance of the W i l l a r d Act, he maintained, was not that it provided a separate state asylum f o r chronics, but that it rescued all * A t the time, the principle of treatment in separate institutions w a s a l r e a d y in operation in E n g l a n d , G e r m a n y and F r a n c e , h a v i n g arisen out of v e r y much the same conditions of pressing necessity as w e r e responsible f o r the origin of W i l l a r d . (See Henri Falret, in an interesting p a p e r , "On the Construction and Organization of Establishments f o r the I n s a n e , " published in the American Journal of Insanity, 1854. v . 10, pp. 2 1 8 - 6 7 . )

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the insane from the blighting environment of poorhouses and placed them in a properly conducted institution where they would receive special care. There they could be comfortably supported at a cost per week well within the reach of every county.* According to D r . Cook, the creation of the Willard Asylum was an important step in advance, since it recognized f o r the first time in explicit terms the vital principle that the chronic, as well as the recent cases, were entitled to proper care and treatment in state institutions. H e challenged the assertion of those opponents of the Willard experiment who branded it as " a retrograde step," and who maintained that the separation of chronic and acute cases was wrong in principle and led to abuses in practice. T h e opposition to the principle of separate care for the chronic insane was led by D r . John B. Gray, superintendent of the Utica State Asylum of New Y o r k , and editor-in-chief of the American Journal of Insanity.t The opposition's main arguments might be briefly summed up as follows: ι. All insane persons are essentially sick, and are entitled to therapeutic treatment, whether chronic or recent cases. 2. Chronic cases are not necessarily incurable. Some recover after an illness lasting many years. It would work an injustice on chronic cases who were not beyond cure to remove them from curative institutions. 3. At present, it is impossible for a physician to pronounce with certainty w h o are, and who are not, curable or incurable. T o main• A s has a l r e a d y been noted, the counties of N e w Y o r k w e r e charged with the expense of maintaining dependent insane at the state asylum. T h e W i l l a r d A c t fixed a m a x i m u m c h a r g e upon counties of two dollars per week f o r each inmate chargeable to them. T h i s rate w a s later found to be too low, and w a s raised to three dollars per week. t P r e v i o u s to the p a s s a g e of the W i l l a r d Act, D r . G r a y succeeded f o r a time in p e r s u a d i n g D r . W i l l a r d that the latter's proposal f o r a separate institution w a s inimical to the interests of the chronic insane. A t W i l l a r d ' » suggestion he d r e w up a substitute bill, p r o v i d i n g f o r two additional state hospitals of the mixed type recommended e a r l i e r by the county superintendents and the Senate committee of 1857. F o r some unexplained reason, h o w e v e r , G r a y ' s bill w a s suddenly w i t h d r a w n a f t e r h a v i n g been introduced in the legislature, and the o r i g i n a l bill d r a w n up by W i l l a r d w a s voted on and passed.

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tain two separate types of institutions would render it difficult, if not impossible, to correct an error of diagnosis, and to transfer a patient subsequently found curable from an asylum for chronics to a hospital for acute cases. 4. T h e stamp of incurability on inmates of asylums for chronics is unnecessarily cruel and painful not only to many patients, but to their close relatives and friends, w h o are thus robbed of the solace of hope. O n the other hand it gives to unkind relatives a pretext for indifference and neglect. 5. " M a n y that are incurable are monomaniacs. T h e y are deranged on but one or two subjects, and sane on all others. Such surely should not be deprived of any comforts that are afforded the curable class, among the greatest of which is hope, which would be destroyed if they were sent to an incurable a s y l u m . " · 6. W h i l e custodial institutions for the chronic insane might be built and maintained at less cost than hospitals, it would be only at the expense of the inmates, who would thereby be subjected to reduced standards of care and comfort. 7. Vigilance against abuses tends to slacken in institutions where the inmates are regarded as hopeless cases. Separate asylums for chronics, then, would result in lesser safeguards against neglect and abuse. A t the end of the debate in the Association's memorable convention of 1 8 6 6 , several sets of resolutions on provision f o r the chronic insane were offered by opposing sides to the membership f o r adoption. A set of propositions drawn up by D r . Chipley of Kentucky was finally adopted by unanimous vote. 7 T w o of his resolutions were substantially identical with those adopted by the Association in 1 8 5 1 , namely, that the state should make ample and suitable provision f o r all its insane, and • T h i s argument, quoted by D r . G r a y in his rebuttal to Cook's paper, w a s originally advanced by Dr. A m a r i a h B r i g h a m in a letter to Dorothea D i x strongly opposing separate institutions f o r the insane. In an article appearing in the first issue of the American Journal of Insanity ( J u l y , 1884) Dr. B r i g h a m had written: " W e hope never to see such institutions [ f o r the incurable insane only] in this country. On the contrary, let no asylum be established but f o r the curable, and to this the incurable, the rich and the poor should be admitted; let all h a v e the same kind c a r e ; and all indulge the same hope, even if delusive to many, of ultimate recovery, but do not drive any to despair . . . "

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that recent and chronic cases should not be placed in separate institutions. T o w a r d s the close of the meeting, D r . Charles H . Nichols, of the Government Asylum f o r the Insane at Washington, introduced a set of five resolutions calling mainly f o r the division of large states into geographical districts where easily accessible mental hospitals could be constructed, and f o r the enlargement of public hospitals f o r the insane to accommodate a maximum of 600 patients, "embracing the usual proportions of curable and incurable insane in a particular community." Four of D r . Nichols' resolutions were adopted without dissent, but the last one, modifying the mooted maximum-capacity proposition of 1 8 5 1 , was passed only after a sharp debate, and by a very close vote. Despite the Association's emphatic rejection of the principle of separate provision f o r chronic and recent cases, the establishment of the Willard Asylum had the effect of stimulating movements in that direction in several states besides N e w Y o r k . In χ 866 the Massachusetts State Almshouse (now the Tewksbury Infirmary), which had previously received all classes of state paupers, was converted by law into an asylum f o r the harmless and incurable pauper insane, and also f o r the crippled, the epileptic, the feebleminded, and " f o r such other persons who, on account of their infirmities, are unable to support themselves." In Rhode Island, the Asylum f o r the Incurable Insane was opened at Cranston in 1 8 7 0 . ( T h i s was probably the first and only instance when a state's initial institution f o r the mentally ill was opened exclusively for incurable cases.) U p to that time the insane poor requiring institutionalization had been sent to the Butler Asylum, a corporate institution where a nominal fee was charged for public dependents, or else to asylums in neighboring states. A f t e r 1 8 7 0 the state continued to send its acute cases to the latter institution, while the "incurables" were sent to Cranston. In 1885 a law was enacted providing that all acute cases, as well as chronic, be thereafter admitted to the asylum at Cranston, thus ending the separation between the two groups in Rhode Island.

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In California, a movement was set a f o o t in 1 8 6 6 to convert the Stockton State Asylum into an institution exclusively f o r chronics, but this plan met with decisive defeat. T w e n t y years later an act was passed by the California legislature creating an asylum f o r the chronic insane at A g n e w but due to the articulate distaste of the public f o r such an institution, it was soon a f t e r converted into a " m i x e d " hospital. Similarly, the legislature of Connecticut enacted a statute in 1 8 7 7 converting an abandoned home f o r soldiers' orphans into an asylum f o r chronics, but under the weight of public opposition this plan fell through. Attempts to effect a satisfactory compromise between complete separation and non-separation were largely responsible f o r the introduction in the United States of the "cott a g e " and " c o l o n y " systems of institutionalization. Both types had existed in European countries long before their adoption in America, where the acceptance of the plans in theory antedated by many years their application in practice. T h e cottage plan which, in essence, involved the principle of segregation as opposed to congregation (that is, distributing the patients in a number of small buildings, or cottages, instead of congregating them in one massive buildi n g ) , won wide approval among the early practitioners of psychiatry in America. T h e earliest approach to the cottage plan in the United States was effected in those institutions, like the Friends' Hospital at F r a n k f o r d , Pennsylvania, where the classification system of the German psychiatrist, Spurzheim, was put into practice. T h i s system required a large central building f o r administering treatment to curable cases, and separate lodges f o r convalescents, disturbed patients, and harmless and chronic cases. In his first annual report as superintendent of the Worcester Hospital, D r . Samuel B. W o o d w a r d had written in 1 8 3 3 : " I f to this [the existing large building] could be added a cheap building, as a retreat f o r incurables (of which this Institution will always have a large s h a r e ) , this establishment would combine all the advantages which could be derived in a Hospital f o r the insane—a quiet and undisturbed Asylum f o r incura-

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bles; L o d g e s f o r the violent and noisy; the great Hospital f o r the recovery of curable cases, old and recent; and a peaceful and pleasant abode f o r convalescents." 8 In 1 8 7 0 a vigorous, organized campaign f o r the introduction of the cottage system was initiated in Illinois. T h e state legislature, in the preceding year, had voted an appropriation f o r the establishment of two new state hospitals and had l e f t the matter of f o r m and construction to be decided by the B o a r d of State Commissioners of Public Charities, in conference with other officials, including the officers of the existing state hospital at Jacksonville. T h e secretary of the B o a r d of State Commissioners, Frederick H . Wines, one of the foremost social w e l f a r e leaders of his time, had made a comprehensive study of the care and treatment of the insane, and had become convinced that the cottage system constituted a marked improvement over the congregate (usually identified with the Kirkbride) plan then in universal use. U n d e r his dynamic direction a "Conference on Insanity" was called by the B o a r d , to which asylum superintendents of neighboring states were invited. A questionnaire was sent to all known superintendents of American institutions f o r the insane, soliciting opinions on the cottage system. A t the conference, M r . Wines, ably seconded by D r . Andrew M c F a r l a n d , superintendent of the State Asylum at Jacksonville, urged the adoption of a cottage plan f o r the two proposed hospitals. H i s plan was based on the system practiced at the famous colony of Fitz James, a private institution f o r the insane at Clermont, France, which had been founded in 1 8 4 7 . T h e conference, however, considered that the introduction of a cottage system in toto was too radical a move, and adopted a compromise plan expressed in these resolutions : Resolved, T h a t in the judgment of this conference, so far as practicable, a combination, in insane asylums, of the cottage system with that at present in vogue, is desirable. Resolved, T h a t there are weighty reasons for the belief that such a combination is practicable, and that it would increase both the economy and efficiency of asylums for the insane.9

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T h e result of the compromise was the establishment of the Illinois State Hospital at Kankakee in 1 8 7 7 , incorporating the principle of a group of small buildings, or "cott a g e s , " each accommodating about 1 0 0 patients, grouped around a large central building. Although construction was not based on a complete acceptance of the cottage plan, the Kankakee State Hospital marked the first practical application of the principle in America, and paved the way f o r its wider acceptance in the future. T h e main ends sought in the construction of the Kankakee hospital, as stated by M r . Wines, w e r e : " ( 1 ) the cheapening of the cost of building, in order that a larger number of the insane in the State might, with a given appropriation, be furnished with proper quarters, attendance, and medical oversight, thus relieving the county poorhouses of the pressure upon them; and ( 2 ) the application of the principle of graduated restraint, or differentiation in the treatment of the insane, so as to allow to each patient the largest measure of personal liberty of which he is individually capable. Some of the incidental results hoped f o r were : the introduction of a simpler and more natural mode of l i f e ; the disuse, as f a r as possible, of mechanical restraints; and an increase in the amount of useful labor by patients." 1 0 T o d a y , the superiority of the segregate or cottage plan over the old congregate system is a fact generally accepted by leading authorities. Unfortunately, however, due mainly to the failure of legislatures to appropriate sufficient funds to build modern mental hospitals and the general unwillingness to abandon outworn institutions based on the congregate plan, the cottage system has found no application in practice commensurate with its acceptance as an institutional ideal in theory. T h e introduction in the United States of the colony system, which is closely allied to the cottage plan, dates f r o m 1 8 8 5 , when a tract of 2 5 0 acres was purchased and added to the State Asylum at K a l a m a z o o , Michigan, as a " f a r m colony." B e f o r e that, f r o m time to time, American psychiatrists returning from E u r o p e had opened discussions on the vari-

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ous colonies f o r harmless and chronic insane that they had visited on the continent. Because of the general antagonism to separation of chronic and recent cases, however, the application of the colony system to America was frowned upon by institutional authorities. In 1 8 6 3 D r . Richard Hills, superintendent of the Central Ohio Lunatic Asylum at Columbus and one of the earliest outspoken advocates of separation, proposed, in his annual report to the legislature, the establishment of a f a r m colony f o r the chronic insane. 1 1 T h i s colony, he suggested, should be planned on a village basis, approximating as closely as possible normal village life, and might appropriately be named the " H a m l e t H o m e f o r the Chronic Insane." N o action was taken on this proposal. A t the 1 8 6 7 convention of the Association of Medical Superintendents, D r . Benjamin W o r k m a n of the Provincial Lunatic Asylum at T o r o n t o , C a n a d a , read a paper on " A s y l u m s f o r the Chronic Insane in U p p e r C a n a d a , " in which he described how the pressure of overpopulation in the T o r o n t o Asylum had led to the establishment of "branch asylums" f o r the chronic insane situated about three miles f r o m the parent institution. T h e s e "branches," he reported, had proved very satisfactory. 1 2 Interestingly enough, the first f a r m colony in the United States—that at K a l a m a z o o , Michigan—represented a synthesis of the two ideas we have just mentioned. T h e Kalamazoo colony f o r the chronic and harmless insane was based on the village principle of construction advocated by D r . Hills twenty years earlier. On the administrative side it resembled the T o r o n t o plan in that it was a branch of a parent institution, was located about three miles f r o m the latter, and was under the same administration. T h e partial adoption of the "boarding-out" system by Massachusetts in the '8o's—which, in effect, represented still another alternative to poorhouse care of the dependent chronic insane—will be discussed in a later chapter. A s we shall see, the final disposition of the problem of maintaining the chronic and acute insane in separate institutions had a profound influence on the development of the

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two rival systems at present operating in A m e r i c a — s t a t e care and county care. Meanwhile, an important movement toward centralization of administrative control in state agencies was gaining ground. T h i s general centralizing tendency was to play an important p a r t in the evolution of state care.

CHAPTER

XIII

State Care: Exodus from the Poorhouse T N L A R G E measure the movement toward state care was part of a broader, more far-reaching process involving a logical trend toward centralization of public welfare activities. This process had been going on throughout the nineteenth century, but became clearly discernible for the first time in the years following the Civil W a r . (In at least one important aspect, the end of the Civil W a r itself symbolized the triumph of centralization over divided authority.) From the very beginnings of the American colonies, local responsibility had been the keystone on which the structure of public welfare was built. This system operated admirably while the country consisted, more or less, of a patchwork of loosely connected, self-contained communities. But as the nineteenth century—that century of tremendous change in the material conditions of life—advanced towards maturity, the once sufficing policy of exclusively local responsibility in public welfare grew increasingly and painfully anachronistic. It was evident that the governmental superstructure would have to be modified if it were to keep pace with the material changes of life. The chaos and contradictions arising from many-headed, independent authorities had to be reduced to some semblance of order. Uniformity and centralization of authority was the order of the day. Since this centralizing tendency in welfare work profoundly affected the rise of the state care system, it will be pertinent to our study to briefly trace its progress. The steady increase of charitable institutions and agencies —poorhouses, orphanages, asylums, hospitals, etc.—particularly after 1850, brought in its train a series of vexing 246

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problems, most of them arising out of the policy of unsupervised local responsibility. Local officials, together with superintendents and boards of m a n a g e r s in public and semipublic institutions, ruled with absolute authority over their realms. In many instances, to be sure, they were nominally responsible to the governor of the state or to the state legislature. But since the state authorities were invariably too busy with other duties to make inquiries into the stewardship of institutional officials, the latter remained relatively free f r o m higher interference save when they became involved in m a j o r scandals forcing executive or legislative action. Private charitable institutions were f o r the most p a r t entirely unencumbered by governmental restraints of any sort. It is unnecessary to go into details concerning abuses of these well-nigh unlimited powers; it is sufficient to point out that the very existence of unchecked power constituted a constant source of wrongdoing. M o r e o v e r , because each institution was governed as a virtually independent entity, there was a complete lack of uniformity in administration. Anarchy was r a m p a n t . Meanwhile, contradictions between policy and practice were placing the various states in an untenable position. M o r e and more, as local facilities and local treasuries found it increasingly difficult to cope with the expanding public welfare needs of a swiftly-changing society, the states were becoming involved in the financing of charitable institutions. They were pouring out funds in larger amounts f o r the construction and support of such institutions. In return, the state usually required no accounting beyond reports submitted annually to the executive power or legislature. Like as not, these r e p o r t s would go unread. T h u s , while the state served as a heavy subsidizing agent, it was an irresponsible one. T h e incongruity of this situation grew all too evident. T h e solution obviously lay in the direction of g r e a t e r state responsibility, of a more active role in the supervision and administration of public welfare. By investing supervisory powers in a central authority a potent check could be raised against abuses, and a g r e a t e r degree of uniformity in the operation of charitable institutions could be attained.

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E v e n more important, in the eyes of many who raised the demand f o r a central state authority, was the question of economy. A centrally supervised or controlled w e l f a r e system, it was believed, would result in greater efficiency and less overlapping of functions, and in definite savings in state expenditures. Massachusetts was the pioneer state in the establishment of a central public w e l f a r e body. In 1 8 5 8 its legislature appointed a joint committee to investigate the whole system of state charitable institutions, and to formulate recommendations. In its report, submitted the following year, the committee pointed out that there were, at the time, nine state institutions of a charitable nature, three of which were mental hospitals (Worcester, Taunton and N o r t h a m p t o n ) . 1 Of the nine institutions, all save one had been erected during the preceding decade. " E a c h of these new [state] institutions," it was reported, " h a s been created without especial reference to others, and in no degree as a part of a uniform system. It happens accordingly that there are anomalies in their organization and management, increasing the expense of conducting them, and impairing their efficiency."* In its main recommendation, the committee urged the creation of a permanent board of charities empowered to supervise the whole system of public charities within the Commonwealth, in order to secure the greatest degree of usefulness at the least expense. It was proposed that a ro•Compare this statement with the arguments advanced by Governor Reuben E. Fenton of New York in his annual message to the legislature for 1867, which led to the creation of a board of charities in that year: "For some years past, the State has made annual appropriations in the support of Orphan Asylums, Hospitals, Homes for the Friendless, and other charitable institutions. No adequate provision, however, has been made by law for the inspection of these and other corporations of a like character, holding their charters under the State, or for any effectual inquiry into their operation and management. There are a great number of these institutions, and the amount contributed for their support by public authorities and by public benevolence is large, and so many persons—the aged, the helpless, the infirm and the young—fall under their care, that I deem it expedient that the State should exercise a reasonable degree of supervision over them. T o this end I recommend a board of commissioners, in such manner as the Legislature may deem proper, to serve without compensation, but whose actual expenses shall be paid . . ." (Ménagés from the Governors of Nevi York. v. 5, pp. 447-48.)

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tating board of five members be appointed by the governor, to serve without compensation, but to be reimbursed f o r actual expenses. In addition to the five members, the employment of a salaried secretary was suggested. T h e recommendation of the committee was f a v o r a b l y acted upon in 1 8 6 3 , when the Massachusetts legislature created the first state board of charities in the country. Other states soon fell in line. During the next decade, ten similar boards were organized: Ohio and N e w Y o r k in 1 8 6 7 ; Illinois, N o r t h Carolina, Pennsylvania and Rhode Island in 1 8 6 9 ; Wisconsin and Michigan in 1 8 7 1 , and Kansas and Connecticut in 1 8 7 3 . T h e names of these boards varied widely,* but in most of them, the set-up and functions differed but little. In some instances, the scope of the board's work was limited to charitable institutions; in others, it was extended to the correctional fields also. W i t h one exception the powers of all these early boards were restricted mainly to visitation and inspection of institutions and the right to remove and transfer inmates under certain conditions. Licensing power was added to these functions in some instances. Rhode Island alone, f r o m the beginning, placed in the board's hands the administration and control of state institutions, together with wide supervisory powers. T h e same act creating the B o a r d of State Charities and Corrections in Rhode Island ( 1 8 6 9 ) provided f o r the establishment of a state workhouse, a house of correction, a state asylum f o r the incurable insane, and a state almshouse. A l l these institutions were to be located in the town of Cranston and were placed under the direct control of the state board. 2 * " I n Massachusetts and Ohio, the authority w a s called the B o a r d of State C h a r i t i e s ; in North C a r o l i n a and P e n n s y l v a n i a it w a s the B o a r d of P u b l i c C h a r i t i e s ; and the w o r d s 'public charities' w e r e in the names of the N e w Y o r k (State Commissioners) and Illinois ( B o a r d of Commissioners o f ) authorities. Rhode I s l a n d alone of these states used the w o r d 'corrections,' while Wisconsin had the idea of ' r e f o r m ' (State B o a r d of Charities and R e f o r m ) ; and M i c h i g a n spelled out the whole purpose in the title, ' B o a r d of State Commissioners f o r the S u p e r v i s i o n of C h a r i t a b l e , P e n a l , P a u p e r , a n d R e f o r m a t o r y Institutions.' " ( B r e c k i n r i d g e , Sophonisba P . Public Welfare Administration in the United Stales: Select Documents. Chicago, 1927. 786 pp., p. 243.)

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I n those states limiting the duties of a b o a r d to institutional visitation and inspection, without administrative o r corrective p o w e r s , this agency w a s in effect reduced to a m e r e a d v i s o r y status. I t could f e r r e t out abuses and evils, but lacked the authority to eliminate o r alleviate them. It could d r a w up plans f o r r e f o r m s and improvements, but had no p o w e r to put them into practice. It could only recommend such measures to a higher authority. So complicated w e r e the processes leading to remedial action that recommendations o f t e n became hopelessly entangled in the inv o l v e d mechanism, and w e r e lost sight of b e f o r e reaching the point w h e r e p r o g r e s s i v e action could be applied. D e s p i t e functional handicaps, h o w e v e r , these early b o a r d s p r o v e d to be v e r y important f a c t o r s in the p r o g r e s s of public w e l f a r e . T h e y w e r e particularly effective in mobilizing public opinion behind r e f o r m movements, especially those in behalf of the mentally ill. S e v e r a l b o a r d s w e r e staffed by men w h o combined r e m a r k a b l e ability and intelligence with a genuine zeal f o r social service. U n l i k e some of their present-day successors, they did not r e g a r d their offices as m e r e l y h o n o r a r y posts with nominal duties. T h e y t o o k up their tasks with dynamic energy, and w o r k e d incessantly f o r r e f o r m . M e n like Samuel G r i d l e y H o w e and F r a n k l i n B . Sanborn of M a s s a c h u s e t t s , F r e d e r i c k H . W i n e s of Illinois, G e n e r a l Roeliff Brinkerhoff of Ohio, W i l l i a m P . L e t c h w o r t h of N e w Y o r k — t h e s e w e r e keen and articulate critics of the w r o n g s rooted in the social o r d e r . W h e n their searching eyes noted evils and abuses, they d a r e d to point them out, even at the risk of e m b a r r a s s i n g people in high places. S o sweeping w e r e the r e f o r m s a d v o c a t e d by certain b o a r d s on behalf of the dependent classes that they aroused the fierce a n t a g o n i s m of the state officialdom. A t times, the politicians retaliated by abolishing a b o a r d outright, o r else emasculating it by r e f u s i n g to a p p r o p r i a t e f u n d s necessary to its p r o p e r functioning. F o r instance, the N o r t h C a r o l i n a B o a r d of Public C h a r i t i e s , in its first annual report to the G e n e r a l A s s e m b l y ( 1 8 6 9 ) , not only v i g o r o u s l y protested against the abominable treatment of dependent insane in

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public institutions, but arraigned the prevailing system of poor relief in toto. " T h e whole system, or rather want of system, that seems to have grown up by accident and without any benevolent concern f o r the w e l f a r e of the pauper classes, or the reformation of the erring or vicious, needs patient and thorough revision," it declared.® So well did the B o a r d champion the cause of the insane and other dependent classes, and so insistent was its demands f o r immediate reform, that the harrassed legislature in 1 8 7 3 abruptly terminated its existence by the simple expedient of neglecting to appoint new members at the expiration of the terms of incumbents, as provided by law. It was not until 1889 that the B o a r d was revived. T h e Ohio Board, organized in 1 8 6 7 , experienced a similar f a t e . It was abolished in 1 8 7 1 , a f t e r making repeated exposés of the plight of the pauper insane and others dependent on the public bounty, and calling f o r drastic changes in the system of public w e l f a r e . T h e first report of the Illinois B o a r d of State Commissioners of Public Charities ( 1 8 7 0 ) , prepared by its dynamic secretary, Frederick H . Wines, included a searching analysis of the whole philosophy and structure of public welfare. It contained many biting criticisms of existing abuses, together with recommendations f o r reform. W e have mentioned, in the preceding chapter, the " C o n f e r e n c e on the Insane" called by the board in 1 8 7 0 as one of its first official acts, and of its influence in introducing the cottage plan of mental hospital construction into the United States. A l s o indicative of the progressive tendencies of these early state boards is the fact that in 1 8 7 0 , only one year a f t e r its establishment, the Pennsylvania B o a r d of Public Charities adopted a resolution urging the "establishment by the state, within a reasonable time, of sufficient accommodations f o r the maintenance and treatment of all the insane who may not be cared f o r in private hospitals." 4 R e f o r m s in the care and treatment of the mentally ill advocated by these early boards varied somewhat in detail, but on one point they were unanimously agreed : Poorhouses were improper places f o r the confinement of the men-

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tally ill, and the latter should be withdrawn from such institutions at the earliest possible moment. In those formative years there was also general agreement that all the insane requiring public provision should be supported in stateowned hospitals or asylums. This position was perhaps best summed up in the first report of the Wisconsin State Board of Charities and Reform ( 1 8 7 1 ) , recommending that all the insane in local institutions "be removed from their present quarters and placed in an insane hospital." With the completion of the State Hospital at Oshkosh, then in process of construction, it was hoped that "sufficient accommodations may be found for them all, but if not, that the state will not stop building and enlarging until this end shall be fully secured."* In New Y o r k the State Board of Charities (as it was known after 1 8 7 3 ) was confronted with a most difficult problem in relation to provision f o r the mentally ill from the very moment of its organization. With the passage of the Willard Act in 1865, it had been confidently expected that the question of providing f o r the dependent insane with a maximum of humanity, efficiency and economy had been at last satisfactorily solved. Henceforth, it was assumed, all recent cases of mental illness would be sent to Utica Asylum f o r treatment, while all chronics would be cared for at the Willard Asylum at greatly reduced cost. In this way all the insane of the state would be the beneficiaries of comfortable provision in state-owned institutions, and the ills arising from the confinement of insane persons in poorhouses would forever be avoided. Alas f o r these expectations! Hardly was the Willard Asylum opened in 1869 than overcrowded conditions promptly appeared, together with a host of related evils. When it had been established in 1865 as the largest institution of its kind in America, with a capacity of 1,500 inmates, it was expected to comfortably accommodate all the chronic insane ' T h i s attitude, be it noted, stands out in s h a r p contrast to the policy adopted by the Wisconsin B o a r d a f e w y e a r s later, a d v o c a t i n g the introduction of the county c a r e system as opposed to state c a r e .

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then confined in poorhouses. H a d the original intention been carried into effect—that is, the removal of all chronic cases f r o m almshouses and the maintenance thenceforth of all cases of insanity in state institutions (even though counties continued to be charged with maintenance cost)—it would have marked a sizeable step toward the realization of state care. But when the Willard Asylum was opened at Ovid, it was found that the number of chronic insane in the state had increased to such an extent in the years intervening between its creation and completion that its capacity was already inadequate to accommodate them all. T h e asylum quickly filled up and overflowed with chronic cases transferred from Utica and from local poorhouses and jails. Within a short time the authorities were forced to cry out " H o l d , enough 1" and to close the doors to further admissions. Meanwhile hundreds of additional cases of insanity were pouring into the poorhouses. T h e r e they remained : there was no room f o r them in Willard. A n embarrassing situation arose. On the one hand, the law required local authorities to send all chronic cases to the new state asylum. On the other, the inability of Willard to receive additional cases compelled these authorities to violate the state laws in spite of themselves. By 1 8 7 1 the predicament had become so acute that the legislature was constrained to enact a new law authorizing the State Board of Charities to exempt certain counties from the provisions of the Willard Act. Such exempted counties were permitted to provide f o r their own chronic insane in local institutions.'" Nominally, counties receiving such exemption were required to meet certain standards of care. But in reality the "asylums" they maintained were usually either part and parcel of the poorhouse proper, or mere appurtenances thereto. There the mentally ill were generally treated in a manner no whit different than the pauper inmates except, of course, in the imposition of greater restraints. N o regard • T h e o r i g i n a l W i l l a r d A c t , as p a s s e d in 1 8 6 5 , h a d a l r e a d y e x e m p t e d t h r e e counties ( N e w Y o r k , M o n r o e a n d K i n g s ) on the g r o u n d t h a t these counties p r o v i d e d s a t i s f a c t o r i l y f o r t h e i r o w n i n s a n e in s p e c i a l institutions.

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was given to their special needs—medical, dietary, occupational, etc. T h e Willard Act, in charging the counties with the cost of indigent and pauper insane maintained at Willard, had specified that no more than two dollars per week per inmate should be billed to the county of settlement. However, when it was realized that adequate care could not be rendered at so low a rate, the price of maintenance was raised to three dollars per week. It was subsequently reduced, under county pressure, to $ 2 . 7 5 per week. M a n y county authorities balked at paying what they considered a high rate, feeling that they could provide f o r their own insane in the local houses at much less cost. ( T h e cost of maintaining insane charges at county almshouses averaged at the time about $ 1 . 5 0 f o r each person.) With this thought dominant, county after county applied for, and received, exemption from the Willard Act in accordance with the law of 1 8 7 1 . B e f o r e many years had passed, nineteen counties (more than one-third the total) were granted exemption. Thus was defeated the main purpose of the Willard Act, namely, to remove all the insane from the poorhouses. T h e new policy of permitting certain counties to care f o r their own insane, inaugurated as a temporary expedient, proved highly unsatisfactory. T h e conviction spread among enlightened people that whatever improvements were made, and however honest its management might be, there were inherent evils in poorhouse care of the insane which could never be obliterated. A poorhouse could function well only as a home f o r the aged and infirm; it could never be successfully blended to serve as an asylum f o r the mentally ill in addition to its other functions. Dissatisfaction with the prevailing condition of the insane poor mounted steadily. Meanwhile, with the increasing number of insane persons and the growing complexity in public provision f o r their care and treatment, it soon became evident that the State Board, burdened with its manifold duties, could not devote sufficient attention to this problem without an organizational change. T h e need f o r a separate state authority which could devote full time and undivided attention to the

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supervision of institutions f o r the mentally ill was clearly indicated. Besides, the public was growing restless due to periodic scandals involving illegal and unjust commitments of sane persons to asylums. A d d e d to these factors were the ever-recurring revelations of intramural abuses of asylum inmates. A responsible head was required to act in a supervisory capacity and to serve as a liaison officer, in order to maintain public confidence in the institutional care of the insane. In 1 8 7 3 , N e w Y o r k took a partial step toward solution of this problem by creating a State Commissioner in Lunacy, not as a separate authority, but as an ex-officio member of the State B o a r d of Charities, directly responsible to that body. 5 H e was required to examine into the condition of the insane and "idiotic" of the state, to visit and inspect institutions f o r their custody and treatment, and to report annually to the board. H e was also directed to collect information on methods of caring f o r the mentally ill in other states and countries. N o remedial powers were vested in him: his was merely an advisory post. T h e same act creating this office extended the powers of the State B o a r d to include the right to license all establishments f o r the insane, public and private, none of which might be operated without such license. N e w Y o r k was not the first state to create the office of commissioner in lunacy on a permanent basis. A s early as 1 8 4 5 , Vermont had appointed a Commissioner of the Insane, whose duties, however, were almost exclusively confined to visiting and inspecting the Vermont Asylum (later the Brattleboro R e t r e a t ) and to report yearly on its condition to the legislature. A similar office was created in Connecticut some years later, in connection with official periodical inspection of the H a r t f o r d Retreat in relation to public charges maintained there. T h e N e w Y o r k State Commissioner in Lunacy, limited though his powers were, functioned in a f a r wider field than any other permanent officer of his kind up to that time. T h e voice of the State Lunacy Commissioner soon swelled the chorus raised in criticism of the chaos in the care of the

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mentally ill.* In the decade 1 8 7 1 - 1 8 8 1 , f o u r additional state institutions f o r the insane were opened,! but the inflow of insane persons into almshouses continued unabated. T h e i r numbers mounted by the hundreds. On the other hand, the drive toward state care was gaining strength. By 1880, the forces of progress had formed a solid united front on this issue. In its report f o r that year, the State Board of Charities came out categorically against the system of permitting counties to care f o r their chronic insane. "Unless the state promptly extends its accommodations f o r this class," it declared, "the work must necessarily be taken up by the counties. T h a t , it is believed, would be a public calamity, as experience has fully shown that the efforts of counties to provide f o r their chronic insane have in most cases proved failures." In this and in subsequent reports it bombarded the legislature with urgent appeals f o r a state care system. An important factor in the final triumph of state care in N e w Y o r k was the work of the State Charities A i d Association, a semi-public w e l f a r e body founded in 1 8 7 2 , which carried on an incessant propaganda campaign f o r the cause during the decade leading up to 1890. E a r l y in its development the Association had formed a standing committee on the insane, which soon became a focal point of activity. A t the head of the Committee was Louisa L e e Schuyler, founder of the S . C . A . A . , and its outstanding personality. She proved to be a most active agent in pushing to a successful conclusion the fight f o r state care. F r o m its voluntary visiting committees (which exercised the privilege of visitation and inspection of all public charitable institutions, • D r . J o h n O r d r o n a u x , professor of medical jurisprudence at Columbia University, w a s the first to be appointed to this office. He w a s succeeded by D r . Stephen Smith, w h o held the post until it w a s superseded by the State Commission in L u n a c y in 1889. t T h e Hudson R i v e r State A s y l u m at Poughkeepsie w a s opened in 1871 ; the Middletown State Homeopathic A s y l u m , established through the insistence and aid of a group of citizens w h o wished to see the H a h n e m a n n i a n method applied to the treatment of the mentally ill, w a s opened in 1 8 7 4 ; the B u f f a l o State A s y l u m w a s opened in 1880, and the Binghamton State A s y l u m f o r the Chronic Insane, the second of its kind in N e w Y o r k , in 1 8 8 1 . T h e latter w a s converted f r o m a f o r m e r inebriate asylum originally opened in 1859, but abandoned as a f a i l u r e twenty y e a r s later.

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granted by special legislation) the organization received with disheartening regularity reports of terrible treatment of the mentally ill in poorhouses and county asylums throughout the state. A t the same time, the committee on the insane was gathering information on the care of the mentally ill in this country and abroad, with a view toward suggesting concrete legislative action on this score. Allied with the forces advocating state care was the National Association f o r the Protection of the Insane and the Prevention of Insanity, the energetic, though short-lived, reform society which operated mainly in N e w Y o r k . D r . Stephen Smith, State Commissioner of Lunacy f r o m 1 8 8 2 to 1 8 8 9 , was an influential figure in the movement, second in importance only to Miss Schuyler. A s early as 1 8 8 4 , he had framed a state care bill and approached M i s s Schuyler with the suggestion that the S . C . A . A . sponsor it.® T h i s bill served as the basis f o r the one introduced into the legislature under S . C . A . A . sponsorship some years later. W i t h the approach of the final decade of the nineteenth century, the r e f o r m movement in behalf of the mentally ill in N e w Y o r k was advancing in full swing along three parallel fronts. Its main objects w e r e : ( 1 ) removal of all insane persons f r o m almshouses; ( 2 ) discontinuance of the practice of maintaining separate institutions f o r the chronic and acute insane; ( 3 ) state control and supervision of all institutions f o r the mentally ill. In 1 8 8 7 the State Charities A i d Association sponsored a state care bill that was introduced into the legislative sessions of 1888 and 1 8 8 9 , failing of passage both times. It is noteworthy that the annual convention of the Association of Medical Superintendents held in 1888 unanimously adopted a resolution, drawn up and submitted by D r . G. Alder Blumer (then assistant physician at the Utica State Asyl u m ) , in which it went on record as "cordially endorsing" the principle of state care as embodied in the bill introduced by the S . C . A . A . 7 Simultaneously, the N e w Y o r k Neurological Society passed a resolution calling f o r the transfer of all insane persons f r o m poorhouses to state hospitals.

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T h o u g h the state care act f a i l e d of p a s s a g e in 1 8 8 9 , another bill i m p o r t a n t to the p r o g r e s s of provision f o r the insane did become l a w in that session. T h i s w a s the act creating a state commission in lunacy, consisting of three members, in place of the one-man commissionership established sixteen y e a r s b e f o r e . C u r i o u s l y enough, this bill w a s d r a w n up and v i g o r o u s l y pushed by D r . Stephen Smith, in f a c e of the f a c t that it abolished the office he held. T h e new l a w p r o v i d e d that the C o m m i s s i o n be composed of a physician, a l a w y e r , and " a citizen of reputable c h a r a c t e r . " * It w a s constituted as an independent body directly responsible to the g o v e r n o r , instead of to the State B o a r d of Charities as h a d been h e r e t o f o r e the case with the commissionership. T h e p o w e r s of supervision, licensing, t r a n s f e r and r e m o v a l in m a t t e r s relating to the mentally ill that had been vested in the State B o a r d of C h a r i t i e s w e r e now t r a n s f e r r e d to the C o m m i s s i o n in L u n a c y , and considerably extended. Chief a m o n g its duties, the C o m m i s s i o n w a s required to meet at least q u a r t e r l y ; to keep records of e v e r y insane person admitted and maintained in institutions; to visit and inspect, at least twice each y e a r , " e v e r y asylum and institution in which the insane are in legal custody in this s t a t e ; " to g r a n t licenses to institutions f o r the insane and to r e v o k e them, if n e c e s s a r y ; to supervise the correspondence of institutional• I t should be mentioned that the Association of M e d i c a l Superintendents c a r r i e d on a long and strenuous struggle against the creation of commissions in lunacy. E x t r e m e l y anxious to maintain independent authority over their institutions, and deeply resentful of any action regarded by them as "outside i n t e r f e r e n c e " and " o v e r - s n o o p i n g , " the members of the Association periodically issued broadsides against the commission idea. A s early as 1863, an Association resolution had bluntly stated: " T h e appointment of Lunacy Commissioners, with a v i e w to official visits, etc., or any supervision of State or corporate institutions f o r the insane, is to be deprecated as not only wholly unnecessary, but injurious and subversive of the present efficient system of control." In 1875 it had a g a i n voiced its bitter antagonism t o w a r d s lunacy commissions in a series of eleven resolutions d r a w n up by Dr. I s a a c R a y , one of which r e a d : " R e s o l v e d , T h a t any supernumerary functionaries, endowed with the p r i v i l e g e of scrutinizing the management of the hospital, even sitting in judgment on the conduct of attendants and the complaints of patients and controlling them, directly by the exercise of superior p o w e r or indirectly by stringent advice, can scarcely accomplish an amount of good sufficient to compensate f o r the harm that is sure to f o l l o w . " (Proceedings of the A s s o c i a tion, 1875. American Journal of Insanity, 1876. v. 32, pp. 345-54.)

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¡zed insane persons; to afford all such persons opportunities f o r private interviews to air real or imaginary abuses; to investigate cases of alleged wrongful detention or custody, or cruel and negligent treatment; and to report annually to the governor. Similar trends toward the creation of lunacy commissions were already evident in other states. In fact, N e w Hampshire in 1889 passed a law constituting the B o a r d of Health as a Commission in Lunacy besides its other functions. In many states special lunacy committees had been organized within state boards. In M a r y l a n d a State Commission of Lunacy was created in 1886, with supervisory powers over all public, corporate and private institutions in which insane persons were kept. T h e Commission consisted of four members, two of whom were physicians, with the attorneygeneral of the State serving as an ex-officio member. Massachusetts early recognized the growing importance of lunacy supervision. In 1 8 7 9 the State Board of Charities and the Board of Health were merged into a Board of Health, Lunacy, and Charity—the first time in America that the term "lunacy" was made part of a state board's title. A second reorganization, in 1886, created two separate bodies, one of which was called the Board of Lunacy and Charity. In 1898 a separate B o a r d of Insanity was established in Massachusetts, the first independent board of its kind in the United States. M a n y of our present state boards and departments of mental hygiene evolved out of such committees and commissions in lunacy. In its very first report ( 1 8 8 9 ) the N e w Y o r k Commission in Lunacy placed itself on record as unqualifiedly in favor of state care and of non-separation of chronic and acute cases of mental illness. 8 In 1890, thanks to the favorable mass pressure that had been gradually accumulating, and despite the stubborn opposition of certain local authorities in exempted counties, the State Care Act was passed, opening up a new epoch in the care and treatment of the mentally ill.9 A s originally enacted, the statute provided f o r the division of the state into hospital districts, in each of which a state hospital should be located. A l l insane persons, acute

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and chronic alike, within such districts were to be received into the district hospital. T h e two existing state asylums f o r chronics exclusively, W i l l a r d and Binghamton, were thenceforth to be operated on the same basis as the other state institutions f o r the mentally ill, admitting all cases within their respective districts. T h u s was abolished the system of providing separate institutions f o r the chronic and recent insane in N e w Y o r k . T h e law directed that all the insane in almshouses be transferred to state hospitals as quickly as accommodations could be made f o r them. T h r e e counties—New Y o r k , Kings and M o n r o e — w h o s e provision f o r their own insane was regarded as adequate, were exempted f r o m the terms of the act, as they had been exempted f r o m the W i l l a r d Act of 1865. 1 8 9 5 , however, these counties were also brought under the terms of the act, thus completing the state care system in N e w Y o r k . T h e whole cost of care and treatment was now borne by the state, in contrast to the former policy of charging the counties of settlement with the cost of maintaining the dependent insane in state institutions. By the terms of the act, inexpensive, detached buildings of moderate size were to be immediately erected on the grounds of existing state hospitals, of sufficient capacity and number to provide f o r all the mentally ill who were then confined in county institutions. T h e State Commission in Lunacy was authorized to recommend the erection of additional institutions as necessity demanded. In keeping with the progressive spirit of the State C a r e Act, a statute passed the same year ordered that the term " h o s p i t a l " be substituted f o r " a s y l u m " in all state institutions f o r the insane. T h e most important features of the state care legislation of 1 8 9 0 may be summed up as f o l l o w s : ( 1 ) it provided f o r the removal of all the insane poor f r o m the poorhouses; ( 2 ) it carried the principle of state care to its ultimate conclusion, namely, support of all the indigent insane (except those in private institutions) in state hospitals at state expense ; ( 3 ) by districting the state, and by obliging each state hospital to admit all the insane in its district, it abolished the legal distinction between chronic and acute cases; ( 4 ) by

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specifically ordering the substitution of the term "hospital" for "asylum" in all public institutions for the insane, it inaugurated a significant change in nomenclature, symbolizing the new ideal of having all such institutions curative in name and intent. T h e State Care Act, obviously, was not original in all its provisions: some had been anticipated at least in principle in other states long before. F o r example, the principle of state care seems to have been implicitly stated in the Constitution of North Carolina, as revised in 1868—nearly a quarter-century earlier than the enactment of the New York law. In a clause of the Constitution of 1868, we find this passage : " T h e General Assembly shall provide that all the deaf, mutes, the blind, and the insane of the State, shall be cared for at the charge of the State." (Article X I , Section 10.) But whatever its original intent may have been, this clause was interpreted by the Assembly as applying only to those insane persons maintained in the existing state hospital at Raleigh. A large percentage of mentally ill dependents continued to be confined in local poorhouses—at local expense. Michigan, in 1877, took an important stride toward state care with the passage of an act prohibiting the placing of any insane person in a county almshouse after the completion of the Eastern State Hospital at Pontiac, which was opened in 1878. Thereafter, all the insane were to be supported in state hospitals. T h e act contained this unique feature : pauper and indigent patients maintained for two years continuously at a state hospital were to be supported at county expense; if they remained longer than two years, the burden of support fell upon the state. 10 Although overcrowded conditions in the state hospitals resulted in the practical nullification of some of its provisions, this statute probably constituted the most advanced legislation relative to public provision for the mentally ill up to that time. We might add one more instance of state care tendencies in states other than New York previous to 1890. In 1886, the legislature of Vermont passed an act, one section of which provided: "Insane persons in any town destitute of

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the means to support themselves, and having no relative in the state bound by law to support them, shall be supported by the s t a t e . " 1 1 H o w e v e r , it can be said f o r the N e w Y o r k State Care A c t that it truly marked the culminating point of a great movement, and the beginning of a new period. Embodied in it were the most sweeping legislative provisions in behalf of the insane ever enacted in the United States. W h a t is even more important, the law not only stated high-minded principles; it provided the instrumentation f o r carrying them into practice. It set into motion an impressive exodus of the mentally ill f r o m the poorhouses of the state. It constituted a momentous victory that brought renewed confidence and strength to the forces of progress in the care and treatment of the mentally ill. T h e great step taken by N e w Y o r k in 1 8 9 0 was bound to have a deep influence on other states throughout the country. T h e principle of complete state care (as well as the creation of commissions in lunacy) was adopted in state a f t e r state following its momentous inauguration in N e w York. Meanwhile a rival plan, the county care system, had been introduced and developed in several states, notably Wisconsin. So closely was this plan identified with the latter state that it became known (and still is known to this day) as the "Wisconsin system." T h e county care plan involves county provision f o r all chronic cases of insanity and state provision f o r acute cases, with both state and county participating in the costs. L i k e nearly all lines of development in the history of the care and treatment of the mentally ill, this system did not arise as the practical result of a definite long-range plan. Rather was it the outgrowth of a pressing need that demanded immediate action, without regard to its ultimate effects. T h e more or less elaborate body of theory that grew up around the system of county care was in large measure formulated ex post facto, as a rationalization of a condition already existing. In a very profound sense, the county care system was not

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"chosen"; it was forced by the exigencies of a desperate impasse. In most instances its main precipitating factor was overcrowding—that chronic ailment of institutionalized care of the insane throughout modern history. In Iowa, f o r example, a crisis in the care of the insane occurred in 1 8 7 8 , when the two state hospitals became so overcrowded that they were forced to close their gates against many new cases requiring treatment. In desperation the hospital authorities took advantage of a hitherto inoperative statute permitting them to return harmless and incurable patients to their places of settlement. A s a result large numbers of dependent insane persons were suddenly loosed upon the county poorhouses. This action had the effect of merely shifting a problem of overcrowding from one type of institution to another. T o meet the critical situation, many counties hastily built "asylums"—buildings which were closely connected with the poorhouses and often indistinguishable from the latter. Called into being as temporary expedients to meet an emergency situation, these asylums gradually became permanent fixtures. T h e i r existence had to be reckoned with in all subsequent measures affecting public provision f o r the mentally ill in Iowa, and played a determining part in most of the legislation that followed. Thus evolved in Iowa the county care system that obtains there to this day. 1 2 F o r the classic development of the county care system, however, one must turn to Wisconsin. In that state, the evolution of county care followed a circuitous and interesting course. Perhaps no single group was more instrumental in deciding its final form than the State Board of Charities and R e f o r m (later the State Board of Control), established in 1 8 7 1 . A s in most other states, the problem of public provision f o r the mentally ill was a major concern of the Board f r o m the very outset. A t first, the policies adopted by the Wisconsin Board in relation to the care of the insane were similar to those advocated by nearly all contemporary state bodies of its type. T h e recommendations contained in its early reports clearly reflected such policies; they insisted that all the insane were entitled to state care, that the poorhouse was not, and never could be, a fit place f o r the custody of

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any part of the insane, chronic or acute. A s a means of providing suitable maintenance f o r all the mentally ill, the Board recommended the enlargement of existing state hospitals, and the building of additional ones. But as fast as additional accommodations could be furnished, the increase of insanity always remained several leaps ahead of the total capacity. Concluding that this situation was due mainly to the steady accumulation of chronic cases, the B o a r d next recommended the erection, on the grounds of one of the existing hospitals, of an asylum large enough to accommodate all the chronic insane found in almshouses. Institutional rivalry, together with the opposition of county officials, prevented the adoption of this proposal. In its annual report f o r 1 8 7 6 , the Wisconsin Board brought f o r w a r d still another plan. It pointed out that the two state institutions f o r the insane were badly overcrowded. A large percentage of the mentally ill were confined in county jails and poorhouses. Of the 1 , 2 0 0 insane persons in the state, it was estimated, nearly 1,000 were chronic cases. W h y not build a large separate asylum f o r the latter group? A s a supporting argument, the board cited the alleged success of the Willard Asylum in N e w Y o r k , opened several years before. 1 3 Again failing to obtain action, the Board in the following year advanced still another compromise; namely, that the state hospital at Madison be converted into an asylum f o r chronics, leaving the Northern State Hospital at Winnebago to receive recent cases only. Once more the opposition of county officials to any and all forms of state care prevailed, and this proposal also was rejected. In 1878 the State Board suddenly reversed its longstanding policy and came out in f a v o r of county care f o r the chronic insane, mainly on the supposition that the average per capita cost of maintenance f o r this class in a county asylum would be less than one-half the per capita expense in state hospitals. T h e board cited other reasons f o r its change of heart. Within the previous six years, the state had almost trebled its mental hospital capacity without materially reducing the number of insane persons still confined in poorhouses. During that time, the Board felt, a noticeable im-

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provement in the condition of the insane in local institutions had been manifested, especially in those counties which owned asylums partly or wholly separated f r o m the poorhouse proper. In view of these and other observations, the B o a r d concluded that it was neither practicable nor desirable to furnish state care f o r the chronic insane poor. I t was deemed more advisable f r o m the viewpoint of expediency and economy to assign the care of this class to county institutions. A bill was accordingly drawn up by the B o a r d providing f o r the establishment of county asylums f o r chronic cases, with state hospitals treating only " c u r a b l e " patients. T h i s bill was passed by the legislature, but in so modified a f o r m as to defeat its original purpose. It permitted counties to build (with the approval of the governor and the State B o a r d of Charities and R e f o r m ) their own institutions f o r the insane. But it contained no proviso stating definitely that this privilege should apply only to chronic cases, as was originally intended.* U n d e r this act, a county hospital f o r the insane was established in Milwaukee. Opened in i 8 8 o , the Milwaukee County Insane Asylum thereafter received all dependent insane persons, chronic and acute, residing within its limits. In 1 8 8 1 , largely through the efforts of the State B o a r d of Charities and R e f o r m and particularly of its president, A n d r e w E . Elmore, a statute was enacted which finally crystallized the county care system, thereafter known as the "Wisconsin plan." 1 4 According to the provision of the new law, counties which, in the judgment of the State B o a r d , "possessed accommodations f o r the proper care of the chronic insane," would thenceforth upon receiving proper certification be paid $ 1 . 5 0 per week f r o m the State treasury •Wisconsin Lavis of 1878, Chapter 2Ç8. A section of the act did provide that " w h e n e v e r any insane person, committed to said county asylum . . . shall be found to belong to the class defined as acute insane, and to require permanent and special treatment f o r the purpose of cure, said persons may be transferred to the state hospital f o r the insane." T h e permissive nature of this clause robbed it of any practical effectiveness. By the terms of this act, the State undertook to pay half the expense of erecting county asylums, provided that the total cost did not rise above $600 per patient, and to pay eighty per cent of the maintenance cost f o r each dependent patient.

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f o r each chronic insane person maintained in such institutions. ( A later amendment raised this r a t e to $ 1 . 7 5 per w e e k per inmate.) C o n v e r s e l y , counties to which patients in state hospitals w e r e c h a r g e a b l e w e r e required to share in the maintenance cost to the extent of $ 1 . 5 0 per week, plus clothing costs. R u l e s relating to the m a n a g e m e n t of county institutions f o r the chronic insane w e r e to be prescribed by the state b o a r d . W h e n e v e r , in its opinion, any county did not p r o p e r l y care f o r its mentally ill, the B o a r d w a s a u t h o r i z e d to r e m o v e insane persons, and to t r a n s f e r them to other county institutions. T h e r e they w e r e to be maintained at the fixed rate of three d o l l a r s w e e k l y , the cost to be s h a r e d equally by the state and the c h a r g e a b l e county. R e g u l a t i o n s concerning restraints, ventilation, heating, p r o p e r attendance, the appointment of visiting physicians, etc., w e r e d r a w n up by the B o a r d to g o v e r n county care. O r i g i n a l l y , the Wisconsin l a w w a s intended to c o v e r only those chronic cases not a l r e a d y cared f o r in one of the state hospitals. A later amendment to the county care act, h o w e v e r , m a d e it m a n d a t o r y to r e m o v e all chronic cases f r o m state hospitals to county institutions. A l s o , the provisions c o v e r i n g county asylums were so altered as to make counties which maintained their insane in p r o p e r l y certified poorliouses eligible f o r state aid on the same terms as those counties which possessed s e p a r a t e asylums. T h e Wisconsin plan, as finally developed, p r o v i d e d a s a f e g u a r d against the possibility of h o p e f u l cases being committed to county institutions. A provision made it m a n d a t o r y t h a t all new cases of insanity, w h e t h e r deemed curable o r not, be automatically sent by county authorities (except in the case of M i l w a u k e e , which possessed its own h o s p i t a l ) to a state hospital f o r treatment. I f , a f t e r a certain period of o b s e r v a t i o n and treatment, the hospital authorities f o u n d a patient to be chronic o r incurable, they w e r e a u t h o r i z e d to t r a n s f e r him to a county institution w h e r e he remained unless other provision w e r e m a d e f o r his care. Such w e r e the principal f e a t u r e s of the county care system a d o p t e d in W i s consin. A s w e h a v e noted previously, s e p a r a t e care f o r chronic

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and recent cases in county and state institutions, respectively, had been in actual operation in many states long before the passage of the county care act in Wisconsin—often in direct contradiction to existing statutes. But it was Wisconsin which first crystallized the practice into a complete and comprehensive system. When, in 1890, the State Care Act was passed in N e w Y o r k , the country was confronted f o r the first time by the spectacle of two opposing systems functioning in two different states in accordance with definite, concrete plans. T h e issue of county care versus state care was clearly outlined at last, and advocates on both sides entered into a sharp and passionate debate on the merits and drawbacks of the systems. T h e N e w Y o r k State Board of Charities on the one hand, and the Wisconsin State Board of Control, on the other, became the chief rallying-points f o r the opposing factions. A r r a y e d on the side of the former was the Association of Medical Superintendents (which became the American Medico-Psychological Association in 1 8 9 3 ) . T h e Association drew the particular fire of the county care defenders, who sharply impugned its motives, declaring that its members favored state hospitals f o r all the insane mainly out of the selfish desire to protect and extend their "vested interests" in such hospitals. T h e Wisconsin system did not lack eloquent advocates in other states.* A t any rate, the controversy over the respective systems ' F r a n k l i n B . Sanborn, f o r many y e a r s secretary of the Massachusetts State B o a r d of C h a r i t i e s and one of the most influential leaders in social w e l f a r e of his time, v i g o r o u s l y endorsed the Wisconsin system. A s e a r l y as 1865, he had collaborated with D r . J o h n S. Butler, then superintendent of the H a r t f o r d Retreat, in p r e p a r i n g a plan of separate provision f o r the chronic insane to be laid before the Association of M e d i c a l Superintendents f o r consideration. In 1892, he made the f o l l o w i n g declaration before the National Conference of Charities and Correction: " I make the assertion, and I challenge any one to prove the contrary, that the State of Wisconsin comes at this moment n e a r e r to the ideal standard of p r o v i d i n g f o r e v e r y insane person the treatment best adapted to his needs than any State in the Union. I h a v e studied this matter f o r years, h a v e watched and examined the Wisconsin system, and h a v e repeatedly stated (and it has never been d i s p r o v e d ) that the insane of Wisconsin are better provided f o r in all the essentials of treatment than the insane of a n y other State." (Proceedings of the National Conference of Charities and Correction, 1892. p. 364.)

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waxed fiercely during the last decade of the nineteenth century. T h e annual meetings of the National Conference of Charities and Correction (now of Social Work) in particular provided an auspicious forum for the champions of both sides. Let us sum up the advantages claimed for the contending systems, as brought out in the debates. On behalf of the Wisconsin plan of county care, its advocates averred that: ι . It was more economical than state care, resulting in large savings to both state and counties. 2. It was no less h u m a n e than state care. I t permitted an even greater degree of liberty for the mentally ill. Restraints found necessary when chronics were associated w i t h acute and disturbed patients could be dispensed with in county institutions. 3. I t permitted greater opportunities for employment of chronic inmates, profitable to both the public purse and the individual's health. 4. T h e individual was maintained close to his home environment, easily accessible to relatives and friends w h o might wish to visit him. T h e familiarity of his surroundings w a s certain to be beneficial. 5. T h e Wisconsin plan was in reality a "system of county care under state control," since county institutions were under the strict and constant supervision of the State Board of Control. T h e latter body had the power to w i t h d r a w certification and to transfer insane persons to other counties if the standards of care fell below the requirements set by the Board. 6. Chronic cases, except f o r a very small percentage, were beyond recovery and therefore did not require hospital treatment. 7. By removing chronic cases f r o m state hospitals, the Wisconsin system permitted a more concentrated attention to the treatment of recent and recoverable cases. 8. I t made possible the care of a large proportion of the mentally ill in small institutions, while state institutions for the insane were invariably constructed on a gigantic scale. In this respect, at least, it came closer to the ideal size urged by the Association of Medicai Superintendents itself. 9. It provided a means whereby increase in the insane population of a state could be met easily and inexpensively, and obviated the administrative and legislative complexities attending the establishment of new state institutions. 10. Since the Wisconsin l a w provided that all cases of insanity be automatically passed t h r o u g h the state hospitals for treatment, it

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guaranteed a period of therapeutic treatment to all, precluding the danger of sending recent and promising cases to county asylums first. Insane persons were transferred from state hospitals to county institutions only when certified as chronic by hospital authorities. I I . T h e constant supervision of the State Board of Control curbed the "proverbial stinginess and political manipulations" popularly associated with county administrations. Conversely, the financial aid rendered by the state acted as a positive stimulus to good care on the part of the county officials. 15

T h e case for state care was presented in impressive detail by Oscar Craig, a prominent member of the N e w York State Board of Charities, in a paper read before the National Conference of Charities and Correction in 1891. The following series of arguments advanced in favor of the state care system is based largely on his paper: 1. T h e medical supervision of the average state hospital, with daily or even semi-daily inspection of all patients by competent and trustworthy physicians, and the absence of anything resembling such medical routine in the average county poorhouse or asylum, are reasons enough for exclusive state care of the insane. A strong point advanced against county care was the general policy in localities operating under this system of auctioning off the post of visiting physician to the lowest bidder, a policy hardly calculated to attract the best medical talent available in a community. In other localities, which offered more attractive remuneration to the visiting physician (very few had physicians regularly in attendance), the post was regarded as a legitimate link in the spoils system; fitness was based not so much on personal ability as on political loyalty. 2. State hospitals are invariably located in more healthful and beautiful surroundings, and on grounds far more expansive than the average county institution, a factor more conducive to greater comfort and better chances for health and recovery. 3. T h e small size of county institutions, far from constituting an advantage, actually provides a serious obstacle to the proper classification of inmates—always an important factor in the care and treatment of the mentally ill. Inasmuch as 100 patients require as many classifications as do ι,ΟΟΟ, it is obvious that the state institution, with its more abundant capacity, and its relatively large number of wards or buildings has a decided advantage in the matter of adequate classification over even the best-conducted county asylums.

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4. T h e labor of the state hospital patient is usually assigned and conducted under medical supervision w i t h the primary emphasis on its therapeutic effects on the patient, while the labor of the inmate of the county asylums is invariably carried on with economic considerations foremost. T h e benefit to the patient is only a secondary consideration. 5. I n fine, the state institution nearly always, and the county asylum very seldom, treats its mentally ill patients as sick persons, as in fact they are whether their illness is recent and curable or chronic and incurable. 6. T h e degrading, demoralizing associations of county care, due to the general procedure of placing the insane in the poorhouse or in an adjoining or adjacent building under the control of poorhouse officials, cannot but have a negative effect on the well-being of the chronic mentally ill, a large number of whom retain the capacity to think clearly and react sensitively to many matters affecting their lives. 7. Individual care and treatment is practicable to a greater degree in state institutions despite, or even because of, their larger size, since they afford greater and more varied medical facilities, more extensive and inspiring surroundings, and means f o r more correct and complete classification. I t can differentiate the treatment in accordance with differing cases, and with changes in the same case. 8. T h o u g h the idea of placing chronic and acute cases in the same hospital is not essential to state care, it is a characteristic of most state care systems. It has one important advantage in the opportunity it affords for transferring cases back and forth between hospital treatment and custodial or domiciliary care, as occasion requires—a facility seriously lacking under county care systems, where curative and custodial institutions might be widely separated and transfer of patients between the t w o rendered difficult. 9. T h e supervision of a lunacy commission or other central authority is greatly facilitated by the existence of a small number of large institutions as f a r as visitation and inspection is concerned ; conversely, it is rendered difficult when a large number of small institutions are scattered through the state. 1 0 . T h e state care plan is much simpler in its administrative aspects, since it operates mainly among state institutions, while the county care system involves divided authority among county and state agencies. T h e cumbersome and complicated machinery necessary to the operation of the latter leads to much friction and confusion. 1 1 . County care, f o r obvious reasons, is more likely to be influenced by the evils of political patronage than state care, where civil service

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competition is more apt to be the rule in the selection of institutional staffs. Again, the wider opportunities of the state in the matter of selectivity of personnel constitute a decided advantage over the necessarily narrow range of county selection. 16

In varied f o r m s and degrees the state care system was adopted by many states following its introduction in N e w Y o r k in 1 8 9 0 . A t present ( 1 9 3 7 ) , some twenty-four states operate under well-defined systems of state care. T h e county care plan is in practice in a f e w states, notably Wisconsin, Pennsylvania, I o w a and N e w J e r s e y . In still other states, no definite plan of public provision f o r the mentally ill has ever been formulated. Methods of care and treatment are of a patchwork character, representing merely the accretion of temporary expedients. T h e introduction of state care undoubtedly marked one of the great milestones in the history of the treatment of mental illness in the United States. But, as in all progressive movements, there were some over-enthusiastic supporters who believed that with its adoption the trumpets of jubilee would sound the dawn of the millennium f o r the mentally ill, and these were doomed to deep disillusionment. M a n y ills, many abuses, still remained. Centuries-old obstacles to progress were yet to be overcome. It was one thing to try to eradicate long-standing evils by decree; it was f a r more difficult to put an end to them in practice.

CHAPTER

XIV

Psychiatry Emerges from Isolation Ι Λ Η Ε study o f the human mind is the noblest branch o f medicine." Some three hundred years have passed sincc the g r e a t jurist, Grotius, expressed this conviction at a time w h e n thousands o f mentally disordered persons were being burned and hanged as witches. It was only within the past century, h o w e v e r , that general medicine consented to t a k e unto its bosom this "noblest b r a n c h " and to acknowledge it as a legitimate child. It is a significant commentary on the long isolation of the profession ministering to the mind diseased that only a score of years a g o one o f its most prominent members, T h o m a s W . Salmon, found occasion to say that psychiatry w a s still " t h e Cinderella of medicine." So long had the public at large, as well as the general practitioners of medicine, thought of healers of mental disorders in terms of priests, mystics and wonder-workers, that only with the greatest difficulty did it achieve recognition as a scientific specialty. T h i s traditional attitude was not without foundation in fact, because it is indeed only a matter of several decades since psychiatry has risen to a level approaching scientific technique. T h e isolation of psychiatry until recent years w a s not entirely the result o f the general indifference, neglect and active hostility on the part of society t o w a r d the problems of mental disorder and its treatment. It w a s rooted partly in the narrowness of the specialty itself throughout most of its history, a narrowness due to natural, inevitable conditions and to seclusive tendencies manifested by members of the specialty themselves.

Λ

T h r o u g h o u t the nineteenth century the mental hospital had preserved a strange and unhealthy isolation f r o m the 272

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main streams of community life. Often situated in rural districts, it w a s at times difficult of access even by r a i l r o a d in those days before the advent of the automobile and other modes of r a p i d transportation and communication broke down distances and drew r u r a l and urban communities closer together. In more than one sense, the typical institution w a s aptly termed a "monastery of the m a d . " T h e fact of this physical isolation f r o m the centers of social and scientific activities tended to create a corresponding feeling of cultural isolation in the medical staffs of mental hospitals, living hermit-like existences for long periods of time. A newly-appointed medical superintendent might come to his duties fresh with enthusiasm, scientific curiosity and l o f t y ideals. M o r e often than not, however, he soon found himself swept into a maelstrom of administrative details that demanded most, if not all, of his attention. Inevitably there was the problem of chronic overcrowding to be dealt with, problems of personnel, problems of keeping the physical structure in repair, and the daily problem of feeding and housing his charges. In most instances he w a s constantly beset with the problem of stretching a n i g g a r d l y appropriation to its maximum limits in maintaining the institution. (Only in r a r e cases did a public asylum receive appropriations sufficient to provide elementary comforts for its patients or inmates.) It w a s a very unusual institutional head who m a n a g e d to keep his medical identity f r o m being absorbed by the business executive. A f t e r some y e a r s of the deadening routine of asylum administration, the scientific interest of the a v e r a g e medical superintendent became so dulled that he would not engage in scientific w o r k even if he had the time. T h e r e were outstanding exceptions, of course. L u t h e r V . Bell of the M c L e a n H o s p i t a l , one of the founders of the American Psychiatric Association, w a s constantly e n g a g e d in original research of a clinical nature and gained a wide reputation for his description of Bell's Disease, a f o r m of acute mania. A m a r i a h B r i g h a m of the Utica State H o s p i t a l , another member of the Association, retained a lively interest in the scientific aspects of the specialty until his death, and

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was instrumental in introducing the works of some of the most important European psychiatrists to this country, chiefly through the medium of the American Journal of Insanity, which he founded. Isaac Ray, while mainly interested in the medico-legal and administrative aspects of his profession, made several valuable contributions to mental pathology, and in 1 8 6 3 wrote a book on Mental Hygiene. Joseph Workman of Toronto regularly contributed papers of clinical and pathological interest to the proceedings of the Association and to the Journal during the 1850's and 1860's. In succeeding decades scientific work was carried on or encouraged, in varying degrees, by men like John P. Gray at Utica, Pliny E a r l e at Bloomingdale and Northampton, W . L . Worcester at Kalamazoo and Little Rock, S. V . Clevenger at Cook County Asylum and E d w a r d Cowles at McLean. But these men were exceptions to the rule. In general the scientific aspects of psychiatry absorbed but little of the time and energy of the average medical superintendent and his assistants. T h i s lack of interest and activity is well reflected in the proceedings of the American Psychiatric Association and in the pages of the American Journal of Insanity during the first half-century of their concurrent existence. One finds that the dominating subjects of discussion were those dealing with the practical management of institutions rather than with the scientific study of mental disease. Quite naturally so, in an important sense, f o r the problems of architecture, of plumbing, heating and ventilation, of food supply and of income-producing labor f o r patients, were problems forced upon the institutional heads by circumstances over which they had little or no control. W e have already noted their great contributions to the sound organization of the early institutions. A s f o r the assistant physicians in asylums, their opportunities f o r indulging scientific interests, as a rule, were either strictly limited or nonexistent. Understafling, like overcrowding, has been a characteristic feature of the average state hospital f r o m the very beginning. A n understaffed

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personnel usually signified an overworked personnel. T h e terrible demon of dull routine stalked the member of the medical staff as it did the superintendent. H a r r i e d by his own administrative problems, his own scientific interests frustrated, the latter was seldom inclined to encourage and stimulate scientific work among his assistants. Still other factors which we have not the space to consider contributed to the discouragement of scientific w o r k in the average mental hospital (or, more properly, asylum) of the nineteenth century. T h e sum total of these factors might be epitomized as f o l l o w s : isolation, physical and cultural, f r o m the main currents of social and scientific l i f e ; the deadly grind of routine ; and the fact that psychiatric practice in this and other countries still lacked a sound base of scientific theory. Until the final decades of the nineteenth century, psychiatric practice was almost entirely confined to institutions f o r the insane. Extramural psychiatry was all but unknown, and was frowned upon by the leading specialists, who were the medical superintendents of their day. Little thought was given to medical care in most institutions, which were frankly administered along boarding-house principles. T h e scientific literature on mental disease f r o m the pens of asylum staffs was very meagre. Writing in 1 8 7 6 on the state of American medical literature, D r . J o h n Shaw Billings dolefully remarked : Our literature of insanity and the pathology of mental disease is insignificant in comparison with the importance of the subject and the opportunities existing for its study . . . Considering the number and size of asylums for the insane in this country, and the amount of money which has been spent upon them, it is rather curious that the medical officers connected with them should have contributed so little to the diagnosis, pathology or therapeutics of diseases of the nervous system. 1

T h e pressures that finally succeeded in forcing American psychiatry to emerge f r o m its institutional boundaries came f r o m a number of directions. N o t the least were the expansive forces within the psychiatric profession itself, reach-

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ing outward from its narrow base. A nuclear point for the external forces which operated to drive psychiatry into broader pastures was afforded by the infant and very voluble profession of neurology. We might here attempt a distinction between neurology and psychiatry. While there is no clear line of demarcation between the two, neurology may be broadly defined as the medical specialty that deals with the nervous system and its diseases (including those which do not impair mental processes) while psychiatry concerns itself with the study and treatment of personality disorders. There has also developed the borderline group of neuropsychiatrists, who deal with the disorders of both the nervous and mental systems. Neurology as a profession in America was practically created by the Civil War. That bloody conflict presented medical men with an extraordinary opportunity for studying and treating injuries to the nervous system due to gunshot wounds and other causes. It was to neurology what the World War later was, in a measure, to psychiatry. Many a general practitioner and surgeon who served in the medical department on either side during the Civil W a r emerged from the conflict as a practicing neurologist. Prominent among these was William A. Hammond, who was appointed United States Surgeon-General and later became one of the foremost neurologists of his time. It was Hammond who introduced the most renowned neurologist of them all, S. Weir Mitchell, into the profession. In 1863 he put Mitchell in charge of a temporary hospital at Philadelphia for soldiers suffering from nervous disorders. This event placed Dr. Mitchell (who had previously dabbled in various types of physiological research while practicing general medicine) in contact with a rich store of neurological material, and changed the course of his career. Mitchell's best known contribution to neurological thought and practice was his "rest cure" for nervous and mental ailments, consisting mainly of complete rest, seclusion, overfeeding and massaging. (This system of rest treatment was first formulated in his Fat and Blood, published in 1 8 7 7 . ) There were many other neurologists of note who served their novitiate in the Civil War.

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During the 1870's, neurology rose rapidly into a position of great influence in American medicine. T h e New Y o r k Neurological Society was established by a distinguished group in 1 8 7 2 . T w o years later the Journal of Nervous and Mental Diseases, chief organ of the profession in this country, was founded by J . S. Jewell of Chicago. In 1875 the American Neurological Association was organized, with D r . Jewell serving as its first president. Between the neurologists and the institutional psychiatrists there quickly developed a feeling of mutual distrust, suspicion and hostility. The study and treatment of mental and nervous disorders seemed to the "old guard" of the Association of Medical Superintendents to be inseparably bound up with the institutions they managed. T h e y were inclined to regard the neurologists as upstarts, as trespassers upon a preserve that was theirs by right of preemption. The neurologists, on the other hand, were outspoken in their criticism of the management of the mental hospitals of the time. They heaped ridicule upon the medical superintendents as persons who were at best merely efficient business executives, without either scientific knowledge or interest, and berated them roundly for their apparent indifference to scientific research. One has only to read the periodicals of the rival professions published during the 1870's and '8o's to appreciate the bitterness and animosity between the specialties. Unfortunate though this intense rivalry of the early years may have been in certain respects, it exercised a decidedly healthy influence in others. Free criticism is invariably a strong factor, even a necessary one, in the setting up and raising of standards in any field of human activity. From the first, certain neurologists placed themselves in the position of prosecutors-at-large who sought out evidences of asylum abuses, exposed them to the public view and demanded retribution of the guilty. Many of these neurologists were actuated by the best of motives in their critical pursuits. They were true reformers, shocked by existing evils and abuses, and striking out for their elimination. Others acted, no doubt, from motives of "enlightened self interest," find-

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ing justification in serving the public weal while at the same time enhancing their own reputations. Still others among the critical neurologists were merely self-interested. F o r what could serve their own practice better than to stir up public suspicion and distrust o f the institutional psychiatrists, thus diverting potential clients to their own offices? W h i l e nearly all psychiatric practice was carried on within the walls o f institutions f o r the insane, most neurologists at that time were engaged in private practice o r in academic posts, o r both. A negative result o f the neurological attacks on asylums f o r the insane was to heighten public distrust and f e a r s o f these institutions, buttressing the popular unwillingness to send sick relatives and friends thereto, and thus impeding adequate popular support and the early treatment o f patients so essential in many cases. T h e r e was an important positive effect, however. S m a r t i n g under the blistering and incessant attack o f the neurologists,* the institutional psychiatrists, or " a l i e n i s t s " ( a term now exclusively applied to the psychiatrist in his role as expert witness in court proc e d u r e ) , were constrained to put their house in order. Conversely, the vigorous counter-attacks o f the psychiatrists helped check the frequently overbearing arrogance o f some o f their self-appointed critics and also did much to aid the l a t t e r in overcoming their own weaknesses. L e t it be noted here that the " b o r d e r w a r s , " as D r . R i c h a r d Dewey called them, between both professions are now f o r the most p a r t only of historical interest. T o d a y a common basis f o r understanding exists. M a n y neurologists are members o f the American Psychiatric Association and many function as staff members o f mental hospitals, while many psychiatrists are members o f the A m e r i c a n Neurological Association and many are engaged in private practice. One o f the earliest f r o n t a l attacks o f importance on the •A significant i n d e x to the e x t e n t to w h i c h these c r i t i c i s m s w e r e prosecuted is afforded by t h e a c t i v i t i e s of the N e w Y o r k N e u r o l o g i c a l Society's " C o m m i t t e e on A s y l u m A b u s e s " in t h e e a r l y '8o's. T h i s C o m m i t t e e m a i n t a i n e d a keen and relentless v i g i l o v e r a s y l u m s in N e w Y o r k S t a t e , and its c h a r g e s a g a i n s t institutional m a n a g e m e n t s ( m a n y of t h e m w e l l - f o u n d e d ) led to s e v e r a l l e g i s l a t i v e i n v e s t i g a t i o n s , most o f w h i c h , h o w e v e r , a c c o m p l i s h e d little g o o d .

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institutional superintendents came f r o m the pen of E d w a r d C . Spitzka, a leading neurologist of his d a y . In an article on " R e f o r m in the Scientific Study of P s y c h i a t r y , " published in 1 8 7 8 , D r . S p i t z k a a r r a i g n e d the institutional officers f o r their lack of scientific study on the one hand, and f o r their evident unwillingness to p r o v i d e e x t r a m u r a l neurologists with material f o r pathological research on the other. 2 In 1 8 9 4 S. W e i r M i t c h e l l c a r r i e d the attack on the institutional medical officers to a climax in a r e m a r k a b l e address delivered at the fiftieth annual meeting of the A m e r i c a n M e d i c o - P s y c h o l o g i c a l A s s o c i a t i o n . * I n v i t e d by the Association to criticize " b o l d l y and with no r e g a r d to p e r s o n s , " D r . M i t c h e l l took his hosts at their w o r d and proceeded to lecture the assembled phychiatrists in t e r m s stripped of all pretense of polite discourse. C h a r g i n g the asylum staffs with responsibility f o r their isolation f r o m general medical practice, he d e c l a r e d : " Y o u w e r e the first of the specialists and you h a v e n e v e r come back into line. I t is easy to see h o w this came about. Y o u soon b e g a n to live a p a r t , and you still do so. Y o u r hospitals are not o u r hospitals; your w a y s are not o u r w a y s . Y o u live out of r a n g e of critical s h o t ; you are not preceded o r f o l l o w e d in y o u r w a r d w o r k by clever rivals, o r w a t c h e d by able residents f r e s h with the learning of the s c h o o l . " T h e annual reports of medical superintendents, D r . M i t c h e l l continued, contained " t o o c o m f o r t a b l e assurance of s a t i s f a c t i o n , . . . too many signs of contented calm born of isolation f r o m the active living s t r u g g l e f o r intellectual light and air in which the best of us l i v e . " W a r m i n g up to the " u n c o n g e n i a l t a s k of being d i s a g r e e a b l e , " he s h a r p l y criticized the asylum superintendents f o r the p o v e r t y of research in their institutions. A d m i t t i n g the p a r t i a l validity of the superintendents' defense that they lacked time, money and adequate assistance f o r sound research, he insisted that they w e r e not wholly f r e e f r o m blame since in m a n y instances they f a i l e d to make strong, urgent d e m a n d s f o r necessary equipment and personnel in their reports and other writings. • T h e n a m e of the o r g a n i z a t i o n h a d been c h a n g e d in 1893 f r o m the A s s o c i a tion of M e d i c a l S u p e r i n t e n d e n t s of A m e r i c a n I n s t i t u t i o n s f o r the I n s a n e .

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T o o many asylums, he said, were still featured by insufficient and ill-planned employment of patients; absence of recreational and exercising facilities; monotony of diet; and too frequent use of mechanical r e s t r a i n t — f a c t o r s that served to give to the average asylum the appearance of a dismal prison. " T h e r e is another function which you totally fail to fulfill," he added, " a n d this is by papers in lay journals to preach down the idea t h a t insanity is always dangerous, to show w h a t may be done in homes, or by boarding out the quiet insane, and to teach the needs of hospitals until you educate a public which never reads your reports, and is absurdly ignorant of w h a t your patients need." 3 Mitchell's insistence t h a t g r e a t e r emphasis be placed upon extramural treatment of mental patients reflected a growing movement to expand psychiatric t r e a t m e n t beyond the confines of institutional walls. Passing on f r o m f o r t h r i g h t criticism to positive recommendations f o r improving the asylum atmosphere, D r . Mitchell urged the appointment of intelligent assistant physicians who should enjoy periodic vacations of sufficient length to keep them f r o m growing stale on the job. It was the bounden duty of the asylum head (who should be a neurologist) to keep alive the intellectual and scientific curiosity of his staff by constantly inspiring them with his own example. M o r e trained nurses should be introduced into mental hospitals to facilitate individualization of treatment. M a n y more recommendations did he make in his eloquent and pointed oration, most of which were f a r better suited to the ideal mental hospital f o r private upper-class patients than to the practical possibilities of state hospital management. T h e asylum superintendents suffered his withering blasts with a surprising degree of patience and toleration, although one can well imagine their faces reddening under the scorching fire of r e p r o o f . While, in truth, his criticisms were on the whole basically sound, nevertheless, he did indulge in hyperbole and in some strange speculations t h a t have been negated by the test of time. Some of his views were premised on imperfect knowledge of the real situation, while his recommendations were

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largely of an idealistic and impractical nature. T h e injustice of some of his harsher condemnations of asylum superintendents was pointed out by D r . Walter Channing in a reply to D r . Mitchell's charges, published in the American Journal of Insanity in 1895, and also in an eloquent defense of the old superintendents delivered some thirty years later by William A . White. 4 Surely, Richard Dewey was justified in comparing certain aspects of D r . Mitchell's criticisms to that of " a naval commodore who should assail the army f o r not winning victories upon the high seas." But some of the points raised by Mitchell struck home at vital defects in the existing asylum system. Beginnings had already been made here and there in the mending of some of the shortcomings pointed out by Mitchell. One of his chief criticisms was directed at the general scarcity of trained personnel in mental hospitals. T h e first permanent training school f o r nurses in an American institution f o r the insane had been instituted by D r . E d w a r d Cowles at M c L e a n Asylum in 1 8 8 2 . * A similar school was inaugurated at the Buffalo State Hospital the following year, and the training school idea spread slowly to other institutions during the next decade. Incidentally, Dr. Cowles, who was responsible f o r many progressive innovations in America, was also the first to introduce the use of women nurses in male wards. In the beginning this step aroused the bitter opposition of shocked Victorians, but it proved so successful that it won adoption in many other asylums. Women physicians seem to have been employed first in the state hospitals of Pennsylvania. T h e r e the novel experiment of placing a woman in medical control over the female wards was introduced in 1 8 8 0 when D r . M a r g a r e t A . Cleaves took over the medical direction of these wards at the Harrisburg State Hospital, while D r . Alice Bennett performed the same function at the newly opened Norris• I t is interesting to note, in this respect, that D r . T h o m a s S. K i r k b r i d e had planned to establish a training school f o r attendants at the P e n n s y l v a n i a Hospital f o r the Insane as early as 1843, but w a s unable to c a r r y through his project. T r a i n i n g schools f o r nurses in g e n e r a l hospitals date f r o m Florence Nightingale's activities in G r e a t B r i t a i n , resulting f r o m her experience in the Crimean W a r of 1854.

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town State H o s p i t a l . * In 1 8 9 0 a law was passed by the N e w Y o r k legislature authorizing the appointment of at least one woman physician in each state hospital. A sore point touched upon by D r . Mitchell was the obvious lack of specially trained physicians on the staffs of most mental hospitals. But to place the entire blame f o r this situation on the shoulders of the medical superintendents was hardly f a i r . T h e chief fault lay with the prevailing indifference to the subject of mental disorder displayed in all but a few of the medical schools in this country. Until the 1 8 7 0 ' s even occasional lectures on mental and nervous diseases, not to speak of systematic courses, were extreme rarities in our medical schools. It appears that no systematic course was given on these subjects anywhere in America f r o m Benjamin Rush's death in 1 8 1 3 until 1 8 6 7 , when William A . H a m mond was appointed professor of nervous and mental diseases at the Bellevue H o s p i t a l Medical College in N e w Y o r k City. A year later a lectureship in mental diseases was established at the College of Physicians and Surgeons f o r D r . E d w a r d C. Seguin, son of the famous pioneer in the training of mental defectives. D r . Isaac R a y conducted summer courses in psychiatry at the Jefferson Medical College of Philadelphia during the years 1 8 7 0 - 7 2 . 5 Aside f r o m these and a f e w other courses, the subject of insanity was hardly mentioned in medical lectures, or in medical textbooks of the time. It is significant that Benjamin Rush's Medical Inquiries and Observations upon the Diseases of the Mind, published in 1 8 1 2 , remained the only American systematic treatise on mental disorder until 1 8 8 3 , when two new texts appeared. It is also significant that both these works were written by neurologists—William A . H a m m o n d and E . C. Spitzka.® • I n 1879 the P e n n s y l v a n i a legislature had enacted a statute providing that "in all hospitals or asylums now built or h e r e i n a f t e r to be built, and under the control of the State, and in which male and f e m a l e insane patients are received f o r treatment, the trustees of said asylums or hospitals m a y appoint a skillful f e m a l e physician w h o shall reside in said asylum or hospital, and w h o shall h a v e the medical control of said f e m a l e inmates, w h o shall report to the superintendent and also to the trustees." (Quoted in the Sixth Report of the State Committee on Lunacy of Pennsylvania, 1888. pp. 2 2 - 2 3 . )

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Cognizant of the appalling lack of psychiatric instruction, the Association of Medical Superintendents early launched a campaign for the inclusion of special courses on the subject, a campaign which it has carried on to this day. A s f a r back as 1 8 7 1 the Association passed a series of resolutions dealing with this topic, the first of which reads in part : Resolved, That . . . it is the unanimous opinion of this Association that in every school conferring medical degrees, there should be delivered, by competent professors, a complete course of lectures on insanity and on medical jurisprudence, as connected with disorders of the mind.7

In spite of the continued agitation f o r more adequate psychiatric instruction, however, the introduction of special courses in general medical schools proceeded at a snail's pace. Among the unfortunate results of this indifference to psychiatric problems was the fact that physicians who took up work in institutions for the mentally ill invariably came without any previous special instruction or training at all. Their knowledge of mental disorders consequently had to be picked up empirically, bit by bit, during the course of a routinized life in the asylum that gave them little time for delving into research problems of their own. Progress of Research in Mental Disorder. W e may gather from the aforementioned facts that up to the time of Weir Mitchell's address, facilities for, or even encouragement o f , scientific research in the mental hospitals of this country were all but nonexistent; only in a few hospitals was research even feebly carried on. Many institutions even neglected to perform elementary autopsies on the brains of deceased patients. Most of the original research that was carried on was undertaken on the initiative of neurologists —men like Hammond, Mitchell, Spitzka, Seguin and Dana. A s we have indicated, it was largely because of the pressure of this group that research was stimulated among psychiatrists in our mental hospitals. In 1868 Dr. John P. Gray had a pathologist, Edward S. Hun, installed at the State Asylum at Utica, New York, to carry on systematic research. Commenting on this initial

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step in organized pathological research in an American asylum, Adolf M e y e r expressed the opinion "that this appointment was to quite an extent a gesture to meet the increasingly vigorous onslaughts of outsiders and neurologists and not a response to a compelling need and eagerness f o r investigation." 8 D r . G r a y recommended the following major lines of pathological research: examination of secretions in all stages of the disease; observing the pulse under the sphygmograph in order to "determine its force and character," and to show influences of medicine on the circulation ; ophthalmic examinations; study of the skin, its temperature, color, etc., in the several kinds and stages of the disease; post mortem appearances, gross and microscopic; and photographic representations of morbid conditions and specimens. T h i s line of research ultimately proved to be quite barren in results. T h e trend of psychiatric thought had by this time begun to shift f r o m an emphasis on " m o r a l " causes (causes that would be included today in the term psychogenic) to an emphasis on physiological causes. T h i s trend, incidentally, was largely due to the rise of materialism during the nineteenth century. T h e old metaphysical speculations concerning insanity were being discarded, and the pendulum of professional opinion was swinging violently in the opposite direction. T h e causes of mental disorder were no longer being sought in divine dispensations or metaphysical mysteries, but in the anatomy and physiology of the brain. T h e causes of insanity, said G r a y in 1 8 7 2 , " a s f a r as we are able to determine, are physical; that is, no moral or intellectual operations of the mind induce insanity apart from a physical lesion." 9 In a paper read the previous year before the State Medical Society of N e w Y o r k , G r a y had presented an interesting indication of the rise of the physiological concept of mental disease. H e quoted his predecessor, Amariah Brigham, as having declared in his 1 8 4 3 report f o r the Utica State Asylum, that, "with Pinel, Esquirol and Georget, we believe that moral causes are f a r more operative than physical." ( M o r a l causes were those "acting through the emotions, passions, sentiments and affections;" physical causes

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were those "producing their effects, through physical impairment, diseases or injuries.") D r . G r a y drew up a table revealing that in 1 8 4 3 over 46 per cent of the admissions to Utica were assigned to moral causes, while in 1 8 7 0 over 85 per cent of the cases admitted were ascribed to physical causes and none at all to moral causes, the remainder being listed as "unascertained." 1 0 This physiological approach dominated research in mental disease during the last quarter of the century. A t the same time the scientific study of insanity was gradually moving out of the ward, where the great clinical observations of Pinel, Esquirol and Griesinger had been made, into the dead house, whence came increasing hundreds of brains to be subjected to pathological study. T h e first great step toward organized psychiatric research in this country was taken in 1 8 9 5 with the establishment of the Pathological Institute of the N e w Y o r k State Hospitals. T h e Institute was founded as an integral part of the state hospital system organized under the epochal State Care Act of 1890. Located in N e w Y o r k City, its first director was Ira Van Gieson, a neuropathologist. D r . Van Gieson was an enthusiastic research worker with some original ideas on the correlation of all the sciences, but was more fitted by temperament f o r the pursuit of independent research than f o r the direction of fellow researchers. In the beginning the activity of the Institute was strictly confined to laboratory work. T h e aims pursued, as stated by D r . Van Gieson, w e r e : "to carry on studies on abnormal mental life and their neural concomitants, based on psychology, psychopathology, experimental physiology and pathology, cellular biology, pathological anatomy, comparative neurology, physiological chemistry, anthropology and bacteriology." 1 1 During the early years there were no facilities f o r clinical observation. Receiving morbid materials from the various state hospitals of N e w Y o r k , the Institute served as a clearing house f o r pathological study and information for the entire system. In 1902 D r . Adolf M e y e r , who had already won wide recognition f o r his outstanding research work at Kankakee

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and Worcester hospitals, succeeded D r . Van Gieson as director. Soon after, the Institute was removed from its expensive quarters in the Metropolitan Building in New Y o r k City to W a r d ' s Island, where the Manhattan State Hospital was located. T h i s change of site, bringing the Institute into direct contact with a hospital f o r mental diseases, afforded a splendid opportunity f o r clinical observation in addition to the regular laboratory research. Exploiting this important advantage to the full, D r . M e y e r soon organized a clinical department of the Institute, and started training courses f o r staff physicians sent f r o m the state hospitals of N e w Y o r k . W e shall have occasion to speak at greater length of the profound changes in American psychiatric study and practice brought about by D r . Meyer's system of psychobiology, evolved in part during his association with the Pathological Institute. One of the greatest services of M e y e r was to free psychiatric research in America from its dependence on the dead house and its almost complete concentration on morbid materials, and to turn its attention to the living material represented by the individual patient, studied as an organism in relation to his environment. Symbolizing this important shift in emphasis, the name of the Pathological Institute was changed in 1908 to the Psychiatric Institute at D r . Meyer's insistence, in conformity with the expanded aims and methods developed under his leadership. Psychiatry Enlists Social Work. M e y e r ' s dynamic approach to the problems of psychiatric research and treatment did much to precipitate the long-pending confluence of social work and psychiatry in America. T h i s collaboration had existed in Europe f o r many years before its adoption in this country. D r . M e y e r , in common with other advanced psychiatrists at the turn of the century, was insisting that it was the patient, and not the disease, that had to be treated and cured. M e y e r went f u r t h e r : it was not enough to study the individual as an isolated physical unit, as the mechanical materialists had done; it was quite as important to study the environment whence he sprang and in which he developed. H e conceived of the brain not only as an anatomical entity,

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but as man's social organ, acted upon and reacting to external social stimuli. H e saw mental disorder as a maladjustment of the whole personality, rather than as a brain disease in the purely physiological sense. Until his time, it had been quite common in American mental hospitals to label a newly admitted patient with a one-word disease term, to scrawl the name of the supposed affliction on his case card and to end the diagnosis there. M e y e r insisted on complete case records, including data on all ascertainable aspects of the patient's makeup and lifehistory: social, economic, hereditary, physical, mental and emotional. When he took over the directorship of the Pathological Institute and organized the clinical department in connection with the Manhattan State Hospital, he especially emphasized the value of getting past histories of each case. In other words, to prepare a comprehensive case record of the patient, the mental hospital had to reach out into the community. A contact between hospital and community must be established. Visits had to be made to the patient's home and to his place of employment, to his relatives or friends, f o r first-hand information concerning the personal and environmental background of the individual's illness. A t first the physicians made these visits and worked up the case histories themselves. But it soon became evident that a division of labor was necessary in obtaining these histories. D r . M e y e r states that in 1 9 0 4 he enlisted the voluntary service of M r s . M e y e r in visiting his patients at W a r d ' s Island and also their families in the city: " W e thus obtained help in a broader social understanding of our problem and a reaching out to the sources of sickness, the family and the community." 1 2 L a t e r , the value of utilizing trained social workers to obtain case histories, in addition to aftercare work, impressed itself upon institutional psychiatrists until the social service department became recognized as an indispensable part of every modern state hospital system. In the meantime, while this call f o r social service was developed from the inner needs of psychiatry, a simultaneous drive had been proceeding from the social work profession toward psychiatry. From the very beginnings of social work

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as an organized profession in the 1870's, the subject of mental disorder in its social aspects had taken up a considerable part of the proceedings of the National Conference of Social W o r k . T h e social worker constantly came in contact with this problem at several points. T o begin with, provision f o r the indigent insane constituted one of his major tasks. T h e r e was also the problem of looking after the families of individuals who had been the breadwinners before being incapacitated by mental illness. One of the serious questions confronting social workers revolved around the readjustment of mental patients returning from state hospitals to normal community life. It often happened that a patient discharged as cured was unable to readjust himself to communal existence. Such a person, unaided, might break down again under the strain, with consequent readmission to a hospital, perhaps permanently this time. T h e environmental conditions he met upon returning to society were never quite the same as when he was first hospitalized. H e was invariably burdened with new handicaps, one of the heaviest being the "stigma of insanity" with which the ex-patient of a "madhouse" was branded. T h e patient cured of pneumonia or typhoid or appendicitis might return to take up his affairs at the point where his temporary illness had interrupted his normal routine. But not so the recovered mental patient. H e was a marked man. H e had been " c r a z y " , and didn't the popular saying go, "once insane, always insane"? H i s relations with his family or friends thereafter were likely to be strained, at least for some time ; his " t e r m " in a mental hospital stood as a serious obstacle to reemployment. Under these added strains many a mind gave way again, rendering the individual socially inadequate. Another concern of the social worker was the fact that many times a patient in a mental hospital recovered, or at least improved sufficiently to warrant return to the community, but his discharge had to be delayed because of socio-economic difficulties. T h e r e might not be any home or family to which he could be sent, or he might find it impossible to get employment at once so that he could start

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life anew on a self-supporting basis. Often, in such instances, there remained only one of two choices f o r the hospital superintendent, neither of which could be a satisfactory one : the patient could be retained in the hospital or be transferred to the poorhouse, where he might spend the rest of his life as an unhappy public dependent. T h e r e still existed no medium or agency through which the recovered patient could be given the initial help and advice that might start him off on the road to independence. T h e situation was a serious one, revealing the vicious end-results of a policy of laissez-faire. It called f o r solution, a solution that found its earliest expression in the rise of the after-care movement. The after-care movement had its beginnings in America during the last decade of the nineteenth century, when it won vigorous champions among psychiatrists, neurologists and social workers. T h e principle behind this movement was to provide adequate financial, medical and moral assistance to patients discharged from mental hospitals, in order to aid their adjustment to the outer world and to check relapses due to social handicaps. T h e after-care movement was first introduced in 1 8 2 9 by D r . Lindpainter, director of the Eberbach Asylum in Nassau, Germany. In France, a "Société de Patronage" was founded by D r . Falret in 1 8 4 1 f o r this purpose in the Department of the Seine. T h e idea was gradually adopted on a nation-wide scale under government auspices. A similar society, called the "Guild of Friends of the Infirm in M i n d , " was established in England in 1 8 7 1 . In this country, prominent psychiatrists and neurologists including Richard Dewey, Peter M . Wise, Frederick Peterson, Adolf Meyer, Henry R . Stedman, Charles L . Dana and F . X . Dercum, joined by many eminent social workers, strongly advocated the forming of after-care associations during the nineties and early 1900's.* In 1896 the State • A paper on this subject w a s r e a d before the 1893 meeting of the A m e r i c a n Medico-Psychological Association by Dr. P. M . Wise. T h e f o l l o w i n g y e a r the A m e r i c a n Neurological Association appointed a Committee on A f t e r - C a r e consisting of Drs. Stedman, D a n a and Dercum. In 1894 and 1895, Dr. R i c h a r d D e w e y presented papers on a f t e r - c a r e b e f o r e the National Conference of Charities and Correction. D r . M e y e r advocated a f t e r - c a r e in several important papers t h e r e a f t e r .

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C h a r i t i e s A i d A s s o c i a t i o n of N e w Y o r k (which had played such a prominent p a r t in f o r c i n g the p a s s a g e of the g r e a t State C a r e A c t of 1 8 9 0 ) a u t h o r i z e d its Committee on the Insane " t o inaugurate and maintain, f o r convalescents leaving hospitals, w h o m a y be friendless, a system of ' a f t e r care,' w h e r e b y they may be strengthened in health, protected and c a r e d f o r until able to support t h e m s e l v e s . " 1 3 T h e plan w a s held in abeyance f o r a decade, h o w e v e r . In J a n u a r y , 1 9 0 6 , a conference attended by members of the State Commission in L u n a c y , the superintendents of all but one of the fifteen S t a t e hospitals f o r the insane, and officers of the S t a t e C h a r i t i e s A i d A s s o c i a t i o n , a d o p t e d several resolutions supporting a plan f o r the launching of a statewide a f t e r - c a r e system, on the basis of p r i v a t e p h i l a n t h r o p y , by the State C h a r i t i e s A i d A s s o c i a t i o n . T h e f o l l o w i n g month, a subcommittee on a f t e r - c a r e of the insane w a s o r g a n i z e d by the A s s o c i a t i o n under the chairmanship of M i s s L o u i s a L e e Schuyler. T h e subcommittee immediately launched plans f o r the establishment of a f t e r - c a r e committees f o r each state hospital, to w o r k under the general direction and control of the statewide subcommittee. In the same month the " M a n h a t t a n A f t e r - C a r e C o m m i t t e e of the S . C . A . A . " w a s f o r m e d — t h e first functioning committee of its kind in this country. S h o r t l y a f t e r w a r d M i s s E . H . H o r t o n , a trained social w o r k e r , w a s e n g a g e d as a f t e r - c a r e agent in the A s sociation. H e r initial assignment consisted of aiding the M a n h a t t a n A f t e r - C a r e C o m m i t t e e . 1 4 M i s s H o r t o n in consequence w a s p r o b a b l y the first psychiatric social w o r k e r in A m e r i c a . O t h e r hospital district a f t e r - c a r e committees w e r e soon o r g a n i z e d , their m a j o r purposes being to find suitable homes and employment f o r needy ex-patients, to render other social services as needed, and to exercise general supervision o v e r them during the period immediately f o l l o w i n g their discharge. Such w e r e the beginnings of direct collaboration between social w o r k e r s and psychiatrists in A m e r i c a . In Boston, about the same time, D r . R i c h a r d C . C a b o t w a s introducing similar innovations in c o l l a b o r a t i v e w o r k between the two p r o f e s s i o n s . T h e subsequent development of this confluence,

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which received tremendous impetus in the period f o l l o w i n g the W o r l d W a r , will be discussed in a later chapter. Evolution of the Psychopathic Hospital. A n o t h e r development of m a j o r importance in A m e r i c a n psychiatry that symbolized the extension of the practice beyond asylum confines was the rise of the first psychopathic hospitals and w a r d s at the turn of the twentieth century. T h i s type of institution w a s in operation in G e r m a n y long b e f o r e it w a s finally introduced into the U n i t e d States. T h e functions of a modern psychopathic hospital may be briefly described as f o l l o w s : I t is usually located in l a r g e towns and cities. It provides first care, examination and observation f o r persons suffering or believed to be suffering f r o m mental disorder, pending commitment to a general mental hospital. It administers short, intensive treatment in incipient and acute cases. It provides educational facilities f o r medical students. I t functions as a center f o r clinical and pathological research in nervous and mental disorders. It serves as a clearing house which sorts out those persons whose mental aberrations are not of such kind o r degree as to render them socially inadequate f r o m those whose disorder requires commitment to a mental hospital. T h e r e are f o u r m a j o r types of psychopathic hospitals: ( i ) that connected with a university; ( 2 ) that connected with a general hospital; ( 3 ) that connected with a hospital f o r mental diseases; and ( 4 ) that which operates independently. W h i l e the psychopathic hospital came as a belated innovation in A m e r i c a n psychiatric practice, its need w a s early expressed in this country. T h e v e r y term, "psychopathic hosp i t a l , " is of American origin, and w a s used in the title of a paper by Pliny E a r l e in 1 8 6 7 wherein he urged the establishment of separate hospitals f o r the "acutely insane." T h e first strong movement in the direction of psychopathic hospitals in this country w a s started by the C a l i f o r n i a State B o a r d of H e a l t h soon a f t e r its establishment. In its second biennial report ( 1 8 7 1 ) this body, composed of progressive individuals with an unusual interest in the problems of the mentally ill, published a paper written by one of its mem-

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bers, D r . A . B . Stout of San Francisco, advocating the establishment of "probationary asylums" in the large towns f o r the treatment of "ephemeral attacks of mental alienation." 1 5 " I n an extended meaning of the w o r d , " D r . Stout explained, "probationary signifies tentative, or an institution in which the effort is made to afford relief by quick and prompt intervention in the incipiency of mental disorders." A large percentage of "permanent insanity," he declared, was due to the failure to apply prompt treatment while the disease was in its incipient stage. " G i v e it [insanity] no foothold; it will fail to hold possession. A s things now are, parties interested, in the most loyal faith, rush around f o r relief, but can only find it a f t e r protracted and expensive delay." D r . Stout drew up a bill providing f o r a "probationary asylum" to be established in San Francisco. T h i s bill was introduced into the state legislature but went down to defeat. D r . Stout and his fellow members on the B o a r d of H e a l t h continued their efforts in this cause but it was some years before California adopted the idea, and then in a f o r m f a r removed f r o m the ideal of D r . Stout. During the 1 8 7 0 ' s there was quite a public clamor in N e w Y o r k City revolving around frequent instances in which mentally disordered persons were arrested and brutally beaten by the police, locked up in station houses and sent to the penitentiary or workhouse b e f o r e their mental condition was discovered—in flagrant violation of a state law prohibiting the detention of insane persons in jails or prisons. Leading neurologists residing in the city were particularly critical about this state of affairs. In response to the public pressure f o r better care of mentally ill persons pending commitment, the city constructed an "Insane P a v i l i o n " at Bellevue Hospital in 1 8 7 9 . Formerly, persons brought to the hospital and supposed to be mentally disordered had been detained in the "alcoholic w a r d s " together with cases of acute alcoholism. T h e new building f o r the mentally ill was divided into two wards f o r female and male patients, and contained twenty-four "cells." It was intended "only f o r patients whose sanity is in question, where they may be kept under observation until proper commit-

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ment papers can be made out f o r their transfer to other institutions." 1 8 T h e "insane pavilion" at Bellevue did not constitute a psychopathic hospital in the modern sense of the term. It was a detention hospital, pure and simple, affording no therapeutic treatment f o r its patients. Nevertheless, while its functions were restricted to detention and observation, the "insane pavilion" at Bellevue marked an important step f o r w a r d in the evolution of the modern psychopathic hospital. (Out of this pavilion, in fact, evolved the well known psychopathic hospital of Bellevue.) Similar detention or observation wards were established at the Philadelphia General Hospital ( " O l d B l o c k l e y " ) in 1890. 1 7 A s with Bellevue, the alleged insane admitted into " O l d B l o c k l e y " previously had been thrown into the " D r u n k " wards. In 1 9 1 2 the observation wards were reconstituted by legislative enactment into "psychopathic w a r d s , " under the supervision of neuropsychiatrists. T h e first psychopathic w a r d in a general hospital in America fulfilling the function of actual therapeutic treatment besides detention and observation was established at the Albany Hospital in 1 9 0 2 . " P a v i l i o n F " was added to the hospital in that year " f o r the detention and care of persons afflicted with nervous and mental disorders," upon the initiative of D r . J . M o n t g o m e r y M o s h e r , who directed its operation f o r many years thereafter. 1 8 Since 1 9 0 2 , psychopathic wards or hospitals have been established in connection with general hospitals in many of the large municipalities. While the movement f o r psychopathic wards in general hospitals grew largely out of the desire to provide decent accommodations f o r doubtful cases of mental disorder in cities pending commitment proceedings, the university psychopathic hospital arose mainly out of the need f o r adequate psychiatric research and education. T h e first American institution of this type was founded at the University of Michigan in 1 9 0 1 . F o r some years previously D r . William J . Herdman, professor of mental and nervous diseases at the University, had resorted to periodic visits to a state asylum in carrying out the clinical part of his course. T h e Uni-

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versity had also entered into more or less informal agreement with the state hospitals whereby it acted as a center of pathological research f o r all of them, as was the case with the Pathological Institute in N e w Y o r k . This loose arrangement proved unsatisfactory f o r several reasons. D r . Herdman, recognizing the advantages of a psychopathic hospital at the University itself, carried on a persistent campaign toward this end. H i s efforts were rewarded in 1 9 0 1 when the state legislature passed an act authorizing the construction and equipment of a psychopathic ward of forty beds at the University Hospital. A sum of $ 5 0 , 0 0 0 was appropriated f o r this purpose. T h e psychopathic ward was opened in 1906 under the direction of D r . Albert M . Barrett, whose official title was Pathologist of the State Asylums. Under an act of 1907, the institution was reorganized as the State Psychopathic Hospital at the University of Michigan, to serve as a "state hospital specially equipped and administered f o r the care, observation and treatment of insanity and f o r persons who are afflicted with abnormal mental states but are not insane." 1 ' T h e act further provided that "there shall be maintained as a part of the Psychopathic Hospital at the University of Michigan a clinical pathological laboratory f o r the Michigan state hospitals f o r the insane, and a laboratory in which research into the phenomena and pathology of mental diseases shall be carried on." T h e first psychopathic hospital connected with a state hospital f o r mental diseases was opened in Boston in 1 9 1 2 . A s early as 1 9 0 0 D r . Owen Copp, executive secretary of the Massachusetts State Board of Insanity, had urged the establishment of a psychopathic hospital in a special report. T h e agitation was continued throughout the first decade of the century by that energetic crusader f o r progressive lunacy legislation, D r . L . Vernon Briggs. In 1909 the state legislature enacted a statute appropriating $600,000 f o r the establishment in Boston of a hospital " f o r the first care and observation of mental patients and the treatment of acute and curable mental diseases and f o r an out-patient department, treatment rooms and laboratories f o r scientific re-

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search as to the nature, causes and results of insanity." T h e Psychopathic H o s p i t a l w a s opened in J u n e , 1 9 1 2 , as a department of the Boston State H o s p i t a l , which had been transferred f r o m city to state control f o u r y e a r s earlier. D r . Ε . E . Southard, one of the foremost psychiatric researchers in the United States, w a s chosen as first director, a position he retained until his death in 1 9 2 0 . In the latter y e a r , the Psychopathic H o s p i t a l w a s separated f r o m the administration of the Boston State H o s p i t a l , and functioned t h e r e a f t e r as an independent unit under the control of the State D e partment of M e n t a l Diseases. In its report f o r 1 9 1 0 , the State B o a r d o f Insanity of Massachusetts outlined the function of a model psychopathic hospital so fully that I quote f r o m it at some length: T h e Psychopathic Hospital should receive all classes of mental patients for first care, examination and observation, and provide short, intensive treatment for incipient, acute and curable insanity. I t s capacity should be small, not exceeding such requirement. An adequate staff of physicians, investigators and trained w o r k e r s in every department should maintain as high a standard of efficiency as that of the best general and special hospitals, or that in any field of medical science. Ample facilities should be available for the t r e a t m e n t of mental and nervous conditions, the clinical study of patients in the wards, and scientific investigation in well-equipped laboratories, with a view to prevention and cure of mental disease and addition to the knowledge of insanity and associated problems. Clinical instruction should be given to medical students, the f u t u r e family physicians, who would thus be taught to recognize and treat mental disease in its early stages, when curative measures avail most. Such a hospital, therefore, should be accessible to medical schools, other hospitals, clinics and laboratories. I t should be a center of education and training of physicians, nurses, investigators and special workers in this and allied fields of work. Its out-patient department should afford free consultation to the poor, and such advice and medical treatment as would, with the aid of district nursing, promote the home care of mental patients. I t s social workers should facilitate early discharge and after-care of patients, and investigate their previous history, habits, home and work-

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ing conditions and environment, heredity and other causes of insanity, and endeavor to apply corrective and preventive measures. 20

Implicit in the last p a r a g r a p h is an important development in psychiatric h i s t o r y — t h e adoption of the out-patient department in mental hospitals. T h i s development in A m e r i c a dates back to 1885. In N o v e m b e r of that year, a dispensary f o r the free treatment of persons suffering with "incipient mental disease" was opened in the out-patient department of the Pennsylvania H o s p i t a l at Pine Street, Philadelphia. M o r t o n , the historian o f the Pennsylvania H o s p i t a l , tells us that " t h e service was regarded at that time as experimental . . . It was undertaken under a conviction that in a city of one million inhabitants, a large number were suffering f r o m premonitory symptoms of insanity as nervous prostration and depression, who might receive timely advice and treatment, and that a f u r t h e r development of mental disorder might thus be arrested." 2 1 T h e dispensary w a s operated by members of the medical staff of the Department for the Insane of the Pennsylvania H o s p i t a l under the direction of the superintendent, D r . John B. Chapin. A f e w months later the trustees of the State H o s p i t a l f o r the Insane at W a r r e n , Pennsylvania, of which D r . John C u r w e n was superintendent, followed suit by adopting this resolution : Resolved, T h a t the Physician-in-Chief and Superintendent be requested to give notice that from two to six o'clock of the afternoon of the second and fourth Wednesdays of each month, he will give advice and counsel to those who may feel that the symptoms of mental disorder are developing in themselves, or in any member of their family. 2 2

Such were the beginnings of out-patient departments f o r mental patients, which were later to become an outstanding f e a t u r e of psychiatric care and treatment. " N e r v e clinics," f o r the treatment of nervous disorders, had been established earlier in Philadelphia ( 1 8 6 7 ) and Boston ( 1 8 7 3 ) . N o w let us return to our account o f the rise of psycho-

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pathic hospitals. In 1 9 1 3 , the year following the opening of the Boston Psychopathic Hospital, the Henry Phipps Psychiatric Clinic was opened in connection with the Johns Hopkins Hospital at Baltimore. T h e Henry Phipps Psychiatric Clinic (which has all the features of a psychopathic hospital) has been under the direction of D r . Adolf M e y e r since its inception, and is generally recognized as one of the great centers of psychiatric research and education, not only of this country, but of the world. Meanwhile a movement f o r a psychopathic hospital located in N e w Y o r k City (in addition to the psychopathic wards at Bellevue) had been under way f o r a number of years. In 1904, thanks largely to the efforts of D r . Frederick Peterson, then president of the N e w Y o r k State Commission in Lunacy, D r . Adolf Meyer, and officers of the State Charities Aid Association, the state legislature passed a law authorizing the city of N e w Y o r k to "acquire a site and to lease the same to the State f o r the establishment thereon of a Reception Hospital f o r the Insane." A n initial appropriation of $300,000 was made f o r this purpose. A site was actually selected but was later found unsatisfactory, and the entire plan was dropped until 1920, when a new plan f o r a psychopathic hospital to be integrated with the work of the Psychiatric Institute (then on Ward's Island) was adopted, and $700,000 was appropriated by the legislature. By a happy coincidence plans were then in progress f o r the erection of the great Columbia-Presbyterian Hospital Medical Center in upper Manhattan, and, largely through the efforts of D r . Thomas W . Salmon and D r . C. Floyd Haviland, cooperation between the two new institutions was agreed upon and the necessary legislative authorization was obtained. In 1929 the N e w Y o r k State Psychiatric Institute and Hospital was opened under the direction of D r . George H . Kirby as an affiliated unit of the largest medical center in the world. T h e control of the Institute remained in the hands of the N e w Y o r k State Department of Mental H y giene. Rising twenty stories above the Hudson River in a fireproof building of beautiful design, with a bed capacity f o r two hundred patients and thoroughly equipped with

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therapeutic, research and educational facilities, the N e w Y o r k State Psychiatric Institute and Hospital ranks as one of the finest institutions of the kind anywhere. It enjoys the dual advantage of affiliation with a great medical school (the College of Physicians and Surgeons of Columbia University) and a general hospital of the first order. Like the aforementioned Psychiatric Institute, the Payne Whitney Psychiatric Clinic is connected with a great medical center in N e w Y o r k City, the result of an amalgamation between a medical college and a general hospital, in this case forming the N e w Y o r k Hospital-Cornell Medical College Association. Built at a cost of over $2,000,000, the Payne Whitney Psychiatric Clinic was opened October 1 , 1 9 3 2 . Notable features of this development are its extensive therapeutic resources in both the in-patient and out-patient services, its visiting and consulting psychiatric service f o r the medical and surgical departments of the general hospital with which it is connected, and its relations with the longestablished Westchester Division of the N e w Y o r k Hospital at White Plains, N e w Y o r k , formerly called Bloomingdale Hospital. T h e extension of this psychiatric service was made possible largely through the efforts of D r . William L . Russell, general director of the psychiatric work of the N e w Y o r k Hospital and professor emeritus of psychiatry at the Cornell University Medical School. Among the other noteworthy psychopathic hospitals in the United States connected with medical colleges of universities are the Michigan Psychopathic Hospital at Ann A r b o r , the Colorado Psychopathic Hospital at Denver, and the Iowa State Psychopathic Hospital at Iowa City. Psychopathic hospitals or wards of the four major types have been established in many large cities and university centers throughout the country. W e have traced broadly in this chapter some of the significant advances at the turn of the twentieth century that heralded the coming of age of psychiatry in America. W e have seen the process stimulated during this period by the development of new facilities and techniques in psychiatric education, training and research. Of equal significance was

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the breaking away of psychiatry f r o m its n a r r o w institutional shell by the growth of private practice, the rise of out-patient departments and psychopathic hospitals, and the beginnings of the employment of social case w o r k techniques in the care and treatment of the mentally ill.

CHAPTER

XV

The Mental Hygiene Movement and Its Founder

T

H E opening decade of the present century was extraordinarily rich in the rise of r e f o r m movements—political, economic and social. In the field of social welfare, particularly, there was a striving f o r new goals, accompanied by inevitable changes in the approach to social problems and their solution. T h e r e was a growing conviction t h a t radical measures were required in dealing with the m a j o r social ills: poverty, delinquency and disease. T h e cyclic interaction of these evils was discerned with increasing clarity. Poverty was a prolific m o t h e r of both delinquency and disease; disease, in its turn, bred more poverty, and so ran the vicious cycle. T o break this cycle, it was now manifest, emphasis must be placed not on therapeutics, not on patching-up, but on the drastic application of preventive measures. Prevention became the keynote in social work and in public health as the new century opened. T h e phenomenal rise of the eugenics movement during this decade was in large measure a reflection of the rise of the preventive ideal. W h i l e eugenicists were concentrating on problems of heredity, o t h e r groups, more aware of the environmental causes of human misery, were devoting themselves to the herculean task of eliminating social and economic conditions unfavorable to the health and happiness of the race. Developments within the field of public health undoubtedly exerted a decided influence on the growth of the preventive ideal. T h e epochal discoveries of Pasteur, Koch and the other pioneer microbe hunters had, in a remarkably short 300

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period, made possible the prevention of diseases that had hitherto taken huge annual tolls in human life. M a n was at last beginning to master his unseen enemies in the microscopic world. One a f t e r another, disease-bearing germs were being discovered and destroyed. In a f e w decades, through the application of sanitation and hygiene, dread scourges like cholera, bubonic plague and typhus all but disappeared f r o m the western world. T h e dramatic conquest of yellow f e v e r by W a l t e r Reed and his associates at the turn of the century was an important factor in making America healthconscious. If the practical abolition of a number of man's greatest plagues had so quickly followed upon the discovery of their causes, why couldn't the field of exploration and prevention be extended to other diseases? On many fronts, the fight against disease was intensified. Originating largely with individuals, by the turn of the century this fight was increasingly taking on an organized f o r m . Scientific data concerning the causes, cure and prevention of diseases were piling up at so rapid a pace that organization was necessary to collect and collate such data, to broadcast the information to the public, to awaken that public to the recognition of life factors h a r m f u l to the individual and to society, and to stimulate activities leading to the amelioration or elimination of factors injurious to health. Fittingly enough, Fielding H . Garrison, in his History of Medicine, refers to this period as the "beginnings of organized preventive medicine." It is no accident that the decade under discussion produced such organizations as the National Tuberculosis Association (established 1 9 0 4 as the National Association f o r the Study and Prevention of Tuberculosis) ; the American Social Hygiene Association (which grew out of the American Federation f o r Sex Hygiene, organized in 1 9 1 0 ) ; the American Child H e a l t h Association (organized 1 9 0 9 as the American Association f o r the Study and Prevention of Infant M o r t a l i t y ) ; and the National Committee f o r Mental Hygiene, formally organized in 1 9 0 9 , though its inception dates one year earlier. It was within this f r a m e w o r k of developments, which we have hastily sketched, that the mental hygiene movement

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originated in 1 9 0 8 ; it is only with this b a c k g r o u n d in mind that its beginnings and e a r l y rise can be properly understood. T h e social climate w a s propitious f o r such a movement. I t s rise w a s an inevitable result of the clear and unmistakable trends of the time. In general, then, it may be f r e e l y stated that the mental hygiene m o v e m e n t developed out of the s a m e b r o a d f o r c e s t h a t b r o u g h t into existence similar m o v e m e n t s in other fields about the same time. In s e v e r a l important respects, h o w e v e r , this particular movement w a s unique in origin. F e w movements have been f o u n d e d under such e x t r a o r d i n a r y circumstances as this one. F e w f o u n d e r s of c o n t e m p o r a r y m o v e m e n t s h a v e had careers so unusual as that of C l i f f o r d W h i t t i n g h a m B e e r s . B o r n in N e w H a v e n , Connecticut, on M a r c h 3 0 , 1 8 7 6 , B e e r s ' s b o y h o o d and early y o u t h f o l l o w e d a pattern not m a r k e d l y different f r o m that o f the a v e r a g e youngster of his native city. A t eighteen he entered Y a l e U n i v e r s i t y , fired with the not unusual ambition to become a successful business man and make a lot of money a f t e r graduation. B u t during his u n d e r g r a d u a t e y e a r s , a f a m i l y misfortune occurred that w a s to affect the w h o l e course of his future. A n older b r o t h e r w a s suddenly seized with epilepsy. U n d e r the stress of this nerve-racking experience, C l i f f o r d B e e r s became p r e y to an obsession that he, too, w a s destined to f a l l victim to the d r e a d disease. F o r six y e a r s he lived under the d a r k e n i n g s h a d o w of this f e a r , while his unhealthy mental condition remained unperceived by his companions and elders. H i s a b n o r m a l obsession he r e v e a l e d to n o n e : none of his acquaintances or mentors even suspected that he w a s in other than a nervous condition of no serious import. G r a d u a t i n g at Y a l e in 1 8 9 7 , B e e r s entered upon a business career. T h r e e y e a r s later disaster o v e r t o o k him. T h e f e a r of epilepsy which had been insidiously g r o w i n g upon him f o r six y e a r s now seized complete domination of his mind. One sunny noon in J u n e , 1 9 0 0 , he t h r e w himself f r o m the w i n d o w of his room, located on the f o u r t h floor of his f a m i l y dwelling, in a suicidal attempt, caused by his delusional belief that he had become an epileptic, to which affliction he p r e f e r r e d death. T h a n k s to a last-minute whim of a

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sick mind, however, he dropped f r o m the window sill by his hands, landing feet first on s o f t earth a bare three inches f r o m a stone pavement. On that f a t e f u l three inches hinged not only the life and death of a man, but the birth of a world-wide movement. As it was, he escaped with no other physical injuries than broken bones in each f o o t and a sprained but unbroken spine, conditions which were but temporarily incapacitating. A strange t r a n s f o r m a t i o n now took place in his mental processes. T h e obsessive f e a r of epilepsy t h a t had gradually gained possession of his mind, resulting in the impulse to suicide, was forever dispelled the moment he struck the ground. Instead, the sick mind was now stormed by a train of delusions, alternating f r o m those of persecution to those of grandeur, that ruled over his thought f o r the next three years. T h e s e years he spent as a patient within the walls of three mental hospitals in Connecticut, except f o r a few months spent in the home of a friendly attendant in a town near N e w H a v e n . A cross-section of the three m a j o r types of institutions f o r the insane was represented by these hospitals; the first to which Beers was committed was a privately owned asylum run for profit, the second a private, non-profitmaking institution, and the third a state hospital. In all three he was treated in the harsh and crude way that was all too prevalent at that time. H e was beaten mercilessly, choked, spat upon and reviled by attendants, imprisoned f o r long periods in dark, dank padded cells, and forced to suffer the agony of a strait-jacket f o r as many as twenty-one consecutive nights. Once, a f t e r a particularly excruciating experience, he scribbled on the wall of his room this ironic inscription: " G o d bless our H o m e , which is H e l l . " A large measure of this treatment had its source in the prevailing ignorance concerning insanity—ignorance not only of proper therapeutics, but of the very nature of mental disorder, i f , here and there, enlightened people were recognizing "insanity" as an illness no more mysterious in essence than physical disease, the popular mind still held it in g r e a t awe and dread. It was still regarded less as an illness than

304

T H E MENTALLY ILL IN AMERICA

as a family disgrace and as a f r i g h t f u l visitation for some evil or sin committed by the victim. T h e r e were still institutions where, in practice, notwithstanding the encouraging language of their annual reports, many of the insane were being treated as sub-humans, stripped by their disease of all claims to human dignity. Inhuman punishments were inflicted by ignorant attendants upon Beers and other patients f o r harmless eccentricities or innocent, playful acts directly attributable to the sick state of their minds—actions that they could no more control than a paralytic can control the affected parts of his body. T h e i r reason was acknowledged to be impaired by the very fact of their presence in supposedly curative institutions, yet they were often expected to act like perfectly rational beings and were meted out swift and humiliating punishments for failing to do so. Liberty-loving, strong-willed, and aggressively independent in spirit, Clifford Beers rebelled against the frequent resort to senseless brutality on the part of attendants and its apparent toleration by some of the physicians. H i s own keen sensitivity to injustice was touched to the quick; the memory of those scenes remained with him always. During the first two years of his illness Beers suffered f r o m delusions of persecution or self-reference manifested in the feeling that he had committed some vague, unpardonable crime, and that he was being shadowed by detectives, government agents, and the like. At the end of this time these delusions vanished quite dramatically, never to reappear, and Beers passed f r o m a state of profound depression into one of extreme exaltation. It was during this period of elation, accompanied by definite symptoms of approaching recovery, that the idea of starting a world-wide movement for the protection of the insane took shape in his mind. Such harsh and stupid treatment as he had suffered at the hands of hospital officials and employees must be abolished. H e had seen other patients subjected to like brutality and even worse. H e had reason to believe that at least one of his fellow patients had been beaten to death. These infamies burned deeply into his soul. T h e r e welled up within him an overpowering determination to put an end to

Pitie

CLIFFORD W H ITTI NG HAM

BEERS

Founder of the Mental Hygiene Movement

Ma
274·> 2 9'> 3 1 1 Earlswood ( E n g l a n d ) School for Idiots, 339 East, Ε. M., 372 East Cambridge, (Mass.) jail, 15859 Eastern Lunatic Asylum (State Hospital), Lexington, Kentucky, 71, 106-8, 120, 147, 230 Eastern Lunatic Asylum (State Hospital), Williamsburg, Virginia, founding of, 66, 69-71 ; 112, 152-53, 192, 196, 230 Eastern New York Custodial Asylum, see Letchworth Village Eastern State Hospital, Pontiac, Michigan, 261 Eberbach Asylum, Nassau, Germany, 289 Eddy, Thomas, 98-102 E d w a r d II, king of England, 388 Egypt, ancient, treatment of mental disease in, 3 ; exorcism in, 4 Ehrlich, Paul, 473 Elgin (Illinois) State Hospital, 441 Elizabethan Poor Law, 44 Elkind, Henry B., 488 Elmore, A n d r e w E., 265 Endocrine therapy in mental disease, 482-83 England, early legal provision for insanity in, 388 ; legal tests for responsibility of the insane in, 390 ff. Epilepsy, Hippocratic theory of, 8

519

Epileptics, colonies for, 381-83, distribution of institutions for, 382 ff. ; census of, 383 Erskine, Lord, 392-93, 397 Esquirol, J. E. D., 78, 145, 340, 465 Estabrook, A r t h u r H., 358, 359, 372 Eugenics, rise of, 300; definition of, 356—57, practical aims of, 357 Eugenics movement, 356 ff. Europe, early asylums in, 16; witchc r a f t in, 18 ff. Exhibiting insane for fees, 63 ff. Exorcism, in Egypt, 4; in medieval times, 17 Falret, Henri L., 237, 289, 338 Family care, in colonial times, 47-48 ; in Kentucky, 106-7 Family care system, in Massachusetts, 449-50; in New York, 450; advantages of, 450-51 Federal Public W o r k s Administration, building p r o g r a m of, 449 Feeblemindedness, see Mental defect Fenton, Reuben E., governor of New York, 248 Fernald, W a l t e r E., 321, 346, 351, 360, 363, 366, 367, 383 Fernald School, see W a l t e r E. F e r uald School Ferrus, G. Μ. Α., 337-38 Fever therapy in general paresis, 473-74 First International Congress on M e n tal Hygiene, 329, 438, 444, 452 Fitz James Colony, Clermont, France, 242 Fletcher, Horace, 310 Florida, commitment in, 412, 427 Focal infections, theory of, 475-76 Fouquier, Francis, governor of Virginia, 69-70 Franklin, Benjamin, 58, 60 Free association, theory of, 468 Freud, Sigmund, 444, 467-72 ; early American supporters of, 470, 475 Friends Asylum (Hospital), F r a n k ford, Pennsylvania, 95, 97, 108, 136, 202, 206, 241, 422 Fuller, M a r g a r e t , 164 Functional psychoses, prolonged sleep treatment in, 477 ff. ; prevention of, 491 ff.

520

INDEX

G a l e n , 25 G a l l i p o l i (Ohio) Asylum for Epileptics and Epileptic Insane, 381 G a i t , John M., 7 1 , 152 ff., 192, 196 flf. Galton, Francis, 349, 356-67 Gantt, W . Horsley, 475 G a r r i s o n , Fielding H., 301 G e n e r a l paresis, recent advances in treatment of, 4 7 2 8 . ; f e v e r therapy in, 473 G e o r g e III, king of England, insanity of, 81, 133-34, 392 G e o r g i a , criminal insane in, 409, 413 G e o r g i a Lunatic Asylum, Milledgeville, 140 G e r a r d ' s Herball, 28 G e r m a n y , eugenic sterilization in, 375 Gheel Colony, 14, 450 Glueck, Bernard, 326, 481 Glueck, Sheldon, 394-95, 4 1 5 - 1 6 » . G o d d a r d , Henry H., 353-54, 358, 360-61, 364, 365, 368 Godding, W . W., 184, 194 Gosney, E . S., 3 7 1 , 372 Government Hospital f o r the Insane, 184, 240; see also St. Elizabeths Hospital G r a n t , Madison, 372 G r a y , George, 1 8 1 G r a y , John P., 216, 238 ff., 274, 283, 284, 285 Greece, ancient, mental disease in, 5-9, 1 1 ; temple sleep in, 6-7 Greek medicine, contributions of, to mental medicine, 7 Greenhill, James, 30 Griesinger, William, 193 Grimes, John M., 382, 383, 448 Grotius, 272 Guggenbühl, J., 339 G u i l d of Friends o f the Infirm in Mind, England, 289 G y r a t o r , Dr. Rush's, 79 Habeas corpus, 4 1 3 , 435 Habit clinic, in Boston, 326 Haines, Thomas H., 436-37 Haidane, J . B. S., 375 Hale, John, 31 Hale, Matthew, 19, 387-88 n., 390-91 H a l i f a x (Nova Scotia) Hospital f o r the Insane, 175

Hall, Basil, 1 3 5 - 3 6 Hall, G . Stanley, 469, 470 Hamilton, Samuel W., quoted, 448 Hammond, William Α., 227, 276, 282, 28 3 Hancock, Thomas, will of, 67 ff. Hard Cash, " r e f o r m " novel, 422-23 Harrisburg (Pa.) State Hospital, 281 Harsnett, Samuel, Archbishop of York, 22 Hartford Retreat, 1 1 0 - 1 2 , 1 1 5 , 1 3 5 36, 138, 148-49, 152, 192, 195, 198, 200, 201, 255, 2Í7 Harvey, William, 25 Haslam, John, 82 I l a v i l a o d , C. Floyd, 297 Hawkins, good and evil test of, 391 Hazard, Thomas G., 169 Healing wells, 1 3 - 1 4 Healy, William, 324, 414 Heidelberg Psychiatric Clinic, 466 Heinroth, Johann Christian, 193, 203 Helmont, J e a n Baptiste van, 25 Hercules, insanity of, 6 Herdman, William J . , 293-94 Heredity and mental defect, 3 4 8 - 5 1 ; rise of study of, 356-69; and mental disease, 492; see also Eugenics, Sterilization, etc. Hill, Gardiner, 2 1 4 Hills, Richard, 244 Hincks, Clarence M., 328, 329, 494 Hippocrates, 8 ff., 25, 229, 465, 473 Hoch, August, 310 Hogben, Lancelot, 357, 365, 373-74 Holmes, Justice, decision of in Buck v. Bell sterilization case, 369 Holt, L. Emmett, 483 Hopkins, Matthew, i8 Horton, Ε. H., 290 Hoskins, R. G., 482-83 Hospital, psychopathic, see Psychopathic hospital Hospitals, mental, see Mental hospitals; see also Institutional care, Institutionalization Howard, John, 58 Howe, Samuel Gridley, 168, 250, 3 4 1 42, 343. 346-47. 354 Hudson (N. Y . ) Lunatic Asylum, 192, 196 Hudson R i v e r (N. Y . ) State Hospital, 256

INDEX H u m a n Betterment Foundation, 371 Humanitarianism, rational, rise of, 5 7 ; sentimental, philosophy of, 186 Hun, E d w a r d S., 283 Huntington, Ellsworth, 372 Hutchings, Charles W., 474 Huxley, J u l i a n , 357 Hydrotherapy, evolution of, in mental hospitals, 445 Hypoglycemic therapy, see Insulin therapy Hypothetical question, in psychiatric testimony, 400-1 Hysteria, 467, 468 Idiocy, definitions, 332, 340 n., 354; heredity in amaurotic, 364 Idiots as court jesters, 333 Idiots Act, England, /8S6, 340 Illinois, Conference on the Insane, 1870, 242, cottage system in, 2 4 2 4 3 ; personal liberty bill in, 307; compulsory jury trials f o r the insane in, 425-26 Illinois B o a r d of State Commissioners of Public Charities, 242, 249, 251 India, feebleminded in, 334 Indiana, statute on compulsory sterilization in, 369; mental examination of defendants in, 402 I n d i a n a State Reformatory, sterilization in, 369 n. Individual psychology, 471 Industry, mental hygiene in, 327-28 Infantile sexuality, 468-69 Insane, provision for in colonial times, 39 ff. ; correctional institutions, 51 ff. ; almshouses as custodial institutions for, 53, 1 1 4 ff. ; medical treatment of, in Pennsylv a n i a Hospital, 60 ff. ; exhibiting o f , 63 ff. ; mechanism of terrorization for, 81 ff. ; beginnings of humane treatment of, 84 ff. ; moral treatment of, 89 ff. ; boarding out of, in Kentucky, 106-7, , 2 ° ; condition of, in New Y o r k poorhouses, 1 3 0 ; Dorothea Dix investigates condition of, in jails and almshouses, 166 ff. ; regarded as w a r d s of the nation, 1 7 7 ; condition of, in Scotland, 1 7 9 ; non-restraint in care o f , 2 1 3 ff. ; evolution of state rare

521

for, 229 ff. ; increase of, o v e r g e n · eral population, 2 3 1 ff. ; county care of, 234, 256, 262 ff. ; evolution of cottage system f o r , 241 ff. ; e v o lution of colony system for, 243 ff. ; etate care of, 259 ff. ; criminal responsibility of, 388 ff. ; tests f o r , 396 ff. ; criminal trials of, 3 9 3 ; criticism of l a w s relating to criminal responsibility of, 398 ff. ; limited responsibility of, in Nebraska, 401 ff. ; commitment of, 4 1 7 ff. ; justifications and limitations of the common l a w concerning restraint o f , 421 ff. ; compulsory j u r y trials for, in Illinois, 425 ff. ; detention o f , pending commitment, 4 3 3 - 3 4 ; discharge and parole of, 434-37 Insane, chronic, proposals f o r p r o v i sion of, 239 ff. ; establishment of state institutions for, 240-41, provisions for, in C a n a d a , 2 4 4 ; county care systems for, 262 ff. Insane, criminal, see Criminal insane Insane, dangerous, definition of, 409 Insane, dependent, see Dependent insane Insanity, medieval remedies for, 12 ff. ; attitude of Moslems towards, 1 5 - 1 6 ; moral treatment of, 91 ff. ; causes of, listed in early hospital statistics, 1 4 6 ; fallacies in reporting cures of, in early statistics, 148 ; curability of, 148 ff. ; and the criminal l a w , 386 ff. ; definitions o f , 386-87; legal concept of, 387; legal provisions for, in R o m a n l a w , 3 8 8 ; legal provisions f o r , in medieval England, 388; criminal responsibility and, 389 ff. ; determination of, by j u r y trial, 437 ff. Institute of J u v e n i l e Research, 324 Institutional care and treatment, modern trends in, 440 ff. Institutionalization of the insane, rise of, 186 ff. ; aims of, 187 ff. Insulin therapy f o r mental disease, 479-81 Intelligence quotient ( I . Q . ) , 354, 362 Intelligence tests, American revisions of, 354; limitations of, 362 International Committee f o r M e n t a l Hygiene, 329

522

INDEX

Iowa, county care system in, >6} ; personal liberty bill in, 425 Iowa State Psychopathic Hospital, 298 Isle of Jersey, Dorothea Diz in, 181 Itard, Jean M. G., 335—37 Jackson, James, 103-4 Jacksonville (Illinois) Experimental School for the Feebleminded, 344 Jacksonville (Illinois) State Hospital, 242, 306, 423-24 Jacoby, George W., 382 James, William, 308, 309, 310, 316 Jarrett, Mary C , 321, 322 J e r v i s , E d w a r d , 20J, 227, 233

Jefferson Medical College, 282 Jelliffe, Smith Ely, 470, 478 Jennings, H. S., 357, 373, 3*4-85 Jewell, J. S., 277 Johnson, Alexander, 315-16, 367 Journal of Nervous and Mental Diseaie, founding of, 277 Journal of Psycho-Asthenici, founding of, 346 Judge Baker Foundation, 324 "Jukes," the, 349-50 Jung, C. G., 469, 471 Jury trials, for the insane, in Illinois, 425 ff. ; criticism of, 437-38 Juvenile delinquency, prevention of, 325 Juvenile Psychopathic Institute, 324 Kalamazoo (Michigan) State Hospital, introduction of colony system at, 243-44; 274 Kallikak Family, The, 358, 365 Kankakee (Illinois) State Hospital, cottage system introduced at, 243, 285. 425, 454 Kansas State Board of Charities, 249 Kellogg, Theodore H., 470 Kentucky, early care and treatment of mentally ill in, 106-8, 120 Kentucky Institution for the Education of Feebleminded Children and Idiots, Frankford, 344 Kentucky Pauper Idiot Act, 1793, 339 Kenworthy, Marion E., 325 Kerlin, Isaac N., 346 Kirby, George H., 297, 443-44

Kirkbride, Thomas S., 140, 151, 154, 192, 194, 206-10, 217-18, 281 Kirkbride plan, 210-12 Kite, Elizabeth S., 359 Kittredge, Thomas, 31 Klaesi, 478 Knight, H. M., 346 Kostir, Mary S., 359 Kraepelin, Emil, 465-67 Kretschmer, Ernst, 482 Kuhlmann, Fred, 354 Lathrop, Julia, 310 Laughlin, H. H., 372 Law and insanity, see Commitment, Criminal insane, Insane, Insanity Leopold-Loeb, case of, 402 Letchworth, William P., 250, 382 Letchworth Village, 380 Levy, David, 325 Limited responsibility and mitigation of punishment in criminal trials, 401-2 Lincoln Asylum, England, 214 Lincoln (Illinois) School for the Feebleminded, 344 Lindpainter, Dr., 289 Linnaeus, 335, 466 Locke, John, 336 Lombroso, Cesare, 482 Lossing, Β. J., quoted, 182 Louis XV, king of France, 389 Louisiana, mental examination of defendants in, 402 Lowell, Josephine Shaw, 350 Lowrey, Lawson, 325 Lucid intervals, theory of, 390 Lunacy, see Insanity, Mental disease Lunacy, State Commissioner in, in New York, 255-56 Lunacy Commissions, creation of, 258-59 Lunacy Law Reform Society of London, 311 Luther, Martin, 19, 233-34 Lycurgus, laws of, 333 Mackenzie, Colin, 105-6 McFarland, Andrew, 154, 242 McLean Asylum, 102-5, *3®> I 5 I . '9*1 197» '98. 273. »74. ζ*'» 4 « . 44» "Mad shirt", 61 Madison (Wis.) State Hospital, 264

INDEX Magic and mental disease, 1-2 Maine State Hospital, Augusta, 140, 153 ff., 192, 216 Maintenance cost, average, of mental patients, 452 Manhattan (New York) State Hospital, 286, 287 Manic-depressive psychosis, incidence of, 485-86 Mann, Horace, 137, 168, 173, 177, 229 Marcy, W . L., governor of New York, '39 Marcy (New York) State Hospital, 474 Marks, Marcus M., 310 M a r r i a g e laws for mental defectives, 376 Marsh, Anna, bequest of, 140-1 Maryland, mental examination of defendants in, 403 Maryland Hospital, 105-6 Maryland State Commission of Lunacy, 259 Massachusetts, first statute on insanity, 1676, 43 ; colonial settlement law in, 44; poorhouses in, 128; nonrestraint law in, 227; boarding out system in, 244; establishment of a central public w e l f a r e body in, 248 ff. ; early provision for mental defectives in, 341-42 ; provision for defective delinquents in, 351; mental examination of defendants in, 404; law affecting the dangerous insane, ¡7Q7, 419; voluntary admission law in, 431 ; family care system in, 449 Massachusetts Board of Lunacy and Charity, 259 Massachusetts Board of State Charities, 249, 267, 312 Massachusetts Department of Mental Diseases, 404, 405, 413, 456 ff.; traveling clinics of, 378, 459 Massachusetts General Hospital, 104 Massachusetts lunacy commission, 1854, 233 Massachusetts School for Idiotic and Feebleminded Youth, 342 Massachusetts State Almshouse, tee Tewksbury Infirmary

523

Massachusetts State Board of Insanity, 2 59i 294-96 Massachusetts State Farm, Bridgewater, 351 Mather, Cotton, 32-34, 36 n. M a t t e a w a n (New York) State Hospital, 411 Mechanical restraint, 79, 213 ff. Medical practice in the colonies, 27 ff. Medical superintendent, problems of, in mental hospitals, 273, 274 Medicine, preventive, beginnings of, 300-1 Medieval ages, remedies for insanity, 12 ff. ; exorcism in, 17 Meduna, L., 481 Mendel, Gregor, and laws of heredity 353. 356. 364 Mental defect, definition of, 331-32; classification of, 332; and demoniacal possession, 333 ; rise of the study of hereditary factors in, 348 ff. ; and social ills, 349; changing concepts in, 3J3 ff. ; psychological criteria for g r a d i n g of, 362; fields of inquiry in, 363 ; changing criteria of, 363 ff. ; and Mendelianism, 364; and crime, 366; general attitudes towards, 366; segregation in, 367-68; sterilization in, 368 ff. ; environmental influences in, 376, 384-85 ; special classes for, 376-77 Mental defectives, care of, in colonial times, 48 ; among ancient and primitive peoples, 333; during the Middle Ages, 334-35; early attempts at training, 337 ff. ; early provision for, in America, 339 ff. ; first state institutions for, 341 ff. ; delinquent, provision for, 351; alarmist attitude toward, 351 ff. ; classification of, 354-55, as menace to society, 359 ff. ; new classification system for, 361; census of, 368; marriage laws for, 376; registration of, 376 ; social control of, 376 ff. ; mental hygiene clinics for, 377 ff. ; census of institutions for, 378 ff. ; colony system for, 379 ff. ; parole of, 383-84; boarding out of, 384-8$

52+

INDEX

Mental disease, and magic, 2 ; and demoniacal possession, 2 ff.; therapy in, in ancient times, 3 ff. ; progress of research in, 283-86; social aspects of, 288 ff. ; in the United States Army, 3 1 7 ; chemical approach in, 476; physique and, 482 ; endocrine therapy in, 482 ff. ; recovery rate in, 484; census of, 486; economic cost of, 486; apparent increase of, 487 ff. ; effect of depression on, 489 ff. ; prevention of, 491 ff. ; heredity in, 492; social environment and, 493 ff. ; see also Insane, Insanity Mental examination, of defendants, 402-6 Mental hospitals, early statistical records in, 145 ff. ; early aims and treatment in, 188 ff. ; early plans for construction of, 208 ff. ; advantages of cottage system in, 2 1 2 ; mechanical restraint in, 2 2 1 ; problems of medical superintendents in, 273, 274; lack of research in, 274 ff. ; nurses and women physicians in, 281 ff. ; pathological research in, 284; evolution of social service in, 287; evolution of nursing service in, 442 ff. ; psychotherapy in, 443 ; development of occupational therapy in, 444; hydrotherapy in, 44; ; minimum standards for, 445 ff. ; overcrowding in, 448 ff. ; during the depression, 449; research facilities in, 453 ; political interference in, 453 ff. ; children in, 459; number and distribution of, 460 ff. Mental hospital administration, criticisms of, 226 ff. Mental hygiene, origin of term, 1843, 309 ff. ; and social work, 318 ff. ; and child guidance movement, 323—26; in prison clinics, 326-27; in industry, 327; organizational growth of, 328-30; internationalization of, 328 ff. ; goal of, 496 Mental hygiene clinics, for mental defectives, 377 ff. ; traveling, in Massachusetts, 459 Mental hygiene movement, origin

and development of, 300 ff. ; influence of World W a r on, 317 ff. ; influence of, on other fields, 318 ff. ; influence of, on social work, 322 ff. ; 25th anniversary of, 330 Mental hygiene societies, number of, 1936, 328 Mental patients, census of, 1934, 460 Mental tests, in mental deficiency, 355—56 ; critique of, 361 ff. Mesmer, Anton, 468 Meyer, Adolf, 284-87, 289, 297, 309, 310, 444, 463, 466, 483-84 Michigan, introduction of colony plan in, 244-4J I central public welf a r e authority in, 249 n., state care in, 261 Michigan State Psychopathic Hospital, 293-94, 2 9$ Middlesex Asylum, Hanwell, England, 2 1 4 - 1 5 Middletown (New York) Homeopathic Asylum, 256 Miller, William, and "Millerism," 146-47 Milwaukee (Wisconsin) County Insane Asylum, 265, 266 Minnesota School for the Feebleminded, Faribault, 346 Missouri, sterilization bill in, 374-75 Mitchell, S. Weir, 276, 279-82, 283 Montessori system in education, 339 Moon, influence of, in mental disease, 30, 82-83, 387-88 n., 390-91 Moore, J . W., 473 Moral treatment of insanity, rise of, 89 ff. More, Thomas, 13 Morgan, T . H., 365 Morningside Hospital, Portland, Oregon, 461 Mosher, J . Montgomery, 293 Moslems, attitude of, toward the mentally ill, 1 5 - 1 6 Muller, H. J., 357 Municipal mental hospitals, origin of, 1 4 3 - 4 5 ; census of, 461 Murray, Lindley, 93, 100-1 Music therapy in mental hospitals, 445 Myers, G a r r y Cleveland, 490 Myerson, Abraham, 492

INDEX Narcosis therapy io mental disease, 478 ff. National Association for the Protection of the Insane and the P r e v e n tion of Insanity, 2$7, 3 1 1 - 1 4 National Association for the Study of Epilepsy, 382 National Committee for Mental Hygiene, 301; founding of, 3 1 0 ; objectives of, 314 ff. ; surveys of existing mental hygiene facilities by, 3 1 6 ; and development of psychiatric social work, 321 ; surveys among school children by, 325 ; psychiatric study of prisoners by, 326 ; growth of, 328, 378, 449, 456, 489, 494 National Conference of Charities and Correction, tee National Conference of Social W o r k National Conference of Social W o r k , 267 ff., 269, 288, 289, 3 1 1 , 312, 321 ff., 360 National Crime Commission, 404 Nebraska, limited responsibility of insane in, 401-2 Ncbuchadnezzar, insanity of, 3 Nerancy, John T., 441 Nerve clinic, in Philadelphia, 296; in Boston, 296 Neurology, American, rise of, 276 ff. ; influence of, in psychiatry, 278 ff. Neuroses, increase of, 488 ff. N e w a r k (New York) Asylum f o r Feebleminded Women, 351 New England Renaissance, ideals of, 163-64 "New England System" for paupers, 117 ff. New Hampshire, criminal responsibility in, 396 New Hampshire Asylum, Concord, 140, 141, 154 New Hampshire Commission in Lunacy, 259 New Jersey, county care plan in, 271 New Orleans Charity Hospital, 1 3 1 New York, pauper insane in, in the early 19th century, 123 ff. ; poorhouses in, 127 ff. ; survey of insane and feebleminded in, 1856, 233 ; state care in, 234 ff. ; central public w e l f a r e body in, 249; provision f o r

525

chronic insane in, 252 ff. ; for mental defectives, 341 ff. ; f o r defective delinquents, 351 ; statute of 1788, 4 1 9 ; qualifications of commissioner of mental hygiene in, 4)7 New York City Idiot Asylum, R a n dall's Island, 344; Insane Asylum, W a r d ' s Island, 203, 3 1 4 ; Lunatic Asylum, Blackwell's Island, 144, 307 New York Hospital, origin and development of, 97-102, 298 New York M e n t a l Hygiene Law, definition of mental defect in, 331 ff. ; on t e m p o r a r y commitment, 433; on commitment methods, 439 New York Neurological Society, 257, 27.7, 278 New York Prison Association, 349 New York Psychoanalytic Society, 470 New York School of Social W o r k , 3 2 1 N e w York State Asylum for Idiots, Syracuse, 312, 347, 350 ff. ; Institution f o r Defective Delinquents, Napanoch, 3 5 1 ; Lunatic Asylum for Insane Convicts, A u b u r n , 4 1 1 New York State Board of Charities, 252-53. 255 ff·. 258, 267, 269, 350, 382 New York State C a r e Act, 1890, 229, 259 ff., 262 New York State Commission in Lunacy, 255 ff., 260, 290, 297, 426, 427 New York State Department of Mental Hygiene, 218-19, 297. 4 2 7. 45°. 456 ff., 459 New York State Lunatic Asylum, see Utica State Hospital N e w York State Medical Society, 284 New York State P a r o l e Board, 327 New York State Pathological Institute, see N e w York State Psychiatric Institute New York State Penal Law, on criminal responsibility, 398 New York State Psychiatric Institute, 285-87, 294, 297-98 Nichols, C h a r l e s H., 184, 185, 240 Nielson, W . Α., 321 Nightingale, Florence, 281 Noguchi, Hideyo, 473

526

INDEX

Non-restraint, origin and development of, 213 ff. ; theory of, 2 1 3 - 1 4 , 224-26; American opposition to, 2 1 5 ff., 226 ff. ; arguments for, 217 ff. ; advocates of, in America, 22728 Non-restraint law in Massachusetts, ign, 227 Norristown (Pennsylvania) State Hospital, 282 North Carolina, state care in Constitution of, 261 North Carolina Board of Public Charities, 249 ff. Northampton (Massachusetts) State Hospital, 155, 203, 248, 274 Northern State Hospital, Winnebago, Wisconsin, 264 Nurses, first training schools for, 281 Nursing, psychiatric, census of schools of, 442 n.; evolution of, in mental hospitals, 442 ff. Occupational therapy, 63, 101 ; fundamental principles of, 444; evolution of, 444-45 Ohio Board of State Charities, 249, 2 51 381

. '

Ohio Hospital for Epileptics, Gallipolis, 381 Ohio State Asylum for the Education of Idiotic and Imbecile Youth, Columbus, 344 Ohio State Hospital, Columbus, 140, 153. 154. »92. 202 Ohio State Lunatic Asylum, Cincinnati, 109-10 Ordronaux, John, 256, 382 Organic psychoses, 486 Oshkosh (Wisconsin) State Hospital, 252 Otis, James, 68 Out-patient department, development of, in mental hospitals, 296-97 Overcrowding in institutions, 449 ff. Overholser, Winfred, 405 Packard, Mrs. E. P. W., 306-7, 42326 Page, Charles W., 227 Paine, Thomas, 56, 57 Paracelsus, 21, 22, 27, 468 Parole, in institutions for mental

defectives, 383-84; in mental hospitals, 434, 436 ff., 451 Parrish, Joseph, 346 Pathological research, tie Research Paulus Aeginata, 1 1 - 1 2 Paupers, insane, care of, in the early 19th century, 1 1 6 ff.; "bid off," 1 1 7 ff. ; contract system for, 120, 126; "dumping" of, 123 ff. ; tee alio Dependent insane Pavlov, and neuroses in dogs, 475-76 Payne Whitney Psychiatric Clinic, 298 Pedigrees of defective, see Defectives Pennsylvania, first known provision for the insane in, 42; county care plan in, 271 ; state provision for mental defectives in, 343 Pennsylvania Board of Public Charities, 249, 251 Pennsylvania Hospital, origin and development of, 58-66; Benjamin Rush at the, 77 ff. ; 91, 98, 140, 1 5 1 , 154, 192, 206, 212, 230, 281, 296, 421, 458 Pennsylvania State Committee on Lunacy, 282 Pennsylvania Training School for Feebleminded Children, Elwyn, 343. 345. 3δο Pepperell (Massachusetts) Private Asylum, 192, 196 Pereire, Jacob Rodrigues, 337 Performance tests, limitations of, 363 Periodicals, intramural, 200-1 Perkins Institution for the Blind, 342 Personal liberty bill, 4, 25-26 Peterson, Frederick, 289, 297, 310, 382, 473 Pharmacology, contributions of, to psychiatry, 476 ff. Philadelphia, center of Quaker reforms in the 18th century, 58 Philadelphia Dispensary for the Poor, 74 Philadelphia General Hospital (Old Blockley), 1 3 1 , 293, 314 Philadelphia Nerve Clinic, 296 Philadelphia Society for Alleviating the Miseries of Public Prisons, 74 Phillips, Wendell, 426 Phillips, William, legacy of, 102-3 Phips, governor of Massachusetts, 38

INDEX Phipps, Henry, 316 Phipps Psychiatric Clinic, Baltimore, 297. 3*4 Physicians, and witchcraft, 2 0 ; ratio o f , to patients, 452 ff. Physiological concept in mental disease, rise of, 284 ff. Pierce, Franklin, President, 178-79 P i l g r i m ( N e w Y o r k ) State Hospital, 462 Pine), Philippe, 5, 9; sketch o f , 89 ff. ; introduces humanitarian ref o r m s at the Bicêtre, 90; at the Salpêtrière, 90 ff.; influence of, on psychiatric practice, 95, 336, 465 P l a t e r , Felix, 23, 465 Political interference, in state institutions, 4S3 ff. Pollock, Horatio M., 450, 486 Poor f a r m s , mental patients in, 451 ff. Poorhouses as custodial institutions f o r the insane, 53 ff., 1 1 4 - 3 1 , 4 5 1 52 ; removal of insane f r o m , 2 4 6 7 1 ; condition of insane in, 130 ff. Poorhouses, in Massachusetts 128 ; in N e w Y o r k , 128 Poor l a w reform in E n g l a n d , 1 2 2 Popenoe, P a u l , 3 7 1 , 372 Powell, T . O., 107-8 Pratt, G e o r g e K . , 490 Present insanity, 406-8 P r e v e n t i v e principle, rise of, 3 0 0 - 1 P r e v e n t i v e psychiatry, 491 ff. Prison clinics, 326-27 Prisons, mental tests in, 355 P r i v a t e mental hospitals, census of, '934, 4« ι Prolonged sleep treatment, in f u n tional psychoses, 477 ff. P r o v i n c i a l Lunatic Asylum, Toronto, 244 Psychiatric clinics, 458 ff. ; see also Mental hygiene Psychiatric instruction, lack of, in e a r l y A m e r i c a n medical schools, 282 Psychiatric nursing, see Nursing Psychiatric testimony, 399 ff. Psychiatry, G e r m a n , in the early 19th century, 1 9 3 ; A m e r i c a n , in the early 19th century, 193 ff. ; slow development of, 272 ff. ; factors influencing development of, in the

527

late 19th century, 27$ ff.; and neurology, 277 ff., 4 6 4 - 6 $ ; institutional, 279 ff. ; social work in, 286 ff. ; 20th century schools o f , 463 ff. ; psychological and organic approaches in, 472 ; contributions of p h a r m a c o l o g y to, 476 ff. ; preventive, 491 ff. ; social, 493 ff. ; see also Mental disease, etc. Psychoanalysis, evolution of, 467 ff. ; opposition to, in A m e r i c a , 4 6 9 ; influence of, 4 7 1 ff. Psychoanalytic R e v i e w , 470 Psychobiology, 483 ff. Psychology, analytical, 4 7 1 ; individual, 471 Psychoses, see Mental disease Psychosis, manic-depressive, census of, 485 ff. Psychopathic hospitals, evolution o f , 291 ff. ; types of, 291 ; functions of, 295 ff. Psychotherapy, evolution of, 443 ff. Public w e l f a r e administration, development of, 246 ff. ; central boards f o r , 248 ff. Puritanism and w i t c h c r a f t , 32 ff. Putnam, J a m e s J . , 470 Quakers, 57 ff., 92-93, 189 Quincy, J o s i a h , 1 2 2 R a l e i g h (North C a r o l i n a ) State Hospital, 175, 261 Rational humanitarianism, philosophy of, 57 ff. R a y , Isaac, 82, 1 4 2 - 4 3 , 1 5 3 - 5 4 . 192. 197. 203-6, 2 1 5 - 1 6 , 2 1 9 - 2 0 , 258, 274, 282, 3 1 0 , 397-99, 422 R e a d , C h a r l e s F., 441 R e a d e , Charles, 422-23 R e c o v e r y rate, in mental disease, 484 Reed, A n d r e w , 339 Reed, W a l t e r , 301 Reil, J o h a n n C., 199 Renaissance, witch mania in, 1 9 R e p r e s s i v e principle, in e a r l y colonial legislation, 43 Research, in mental disease, 282 ff., 453. 472 ff·. 493. 496 Responsibility, criminal, sane, 388 ff.

of

the

in-

INDEX

528

R e s p o n s i b i l i t y , l i m i t e d , in c r i m i n a l trials, 4 0 1 - 2 R e s t r a i n t , m e c h a n i c a l , 2 1 9 ff. ; f o r m s used in e a r l y m e n t a l h o s p i t a l s , 2 2 1 ; effects of, on p a t i e n t s , 2 2 2 Retreat Gazette, Hartford, 200 R h o d e I s l a n d A s y l u m f o r the I n c u r able Insane, C r a n s t o n , 2 4 0 R h o d e I s l a n d B o a r d of S t a t e C h a r i ties a n d C o r r e c t i o n s , 2 4 9 Richards, J. B., 343, 344 Richards, M r s . L a u r a E., 345 Richmond, M a r y E., 320, 3 2 2 Rockefeller Foundation, 3 1 6 Rockland ( N e w Y o r k ) State Hospital, 4 5 9 Rodman, James, 381 R o g e r s , A . C., 346 R o m e ( N e w Y o r k ) State Custodial A s y l u m ( S t a t e S c h o o l ) , 3 5 1 , 3 7 9 ff., 383 Rousseau, J . J., 55 R o y a l C o m m i s s i o n to i n v e s t i g a t e lun a c y s y s t e m o f S c o t l a n d , 1855, itoti Ruggles, A r t h u r H., 329, 482 Rush, Benjamin, achievements of, 7 2 ff. ; e a r l y life of, 7 3 ; m e d i c a l s y s t e m of, 7 5 ff. ; o n p h o b i a s , 7 6 ff. ; t h e r a p e u t i c r e m e d i e s of, 7 7 ff. ; invents new mechanical devices, 7 9 ff. ; i n n o v a t i o n s of, a t P e n n s y l v a n i a H o s p i t a l , 83 ff.; r e f o r m s instituted by, 84 ff. ; influence of, on A m e r i c a n psychiatry, 8 6 - 8 7 , 9 ' . 94· 189, 190, 407, 4 2 1 , 495 Russell, W i l l i a m L., 298, 3 2 1 , 4 3 4

S c h u m a c h e r , H e n r y C., 4 9 0 Schurman, J a c o b Gould, 3 1 0 Schuyler, L o u i s a L e e , 2 5 6 - 5 7 , 2 9 0 S c h w a r z , R u d o l p h , 409 n. Scot, R e g i n a l d , 2 2 S c o t l a n d , c o n d i t i o n s o f i n s a n e in, 1 7 9 ; Royal Commission investigation, 18S5, 1 8 0 - 8 1 Scottish R i t e M a s o n s , N o r t h e r n J u r i s diction, 4 8 5 Scourging, as a remedy for insanity, »3 Seguin, E d w a r d C., 2 2 7 , 2 8 2 , 2 8 3 , 337, 3 3 * " 3 9 . 3 4 4 « · Seneca, 3 3 3 Sennert, Daniel, 23 Sentimental humamtarianism, philosophy of, 1 8 6 S e q u e y r a , J o h n de, 71 Settlement l a w s a n d the d e p e n d e n t insane, in c o l o n i a l times, 45 ff. Shanahan, W i l l i a m T . , 383 S h a r p , H . C., 369 Shaw, Chief Justice of Massachusetts, on r e s t r a i n t of the i n s a n e ,

421-22,

316,

435 Simon, H e r m a n n , 4 4 4 Simon, T h o m a s , 3 5 3 Sing Sing P s y c h i a t r i c Clinic, 3 2 7 Smith C o l l e g e School o f Social W o r k , 321 Smith, S. H a n b u r y , 1 5 4 Smith, Stephen, 2 5 6 ff. Smythe, J a m e s , 1 0 5 - 6 Social e n v i r o n m e n t a n d m e n t a l disease, 4 9 3 ff. Social ills, a n d m e n t a l d e f e c t , 349, 3 5 2 S o c i a l p s y c h i a t r y , 4 9 3 ff. Social r e f o r m , founding of national organizations for, 3 1 1 Social s e r v i c e , in m e n t a l hospitals, 287, 436

3*7. 325. 328. 441. 4 5 ' . 4 9 4 S a l p ê t r i è r e , 78, 88, 90 ff., 3 3 8 Sanborn, Franklin B., 1 8 3 , 1 9 3 , 250, 267 S a n c t o r i u s , S a n c t o r i u s , 26 S a u l , k i n g o f I s r a e l , m e l a n c h o l i a of, 3 S c a t t e r g o o d , T h o m a s , 96 S c h i z o p h r e n i a , see D e m e n t i a p r a e c o x School c h i l d r e n , m e n t a l h e a l t h s u r v e y s of, 3 2 5 ; m e n t a l tests a m o n g , 35$

Social w o r k , p s y c h i a t r i c , 286 ff. ; and mental h y g i e n e , 3 1 8 ff. Société de P a t r o n a g e , 2 8 9 Society f o r I m p r o v i n g the Condition of the I n s a n e , L o n d o n , 311 Society of F r i e n d s , tee Q u a k e r s S o c i o - e c o n o m i c f a c t o r s in m e n t a l disease, 4 9 4 Sodium amytal, 476, 477, 479 Sodium rhodonate, 476 Soranus of Ephesus, 9

S a e g e r t , C. M . , 3 3 9 Sakel, M a n f r e d , 4 7 9 - 8 1 Salem witchcraft, 32-38 Salmon, T h o m a s W . , 272,

297,

INDEX South C a r o l i n a State A s y l u m , C o l u m b i a , ιο8 S o u t h a r d , E . E . , 295, 321-22, 327-28 S p i t z k a , E d w a r d C . , 279, 282, 283 S p u r z h e i m , 241 St. B o n i f a c e H o s p i t a l , F l o r e n c e , 95 St. D y m p h n a ' s s h r i n e , 14 St. E l i z a b e t h s H o s p i t a l , W a s h i n g t o n , D . C . , 184, 438, 460, 46t, 462, 472 ; see also G o v e r n m e n t H o s p i t a l f o r the Insane St. J o h n ' s P r o v i n c i a l H o s p i t a l , 1 7 5 St. J o h n ' s w o r t ( h y p e r i c o n ) , 29 S t a f f o r d , E d w a r d , 29-30 S t a n f o r d - B i n e t test, 362 S t a n t o n , S e c r e t a r y of W a r , 182-83 State administration and supervision, s y s t e m s o f , 250 ff., 456-60 S t a t e c a r e of t h e i n s a n e , e v o l u t i o n o f , 229 ff., m a i n o b j e c t i v e s o f , 2J7 ; a d v a n t a g e s o f , 269 ff. ; p r e s e n t s t a t u s o f , 271 State Charities A i d Association, N e w Y o r k , 256-57, 290, 297, 311, 434 S t a t e h o s p i t a l s , p o l i t i c a l a b u s e s in, 455; state administration and s u p e r v i s i o n o f , 456 ff. ; a n d t h e c o m m u n i t y , 458 S t a t e i n s t i t u t i o n s , r i s e o f , 137 ff. S t a t i s t i c a l m e t h o d s in e a r l y m e n t a l h o s p i t a l r e p o r t s , 145 ff., 154-55, 2 0 í > 205 S t e d m a n , C h a r l e s H a r r i s o n , 192, 201 S t e d m a n , H e n r y R., 289 S t e p h e n , J a m e s F i t z J a m e s , 391 S t e r i l i z a t i o n , e u g e n i c , in m e n t a l d e f i c i e n c y , 368 ff. ; s t a t e I a w 9 f o r , 370; in C a l i f o r n i a , 371 ; l e a d i n g A m e r i c a n exponents of, 371-372; scientific a n d s o c i a l o b j e c t i o n s a g a i n s t , 372—73 ; difficulties in enacting s o u n d e u g e n i c l a w s , 3 7 4 - 7 5 ; in G e r m a n y , 375 ; in m e n t a l d i s e a s e , 492 S t e r n , W i l l i a m , 354 S t e v e n s o n , G e o r g e S., 326 Stockton S t a t e A s y l u m , C a l i f o r n i a , 241 S t o d d a r d , T . L., 372 Stokes, A n s o n P h e l p s , 310 Stout, A . B., 292 S t r i b l i n g , F r a n c i s T . , 191, 192, 19Í S u r g e o n G e n e r a l ' s Office, D i v i s i o n o f N e u r o l o g y a n d P s y c h i a t r y , 317 ff.

529

Sweetser, W i l l i a m , and mental hyg i e n e , 309-10 S y d e n h a m , T h o m a s , 26, 76 Syracuse ( N e w Y o r k ) State Institution f o r the F e e b l e m i n d e d (State S c h o o l ) , 343 T a f t , J e s s i e , 322 T a u n t o n ( M a s s a c h u s e t t s ) State H o s p i t a l , 248 T a y l o r , M a u r i c e , 488 T e m p l e s l e e p , in G r e e c e , 6-7 Tennessee Lunatic Asylum, Nashville, 139-40 T e r m a n , L e w i s M . , 354 T e r r o r i z a t i o n in m e n t a l t h e r a p e u t i c a , 79 ff. T e s t i m o n y , p s y c h i a t r i c , 399-401 T e s t s , legal, f o r the responsibility of t h e i n s a n e , 390 ff. T e w k s b u r y (Massachusetts) Infirma r y , 240 T h o r n , D o u g l a s Α . , 326 T h r o o p , Enos T . , g o v e r n o r of N e w Y o r k , 138 T h u r n a m , J o h n , 154-55 T o d d , E l i , 1 1 1 - 1 2 , 135, 149 Training School for the Feeblem i n d e d , V i n e l a n d , N . J., 353-54 T r a n q u i l i z e r , 79 Treasury of Exorcisms, 17 T r e n t o n ( N e w J e r s e y ) State H o s p i t a l , 171, 185, 475 T r i a l s , criminal, psychiatric testimony in, 399-401 ; l i m i t e d r e s p o n s i b i l i t y a n d m i t i g a t i o n o f p u n i s h m e n t in, 401-2 T r u i t t , R a l p h P . , 325 T u k e , B a t t y , 218 T u k e , D . H a c k , 2, 82, 181, 227, 311, 333. 465 T u k e , S a m u e l , 96, 99, 101, i n T u k e , W i l l i a m , 92-95 T u r n e r , D o u g l a s F r a n k , 375-76 U n c o n s c i o u s , 468 United States A r m y , mental disease in, d u r i n g the W o r l d W a r , 3 1 7 ; m e n t a l tests in, 356 " U t i c a c r i b , " 222-23 Utica ( N e w Y o r k ) State Hospital, 139, 147, 15t, 192, 196, 198, 200, 201, 222, 230, 233, 236, 238, 2 5 2 -

INDEX

530 S3.

»57.

»73.

»74.

183.

î«4.

»85.

341, 4 1 1 ; tee alio New York State Asylum, Utica

Van Gieson, Ira, 285-87 Vermont Asylum for the Insane (now Brattleboro Retreat), 140-41, 200, »55

Vermont Commissioner of the Insane, 255 Vermont State Care Act, 18S6, 261-62 Vesalius, 26 Veterans Administration's facilities, census of, ¡934, 461 Virginia, first state hospital established in, 69-71 ; law of 1806 on the insane in jails, 420-21 Voisin, 338 Wagner-Jauregg, Julius, 473 Walker, Clement, 223 Walter S. Fernald State School, Waverley, Massachusetts, 342 Warning out of vagabonds, paupers and insane, in Colonial times, 45 Warren, John Collins, 103-4 Warren (Pennsylvania) State Hospital for the Insane, 296 Waterston, R. C., 168 Weihofen, Henry, 396, 406 Welch, William H., 330 Western Kentucky Lunatic Asylum, Hopkinsville, 381 Western Lunatic Asylum, Staunton, Virginia, 1 1 2 , 192, 196 Wet sheet pack, 445 Weyer, Johann, 22 White, Samuel, 192, 194, 196 White, William Α., 184, 281, 329, 400, 414, 438, 470, 472, 493 White House Conference on Child Health and Protection, 1930, 332,

Wilkinson, John Gardner, 5 Willard, Frances E., 163 Willard, Sylvester D., 236, 238 Willard Act, New York, 1865, 236 ff., 252 ff., 260 Willard (New York) State Hospital, 236 ff., 238, 240, 252 ff., 260, 264 Williams, Frankwood E., 317, 328, «ι,

493-95

Williams, Roger, 47 Williamsburg, Virginia, first state hospital erected at, 66, 69-71, 233 Willis, Francis, Si, 133-34, 136, 138 Wines, Frederick H., 242-43, 250, 251 Winthrop, John, governor of Connecticut, 29-30 Wisconsin, development of county care of the insane in, 234, 262-69 Wisconsin County Care Act, 1881, 265-66 Wisconsin, public welfare authority in, 249, 252, 263-68 Wise, Peter M., 289, 464 Witchcraft, in Europe, 18 ff. ; and physicians, 20; and puritanism, 3 2 ; in Salem, 32 ff. Witches, insanity of, 20 ff. Woodward, Samuel B., 1 1 1 , 138, 149, »5», 1 9 1 . »92, 24'-42, 340-41

194.

195-96.

201,

37». 379. 3 8 3 - 8 4

Worcester, W. L., 274 Worcester (Massachusetts) State Hospital, 137-38, 155, 169, 191, 192, 195, 201, 230, 241-42, 248, 286, 340, 4 1 1 , 424, 466 Workhouses and houses of correction, insane in, in Colonial times, 51-53 Workman, Benjamin, 244 Workman, Joseph, 274 World W a r , influence of, on mental hygiene movement, 317 ff. Wyman, Rufus, 104

34«. 3 4 7 . 3 5 0

Yates, J . V. N., 123 ff., 127 Yerkes, R. M., 354 York Retreat, 92, 93-95, 96, 99, 100, 102, 110, u t , 154, 181, 196, 3 1 1

Wiggam, A. E., 372 Wigglesworth, Michael, 29 Wilbur, C. T., 346 Wilbur, Hervey B., 312, 342 ff., 345,