Canton Asylum

Man With Apoplexy, courtesy National Institutes of Health, History of Medicine

Asylum doctors tried hard to share information about the developing field of psychiatry, and sometimes discussed interesting cases in journals. In the January, 1869, issue of the American Journal of Insanity, Dr. Judson Andrews gave details about a fifteen-year-old-boy brought into his asylum. The progression of his disease follows:

The boy was healthy and free of insanity until he developed typhoid fever and became delirious in April of 1868. He demonstrated mental disturbances by a change in his character, since he began stealing from neighbors’ gardens and hanging around with “evil associates.” He also became profane, was disobedient to his parents, and danced and sang comic songs. Later, he was hit in the head with a rock thrown by a comrade. The boy was admitted to the asylum that September, and gave no immediate indication of insanity. A few days later, however, he began to do odd things: wash his clothes in a bathtub, eat voraciously, and sometimes vomit food. Otherwise, he was obedient and “anxious to make himself useful.”

In November, he suddenly complained of headache and pain in his stomach, screamed, and passed into a convulsive state. On being examined, he became maniacal for about two hours and then was rational. He complained about a pain in his head, telling the staff that he felt at times “as though he had swallowed tobacco.” At four p.m., he died suddenly.

An autopsy sixteen hours later found a quantity of internal bleeding, and the doctors determined that the boy had died of apoplexy. Apoplexy originally meant any sudden death after the loss of consciousness, and usually indicated what we would call a stroke, today. Though they doctors involved acknowledged that it was unusual to see apoplexy in one so young, rather than revise the diagnosis of insanity that preceded the event, they believed, instead, that the maniacal fit had simply brought it on.

Apoplexy Was Mysterious

An Extraordinary Cure from a British Doctor, courtesy thequackdoctor.com

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American Journal of Insanity

Their own writings provide fascinating insights into the mental health profession’s ever-changing understanding of insanity and how to treat it. Although it was not the only vehicle by which to express current thoughts on the topic, the American Journal of Insanity did have the backing of many authorities in the field. Articles in it ranged from purely practical matters to theoretical speculation concerning the root causes of insanity. My next few posts will give a sampling of what was on the minds of leading alienists in the nineteenth and early twentieth centuries.

In 1863, Dr. John Bucknill wrote an article, “Modes of Death Prevalent Among Insane,” in which he advocated consistency in the way asylum superintendents registered cause of death. Bucknill found that the term exhaustion served as a catchall word that gave little clue as to the actual disease or condition that  took a patient’s life. Reading from asylum obituary tables, Bucknill noted that at one asylum a physician attributed 30% of deaths to exhaustion. “In another report, I find a number of deaths attributed to ‘prostration,’ which is perhaps a synonym for exhaustion; while in another report the terms ‘gradual decay’ or ‘general decay’ appear often to be used to express the same facts.”

The vagueness of words like exhaustion and decay kept asylum physicians from keeping accurate records concerning causes of death among their patients. Bucknill urged physicians to give the names of the disease that killed their patients, and then simply add the precise mechanism that shut them down if they wished. Bucknill gave an example of a patient who died from refusing food because of his delusions. Under the system he currently saw, doctors would say the person died of exhaustion, but Bucknill urged, instead: “Let us say that the patient died of acute mania, or acute melancholia, adding, if we think fit, that the mode of death was anemic syncope from refusal of food.”

Though Bucknill’s concerns might seem trivial today, he was part of a movement to bring consistency and order to a field which had little science or tradition behind it. Because psychiatry was a new field, early practitioners had to hammer out details on such fundamental issues as how to build insane asylums, what to call them, and then how to classify the illnesses they saw within their walls. Actual therapeutic treatment was then another huge issue.

Dementia Praecox Patients, from Emil Kraepelin's textbook, 1899 edition

Religious Melancholia and Convalescence, from John Conolly's book, Physionomy of Insanity, 1858, courtesy Brown University

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Contract Nurses in Cuba, courtesy Naval History and Heritage Command

Like blacks (see last post), women found it hard to enter the medical profession; in the U.S., women were kept out of hospitals almost entirely until the strain of caring for the wounded during the Civil War showed how valuable they were. Though a sprinkling of female doctors gained attention during the mid to late 1800s, most females in medicine were nurses. However, most did not consider work in mental institutions, where patients could be violent and destructive. Asylum nurses were usually men during much of the 1800s, though married couples sometimes worked together in wards. When female nurses did begin to work at large institutions, they did as much grunt work as compassionate care. Nurses were often expected to sweep and mop their wards, and perform many other housekeeping tasks. It is little wonder that they wanted and accepted help from patients. They had little time off, and were expected to follow doctor’s orders without argument.

By the turn of the century, alienists began to rethink their position on the use of female nurses in asylums. An article by Dr. Charles R. Bancroft (medical superintendent at New Hampshire State Hospital) in the October, 1906 issue of the American Journal of Insanity discussed how to use female nurses effectively. The author believed that it would be best to follow the example of regular hospitals, which gave head nurses both responsibility and authority. “There must of necessity be men attendants, but their position should be that of the general hospital orderly whose duty it will be to execute the orders of the head nurse,” said Bancroft. The doctor displayed both chauvinism and insight when he stated: “Woman are naturally better housekeepers than men,” and later, “. . . they are better nurses than men, but their qualifications never show for what they are worth unless the women are in the superior position.”

Navy Nurse Corps, 1908, courtesy Naval History and Heritage Command

Infirmary Nurses in a Toronto Insane Asylum, circa 1910, courtesy Queen Street Mental Health Centre, Archives of Ontario

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Alienist Dr. Allen McLane Hamilton, 1910

Even though alienists (the term for early psychiatrists) treated insanity with vigor and resolution, they usually could not say with any certainty what had caused the condition. An 1879 article, “Early Indications of Insanity,” in The American Journal of Insanity stated that in general, the cause of all insanity could be found in the neglect of, or an infraction of, the “established laws of physical or mental health.” Since this could encompass almost anything, the writer went on to the core of his article, which was how to determine that someone was going insane.

One principle the author (Dr. Judson B. Andrews, assistant physician at the New York State Lunatic Asylum) stressed was that insanity should not be judged by arbitrary standards; instead, it should be judged by noting a change in the person under consideration. This at least allowed for individual personalities and quirks; alarm would arise only when typical behaviors for that individual changed. However, Andrews did believe that there were precursors to insanity that one could watch for. The earliest indication was morbid dreams, when there was no “definite exciting cause.” Even more important was sleep impairment. Andrews described what we might today called “racing thoughts,”  and explained how the condition left a person unrefreshed even when exhaustion permitted sleep.

Other disturbances that were precursors to insanity were: loss of appetite, indigestion (especially with pain and belching), flatulence, heartburn, constipation, and offensive breath.

New York State Lunatic Asylum, circa 1870 to 1885, stereoscopic view

Woman Diagnosed with Insanity Due to Childbirth, courtesy Bethlem Royal Hospital Archives

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Death Caused by Childbirth Insanity

Male alienists often thought that women were more susceptible to certain forms of insanity because of their female body organs (see last post). In the American Journal of Insanity, Dr. Fleetwood Churchill describes the evolution of merry childhood into womanhood, when a female becomes more serious and feels more deeply. “In short, under the influence of bodily development, her mind has expanded,” he says. In an article he published titled “On the Mental Disorders of Pregnancy and Childbed,” Churchill quotes other doctors; one noted that “insanity and epilepsy are often connected with menstruation,” and gave a case where a woman who had been confined for sixteen years, suddenly recovered when her periods ceased.

In a somewhat peculiar case in which the modern reader might find more than the doctor apparently did, a girl of 17 who had menstruated regularly for a year, suddenly stopped. Her mind became clouded, she spoke of herself as a castaway and doomed, and became completely insane. “Neither medicine nor change of air and scene did her any good,” said the doctor whom Churchill quoted. There was a happy ending, though. “The menses suddenly re-appeared, after eight or ten months absence. and she immediately recovered her mental health.”

Lydia Pinkham, Whose Patent Medicine Vegetable Compound Cured Female Problems

A Female Medicine

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Woman Demonstrating the Stages of a Hysterical Attack, courtesy Wellcome Library

Early alienists (mental health specialists) were men. They attributed much of women’s mental health issues to “female” problems with their ovaries or uterus. In 1893, Dr. Thomas Morton, Surgeon to the Pennsylvania Hospital and Chairman of Philadelphia’s Committee on Lunacy, wrote that surgical advances had made surgeries to the abdominal cavity relatively safe. Consequently, procedures removing the uterus and ovaries had been successful and had provided relief for patients with diseases of these organs. He added: “Frequently, such diseases are complicated by hysteria . . . and various forms of well recognized insanity which are thought to originate in and be maintained by the diseased or disordered state of these organs.”

When female organs were removed for disease, women were often relieved or cured of their accompanying mental disorders, said Morton, but just as often, were not. Some surgeons were evidently jumping onto an ovary-removal bandwagon, and Morton cautioned against an overenthusiastic use of these operations. “In many instances, insanity has resulted from this operation,” he warned. Morton gave a strong opinion that unless female organs were actually diseased, there was no justification for removing them. He included in his article a legal opinion from a colleague on the Committee on Lunacy, who concurred. “I am of the opinion that the operation . . . unless necessary to save life, is not only illegal, but, in view of its experimental character, is brutal and inhuman and not excusable on any reasonable ground.”

These two men had almost remarkable restraint toward women in an age when patronization and coercion were much more often the rule. Morton, in particular, recognized that symptoms of hysteria and other common “female” types of insanity might be associated with their uterine or ovarian distress, without being caused by it.

Hospital Demonstration of Hysteria in 1887, courtesy of Science Museum.org

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American Journal of Insanity

Asylum superintendents tended to support each other and their profession, and presented a united front to the public. Though they published studies and treatment-oriented articles in the American Journal of Insanity (AJA) and other medical organs, the AJA in particular reflected much of their philosophy.

In a July, 1868 article, “Admission to Hospitals for the Insane,” the author contended that it was especially unkind to make the insane endure a public hearing on their sanity. “If we find a man sick or wounded in the street, we take him forthwith to the nearest hospital, without stopping to canvass our legal right to restrain him of his liberty,” the author stated.

With the insane, however, relatives force publicity by requiring “an inquisition to establish the delirium or the lunacy,” the article continued. He said that there was no more reason why a magistrate or civil authority should inquire into treatment [for an insane person] than there was to “rescue a patient from the hands of a skillful surgeon who is binding him to an operating table to perform an amputation.”

This article is only one instance of an ongoing disagreement between the psychiatric profession and private citizens about the value of admitting (or coercing) patients into asylums without due process.

Amariah Brigham, founder of the AJA

Mary Todd Lincoln (Judged Insane by a Jury After a 10-Minute Deliberation)

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Missouri State Hospital Nurses, circa 1914, courtesy Missouri State Archives

Many superintendents took the opportunity to observe their patients and write about them, both to enhance their own reputations and to share information with colleagues. The American Journal of Insanity was the most important publication superintendents wrote for, since it had a wide readership among fellow alienists. The titles of their works show far-ranging subject matter:

“The Care of the Insane” by Charles Wagner, Superintendent of Binghamton State Hospital in New York.

“The History and the Use of the Term Dementia” by G. Alder Blumer, Medical Superintendent, Butler Hospital in Rhode Island.

“Night Nurses for the Insane” by C. R. Woodson, Medical Superintendent, Missouri State Hospital.

“The Favorable Modification of Undesirable Symptoms in the Incurable Insane” by A. B. Richardson, Superintendent, State Hospital, Columbus, Ohio.

In his quarter-century tenure as superintendent at the Canton Asylum for Insane Indians, Dr. Harry Hummer wrote one article about insanity: “Insanity Among the Indians.” He read this piece during the 1912 session of the American Medico-Psychological Association, and it was included in the four-volume work, The Institutional Care of the Insane in the U.S.A. and Canada, published in 1916.

Binghamton State Hospital

Butler Hospital for the Insane

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Though meals at asylums ranged in quality, it was far better to voluntarily eat a meal than to decline one. Doctors were concerned when patients refused to eat, often considering the refusal part of their mental condition. No matter how unpalatable a meal was, the alternative was probably worse.

An article in the American Journal of Insanity gave one doctor’s recipe for a meal delivered through a tube in the nostril: ”A mixture of  two or three eggs, half an ounce of sugar, half an ounce of olive oil, and one pint milk or beef tea, strained through coarse linen cloth.”

The whole concoction could be administered within a few minutes. The doctor made no comment on his  patients’ reactions to the procedure.

These pictures show the trauma involved in force-feeding.

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Dr. G. Alder Blumer, courtesy Stanford Medical History Center

The last post discussed the confidence which characterized the field of psychiatry in its early years, specifically 1903. During the American Medico-Psychological Association meeting for that year, members could congratulate each other on the 750 pages of journal material which had been submitted and printed in the American Journal of Insanity. Though some topics or hypotheses might seem off-target to modern readers, they represented an attempt to understand and help patients in asylums recover their reason and return to society.

On a darker, note, however, was the Association’s discussion of insanity in general. The group’s president, Dr. G. Alder Blumer, had addressed the problem of “curtailing the evil of insanity” in one of the sessions. Curtailing insanity did not lie in bettering the treatment of the insane, according to Blumer. That merely perpetuated the problem. Dr. A. B. Richardson followed up these sentiments with this: “The general result [of charity toward the insane] is that the survival of the unfit is extended . . . they are nursed, protected, and housed, brought to a procreative age, and then turned loose on the community.” These prominent psychiatrists feared that the population of the insane would swell, since “they show a greater tendency to rear a proportionally larger family than the normal classes.”

This meeting was held the same year that the Canton Asylum for Insane Indians began its first full year of operation.

Crowded New York Lunatic Asylum

Waupaca County Asylum for the Chronic Insane, circa 1902

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