Tag Archives: American Journal of Insanity

Additional Markers of Insanity

Images of Different Types of Insanity by J.E.D. Esquinol, courtesy Wellcome Images images@wellcome.ac.u

Images of Different Types of Insanity by J.E.D. Esquinol, courtesy Wellcome Images images@wellcome.ac.u

In the April, 1879 issue of the American Journal of Insanity, Dr. Judson Andrews gave some tips for family physicians to use in monitoring the possible development of insanity in their patients (see last post). The physical symptoms were disturbingly commonplace, but Dr. Andrews seemed to hit a bit nearer the mark when he described certain mental signs that might indicate the development of insanity. (In general, he thought these mental symptoms would develop after the physical ones.)

— Emotions might be exaggerated (a little or a lot) or the person might be unable to control expression of the emotion even when he tried.There might not be a cause for laughing or crying in a situation, or the reaction might be out of character for the individual.

An Emotional Patient, Seacliff Lunatic Asylum, New Zealand

An Emotional Patient, Seacliff Lunatic Asylum, New Zealand

— Depression might develop, either as a loss of spirits or a “shading off from the natural cheerfulness of disposition.”

— Patients could experience “forebodings of some indefinite, indefinable evil impending, from which no way of escape lies open.”

–Later, patients would begin to be overly introspective; in reviewing their actions, they would judge themselves far too harshly and negatively.

— Patients could develop difficulty making decisions about simple tasks (like what to wear) and important ones alike; any course they decided upon then yielded to “agonies of doubt” or vacillation.

Other changes might be in personality, dress and personal appearance, and “exaltation or exaggeration.”

Insanity Continued to be a Misunderstood Subject, from a Toronto Newspaper, circa 1915 - 1919

Insanity Continued to be a Misunderstood Subject, from a Toronto Newspaper, circa 1915 – 1919

Unfortunately, many of these symptoms could develop so slowly they would be hard to detect; in other cases they might just be an intensification of the person’s normal personality and also hard to spot. At least, though, concluded Dr. Andrews, insanity had lost its mystery and dread, and “the insane man stands forth simply as a sick man: one, who by reason of cerebral disease, is unable to use his brain.”

This viewpoint was undoubtedly kinder than the fear and judgment insanity had faced in the past.

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Predicting Insanity

An Article from the Trenton Evening New, Nove 7, 1898, Showing a Change in Behavior Leading to an Insanity Diagnosis

An Article from the Trenton Evening New, Nov. 7, 1898, Showing a Change in Behavior Leading to an Insanity Diagnosis

Toward the latter part of the nineteenth century, mental health specialists (alienists) began to alter their approach to diagnosing insanity. Instead of looking at specific behaviors in patients and making a diagnosis from them, doctors thought it made more sense to look at changes in patients’ ordinary behaviors. To paraphrase one expert: Performing a dangerous tightrope stunt would not be considered insanity in a circus performer, but might be in someone who had never done such a thing and suddenly decided to try it.

Of course, neither alienists nor families wanted to wait until someone actually became insane before they intervened. Could there possibly be ways to predict the development of insanity? An article in the April, 1879 issue of the American Journal of Insanity gave some tips for family physicians to use in monitoring the possible development of insanity in their patients. In the words of the article’s author, Dr. Judson Andrews, early indications that might be considered precursors of insanity included:

Front Entrance, New York State Lunatic Asylum Where Dr. Andrews was Assistant Physician

Front Entrance, New York State Lunatic Asylum Where Dr. Andrews was Assistant Physician

— morbid dreams

— impairment of sleep

— a symptom cluster that included loss of appetite and indigestion, with pain, belching, flatulence, heartburn, and offensive breath

— a symptom cluster that included an increased action of the heart, full and strong pulse, a flushed face and slightly elevated temperature of the skin; the appetite might remain the same or even increase, but there would almost always be weight loss

— diseases which might cause the heart to “fail to supply the amount of blood necessary for the nutrition of the brain” or the lungs to “supply the purifying and exhilarating oxygen”

— headache [descriptions of the types of headache people might experience are similar to migraines]

— restlessness in either the extremities or “in the general movement of the whole body”

American Journal of Insanity

American Journal of Insanity

Though it might be alarming to consider any of these physical symptoms an indication of impending insanity, the emotional tips–discussed in my next post–actually could have been red flags.

 

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How to Commit

Elizabeth Packard Being Taken to an Asylum Against Her Will, courtesy National Library of Medicine

Elizabeth Packard Being Taken to an Asylum Against Her Will, courtesy National Library of Medicine

Few patients went to insane asylums voluntarily; most were committed by physicians called in once concerned family members decided a patient’s behavior had reached some sort of tipping point. Committing a patient to an asylum should have been a very serious affair, but it is evident that it was not always done with professionalism and discernment. In an article* published by the American Journal of Insanity (1876), Dr. A. E. MacDonald gave medical students some sound advice about how to examine a patient and determine whether or not to propose commitment.

Dr. Abraham Myerson, Dr. I Veron Brigg, and Dr. Earl K. Holt Examine Defendants, 1934

Dr. Abraham Myerson, Dr. I Veron Brigg, and Dr. Earl K. Holt Examine Defendants, 1934

Many states required the concurrence of two or more physicians to commit a person to an asylum. MacDonald noted that many times a physician–perhaps at the invitation of the family’s physician–was asked to commit a patient to an asylum, rather than to examine a patient. He likened the situation to that of a physician called in to prescribe medicine to a patient without examining him first to see if the medicine were needed. Families would seldom do such a thing, yet with a presumably insane patient, the verdict was often presupposed and the physician essentially called in to rubber-stamp the decision. MacDonald cautioned students to be careful, though, and to examine such a patient thoroughly with an eye to defending himself in a court of law should the patient later sue.

MacDonald went on to say that physicians often encountered two groups within the family: those who wanted the patient committed, and those who didn’t. He also emphasized that much of what he would hear concerning the patient from these family members would be either useless or untrue. He tried to give students a road map of pertinent questions to ask and a systematic way to approach the situation so they could assess a patient objectively.

He also had this bit of advice: “I advise you to make sure of being able at once to recognize your patient from those who may surround him, by learning before you enter the room, some particulars as to his dress or appearance. It is not a little awkward and embarrassing to address yourself to a bystander, under the impression that he is the patient, but it is a mistake that has happened, and might happen again.”

Ambulance Outside Bellevue Psychiatric Hospital, 1895

Ambulance Outside Bellevue Psychiatric Hospital, 1895

*From a lecture delivered before the students of the University of the City of New York, Medical Department, March 10, 1876.

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A Case of Insanity

Dr. Isaac Ray, courtesy National Library of Medicine

Dr. Isaac Ray, courtesy National Library of Medicine

Alienists had many interesting theories about insanity and what caused it, and frequently had to explain their views to the public. Court cases involving an insanity defense could create heated debate on the topic, and an article in the October, 1866, issue of the American Journal of Insanity provided a platform for such a discussion.

The case involved Mary Harris, a citizen of the District of Columbia, who shot her former lover dead. She was acquitted and released because of her insanity at the time she committed the crime. Dr. Nichols, superintendent of the Government Hospital for the Insane (St. Elizabeths), testified to her insanity, but did not mean to imply that she was cured of it. There may have been no legal way to keep her confined, however, so she was “let loose upon the community” in the words of the article’s author, Dr. Isaac Ray.

A Gender-Based Cause of Insanity

A Gender-Based Cause of Insanity

Dr. Ray did not discuss the particulars of that case, but instead went on to discuss a “class” of similar cases, where women committed heinous crimes. Because of the “peculiar influence of those organs which play so large a part in the female economy,” said Ray, these criminal acts may have been prompted not so much by motive as by the woman’s physiology. Ray went on to say, “With woman it is but a step from extreme susceptibility to downright hysteria, and from that to overt insanity.” In his opinion, many women who committed crimes like murder (as revenge), had experienced “a strong moral shock and an irritable condition of the nervous system.” He asked, “Is it strange that a person thus situated, should become insane?” (In Harris’s case, he referenced her “uterine derangement.”)

Alice Mitchell Tried to Murder Freda Ward Due to the Exciting Cause of Thwarted Love and Jealousy; She Was Found Insane

Alice Mitchell Tried to Murder Freda Ward Due to the Exciting Cause of Thwarted Love and Jealousy; She Was Found Insane and Committed to the Tennessee State Insane Asylum

Though Ray’s views seem to be compassionate, they were bad news, indeed, for females accused of insanity who might come before him for assessment. Ray was too ready to believe that their gender made them susceptible to insanity, and that it took so little to push them over the edge.

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Arbitrary Commitment

Elizabeth Packard Being Taken to an Asylum Against Her Will, courtesy National Library of Medicine

Elizabeth Packard Being Taken to an Asylum Against Her Will, courtesy National Library of Medicine

Alienists were notorious for their self-confident belief that they knew what was best for anyone with mental illness. In an essay from the July,1868 issue of the American Journal of Insanity, the (anonymous) author makes a case for doing away with legal procedures for commitment: “. . . other diseases, except those of a highly contagious type, do not call for civil interference nor court publicity.

We do not demand a commission or an inquest to decide whether a man has a fever raging into delirium, or whether he has a general paralysis, or whether a surgeon shall be permitted to amputate his limbs or trepan his skull.”

The writer went on to point out that if anyone saw a person 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.”

Charles Guiteau Said He Was Temporarily Insane When He Assassinated President Garfield

Charles Guiteau Said He Was Temporarily Insane When He Assassinated President Garfield

The author lamented that a patient stricken with insanity was sometimes met with a suspicious relative who wasn’t convinced of his illness even though his other relatives were. Because of this suspicion, the patient, “against the wishes and judgment of the rest,” was then liable to the “questioning of the law and its ministers.” This then led to publicity, which might be detrimental to the patient’s recovery.

Though She Had a Trial, Mary Todd Lincoln Was Involuntarily Committed to an Asylum

Though She Had a Trial, Mary Todd Lincoln Was Involuntarily Committed to an Asylum

 

Most people, of course, would not want to be committed involuntarily to an insane asylum, and welcomed legal safeguards to prevent it. It is amazing to consider how differently alienists and laypeople considered the matter–it almost certainly boiled down to who was in control of the situation.

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How to Test for Insanity

Alienists Sought Help for the Insane

Alienists Sought Help for the Insane

Insanity is an elusive condition, and alienists (early psychiatrists) spent time and effort studying ways to detect it. In an article in the October, 1865 issue of the American Journal of Insanity, Dr. John Tyler admitted that “men differ so widely in their conduct and habits, that what would be manifest insanity in one man, might only be the natural and healthy and common conduct of another.” He also noted that insanity could be recognized more easily than described…one could look at deviations in a person’s normal behavior and recognize insanity. It was much more difficult to describe the person’s insanity in absolute or factual terms, however.

That did not stop Tyler from going on to give some guidelines for assessing insanity in a person:

1. Though he may not abandon friends or former occupations, the insane person begins to see the world and hold ideas only through his own inner lens or “personal laboratory.” Tyler said that these convictions were “coined by him, and not received by another.” That person will be inwardly convinced of something, rather than persuaded to it by outside facts or situations.

2. The madman is inconsistent. Tyler described a patient who insisted he was dead, yet ate, talked, and did other things inconsistent with being dead.

3. The insane person will have a “changed and peculiar expression of the countenance, of the eye, of the manner, movements, attitudes, etc.” Tyler admitted that this type of proof was hard for the layperson to recognize, but that it could be learned through “an acquaintance and domiciliation [sic] with the mentally diseased.”

There was certainly a prevalent belief at that time that a trained professional could detect an insane person just by looking at him. Eccentricity or a vibrant personality may have been a bit dangerous under the watchful eye of one of these self-confident alienists.

Isaac Ray, Asylum Superintendent and Alienist

Isaac Ray, Asylum Superintendent and Alienist

Depiction of Various Types of Insanity by J.E.D. Esquirol

Depiction of Various Types of Insanity by French alienist  J.E.D. Esquirol

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Alienists Gain Prominence

Print of Assassination Attempt, which appeared in Frank Leslie’s Illustrated Newspaper, July 16, 1881, courtesy Library of Congress

Charles Julius Guiteau shot President James Garfield at the Pennsylvania railroad station in Washington, DC on July 2, 1881. He did not try to escape and was apprehended on the spot; when the president died twelve weeks later, Guiteau went on trial for his murder. The public was fascinated and the trial became something of a media circus, with Guiteau’s behavior as avidly reported as the points made by the attorneys for the prosecution and defense. Continue reading

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Case Study

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

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. Continue reading

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What Do They Say?

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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Gender Issues

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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