Medical America in the Nineteenth Century: Readings from the Literature

A Glance at Insanity, and the Management of the Insane in the American States

PLINY EARLE A GLANCE AT INSANITY, AND THE MANAGEMENT OF THE INSANE IN THE AMERICAN STATES Editor's Note Pliny Earle (1809-92) was one of those nineteenth-century physicians who truly could be called an alienist. He spent his professional life caring for and treating the insane. From 1864 until 1886 he was director of the Northhampton Lunatic Hospital in Massachusetts. Earle was concerned by the phenomenon that has been called the "cult of curability" by Albert Deutsch. During the second quarter of the nineteenth century, the previous pessimism over the prognosis of mental illness changed to an attitude of extreme optimism. This was an era when expansiveness and progress were the ideals, and that, in part, may have accounted for the rise of the "cult of curability." The older system of "boarding out" the mentally ill, while adequate for custodial care, was now deemed inadequate because it lacked facilities for actual treatment. Curability of insanity was equated with institutionalization, so in the 1830's and beyond , more and more asylums were constructed. Overcrowding and lack of sufficient facilities for treatment occurred almost immediately, and many insane patients continued to be sequestered in county poorhouses. As the state lunatic asylums reported their results, the public came to believe that treatment of acute cases was the only hope. But as Pliny Earle stresses in the essay below, this zeal gave the public "a false impression, from which sprang hopes and expectations that could never be fulfilled."1 It was to this misleading optimism that Dr. Earle addressed himself. The service he performed was valuable in itself, the more so because as a superintendent of a large hospital he had a vested interest in portraying it in the best possible light. Intimately linked to Earle's plea for more honest statistics was his fight against extravagant expenditure for hospital buildings. If the public were told the truth, then perhaps the high expenditures for fancy buildings might be curbed, Earle argued. Needless to say, these positions won him few friends among his colleagues. One biographer has written that after his Chicago paper of 1879 (reprinted below) the open and secret hostility soon ceased, for the truth of his remarks began to make things clear.2 Proc. Sixth Annual Conf. Charities and Correction, 1879 (Boston: Williams, 1879), pp. 42-59. 1 Earle was not the first to question hospitalstatistics. Thirty years earlier Isaac Rayhad posed the same questions. What can rightfully be called recovery? he asked. "The fact is, however," Ray claimed, "that in the present statistics of recovery, no conventional rule whatever, has been followed. Every individual has decidedwhat should not be called recoveries , just as it seemed good in his own sight." "The statistics of insane hospitals," Am. J. Insanity 6 (1849): 23-52; 30. 2 F. B. Sanborn, Memories of Pliny Earle, M.D. (Boston: Damrell & Upham, 1898), p. 269. 215 216 PSYCHIATRY In coming before you, pursuant to the appointment for the honor of which I am indebted to the Conference of Charities of 1878, I make no pretension of attempting to present for your consideration anything new from that special field of labor in which I am employed, a comparatively small, although far from being an unimportant, part of the broad domain which legitimately comes within the purview of the association here assembled. It is proposed to occupy your attention with a very brief consideration of the general subject of insanity in the United States, contemplated as historical, contemporaneous, and prospective; to lay before you the skeleton of an argument by which, through the experience of the past and ajust comprehension of the present, the subject may be placed in such a light as to render more easy the selection of proper methods of meeting the grave responsibilities of the future. Fifty years ago, in 1829, there were within the limits of the United States but eight institutions specially devoted to the care and the curative treatment of the insane. Only four of them were state institutions; and two of these had been in operation but a few months, since both of them were first opened in the preceding year. At about this time the people of the states began, more generally than theretofore, to take an interest in the subject of insanity, to recognize the fact of the measurable curability of the disease, to direct their attention to the condition of the insane, to perceive the inadequacy of provision for their suitable accommodation and treatment, and to discuss...