Medical America in the Nineteenth Century: Readings from the Literature

Introduction

INTRODUCTION Of all the afflictions that beset man none is more threatening than mental illness. In the nineteenth century, as today, experts argued over its causes, its treatment, even over its definition and classification. The majority of patients were sent to county almshouses, where care was purely custodial, or to state hospitals that were usually over-crowded and understaffed. The movement for reform in the care of the mentally ill was one of several humanitarian concerns at mid-century. The work of Dorthea Dix, for instance, is well known. But progress was very slow. She fought many battles in order to force reluctant state legislatures to spend more money for properly housing and treating their insane. Some states, notably Massachusetts and New York, built good state hospitals, but the cry throughout the century was that mental illness was rising at a rate faster than hospital beds to care for the patients became available. Dorman B. Eaton, the New York lawyer and social reformer,reflected the thought of his time when he wrote: Now, as never before in this country, it [mental illness] is arresting the thoughts of statesmen and moving the hearts of philanthropists. And none too soon. For while science and benevolence, by setting limits to disease and affliction, have extended the duration of human life; while ignorance and crime have diminished, and education has become more extended and profound, insanity, and insanity alone among our great afflictions, has become both more frequent and more fatal in this country.1 At the same time a group of reform-minded humanitarians, some of whom were leading neurologists, founded the National Association for the Protection of the Insane and the Prevention of Insanity. The history of this short-lived group is not of concern here; but its goals, what it stood for and against, clearly summarize the existing problems as seen by a group of perceptive observers. The Association wanted to educate the public to the needs of general asylum reform. Within the asylums it urged the abolition of mechanical restraints, which were Gorman B. Eaton, "Despotism in lunatic asylums," North Am. Rev. 132 (1881): 263-75;263. 213 214 PSYCHIATRY not as much in evidence around 1880 as ten years earlier. The Association pressed for stricter safeguards against illegal commitment and detention of insane patients, a problem of concern to many others as well. Within the asylums, the Association wanted to reduce the despotic rule of some of the superintendents of these institutions, while at the same time urging more scientific or clinical research. Linked with the latter was the plea for more instruction about mental diseases and the care of the disturbed within the curricula of medical schools. In a general way, then, these aims portray what was lacking in the area of the care and study of the mentally ill.2 Bibliographical Note There were many debates in the nineteenth-century psychiatric literature revolving around such subjects as the physical or moral basis of insanity, state versus local control of asylums, moral treatment, and the legal responsibilities of the insane. These have been extensively discussed in the following references: Albert Deutsch, The Mentally III in America, A History of Their Care and Treatment from Colonial Times, 2nd ed., New York: Columbia University Press, 1949—still the first place to look for a general description of the rise of psychiatry in America. As Deutsch and others have pointed out, the care of the mentally ill cannot be separated from the problems of public welfare. See especially , David M. Schneider and Albert Deutsch, The History of Public Welfare in New York State, 2 vols., Chicago: University of Chicago Press, 1941. An older work on which Deutsch and others have often relied is Henry M. Hurd, ed., The Institutional Care of the Insane in the United States and Canada, 4 vols., Baltimore: The Johns Hopkins Press, 1916. Two more recent books that explore psychiatric thought regarding etiology and treatment are Norman Dain, Concepts of Insanity in the United States, 1789-1865, New Brunswick: Rutgers University Press, 1964; and Ruth B. Caplan, Psychiatry and the Community in Nineteenth Century America, The Recurring Concern with the Environment in the Prevention and Treatment of Mental Illness, New York: Basic Books, 1969. For a very thorough description and analysis of the status of psychiatry around 1880, especially for its medico-legal ramifications, see Charles E. Rosenberg 's The Trial of the Assassin Guiteau, Chicago: University of Chicago Press, 1968. A detailed history of one of...