The Insanity File: The Case of Mary Todd Lincoln

2. Commitment

2 COMMITMENT Dazzled by headlines about organ transplants and genetic engineering and the outright disappearance ofdiseases which used to ravage Western society, the modern reader shudders to recall the state of medicine in Mrs. Lincoln's era. The horrors ofmedical science before germ theory are memorably symbolized by the staggering death rate in the Civil War, more the result of disease than of bullets, shells, and bayonets. Yet, even where it is most tempting, it is still dangerous to assume that the course of history presents a tale of unalloyed progress. It is always perilous to regard previous eras as backward or primitive or even quaint. It may be expecially tempting to do so in medical history, but the history of mental medicine since the eighteenth century defies any simple linear characterization . To be sure, the assumptions ofMrs. Lincoln's era were markedly different from our own. Few Victorians in England or America, as one scholar has pointed out, "doubted that there was an essential distinction between the sane or the insane, or that most ofthe latter properly belonged in an asylum. This was one of the verities of the age." We have lost their easy confidence in the ability to determine who is sane or insane, but we have also lost their optimism about the curability of insanity. "There are but few diseases from which so large a percentage ofthe persons attacked are restored," boasted Dr. 27 28] COMMITMENT Pliny Earle, medical head of New York's Bloomingdale Asylum in 1844. Years of sobering experience would later cause Dr. Earle to change his mind, but in his early career he voiced the era's general confidence in curing the insane. In part, that attitude led to the establishment of numerous state hospitals for the insane in the reformist 1830s and 1840s. Because of that confidence also, even liberty-loving Ame:ricans put few barriers in the way of commitment .! As David J. Rothman, a modern critic ofthe nineteenth-century asylum movement, points out, "the promise of effective treatment seemed to obviate the need for procedural protections."2 Illinois, as we have seen already, had stringent procedural protections anyway , but recapturing a sense of an earlier era's confidence in the ability to cure insanity helps put Mary Todd Lincoln's case in fresh perspective. "Putting her away" may not be a fair description of what Robert was doing in 1875. What precisely these early mental institutions did to bring about their success remains to this day something ofa mystery. Gerald N. Grob, the premier historian of mental institutions in nineteenthcentury America, admits that "specific descriptions of care and treatment within mental hospitals are almost nonexistent for this period." Narcotics, laxatives, beer, digitalis, whiskey, and other medications supplemented the doctors' principal therapy, ifit may be called that, "moral treatment." Even modern champions of oldfashioned moral treatment, like J. Sanbourne Bockhoven, have difficulty describing it vividly. Dr. Bockhoven says only that it "meant that the patient was made comfortable, his interest aroused, his friendship invited, and discussion of his troubles encouraged. His time was managed and filled with purposeful activity." All sources agree, however, that moral treatment was dependent on a low doctor-patient ratio and that it could not be effectively administered in sprawling institutions filled mostly with pauper incurables .3 Asylum superintendents were only gradually coming to realize this in Mrs. Lincoln's day. In the end, the form their realization took robbed moral treatment of its just reputation and plummeted asylum superintendents, the medical profession, and most other concerned observers into despair of ever curing any appreciable numbers ofinsane persons. Because moral treatment was always so hard COMMITMENT [29 to describe in any convincing way, the mainstay of its champions was to advertise its results with statistics-statistics so impressive that they still intrigue psychiatrists today. In the heyday of the "cult ofcurability," asylum superintendents reported steadily escalating rates ofcure, often as many as 90 percent ofrecent cases (that is, cases of less than a year's duration before institutionalization). Unsophisticated in the use of statistics and-it must be saidnaturally drawn to self-serving evidence, they based their rates of cure on the number of patients discharged. Rates of cure, which in the early days ofthe mental institutions compared favorably with mid twentieth-century rates, began to fall noticeably in the 1850s. Asylums, especially public ones, took fewer and fewer curable patients and had less...