Asylum on the Hill: History of a Healing Landscape

Epilogue

165 Epilogue The End of Moral Treatment In the summer of 1894, asylum superintendents from all over America convened for their fiftieth annual meeting. They gathered in Philadelphia, where half a century earlier the American moral treatment experiment in psychiatry had begun with Dr. Thomas Kirkbride’s work at the Pennsylvania State Hospital. At this meeting of the American Medico-Psychological Association (formerly known as the Society of the Medical Superintendents of the Insane), neurologist Dr. S. Weir Mitchell delivered a pointby -point critique of America’s asylums and their medical superintendents , many of whom were in his audience. Dr. Mitchell, who had founded the American Neurological Association in 1875 and was its first president, had been invited to give the keynote address and in preparing his remarks had surveyed neurologists across the nation about the “management of the insane in America,” its faults, and suggestions for changes.1 From the political boards that controlled asylum appointments, to a lack of scientific reports or case studies among the lengthy farm production and purchasing annual reports, attendants with no training, and the “superstition ” of the curative nature of moral treatment and its architecture , to the role of the asylum superintendent as business manager and farmer, Mitchell excoriated American asylums, calling them boardinghouses with bad food and locked doors. In his address he described how patients in public asylums “sit in rows, too dull to know despair, watched by attendants; silent, grewsome [sic] machines which eat and sleep, and sleep and eat.” What did Dr. Mitchell propose? A new architecture of asylums , the cottage plan, which would segregate patients according to their ability to pay for their treatment. It should be 166 e p i l o g u e near to a city, its grounds fenced in not by walls, but by railings vine covered and hidden by trees and shrubs . . . and include some forest and wide, cheerful gardens . . . [with] farm and vegetable garden . . . [with] a hospital . . . made up of grouped cottages, each with its family or ten or twelve or less, in each a head nurse and attendants. . . . [A]part stand smaller [individual] homes for those able to pay more. At a distance, hidden by trees, is the administration building, vine clad . . . and flanked by the wards for those who can pay little or nothing . . . with library, reading rooms, billiard and amusement rooms . . . tennis . . . work shops . . . school rooms. These new cottage plan asylums would be supervised by physicians who conducted laboratory research on the treatment of mental illness and staffed by cadres of trained psychiatric nurses. Although moral treatment had achieved a degree of success in treating mental illness,American academic psychiatry had shifted its focus from asylum-based medicine to its twentieth-century inception as a research-based modern medical specialty.2 Asylum medical superintendents no longer enjoyed the status they had attained during the moral treatment era; asylum medicine had become a medical backwater compared to the emerging medical field aligned with science and technology.3 Whereas practitioners of moral treatment asylum medicine were grounded in the work of reform-minded Quakers (Kirkbride,for example,was a Quaker as well as a physician and led his patients in Sunday evening Bible reading),4 the newly emerging psychiatry was founded on the empiricism of science. Dr. Mitchell, in castigating asylum medicine, had said little that asylum physicians themselves had not already said in their reports to their trustees. American asylum superintendents had since the 1880s described in their annual reports the difficulty of maintaining moral treatment. They were overwhelmed and discouraged by crowded conditions, the great numbers of patients, and the seemingly incurable nature of the elderly with dementia and patients with chronic mental illness. Even in Ohio, said to possess one of the best systems of state asylums in the nation, moral treatment had become difficult to practice by the late 1880s.5 The Athens asylum’s Superintendent A. B. Richardson in 1889 noted that because he was responsible for so many patients it was no longer possible for one medical superintendent with a handful of assistant physicians to supervise moral treatment properly. At Epilogue 167 Hilltop asylum in Columbus, Ohio, superintendents were unable to meet with their patients daily.6 Citing a growing recognition of the importance of a trained cadre of supporting staff in a hospital for persons with mental illness, just before Richardson left Athens in 1889 he recommended establishing a psychiatric nursing...