History of Medicine
19th Century Psychiatric Debates
The Case of Mrs. Packard and Legal Commitment
The Superintendents' Association had been involved from its beginning with the rights and protection of patients in civil and criminal matters. In 1868, the Association approved Dr. Pliny Earle's "Project of a Law," which set forth principles for commitment, or coercive admission to a mental hospital as a legal procedure.
In 1860, Elizabeth Packard, who differed with the theology of her clergyman husband, was forcibly placed in an Illinois state hospital. She remained there for 3 years. At that time, Illinois law stated that "married" women could be hospitalized at a husband's request without the evidence required in other cases. Mrs. Packard was able to obtain a release by an action of the hospital, but on her return home, she was locked up by her husband who planned for her admission to an asylum in her native Massachusetts. She eventually gained her freedom in 1863 through a habeas corpus hearing in a local court.
Mrs. Packard then embarked on a vigorous campaign to protect women's rights. She published three books on her asylum experience and that of other women, including The Prisoners' Hidden Life (Chicago, 1868) and Modern Persecution, or Insane Asylums Unveiled (Hartford, 1873). She aroused sufficient public interest and support that a group of influential citizens and social reformers organized in 1880 The National Association for the Protection of the Insane and the Prevention of Insanity. The unremitting antagonism of The Superintendents' Association helped to bring about the demise of the organization within a few years.
In 1869, the Illinois legislature passed a law requiring a jury trial before a person could be committed, a law which remained in effect for 25 years. Iowa enacted a similar law in 1872, and other states took steps to safeguard patient rights. The Superintendents' Association strongly opposed jury trials, on the grounds that it was harmful to patients and professional opinions might be discounted.
The AJI, in an unsigned editorial (presumably) written by Dr. John P. Gray of Utica, wrote, "This fascinating woman… by her feminine wiles had bewitched a whole legislature."
The Question of Patient Restraint
In 1793, Philippe Pinel dramatically struck the chains binding the lunatic women in the Parisian asylum, Hôpital de Bicêtre, and in 1792, the Quaker York Retreat in England began using moral treatment without restraints. In the early 19th-century, Dr. John Conolly, Superintendent of the Asylum in Hanwell, England promoted a non-restraint policy but used patient reclusion and attendants to 'hold' violent patients.
From the beginning, the American Superintendents believed that mechanical restraint was necessary in their hospitals, but it was to be employed at a minimum and never as punishment. But early on Dr. Amariah Brigham employed a cage-like “crib bed” at Utica designed after a European model, and thereafter restraint of one sort or another was used in American institutions well into the 20th century.
In 1875, Dr. (Lord) John Bucknill, a British asylum superintendent, visited ten American asylums. He disagreed with the Superintendents about the use of mechanical restraints, writing that Americans overused restraint despite their highest motives of humanity in his pamphlet, Notes on Asylums for the Insane in America (London, 1876).
The question of mechanical restraint, later supplemented by chemical restraint (drugs), is ongoing, and in recent years government involvement at federal and state legislative and regulatory levels has come into play.
The Neurologists, S. Weir Mitchell, and The Superintendents' Association
The American Neurological Association, organized in 1875, grew out of the Civil War experiences of physicians who had been involved in caring for soldiers with traumatic injuries of the brain and nerves. The neurologists were mainly in private practice and considered mental illness within their purview because the brain was involved. Relations between the neurologists and the Superintendents' Association were marked by mistrust and hostility. Believing that the asylums were mismanaged and providing inadequate care to patients, in some places, the neurologists called on state legislatures to investigate the asylums.
In 1894, to mark the 50th anniversary of its founding, The Superintendents' Association invited Dr. S. Weir Mitchell, a prominent Philadelphia neurologist to address the annual meeting. After querying a number of his colleagues, Dr. Mitchell delivered a scathing address to the superintendents. He said that they had isolated themselves from medicine and they sought no new scientific information through their work, their medical records were inadequate, and their educational efforts among the profession were minimal. The superintendents made little reply to the address. (See: S. W. Mitchell, "Address before the fiftieth annual meeting of the American Medico-Psychological Association," Proceedings of the American Medico-Psychological Association, 1894, v. 1, pp. 101-121).
In 1897, Dr. Bernard Sachs, a New York neurologist, was invited to address the Association's annual meeting. He gave a placating speech saying that both professional groups should be working together in the interest of patients.
Women in 19th-Century American Psychiatry
Women were not welcomed into the medical profession during the first half of the 19th century: medical schools did not admit them. Elizabeth Blackwell was the first American woman to gain admission to a medical school and graduated from Geneva (N.Y.) Medical College in 1847. She spearheaded the push for women to enter medicine. With the support of women and some men, 17 medical schools for women were established but after some 50 years all but The Women's Medical College in Philadelphia closed, as all-male medical schools in Michigan, Iowa, Indiana, and elsewhere began opening their doors to a small number of women towards the end of the century.
Many arguments against women becoming physicians were physiological and neurological: would the education and training required make a woman unfit for her "primary duty," childbirth? And was rest (physical and mental) necessary during menstruation? In 1876, noted physician Mary Putnam Jacobi undertook a study of women's physiology, and specifically blood pressure, during menstruation, proving that menstruation posed no physical constraints on women. She entered her paper on the subject for the Boylston Prize at Harvard University anonymously and won it, much to the chagrin of many opponents to women's medical education. (See: M. P. Jacobi, The Question of Rest for Women During Menstruation, New York, 1877).
Psychiatry in the 19th century was based in the mental hospitals. The asylum superintendents voiced divided opinions about employing women doctors. Dr. John Gray of Utica, Dr. Thomas Kirkbride in Philadelphia, and Dr. John Chapin of Willard (N.Y.) wrote letters to their governors opposing the employment of women physicians, but legislatures especially in New York and Pennsylvania mandated they do so. Dr. S. Weir Mitchell, in his 1894 address at The Association meeting, had urged that women take care of women patients. But discrimination prevailed. Women doctors in many institutions received less pay than their male counterparts performing the same work. They were denied promotions and received little recognition, and as a result many did not remain long at the hospitals.
The earliest record of employment of a woman physician in an asylum was in 1869, when Worcester (Mass.) State Hospital hired Dr. Mary Stinson. Iowa followed in 1873, as did Michigan and hospitals elsewhere. Dr. Alice Bennett, M.D., (also the first woman to receive a Ph.D. from the University of Pennsylvania), remained at Norristown, Pennsylvania for 12 years in charge of the women's division, from 1880 to 1892. Gradually, as more women entered medicine, they were employed at state hospitals. Not until after WWII did the numbers of women physicians increase significantly, however. Eventually, psychiatry became a specialty of choice for many women, and a large number of them entered private practice.
European Influences on American Psychiatry
American asylums were influenced by visits of their superintendents and others to European hospitals. In 1832, Dr. James MacDonald visited Great Britain, France, and Ireland at the request of The New York Hospital prior to the construction of the Bloomingdale Asylum. In 1846, Dr. Luther Bell, Superintendent of McLean (Mass.) Hospital undertook a European trip at the request of the Board planning Butler Hospital in Rhode Island. In 1863, Dr. Tilden Brown visited western European hospitals for the Trustees planning The Sheppard Asylum in Baltimore.
Dr. Pliny Earle, superintendent of several asylums, visited extensively in Europe in 1841 and 1852, publishing reports in The AJI. He also wrote of the German approval to separate 'curable' from 'incurable' patients, a subject debated by the Superintendents' Association during the latter 19th century. Dr. George W. Cook of Canandaigua visited hospitals in England in 1854. In 1860, Dr. Edward Jarvis reported on his visit to English hospital to examine training and employment for patients. In 1868, Dr. Abner Otis Kellogg observed the use of mechanical restraint in European hospitals. Dr. Edward Bruch was impressed by the meager use of restraint in hospitals in England and Scotland.
Books and journals dealing with insanity were regularly reviewed and quoted in The AJI, especially those from Great Britain, France, and Germany. Together with the reports of the travels of the American psychiatrists, they served as an important source of education and influence on practice.
The Dilemma of the Chronic Patient
As the population of the country increased during the latter half of the 19th century, augmented by the entry of thousands of immigrants, the need for beds in the asylums grew sharply. The early superintendents had fixed the size of the asylum to 250 beds so that each patient would be known by the superintendent. By 1866, they had raised the number of beds to 600.
The early optimism about the curability of mental illness gave way as many patients proved to be in need of continuing care. Some European countries, such as Prussia, had placed long-stay patients in separate chronic hospitals which cost less to operate. Debate arose among legislators, superintendents, and hospital boards as to what better pattern of hospital care should be adopted- and economics influenced the debate. The superintendents were strongly opposed to segregation of the chronic patients believing that all patients should have treatment rather than mere custodial care.
In 1865, the New York legislature authorized the building of a 1500 bed hospital in Willard, near Utica, which opened in 1869 to receive transfers of long stay patients from other state hospitals. By 1875, Willard housed 1000 patients. The superintendents continued their strong opposition to segregation of chronic care, and before long Willard began to admit acute patients as well. The solution for the state hospitals was to build “cottages,” smaller residential buildings on their grounds to transfer long stay patients from the active treatment wards.
In 1954, Pilgrim State Hospital on Long Island, N.Y. had a population over 13,000 patients. In 1999, the hospital grounds contained 99 buildings, many of which had housed patients.
A few states adopted the European plan and built small county hospitals to receive long stay patients from the state hospitals. Wisconsin maintained this plan well into the 20th century.
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