In early 19th century America, care for the mentally ill was almost non-existent: the afflicted were usually relegated to prisons, almshouses, or inadequate supervision by families. Treatment, if provided, paralleled other medical treatments of the time, including bloodletting and purgatives. However, in a wave of concern for the oppressed, some took action. Among these, Dorothea Dix was the leading crusader for the establishment of state-supported mental asylums. Through her efforts, the first state hospitals for the insane were built in New Jersey and Pennsylvania. She and other reformers sought humane, individualized care with the rich and the poor housed together to insure high standards for all. The movement was generated by social reform, but throughout the century, mental illness was probed and analyzed, and "cures" prescribed by both the scientific and lay communities.
"Moral treatment" was the predominating philosophy to cure the insane. This system was developed
in late 18th century Europe, and by Benjamin Rush in the United States. It challenged the demonic explanations for insanity and emphasized the role of environment in determining character: improper external conditions could induce derangement. The "moral treatment" system was optimistic that an appropriate environment could facilitate cure, especially for those with acute (not chronic) afflictions.
Essential to this theory was a physiological basis for mental disorder: insanity was caused by brain damage. The brain's surface was soft and malleable and physically altered by outward influence. This idea was closely related to phrenology which assigned specific faculties to sections of the brain.
The notion that mental illness resulted from physical impairment was rarely challenged, but the nature and treatment of ailments were continually debated. To find physical evidence for mental deficiencies, autopsies were performed on mental patients to discover lesions or other abnormalities. Although progress was made in the diagnosis of somatic diseases like tumors or syphilitic derangement, these efforts were frustrating and subjective. Also controversial was the fate of the chronically versus acutely ill: the differences between them, whether they should be housed together, and whether the chronically ill should be treated at all.
Superintendents of early mental institutions were well educated, although not necessarily in medicine, and active in the community. Thirteen heads of institutions, called "alienists," formed the Association of Medical Superintendents, and began the American Journal of Insanity. Asylums were built in rural areas to remove patients from their home environments and to provide fresh air in a bucolic setting. Patients were offered exercise, work, education, and religious instruction. Most alienists did not dispense drugs, but stressed healthy, clean living. They lived near patients, invited the public in for programs, and promoted the view that the insane were not monsters but rather "unfortunate fellow beings." Focusing on societal causes, alienists believed mental health problems could be avoided, especially in the young: children's brains were softer, vulnerable, and more prone to influence.
After the Civil War, faith in "moral treatment" declined because the curability rate had been overestimated, the cost of facilities was high, the government curtailed funds, and the public became disillusioned with "experts" and their failed promises. Repeated failures also frustrated practitioners who responded with an increased use of physical restraint. An influx of immigrants caused overcrowding and a loss of fee-paying private patients. As the medical field was slow to become interested in the care of the mentally ill, there was a lack of trained personnel. The original, more idealistic practitioners were gone, and new managers, many of whom were political appointees, were less inspired and qualified. These alienists became self-protective and isolated from the public. They also feared that "moral treatment" was responsible for the rise in spiritualist movements, considered fanatical and dangerous, and they further tightened the reins of custodial care.
Between 1850 and 1880, viewpoints reverted back to pre-asylum assessments, with the added element of heredity: mental illness resulted from a weak family and vice committed by ancestors. This led to a fatalistic view of cures, and a new wave of books detailing the dangers of bad habits such as alcoholism and masturbation. Influenced by Social Darwinism, practitioners believed mental illness could be eliminated through eugenics. Although there were scientific advances, particularly in neurology, the tendency was to classify ailments rather than investigate through observation. Drugs such as chloroform, bromides, and ether were increasingly used to subdue patients.
By the 1880s, asylum conditions had deteriorated significantly, and neurologists began to vie for control of institutions. They opposed superintendents and questioned the validity of the asylum itself, promoting the clinic instead. In 1880 they formed the National Association of the Insane and the Prevention of Insanity. A public interest in reform ensued with exaggerated stories of asylum abuse appearing in newspapers. By 1884 the neurologists and superintendents were forced into an uneasy truce resulting in medical standards for superintendents, greater control over asylums, oversight commissions, psychopathic hospitals for the acute, out-patient care, and research. Medical education began to include the study of insanity. The word "asylum" was replaced by "hospital" to reduce the stigma of mental illness.
Neurologists made some sound contributions to the field, but they also promoted dubious treatments such as static electricity and the "rest cure." Eventually, neurologists formed two camps: those who focused on somatic cases, and those who embraced psychological theories as medically respectable.
To remove the chronically ill from overcrowded asylums and in a general effort to promote non-restraint, alternative care facilities such as the tent treatment, the free air system, and the cottage system were attempted in the latter part of the century. The Toledo (Ohio) State Hospital was the first mental health institution in the country to be designed exclusively on the cottage system. In spite of such reform efforts, the dominance of Social Darwinism condemned the chronically ill as genetically inferior. It was not until the final years of the century that Sigmund Freud's theories about the unconscious crept into the professional arena.
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Shannon, Bishop Samuel. Nature's Secrets Revealed. Scientific Knowledge of the Laws of Sex Life and Heredity; or Eugenics. Marietta, Ohio: S. A. Mullikin Company, 1914.
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Image 1: Many authors warned of the dangers of masturbation in the 19th century, including Leopold Deslandes in A Treatise on the Diseases Produced by Onanism, Masturbation, Self-Pollution, and other Excesses, published in 1838.
Image 2: Title page from Alexander Walker's Intermarriage: Or the Mode in Which, and the Causes Why, Beauty, Health, and Intellect Result from Certain Unions, and Deformity, Disease and Insanity from Others, published in 1839.
Image 3: The Indianapolis Hospital for the Insane, ca. 1854.
From: utoledo.edu
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