The Encyclopedia Americana (1920)/Insane, Institutional Care of the, in the United States

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INSANE, Institutional Care of the, in the United States.— Previous to the 19th century there was practically speaking no such thing as care of the insane and no hospitals in which to care for them. The mentally ill were either permitted to roam at large, to subsist on begging and other charities, or indifferently confined with paupers in poorhouses or with criminals in prisons, or perhaps more frequently were cared for as best they could be by their people at home. This latter type of care was often not much better than the care that they received in prisons and in poorhouses because their folks were equally ignorant of how to minister to them.

Previous to the beginning of the 19th century there are recorded here and there laws addressed to the problem of the care of the insane. In 1676 a law of Massachusetts delegated the care of the person and the estate of the dependent insane to the selectmen. In 1798 a law was passed in the same State which provided for the commitment to the house of correction of lunatics who were “furiously mad.” In 1811 the Massachusetts General Hospital was incorporated and the McLean Hospital established and subsequently opened in 1818. As early as 1650 in Rhode Island we find the Puritan, Roger Williams, making an urgent appeal on behalf of Mrs. Wilson, urging provision for her, whom he describes as a distracted woman. In 1725 a law was passed permitting inland towns to build houses of correction for vagrants and also for “mad persons.” In 1742 the care of all the insane and imbeciles was given to the town council with power to appoint guardians for their estates. In 1828 the Dexter Hospital was opened and in 1847 the “Butler Asylum for the Insane.” Similar records of legislation are found in a number of the other States, more particularly States along the Atlantic Coast. The earliest action in this country providing for the special care of the insane in specially constructed hospitals was taken by the “Religious Society of Friends” in 1709 and this action resulted in the foundation of the Pennsylvania Hospital in 1751. A portion of this hospital was set apart for the insane and the first patients were admitted in 1752. The first State hospital, however, for the exclusive care of the insane was established in Virginia and is now known as the Eastern State Hospital, at Williamsburg, Va. It was incorporated in 1768 under the name of the “Public Hospital for Persons of Insane and Disordered Minds” and its first patients were admitted in 1773. In 1806 an authorization to a hospital in the city of New York was granted to erect additions and provide suitable apartments for maniacs adapted to the various forms and degrees of insanity. Other important dates in the early part of the 19th century were the owning of an institution for the care of the insane at Frankfort, Pa., by the Society of Friends in 1817, the founding of the Hartford Retreat, in Hartford, Conn., in 1824, the opening of the South Carolina State Hospital for the Insane in 1824, of the Eastern State Hospital at Lexington, Ky., in 1824, of the Western State Hospital at Staunton, Va., in 1828, of one of the buildings of the Blockley Almshouse for the dependent insane in Philadelphia from 1830 to 1834, the Maryland State Hospital for the Insane in 1832, and the New Hampshire State Hospital for the Insane at Concord in 1842.

From this period on the erection of State hospitals went rapidly forward in the different States of the Union. The first law for the creation of a State hospital in New York was passed in 1842. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix (1803-87) whose broad philanthrophy extended over many States of the Union and in Europe as far as Constantinople. It was through her efforts that institutions were erected in Massachusetts, Pennsylvania, New Jersey, Rhode Island, North Carolina and the District of Columbia. Some 30 institutions in this country owe their existence, in whole or in part, according to her biographers, to her efforts.

These laws and the founding of these hospitals as above noted show the origin sporadically of those activities which were addressed toward the more humane and intelligent care of the insane. From the beginning of the 19th century on these activities became more numerous and the demands for better care gradually increased. For the most part, however, throughout the first half of the century and during a considerable period of the latter half, the insane were cared for in a desultory and unintelligent way, largely by local communities, more especially in the various county houses throughout the States. This county house care of the insane placed them on a social par with the paupers, and it not infrequently became a matter of pride to see how cheaply the county could care for these unfortunates. Not only was this true, but the mentally sick patients in the almshouses received practically no medical attention whatever, except as they might be visited occasionally by the physician who was employed to look after the almshouse patients and who almost always was a practitioner in a nearby town and only spent a brief period at intervals at the almshouse or came out on emergencies when requested. He practically never had any experience or any special knowledge of mental illnesses and did little more than look after the physical condition of his patients, generally in a very crude way. The quarters where the mental cases were kept were usually presided over by persons who had no idea of the nature of their problems, were ignorant, often cruel and unsympathetic, so that the lot of these poor people was indeed miserable. They were practically prisoners shut out from all intercourse with their fellows, confined in quarters that were often filthy, dark, unsanitary and unhygienic in every particular, dominated by ignorant and not infrequently cruel caretakers, cheaply fed and clothed, with no medical supervision worthy of the name, and without any effort being made in any direction to bring about an improvement or to effect a crime. The most important move toward the latter part of the century which was made for the better and more humane, more intelligent and scientific care of the mentally ill, was the movement inaugurated in many of the States for State care, namely, provision by the State of public hospitals for the insane, with the consequent removal from the almshouses of this class of patients and transferring them to the State hospitals.

This was the only solution of the neglect and inefficiency of the county care system. The most fundamental defect of the county care system was that the county was too small a political unit to undertake the problem. It had not enough money to properly equip an institution nor did it have a sufficiently broad vision to secure the services of persons competent to handle the problem. All these matters were changed in the State hospitals. The State hospital was well built, well equipped and for the most part well officered, and the improvement in the care of the insane as a result was very great.

In the first period of State hospital care the main effort was to get away from the abuses of the county system and was directed toward humane and philanthropic efforts. The dealing with the mentally deranged patients as though they were sick and trying to effect a cure was as a matter of fact in the minds of the early hospital superintendents, but did not prevent them in many instances from making the mistake of creating enormous asylums for the so-called chronic insane and setting apart single institutions for the care and treatment of the acute cases, thus making out of the asylums places where all hope was lost for those who entered, and overcrowding and overworking the acute reception hospitals beyond their capacity. For many years, for example, the Utica State Hospital at Utica, N. Y., was reserved for the acute cases of the State, while other institutions, as they were built, were reserved for the chronic, incurable class. The next movement was to make out of all of the State institutions hospitals in the real sense of that word, places where the patients would be dealt with as actually ill and an effort made to cure them. The first efforts in this direction were crude, consisting largely in endeavors to treat the patients as patients were treated in general hospitals by keeping them in bed, making observations upon their general physical condition, taking their pulse, temperature, respirations, examining urine, the internal organs, etc., and treating the physical disease which might be found as a result of such examination. This movement did much toward getting better surroundings for the patients, it was contemporaneous with the establishment of training schools for nurses in the State institutions, and its general result was a vast improvement in the quality of care.

Throughout this latter period the hospitals had more or less actively been engaged in a study of the problems of mental disease with a view to discovering their scientific bearings. These researches led to the definite establishment in connection with well-organized State institutions of scientific departments, usually consisting of a laboratory for clinical pathology, and generally also a laboratory for research in pathology. In these laboratories the autopsy material was studied with a view to discovering the correlation between the mental symptoms of the patient and the changes that were found to have occurred in the brain.

Beginning with the latter portion of the 19th century the several States began to appreciate the great extent of the economic problem that was involved in the care and treatment of the insane in their large public hospitals, and there began to be a more or less consistently directed attitude of study of these problems together with a study of methods of administration and control which would look toward higher efficiency and greater economy. The result has been that in most of the States where there are several institutions for the care of the insane that these institutions are controlled by a central body, a lunacy commission or a board of control, usually appointed by the governor. Sometimes these boards of control have still larger powers and include all of the charitable institutions. The details differ in the different States, but central control is the thing aimed at. Along with this central control the scientific departments of the institutions increase in importance and in some instances, as in New York, Massachusetts, Illinois, there are central research departments for all of the hospitals.

The changes in the outlook for the care of the insane largely as a result of all this scientific work have been very great. Interest no longer centres in the autopsy room in attempts to correlate pathological findings and mental symptoms. The interest now is in the living patient and the scientific institutions have elaborated their departments of clinical pathology for the purpose of studying the processes that are going on in the living patient, while psychological investigations, are becoming much more in vogue with the development of definite interests in psychotherapeutics.

The large housing problem which confronts the several States is still dealt with by the State hospitals, none of which are longer considered, however, as institutions for the chronic insane. All of the hospitals are equipped for taking care of all varieties of illness, mental and physical, acute and chronic. It is recognized, however, that in large centres of population there should be easy access to wards where mental illness could be intelligently handled. The result has been the creation of psychopathic wards or institutions in a number of cities: Albany, N. Y., Boston, Ann Arbor, Mich., Baltimore. These institutions care for the great stream of mental cases which come from large urban populations and which ordinarily would be distributed in other wards of the city hospital. For example, the alcoholic wards of Bellevue hospital are under the immediate charge of the psychiatrist in charge of the psychopathic pavilion. Thus are the problems of general medicine and psychiatry coming to be considered together and their respective specialists are coming to be of mutual assistance.

As mental disease has come to be considered more and more a matter of defective psychological adjustment and methods of psychotherapy have been more and more applied, the hospitals have reached out into the communities which they serve and through the intermediation of dispensaries and social workers have endeavored to extend aid to these communities and also endeavored to assist the discharged patients in rehabilitating themselves in the community. The State hospital, therefore, has come in the past hundred years from a condition in which it was merely a place to confine “mad” persons, to be a centre for education in matters pertaining to mental illness and for the rehabilitation of failures and defects in adjustment for the community in which it is located.

As outlined, the problem of the care of the insane has been gradually evolving as it became progressively larger, first a matter for villages and townships, and for counties, and finally a matter for individual State hospitals, receiving patients from a certain number of counties, then a matter for the State as a whole, governing its several State hospitals by a central board. Beyond that there has never been any recognized statutory central control. The superintendents of all of the institutions for the care of the insane have been organized into a medical society which has now been in existence since 1844, originally known as the Association of Medical Superintendents of American Institutions for the Insane. Since 1893 it has been known as the American Medico-Psychological Association. This association has through the years been the clearing-house to which annually was brought all institutional problems and has served most eminently in helping along the work of the care of the insane in several States of the Union. This until recently has been the only agency which in any way correlated the work of the several institutions throughout the country. In 1909, however, there was organized the National Committee for Mental Hygiene under the stimulus and as a result of the unceasing efforts of Mr. Clifford W. Beers. Mr. Beers had himself had a serious attack of mental illness in the course of which he had been a patient in more than one institution. As a result of his experience he felt convinced of the need of an organization which was independent either of political influence or financial or other personal consideration which would help various hospitals to deal with their problems to better advantage. As always happens in large problems the individual elements of which are dispersed over a wide territory, many of the institutions and some of the States remained very backward in their care of the insane. There were no members in their hospitals of the central organization. The American Medico-Psychological Association. As some of the State institutions were as badly off as had been the county asylums, it became the function of the National Committee to endeavor to improve these bad spots throughout the country and in doing so it took an attitude of helpfulness rather than one of criticism and as a result almost always found that defects in methods were due to ignorance, many primitively conducted institutions really believing that they were giving the best possible service that medical science could suggest. Such institutions were quick to avail themselves of the help of the National Committee and a great deal of improvement throughout the country has resulted from its activities. This has been the work of the National Committee until the beginning of the European War, when it turned its attention practically entirely to war work. The great importance, however, which the conduct of this war of necessity attached to mental problems will result in great benefit to this particular department of medicine.

William A. White,
Superintendent Saint Elizabeth's Hospital, Washington, D. C..