AMERICAN PSYCHIATRY, like its counterparts in Europe, was a profession born of the asylum. From the 1820s onward, an almost utopian optimism had taken hold in reformist circles, inspiring a growing conviction that, under a carefully calibrated regimen, the lunatic could be treated without violence or threats and thereby restored to sanity. Enthusiasts for this doctrine of moral treatment proclaimed that insanity, when properly treated in appropriate physical and moral surroundings, was a readily curable condition, more easily cured, some asserted, than the common cold.
Particularly vocal proponents of this view were Samuel Woodward, the superintendent of the Worcester State Asylum in Massachusetts, and Dr. William Awl, superintendent of the Ohio State Asylum. (Awl’s extravagant claims led to his being dubbed “Dr. Cure-Awl.”) But the heads of the McLean Asylum in Boston, the Hartford Retreat in Connecticut, and the Bloomingdale Asylum in New York spoke equally forcibly about the curability of insanity, and the statistics that these men published were widely used to promote the construction of asylums at taxpayer expense.1
A veritable “cult of curability” swept through the ranks of the bien-pensants—men like the New England reformers Horace Mann and Samuel Gridley Howe. The upshot, fueled by the tireless efforts of one of the great moral entrepreneurs of the age, the Boston crusader Dorothea Dix, was the creation of a vast network of asylums all across the United States.2 As the asylum system developed, those running the new institutions often referred to themselves as “medical superintendents of asylums for the insane,” a clumsy title that captured the central role of the institution in the development of their profession. Subsequently, many Americans embraced the term “alienist,” borrowed from the French and derived from one of the French terms for madness, aliéné.
By the closing decades of the nineteenth century, the small, therapeutically inclined institutions of the earlier period had been transformed into mausoleums of the mad, a captive population of several thousand and assorted support staff. Trapped almost as surely as the patients they presided over and experimented on in this series of Potemkin villages, America’s alienists, now increasingly embracing the German label of “psychiatrists,” were an isolated, insular lot.3 The claims of this first generation of alienists, whose early promises to cure 60, 70, even 80 percent of cases proved wildly off the mark, were debunked by one of their own, Pliny Earle, the first superintendent at Northampton State Hospital in Massachusetts and a founder of the American Medical Association, who repented his earlier enthusiasms.4 The extraordinary optimism that had marked the 1830s and 1840s had been replaced by an equally profound pessimism.
The numbers of patients confined in mental hospitals exceeded 150,000 by 1903, and would grow to a half million by 1950.5 With the decline in almshouses, an ever-larger fraction of the whole was composed of the senile and demented, for whom few alternative sources of support and care existed.6 To these patients, who would depart the asylum only in caskets, one could add the cases of tertiary syphilis—“pitiable … wrecks of humanity sitting in a row, their heads on their breasts, grinding the teeth, saliva running out of the angles of the mouth, oblivious to their surroundings with expressionless faces and solid, livid, immobile hands.”7 Such patients, diagnosed as suffering from General Paralysis of the Insane (GPI), made up as many as 25 percent of male admissions. The syphilitic origins of GPI, long suspected, would finally be confirmed in 1913, when Hideo Noguchi and J. W. Moore of the Rockefeller Institute for Medical Research in New York demonstrated the syphilitic spirochete in the brains of paretics.8
To the senile and the syphilitic (and alcoholic), one must add the legions of those who lapsed into chronic insanity. In the mammoth asylums scattered across the late nineteenth-century landscape, a large proportion of the population came to be composed of long-stay patients, and it was this specter of chronicity, this horde of the hopeless, that was to haunt the public imagination, to constitute the public identity of asylums, and to dominate late nineteenth- and early twentieth-century psychiatric theorizing and practice.
In reality, a substantial fraction (perhaps two-fifths or one-half) of those admitted each year were released as recovered or improved within twelve months, and another 10 percent (many of them elderly) died during that period. But those who were not discharged within a year lingered and in most cases became part of the ever-larger fraction of permanent residents. We have no reliable statistics for 1900, but those from 1950 paint a grim picture. Of those then confined in state mental hospitals, “one quarter … have been hospitalized for more than sixteen years, one-half for more than eight years, and three-quarters for more than two and a half years.” This was all the more remarkable since “the turnover of senile cases is very rapid because of their high death rate.” Among schizophrenics, who constituted almost half of the hospital’s population, the median length of stay was 10.5 years.9
The stark contrast between the early promise of the asylum and the dismal reality that it served for many as little more than a living tomb did little for the reputation of the psychiatric profession. When asylum superintendents formed their professional association and held their first meeting in Philadelphia in 1844, it was at the height of optimism about the curability of insanity. Supremely confident that they had unlocked the keys to the therapeutics of madness, and ruling over a rapidly expanding asylum system, alienists saw themselves (and were seen by others) as more efficacious at treating mental illness than their counterparts in the rest of the medical profession were at treating physical illness. That self-confidence was bolstered by the financial security of the asylum superintendent, a situation that compared favorably with the highly uncertain prospects most physicians faced in a desperately overcrowded medical marketplace.10 When regular physicians formed the American Medical Association in 1847, the alienists scornfully rejected an invitation to join forces with their less well-placed professional brethren. A quarter century later, the tables were turned.
Unable to deliver the cures they had blithely promised, alienists found themselves increasingly marginalized by the rest of the medical profession. In the last third of the nineteenth century, neurologists, a rival group of specialists who laid claim to expertise in diseases of the nervous system, were unsparing in their reproaches. It was thus distinctly odd when, on the occasion of the fiftieth anniversary of the American Medico-Psychological Association in 1894, psychiatry’s leadership had the temerity to invite Silas Weir Mitchell, an eminent Philadelphia neurologist, to address their annual conference. Mitchell at first demurred, and then, when pressed, agreed to speak at their annual meeting in nearby Princeton. Twice bidden, not shy: he used the occasion to issue a scathing indictment of the state of American psychiatry.
AMERICAN NEUROLOGISTS EMERGED as subspecialists immediately after the American Civil War. Alongside the mass slaughter, the conflict produced large numbers of casualties who had suffered trauma to their brains, spines, and extremities. Taken together, the wrecked bodies of these soldiers provided a series of naturalistic experiments that elucidated important facets of the human nervous system. War, as always, visited unspeakable horrors on those who fought it, but proved invaluable to the medics who treated them.11
When army surgeons set themselves up as “nerve specialists” in the war’s aftermath, still another set of military casualties crowded their waiting rooms. These were men with mysterious nervous complaints that failed to obey what the neurologists had learned about the structure of the brain and central nervous system, but who nonetheless insisted that their suffering was real and combat-related. Their ranks were joined by civilians, many of them female, equally difficult to diagnose and equally importunate, loudly insisting that their troubles were real and rooted in the nervous system.
These “hysterics,” as they were popularly known, and “neurasthenics” (suffering from weakness or overtaxing of the nervous system) came to constitute a large fraction of the new nerve doctors’ clientele. In exasperation, Weir Mitchell once referred to hysteria as “mysteria,” but, like most of his colleagues, he could not afford to turn these patients aside.12 Not disturbed enough to warrant confinement in an asylum, the ambulatory neurasthenics and hysterics had the wherewithal to pay for their treatment, and their social standing more closely matched that of the professionals whom they consulted. Their demographic profile contrasted markedly with the population that crowded the wards of the state hospitals, helping the neurologists to escape the stigma that asylum doctors increasingly shared with their patients.
Like their eminent French colleague Jean-Martin Charcot, American neurologists insisted that these patients’ troubles had an organic origin and were the result of wear and tear caused by overtaxing of the brains. As specialists in disorders of the brain, neurologists initially laid claim (at least in principle) to expertise in the diagnosis and treatment of insanity—a jurisdictional claim that inevitably brought them into direct conflict with asylum doctors, who for half a century had proclaimed themselves uniquely qualified to treat such patients. Openly scornful of their rivals’ capacities, neurologists dismissed asylum doctors as mere boardinghouse keepers and curators of dead souls, willfully ignorant of the latest scientific advances. Fierce claims and counterclaims of this sort marked the 1870s and 1880s.13
The brash New York neurologist Edward Spitzka was particularly scathing, condemning asylum superintendents as experts in roofing and drainpipes, farms and mechanical restraint, “experts at everything except the diagnosis, pathology and treatment of insanity.” “Psychiatry,” he declared, “is but a subsidiary branch of neurology.”14 His fellow New Yorker William Hammond, who had served as surgeon general of the Union Army in the Civil War, insisted that “there is nothing surprisingly difficult, obscure, or mysterious about diseases of the brain which can only be learned within the walls of the asylum.” General practitioners with a modicum of training in “cerebral pathology and physiology,” he contended, were “more capable of treating successfully a case of insanity than the average asylum physician.”15
Asylum doctors responded vituperatively to such withering assaults. Eugene Grissom, the superintendent of the North Carolina State Asylum, attacked Hammond as “a moral monster whose baleful eyes gleamed with a delusive light,” willing to skew his science on the witness stand to whatever position those paying his large fees desired, an adulterer who had been court-martialed and dismissed from the army for misconduct.16 (Hammond had indeed been court-martialed on trumped-up charges from which he was later cleared, despite a stellar record as surgeon general.)17
Prominent neurologists along the Eastern Seaboard allied themselves with critics of the asylum, denouncing “the absolute and irresponsible power of the superintendents” and attacking “the grated windows, crib-beds, bleak walls, gruff attendants, narcotics and insane surroundings of an asylum.”18 With their lay allies, these critics formed the National Association for the Protection of the Insane and the Prevention of Insanity, and sought to investigate the scandals they alleged to be lurking behind asylum walls. But this breach of professional solidarity brought censure from the medical profession, leading to a rapid, if unstable, cessation of hostilities.
In practice, the institutionalized remained firmly beyond the reach of the new nerve specialists, isolated behind the walls of America’s asylums. And perhaps this was just as well, since, for all their bluster, neurologists had no new therapies to offer this stigmatized group and could not even reach agreement on a scientific description of the terrain—limitations they reluctantly came to concede in their textbooks.19 By the early 1890s, animosities had begun to subside as neurologists distanced themselves from the more extreme forms of disturbance that warranted asylum care.
WEIR MITCHELL’S SPEECH SEEMED likely to reopen old wounds. Striding to the podium, he conceded that what he was about to say violated the usual expectations for such celebratory occasions: “It is customary on birthdays to say only pleasant things,” he began, but those who had asked him to speak had persisted in asking him to do so after he had warned them that he would offer criticism “without mercy.” He had given in to their importunities. “That was a momentary insanity; I have been sorry ever since,” for he now had to face up to “the uncongenial task of being disagreeable.”20
Sorry he may or may not have been, but disagreeable he most certainly was. Medicine and surgery, he pointed out, had made extraordinary progress over the past half century. Psychiatry, he insisted, had been stagnant. “Your hospitals are not our hospitals; your ways are not our ways.” Psychiatrists lived in isolation, cutting themselves off from healthy criticism and scientific progress, and had become “almost a sect apart.” The consequences for profession and patient alike were “evil.” The very title to which the more senior members of his audience clung, “medical superintendent,” he suggested, was “absurd.” Many listening to him had won their jobs through political patronage, still another “grave evil.”21
The invective rained down for an hour and more. Weir Mitchell denounced the “senile characteristics” of asylum boards; the repetition of “old stupidities in brick and stone”; the “neat little comedy” of outside inspections known about in advance and thus incapable of getting at the truth. But this was the least of the problems. The medical superintendent was the “monarch” of all he surveyed, but he was an emperor with no clothes. “Where, we ask, are your annual reports of scientific study, of the psychology and pathology of your patients[?] … We commonly get as your contributions to science, odd little statements, reports of a case or two, a few useless pages of isolated post-mortem records, and these are sandwiched among incomprehensible statistics and farm balance sheet.” Asylum case records put on display an appalling state of affairs, an “amazing lack of complete physical study of the insane, … the failure to see obvious lesions,” and a complete ignorance of the diagnostic technologies indispensable to the practice of modern medicine. These problems were as visible in the most prominent and best-endowed asylums for the rich, as in the meanest, most overcrowded state hospital.22
Psychiatrists had spent a half century attempting to persuade the public of the “superstition … that an asylum is in itself curative. You hear the regret in every report that patients are not sent soon enough, as if you had ways of curing which we have not. Upon my word, I think asylum life is deadly to the insane.” Far from being therapeutic environments, mental hospitals (as they were ironically beginning to be called) had the air of being a prison, with “grated windows and locked doors.… I presume that you have, by habit, lost the sense of jail and jailor which troubles me when I walk behind one of you and he unlocks door after door. Do you think it is not felt by some of your patients?”23
The upshot of such conditions, Weir Mitchell announced, was what he himself had observed in the wards of an asylum in his home city of Philadelphia, where “the insane, who have lost even the memory of hope, sit in rows, too dull to know despair, watched by attendants; silent, grewsome machines which eat and sleep, sleep and eat.” Nor were they the only victims of prolonged confinement: their captors, the psychiatrists, had fallen into the same sort of paralysis. “The cloistral lives you lead give rise, we think, to certain mental peculiarities.… [Y]ou are cursed by that slow atrophy of the energizing faculties that is the very malaria of asylum life.” Indeed, he concluded, “I cannot see how, with the lives you lead, it is possible for you to retain the wholesome balance of mental and moral faculties.”24
It was a remarkable performance, a savage assault in which Weir Mitchell seemed to have sought, point by point, to demolish the entire psychiatric enterprise. Unsurprisingly, when he finally sat down, he was greeted with token applause. Oddly enough, the association then proceeded to elect its distinguished guest an honorary member.
Much of the inevitable grumbling and complaint that followed took place in private. The Swiss transplant Adolf Meyer, then occupying a lowly position as the staff pathologist at Kankakee State Hospital in Illinois but soon to emerge as America’s most prominent psychiatrist, recalled his superintendent, Clarke Gapen, returning from the Philadelphia meeting full of “resentment.”25 Some months later, a semi-official public response to Mitchell’s criticisms appeared in the pages of the American Journal of Insanity. Written by the New England alienist Walter Channing, it was notable for its defensive tone and for statements that inadvertently suggested how close to the mark Weir Mitchell had been. Far from seeking to show that the superintendents were men of science concerned with curing their patients, Channing went out of his way to dismiss the idea that asylum superintendents could perform such roles as an irrelevant fantasy.
Like their predecessors, the current generation of psychiatrists was rescuing the insane “from the tortures of the damned”—the vile treatment they otherwise faced in the community, in prisons, or in almshouses. “The medical superintendent,” Channing pointed out, “is an executive officer.… His real specialty is insane-hospital management.” That meant that, unlike the erudite neurologists whom Weir Mitchell represented, he was not capable of writing an abstruse volume “on the cerebral anatomy of a spider.” But “no man can do everything, and only in a very few cases are scientific and executive talent combined.” Channing acknowledged that “the usual medical superintendent has little taste for science”—but then, he contended, “scientific men, put in charge of institutions, are apt to be failures.” Asylum doctors are rather “able, efficient physicians of business instincts.” Their work, he posited modestly, consists “of giving rest and succor to as many of a wretched and neglected class as a niggardly and ignorant public will allow, and … will never be done till every insane pauper is the ward of the state.”26
For all Weir Mitchell’s invocations of science, Channing quite correctly pointed out that, where mental illnesses were concerned, “their treatment and cure is both unsatisfactory and baffling.” He could have pointed out that neurologists dealt only with milder forms of mental disorder, dispensing an array of tonics and animal extracts that purported to stimulate the nerves, and adding treatment with shiny electrical machines that dispensed static electricity to the same presumed effect. Some made use of the intervention Weir Mitchell himself was famous for inventing, the so-called rest cure, confining nervous patients to bed for weeks at a time, denying them all mental stimulation or outside company, and feeding them a high-calorie diet to build up “fat and blood” and thereby restore their shattered nerves. Affluent but nervous patients who feared their troubles might lead to consignment to an asylum sought out such treatments, and many professed themselves grateful for interventions later generations saw as profoundly misguided.27
In reality rather than in Weir Mitchell’s world of make-believe (for the concluding pages of his indictment had conjured up the vision of a curative, scientifically oriented mental hospital), Channing insisted that “the inmates of an insane hospital are … helpless children” needing to be watched over and protected. And as for the eminent neurologist’s complaints about bolts and bars and mechanical restraint, “hospital medical officers … refuse to deny plain facts, in order to make a good showing.”28
The complacency on display in Channing’s response was hardly universal, but it was widespread. Asylum superintendents could rightly assert that in sheltering those suffering from tertiary syphilis, alcoholism, and the troubles of old age they were relieving society of serious burdens. But mental hospitals purported to be therapeutic institutions. Tightening state controls and sharp cuts to their budgets signaled the impatience of their political masters, and those issues were of far greater moment than the verbal barbs of a jealous rival.
Massachusetts had pioneered the creation of a body charged with uniform oversight of its institutions for “the dependent and vicious classes” in the 1860s. Its State Board of Charities was widely emulated, and while these entities at the outset were somewhat toothless, they were increasingly asserting themselves. Declining cure rates in state asylums provided the rationale for centralizing and rationalizing oversight of the superintendents’ activities and also reining in the costs of institutions, which by then were the largest single item in state budgets. (As late as 1950, state hospitals for the mentally ill absorbed as much as a third of many states’ revenues.)29
As almshouses emptied and were closed down, the decrepit and senile who had previously found refuge there migrated, faute de mieux, to the local state asylum. Charles Wagner, the superintendent of the Binghamton State Hospital in New York, lamented:
We are receiving every year a large number of old people, some of them very old, who are simply suffering from the mental decay incident to extreme old age. A little mental confusion, forgetfulness and garrulity are sometimes the only symptoms exhibited, but the patient is duly certified to us as insane and has no-one at home capable or possessed of means to care for him. We are unable to refuse these patients without creating ill-feeling in the community where they reside, nor are we able to assert that they are not insane within the meaning of the statute, for many of them, judged by the ordinary standards of sanity, cannot be regarded as entirely sane.30
Thus, the ability of the asylum to discharge some fraction of its patients as “cured” suffered a further blow, and the pressures on the asylum superintendents intensified. Calculating “cures” on the total number of patients resident, the measure that ensured the lowest announced cure rate and the one insisted upon by the state bureaucracy, led Utica State Hospital’s recovery rate to fall from 20 percent in 1889 to between 7 and 9 percent over the course of the following decade.
Caught in a vice, New York’s mental hospital superintendents found their budgets slashed—an 1893 statute cut the average cost per patient from $208 to $184 per year—and their powers curtailed. A new three-person lunacy commission insisted on statewide standards, particularly with respect to financial records, and began to intrude into a whole range of decisions, from which personnel to hire to how many paying (and thus desirable) patients the superintendents could admit.
Peter Wise, the superintendent of a new state hospital at Ogdensburg, New York, was soon regretting his accession to a job most of his junior doctors still longed for. As he wrote to his fellow superintendent at Utica, George Alder Blumer, “If only I could give up this unpleasant work, which has become so distasteful to me that I dread the day that dawns and retire with the feeling intensified.”31 A year later, he had managed the trick, moving to be the president of the lunacy commission, whence he could issue the orders, not receive them, and escape the daily grind of running a custodial institution. It was an escape his colleagues could only long for.32
Once small enough to be overseen by a single physician, a state asylum (or state hospital, as it was being relabeled in a desperate attempt to shed the stigma that clung to the term “asylum”) had relentlessly increased in size. In time, a hospital had required the addition of one more physician, and then a phalanx of assistant medical men—and, by the closing years of the nineteenth century, even the odd woman who could be assigned to the special task of coping with the female side of the asylum. Provided with food and lodging and a slender stipend, though often forbidden to marry, these drudges spent years on the dreary routines of life on mental hospital wards. As the growth in the number of asylums slowed in the latter part of the century, the opportunities for advancement to the plum position of superintendent grew ever more remote, prompting the exodus of anyone with ambition and further cementing the low reputation of medical psychologists among the medical profession at large. Soon, superintendents and state bureaucrats were bemoaning “their growing inability to attract young medical graduates to a career in institutional psychiatry.”33
In the words of British assistant asylum doctors, who labored under similar misfortunes, their situation was like that of poor relations waiting impatiently for the demise of a rich, childless relation. The contrast of “the fat salaries of the Superintendents with the lean ones of the assistants” had perhaps been bearable “when the Assistant Medical Officers were few and the Superintendencies ripened in four or five years, but [their elders’ counsel to be patient] loses all its sweet reasonableness when we have to wait ten, twelve, or more years for the golden fruit, and even run the risk of its being plucked by some [politically connected] outsider from over the wall just as we thought it about to drop.”34 Those who could fled, and for the most part only dull time-servers remained.35 A profession once convinced that it could cure had mostly subsided into somnolence, bound by the dull rounds of administrative routine.