Wednesday, April 13, 2016

The Asylum Chronicles: Diagnosis and Treatment of the Insane in the Mid Nineteenth Century

Image by Robert J. Higgins

The topic of insanity in an historical context conjures up images of inmates chained in dark cellars and egomaniacal practitioners who derive perverse pleasure in administering torturous treatments. I tried to put all those preconceived images aside as I set out to learn more about the treatment of the insane during the mid nineteenth century.  This research will set the stage for the fourth book (as yet, untitled) in the Orphans and Inmates series.  

Early understanding of insanity attributed the affliction to a variety of non physical phenomena including demonic possession and supernatural curses.  During the mid nineteenth century, physicians started to distinguish the physical or bodily indications of insanity as opposed to mental indications.  In 1855, Dr. Sanford B. Hunt wrote an article on hysteria in the Buffalo Medical and Surgical Journal.  He discussed the feeble will as the predisposing cause and argued that in different forms of hysteria, the mind became possessed of a dominant thought that it couldn't overcome.  For example, in the case of hysterical coma, the individual became convinced that they couldn't move or respond to external stimuli.  His suggestion in such cases was to force the dominant thought to recede.  He advocated simply leaving the patient alone and allowing the issue to resolve itself, but in cases where the family insisted on a quicker resolution, he suggested a cold water bath, hot cautery iron or ingestion of a foul tasting cathartic.  These treatments attempted to shock the patient back to their senses.  He advocated treatment as needed to prevent a return of symptoms.

Later in the century, physicians became interested in trying to identify the early indications of insanity.  It was felt that if treatment occurred within the first three months after the onset of symptoms, a cure was likely.  Dr. George P. Gray, the Superintendent of the State Lunatic Asylum in Utica, New York,  recommended the appointment of a pathologist to undertake the study of sphymography (recording of the pulse), microscopic examination of morbid tissues, changes in the color and elasticity of the skin, and changes in the nerves and vessels of the eye in an attempt to identify lesions associated with insanity.

In the later decades of the nineteenth century, insanity was understood as a disease of the brain.  An unhealthy brain resulted in an unhealthy mind.  Dr. J.B. Andrews of the State Asylum in Buffalo, New York, defined insanity as a prolonged departure in the individual from his normal mode of thinking, feeling or acting, the result of a disease of the brain.  Such a departure could come on rapidly due to an injury, illness or the abuse of substances such as alcohol or laudanum.  They could also occur gradually.  


Image by Robert J. Higgins

Andrews went on to describe the earliest symptoms in the gradual onset of mental illness as a series of disturbances.  First, there were disturbances of function such as loss of sleep, loss of appetite, indigestion, constipation or a general derangement of secretions. Such disturbances of function could result in disturbances of sensation, such as a headache, or disturbances of feeling such as depression, irritability, or moroseness.

Dr. Andrews also acknowledged general life stress as a potential cause of insanity.

     Lead by the desire to excel in the strife for riches, position and power, or, on the other hand,  compelled to work far beyond their strength, to struggle with poverty and actual want, they press forward, or are forced on by the circumstances of life till some additional burden, in the form of grief, anxiety or ill health, develops the changes indicative of mental disturbance.  (Buffalo Medical and Surgical Journal, v. 22, 1882-1883, p. 394) 

Andrews indicated that most physicians underestimated life stress in the development of mental illness to the detriment of the patient.

Treatment of patients from the Erie County Poorhouse was described in the Report on the Chronic Insane in Certain Counties Exempted by the State Board of Charities from the Willard Asylum Act, 1882.  The asylum was built to house up to 300 patients. There were both dormitory and single occupant cells.  In general, the "filthy and violent" patients were housed on the third floor, the patients able to work occupied the second floor and the "quiet" patients occupied part of the first floor.  

It was the job of the attendants of each ward to see that the patients were washed and dressed in clean clothes each morning.  The report indicated that the availability of water was a problem and that the supply was insufficient to maintain proper hygiene.  The report also indicated that at the time of the inspection, many of the attendants were absent from their posts.  

Those patients, who were able, were put to work either on the farm or around the asylum.   Three meals were served each day, which included at least one serving of meat.  Male inmates who labored to maintain the asylum were given more meat and sometimes alcohol as a reward. 



Image by Robert J. Higgins

The report discussed the concern for the number of mechanical restraining devices in New York asylums in general and warned of their potential for abuse in the use of these devices.  At the Erie County Poorhouse Insane Asylum, restraining chairs, covered and uncovered cribs, handcuffs, and arm restraining muffs were used. The decision to restrain a patient came from the physician, often upon the recommendation of the attendant.  The covered cribs were said to be used only at night and camisoles (straight jackets) were not used.  At the time of the inspection described in the 1882 report, only three patients were restrained, two men and a woman. 


Image by Robert J. Higgins

Fresh air and regular exercise were thought to be important in the treatment of the insane.  The outdoor facilities were typically small fenced in yards.  The women's yard at the Erie County Poorhouse Insane Asylum was described as having trees, settees, and a pavilion with seating.  The men's yard was long and narrow, and had available soft balls made of rags and covered with leather for their amusement.

Progress in the understanding and treatment of mental illness lagged behind that of physical illness.  While the conditions at the Erie County Poorhouse Insane Asylum were not ideal, they represent efforts on the part of policy makers and physicians to improve the treatment of the insane in New York. Again, objectivity is the key to interpreting these data and placing them in the context of an effort to reform what had been truly appalling living conditions earlier in the century.