Speaker: John Langdon
Superintendents of 19th Century mental hospitals struggled to treat illnesses they did not understand. In theory, the approach of Moral Treatment was humane and promising. In practice, clinical tools were limited and the lack of resources negated their effectiveness.
John Langdon is Professor Emeritus of Biology and Anthropology, University of Indianapolis. He has broad interests in human biology, history of science, and general history.
Program: Treating Mental Illness in the 19th Century
Speaker: John Langdon, PhD, Professor Emeritus of Biology and Anthropology, University of
Indianapolis, Scientech Club member
Introduced By: Rick Whitener
Attendance: NESC: 87; Zoom: 30
Guest(s): Steve Buxser, Billy Blythe
Scribe: Terry Ihnat
Editor: Ed Nitka
Talk’s Zoom recording found at: https://www.scientechclubvideos.org/zoom/06222026.mp4
Before 1800 it was thought that rational behavior separated humans from animals. Mental illness was thought to be incurable and it resided in the person’s makeup.
The definition of mental illness was inability to perform economic or domestic tasks and this is still a useful distinction. Those that were felt to be dangerous were caged or chained or otherwise restrained or beaten. Those that were less dangerous were jailed or in “Poorhouses.”
Moral Therapy was initiated in Europe: the word moral being related to the French word for mental. In moral treatment, it was felt that the insanity could be cured, and this led to the construction of large public hospitals for the insane in the United States in the early and mid-1800s.
Types of insanity: 1- melancholia - someone with fixed delusions.
2- mania - a thought disorder with many delusions.
3- dementia - absence of organized thought.
4- Idiotism - absence of thought.
5- epilepsy.
There were external causes reported but the doctors in the large hospitals were skeptical of causation. These could be related to injury, disappointments, drugs, legal problems, fears, sexual excesses.
Causes accepted by the doctors in the hospitals were stressors such as shocks and disappointments, religious excess and lack of sleep. Moral causes or weaknesses included intemperate drug use or intemperate smoking or masturbation or medical causes such as strokes, tumors or diseases such as syphilis. In practice insanity was viewed as a weakness of character and will.
The 19th century hospital viewed insanity as a lack of discipline and a moral failure. They were classified into recent onset and these were felt to be possibly curable, or chronic which had been present a long time and were presumed to be incurable.
Underlying causes and why some people got it and others didn’t was thought perhaps to be related to heredity and there were theories coinciding with the rise of Darwinism and eugenics and some felt it to be related to climate.
The challenge at the hospitals consisted of maintaining somatic health and managing patients and treating the mental illness. There was some overlap and there were questions of how efficient were the treatments and what did the doctors believe they were accomplishing. Treatment consisted of three domains: hygienic, moral and medicinal. Hygienic recommended removal from an unhealthy environment, put in a safe place known as an asylum and be treated with respect, and distract the patients from behaviors that were responsible for their illness. This could be achieved through “voluntary” work such as gardening, farming or carpentry, healthy outdoor exercise, or edifying entertainment such as plays music, card games and maintaining an orderly and predictable routine.
They wished to establish a dependency of the patient with the hospital superintendent for individualized treatment. They needed to break and rebuild the patient’s mind, punish destructive and disruptive behaviors, reward good behavior, with the goal being to strengthen self-control and to wean off dependency on the physician.
Pharmacologic treatment treated the symptoms and treated somatic disorders. There was some limited use of experimenting with electrical treatments.
Other ways of managing patients were use of the camisole i.e. the straitjacket or other restraining devices, but these were looked down upon. Isolation was also used and the patient could be given warm or cold baths or showers or sedatives; these methods were a foreshadowing of the 20th century shock treatments, lobotomies and drugs.
Moral treatment, as practiced at Central State Hospital by Richard Patterson in 1849, consisted of baths and a well-regulated diet, a change of scene from old associations and a change of habits of a life that had been pernicious to health. Useful employment such a farming, gardening carpentry and doing laundry would be the equivalent of occupational therapy. They also recommended regular hours of refreshing sleep and exercise in fresh air. Tonics were given, and in women, hemlock was sometimes used as a sedative for anxiety, mania and as an anti-aphrodisiac. Alcohol was sometimes used as a stimulant and to mask the taste of drugs but this use of alcohol fell into disfavor. Sedatives and narcotics were used sparingly and mainly for insomnia. Opiates were used rarely, and chloral hydrate became the narcotic of choice. Physicians were aware of the dangers of addiction.
Hospitals reported high cure rates, but it was thought perhaps they were selective by admitting favorable cases as they had to emphasize successes in reports to the legislature. Cure had a limited meaning as many patients were readmitted several times.
Richard Patterson felt that harsh treatment, either medical or moral, was not suited to the insane. He recommended the mildest treatments to minimize harm and give patients a reasonable life with an opportunity to stabilize and resume a functional role in society.
What happened to the moral treatment? It was a victim of its own success. Hospitals were overwhelmed by the numbers of patients seeking help. With perpetual overcrowding, hospitals were forced by the legislature to serve too many and to accept uncurable patients. They were unable to scale up to handle more patients with unrealistic expectations. Hospitals were underfunded and short staffed and relied on untrained poorly paid staff. Doctors were limited in what medical relief was possible. 20th century changes in practices consisted of new practices which would probably not have fit what reformers thought was previously acceptable i.e. using shock therapy, lobotomies and tranquilizers. None of these offered a cure as we would define it.
20th century changes forced an end to patient labor as pressures grew to increase productivity of hospitals. These practices which were essentially healthy and akin to occupational therapy were stopped. Government chose outpatient drug therapies as an excuse to phase out inpatient treatment and this was assisted by drug companies’ lobbyists telling legislatures what they wanted to hear.
John Langdon
