The Beginning of Friends' Asylum
The system of care known as moral treatment, which was first employed in America at Friends Asylum, was the standard for the care of the mentally ill in America for decades, reaching the point of a professional hegemony. Based on the belief that a controlled environment could exert a healing influence on the thoughts and behaviors of mentally ill patients, moral treatment was considered by its practitioners and supporters not just to be a therapy, but to be scientifically supported as the best available form of medicine [2] for those with mental illnesses [1]. Moral treatment had its origins in the humanitarian reforms of psychiatric institutions in Europe, and with Quakers who sought to treat their own members in a kindly fashion that aligned with their religious beliefs, but by the time that it became widespread, and that mental asylums had begun being built en masse in the United States, it was considered neither a reform nor a religious therapy, but a form of medicine. This meant that as medical science improved over the 19th century, it accordingly influenced how moral treatment was practiced in psychiatric hospitals like Friends Asylum, an influence that might possibly have not occurred had asylum doctors not positioned moral treatment as a scientific medicine.
Some new medical developments in the 19th century expanded the tools available to medical practitioners. The discovery of drugs accelerated as the industrial revolution increased the capabilities of chemists, and many new medications found use in the asylum. Some were helpful for secondary health conditions patients might be suffering from, like digitalis for alleviating heart conditions, or antifebrin, an anti-fever drug created in 1886. Other drugs acted directly on the feelings or psychiatric symptoms of patients. Morphine and its milder synthetic relative codeine found use in many asylums as painkillers and on occasion as a treatment in and of itself. Morphine was sometimes used to induce sleep or to calm patients, though doctors were wary of its use due to the risk of dependency and addiction. [3]
Originally, Friends Asylum had placed lower value on medical methods than on the religiously inspired moral treatment it practiced. A variety of medical treatments were used on a case-by-case basis even in the very first years of its operation, such as shower baths, blistering patients, or electricity, if it was thought they would be useful, but early superintendents, particularly Isaac Bonsall, first superintendent of the Asylum, were generally skeptical of the use of medicines [4]. However, the Asylum began to adapt and make use of many of the same medical developments that were put into use at other psychiatric hospitals. By the 1880s, doctors at Friends Asylum were using a number of drugs to treat their patients. Patients who were prone to unsettled behavior and who displayed spasms or symptoms of epilepsy would be given chloral hydrate and “bromide of potash”, or potassium bromide during an epileptic episode or when they acted extremely disruptively [5]. Chloral hydrate, often just referred to as ‘chloral’ in the casebooks of Friends Asylum’s physicians, was a sedative and hypnotic drug invented in 1832 [6], while potassium bromide, introduced in 1857, was an anticonvulsant that could stop seizures, but was also appreciated for its sedative qualities and the fact that it quelled sexual arousal [7]. Patients who displayed persistent hallucinations and delusions that seriously harmed their ability to function in everyday life might also receive periodic injections of morphine to calm them. Patients who were unable to sleep regularly would be given nighttime injections of morphine as well, if chloral hydrate had been tried but failed to allow them to sleep. Other drugs like hyoscyamine, useful for alleviating neurological conditions that caused chronic pain or affected the digestive system, also found use in specific cases at the Asylum [8].
One area where medicine saw little improvement in the 19th century was in the treatment of syphilis -- however, syphilis had a significant impact on institutions for the mentally ill. Friends Asylum, like many other hospitals, did not want to accept patients with neurosyphilis, as not only was their insanity due to an infection rather than a true psychiatric illness, there was no hope of curing them, and they would simply remain in the hospital and take up space. However, they were not always able to determine whether an individual’s insanity resulted from syphilis, and given that infection tended to correspond with promiscuity, the resulting insanity was sometimes instead attributed to immoral behavior, particularly in the case of “general paresis of the insane” or GPI [9], the onset of severe mental symptoms and partial paralysis decades after infection. There were no truly effective syphilis treatments before 1910, and the ones that had the greatest effect were drugs based on mercury, with debilitating side effects. Despite these drugs’ harsh reputation, some patients appear to have received drug treatments for syphilis at Friends Asylum. They were treated with potassium iodide and “hydrargyrum bichlorate,” or mercury(II) chloride [10], which was applied topically to lesions or as an ingested solution. [11] Because of Friends Asylum’s private status and the fact that it enjoyed a good if not particularly high profile reputation, it was able to avoid being burdened by a large number of people suffering from syphilis, but because of admitting patients either without knowing of their illness or before the true cause of GPI was understood, there were still 12 paretic patients under care by 1902, out of 142 total patients at that time [12].
New drugs, or other developments of this period like the clinical thermometer or the hypodermic syringe, may have offered a challenge to superintendents and asylum doctors in how they would be integrated into the established models of moral treatment. However, these medical advancements were generally beneficial for psychiatric institutions that practiced moral treatment. There were other changes that represented major shifts in the medicine of mental health, and so posed a threat to the dominance of moral treatment in America. The largest of these was the rise of neurology, an entire clinical field dedicated to the study and treatment of both organic and functional nervous disorders. In 21st century medicine, there is significant overlap between neurology and psychiatry. Conversely, 19th century psychiatry as represented by the mental hospital presented itself as modern scientific medicine despite being formulated on religious theory and the experience of those who worked with the mentally ill, while neurology could claim to being based on clinical and laboratory research on the brain and nervous system. Neurology began to arise as a serious specialty field of medicine in the mid-19th century in Europe, thanks to research in Britain, Italy, Germany and Austria. In most European countries, particularly Germany and Austria, psychiatry was more significantly present in universities and their associated research hospitals, leading to psychiatry proceeding under an investigative lens, as opposed to its managerial and therapeutic focus in America [13]. As the specialty began to be adopted across the Atlantic, neurologists were able to provide outpatient alternatives to treatment in a psychiatric institution. Neurology made inroads in the recurring debate of whether insanity was a disease of brain tissue or brain function by separating nervous conditions such as epilepsy, GPI, and brain-impacting diseases like cancer from true mental disorders [14]. Neurologists were generally pessimistic about the curability of insanity, but they did provide new treatments for mild or emerging cases of mental illness that could be offered in the office or the home -- dietary changes, new drug formulations, electricity, or simple bed rest. They also questioned the validity of institutional treatment as a whole. The hospital plan was not only expensive, it attempted to force a single solution on the complex variety of mental illnesses as well. Leading neurologists like Edward C. Spitzka publicly attacked superintendents for not attempting to conduct any research, even with the large population of potential subjects they had access to, and therefore lacking any real scientific knowledge of the disease they attempted to treat. While Spitzka worked mostly to research the anatomy of the brain and in his own clinical practice, he became increasingly outspoken in his writings and lectures about the inadequate and to his view unenlightened patient care, training of staff, and administration in mental asylums. As he gained a reputation as an expert witness on medicolegal issues around mental health, this viewpoint was increasingly shared by many, not just in the field of neurology, but in legal and government positions [15]. According to Spitzka, the experience working in psychiatric hospitals that superintendents drew their authority from wasn’t anything more than “the routine contemplation of belittling duties” [16]. By the 1880s, thanks to the growing reputation of neurology, many paying patients only entered asylum care after they had already consulted specialists in nervous diseases.
At Friends Asylum, neurology found purchase and began to be added to the repertoire of treatments, which had already been expanded by the new willingness to use medications in patient care. As most nervous conditions were commonly less severe and easier to address than psychiatric illnesses, the Corporation and Board of Managers considered the benefits of providing the services of the Asylum to people with these conditions who could be cured. The first major step to incorporate neurology into the Asylum was the operation of Gurney Cottage from 1885-1889, a residential care home for people with mild nervous conditions who wouldn’t be suited to treatment in the asylum environment. Even after Gurney Cottage closed, the Asylum continued advertising its services to people with nervous diseases [17].
As the scientific foundations of moral treatment appeared to lose influence and many asylums began to encounter serious problems in their operation, pessimism also began to grow within the ranks of psychiatrists. One of the early asylum psychiatrists to break from the faith in moral treatment’s effectiveness was Dr. Pliny Earle [18], one of the original founders of the AMSAII and superintendent of the Northampton State Hospital, who in 1877 published a harshly worded argument against the belief in the curability of insanity. Using a statistical analysis of the data tables available in almost every asylum’s annual reports, Earle argued that superintendents inflated their cure rates by counting periodic recoveries as cures, so that patients repeatedly readmitted and then released would be counted as cured each time. He further showed the fact that cure rates had greatly declined over the forty years that moral treatment had been adopted as mainstream medical practice, and used this to argue that early superintendents and doctors had overexaggerated their successes in order to build support for moral treatment and cement it as the most viable solution in the eyes of the public [19]. The statistical paper that Earle put forward on reasons to doubt the doctors who promoted moral treatment was a serious blow to the psychiatric industry.
In the face of declining cure rates and increasing pressure, the pessimism about moral treatment further manifested in the school of psychiatry (as well as of evolutionary biology and anthropology) calling itself “degenerationism.” Degenerationism was based on the belief that most mental illness was hereditary in nature, and that its appearance in those predisposed to insanity was typically as a result of vice or poor habits. Not only was this obviously a departure from the York Retreat’s belief in the Inner Light that was present in everyone but which might unjustly be ensnared in any person by the emergence of mental illness, degenerationism led to broad fears that there existed an ‘iceberg’ of potentially degenerate individuals in society who would continue passing their undesirable traits on to their children and could not be cured. Degenerationism was decidedly influential on the emergence of eugenics in America. By the end of the 19th century, thanks in large part to degenerationist medical science, eugenic policies like compulsory or forced sterilization of people with intellectual disabilities and the psychiatric evaluation of immigrants had all appeared in some states at the urging of strong public and medical lobbies [20].
These were some of the most significant medical developments that had an impact, positive or negative, on moral treatment in America and at Friends Asylum. While new drugs and the medical specialty of neurology found use at the Asylum, due to how they expanded treatment options for patients, the Asylum also found itself forced to confront a more hostile environment for psychiatric institutions that practiced moral treatment, thanks to increased skepticism and scrutiny levied against them by scientific and professional rivals.
