CHAPTER II

THE EVOLUTION OF THE MODERN HOSPITAL

The medical treatment of mental diseases had its inception, in this country, in the wards of the Philadelphia Hospital, established in 1732 and referred to officially for over a century as an almshouse. It included an infirmary for the "sick and insane," although it apparently had no distinct and separate hospital department for many years. "In 1742," to use the words of Dr. D. Hayes Agnew, "it was fulfilling a varied routine of beneficent functions in affording shelter, support and employment for the poor and indigent, a hospital for the sick, and an asylum for the idiotic, the insane and the orphan. It was dispensing its acts of mercy and blessing when Pennsylvania was yet a province and her inhabitants the loyal subjects of Great Britain." In 1772 it housed as many as three hundred and fifty persons. In 1769 the General Assembly passed an act authorizing the "Managers of the Contributions for the Relief and Employment of the Poor," who had charge of the almshouse, to issue bills of credit for the purpose of relieving their indebtedness. This paper currency was issued in three denominations—one shilling, two shillings and a half crown. The law provided that counterfeiters or persons altering the denomination of these bills should be "sentenced to the pillory, have both his or her ears cut off and nailed to the pillory and be publicly whipped on his or her back with thirty-nine lashes, well laid on, and, moreover, every such offender shall forfeit the sum of one hundred pounds, to be levied on his or her land, tenements, goods and chattels."[9] This certainly must have discouraged counterfeiting. It was not until after the institution was removed to the Hamilton estate in Blockley (now a part of West Philadelphia) in 1834 that it came to be known as the "Philadelphia Hospital and Almshouse," although there was no change made in its organization or functions. In 1902, after one hundred and seventy years of continuous existence, it was finally divided officially for administrative purposes into The Philadelphia Home or Hospital for the Indigent, The Philadelphia General Hospital and The Philadelphia Hospital for the Insane. At that time the hospital was, as it is today, the largest on the American continent. The institution, which has admitted mental cases uninterruptedly since 1732, had over seventeen hundred patients in the department for the insane. In 1917 this number had increased to nearly three thousand.

One of the reasons set forth by sundry petitioners in 1751 for a "small Provincial Hospital" in Philadelphia, which at that time had made provision for the care of indigent cases only, was "THAT with the Numbers of People, the Number of Lunaticks or Persons distempered in Mind and deprived of their rational Faculties, hath greatly increased in this Province. That some of them going at large are a Terror to their Neighbours, who are daily apprehensive of the Violences they may commit; And others are continually wasting their Substance, to the great Injury of themselves and Families, ill disposed Persons wickedly taking Advantage of their unhappy Condition, and drawing them into unreasonable Bargains, etc. That few or none of them are so sensible of their Condition, as to submit voluntarily to the Treatment their respective Cases require, and therefore continue in the same deplorable State during their Lives; whereas it has been found, by the Experience of many Years, that above two Thirds of the Mad People received into Bethlehem Hospital, and there treated properly, have been perfectly cured."[10] This resulted eventually in the opening of the Pennsylvania Hospital in 1752. This institution is a general hospital supported by private funds and has always received mental cases. A separate department for mental diseases was established in West Philadelphia in 1841. Before this was done considerable difficulty was experienced on account of the annoyance of the patients by curious-minded citizens of the neighborhood. This developed into such a nuisance in 1760 that it was suggested "That a suitable Pallisade Fence, either of Iron or Wood, the Iron being preferred, shall be erected in Order to prevent the Disturbance which is given to the Lunatics confined in the Cells by the great Number of People who frequently resort and converse with them."[11] It was also deemed advisable to employ "Two Constables or other proper Persons, to attend at such times as are necessary to prevent this Inconvenience until ye Fence is erected." The public was notified later "that such persons who come out of curiosity to visit the house should pay a sum of money, a Groat at least, for admittance."[12] The Pennsylvania Hospital has played a very important part in the history of the care and treatment of mental diseases in this country. In 1919 it had over three hundred patients.

The first institution designed and used exclusively for mental diseases in this country was the Eastern State Hospital at Williamsburg, Virginia. It was incorporated by the House of Burgesses in 1768 and opened for patients on October 12, 1773. It is interesting to note that the act of incorporation, except in the title, makes no use of the word lunatic, refers frequently to the care and treatment of the patients, authorizes the appointment of physicians and nurses, and specifically designates the institution as a hospital and not an asylum. The original building was one hundred feet long by thirty-two feet two inches wide. During the first year thirty-six patients were admitted. The first pay patient was received in 1774 at a rate of fifteen pounds per annum. An allowance of twenty-five pounds per year was made by the legislature for the maintenance and support of each person admitted. Visiting physicians prescribed for the patients, and the "keepers" for the first few years were not graduates in medicine. The superintendents were, however, physicians after 1841. Known for many years as the "Publick Hospital," the legislature made the mistake of changing this designation to The Eastern Lunatic Asylum in 1841 and it was not until 1894 that it again officially became a hospital. Virginia opened its second institution, The Western State Hospital for the Insane, at Staunton on July 25, 1828. Its third hospital was opened at Weston on September 9, 1859. Virginia is thus entitled to the credit of being the first commonwealth to furnish state care for mental cases and make adequate provision for them.

The next step in the evolution of hospital treatment of mental diseases was taken by Maryland in incorporating a hospital for "The Relief of Indigent Sick Persons and for the Reception and Care of Lunatics" in 1797. The hospital was formally opened in 1798 under the management of the city of Baltimore, which leased the establishment in 1808 to two physicians, who conducted it as a private institution until 1834. It then reverted to the state and was operated as the Maryland Hospital. The institution was removed to Catonsville in 1872 and is now known as the Spring Grove State Hospital, the Johns Hopkins Hospital occupying the site of the original building in Baltimore. Another interesting event in the history of this institution was the founding of what subsequently became the Mount Hope Retreat by the Sisters of Charity, who withdrew from the Maryland Hospital in 1840.

The earliest hospital care of mental diseases in New York was in the wards of the New York Hospital which was opened in 1791. A separate building for mental cases was ready for the reception of patients in 1808. The total number of cases treated up to July 1820 was 1,553. The Bloomingdale Asylum replaced this in 1821, on a piece of property which now belongs in part to Columbia University. Public patients were cared for at the expense of the state until the opening of the New York City Asylum in 1839. Church services were inaugurated in 1819. The hospital buildings furnished accommodations for about three hundred patients. In 1894 the property on Bloomingdale Road was abandoned and the hospital removed to White Plains in Westchester County. It is still known as the Bloomingdale Hospital and is supported entirely by public contributions and the income derived from the care of patients. It has about three hundred and fifty beds.

The activities of the "Religious Society of Friends," which were indirectly responsible probably for the inception of the Pennsylvania Hospital, ultimately led to the establishment of the Friends' Asylum for the Insane at Frankford, Pennsylvania, in 1817. It was under sectarian control until 1834, when its doors were thrown open to all, without regard to religious belief. It claims to be the first institution "erected on this side of the Atlantic in which a chain was never used for the confinement of a patient."[13] The hospital is still in a flourishing condition and has accommodations for over two hundred patients.

Massachusetts at the beginning of the nineteenth century had no hospitals of any kind. In 1764, on the death of Thomas Handcock, it was found that provision had been made in his will for the establishment of a hospital for mental diseases in Boston. An expenditure of six hundred pounds was authorized for the purpose of "erecting and furnishing a convenient House for the reception and more comfortable keeping of such unhappy persons as it shall please God, in His Providence, to deprive of their reason in any part of this Province."[14] The Selectmen of Boston declined this legacy on the grounds that there were not enough mental cases in the vicinity to warrant the existence of such an establishment. This proved to be an error of judgment on their part. In 1811 the Massachusetts General Hospital was incorporated and a fund of over $93,000 was subscribed for building purposes. As it was deemed more urgent, the department for mental diseases in Charlestown was opened first. It was ready for the reception of patients on October 6, 1818, when it admitted a young man supposed to be possessed of a devil. This department became the McLean Asylum in 1826 as the result of a legacy of $25,000 left to the institution by a Boston merchant of that name. The corporation finally received in all an amount approximating $120,000 from the McLean estate. As early as 1822 the first published report of the hospital[15] called attention to the fact that the various amusements offered the patients included "draughts, chess, backgammon, ninepins, swinging, sawing wood, gardening, reading, writing, music, etc." A carriage and pair of horses for the use of patients was purchased in 1828. In 1835 the first pianos and billiard tables were installed and a library of one hundred and twenty volumes placed in the wards. Hot water heating was introduced in 1848. It is interesting to note that in 1827 the visiting committee reported that the rates for the maintenance of patients should not be less than three dollars or more than twelve dollars per week. In 1882 the McLean Hospital established the first training school for nurses connected with any institution for mental diseases in this country. The first class was graduated in 1886. In 1895 the hospital was removed to Waverley, Massachusetts. A chemical laboratory was opened in 1900 and a psychological laboratory in 1904. Hydrotherapy was first used in 1899, and a gymnasium was built in 1904. In 1913 the hospital owned three hundred and seventeen acres of land and had a capacity of two hundred and twenty beds, with a plant valued at nearly two million dollars.

The first provision for the care of mental diseases in Connecticut was a direct result of the activities of the State Medical Society. It was on their petition that the Hartford Retreat was chartered in 1822. Over two thousand persons subscribed to a fund for the opening of the hospital. These subscriptions included "$30 payable in medicine," "One gross New London bilious pills, price $30" and two lottery tickets.[16] About fourteen thousand dollars was subscribed in all, the citizens of Hartford contributing four thousand. The hospital building, designed to accommodate forty patients, was opened on April 1, 1824, and has always been conducted on an unusually high plane. It now averages about one hundred and seventy-five patients.

Mental cases were first provided with hospital care in Kentucky when the Eastern State Hospital was opened in Lexington on May 1, 1824. Governor Adams, who suggested the establishment of this institution, in a message written in 1821 expressed the opinion that it would be of great benefit to the students of Transylvania University, "which would in time repay the obligation by useful discoveries in the treatment of mental maladies."

The State Hospital at Columbia, South Carolina, was opened in December, 1828. A curious fact in connection with its history is that in 1829 the management, having received no patients as yet, advertised for them in the newspapers of South Carolina and adjoining states.

In 1829 the necessity of making further provision for mental diseases in Massachusetts became the subject of a legislative investigation and a committee was appointed "to examine and ascertain the practicability and expediency of erecting or procuring, at the expense of the Commonwealth, an asylum for the safe keeping of lunatics and persons furiously mad."[17] The report of this committee, of which Horace Mann was Chairman, is exceedingly interesting. The following is an illustration:—"To him whose mind is alienated, a prison is a tomb, and within its walls he must suffer as one who awakes to life in the solitude of the grave. Existence and the capacity for pain alone are left him. From every former source of pleasure or contentment he is violently sequestered. Every former habit is abruptly broken off. No medical skill seconds the efforts of nature for his recovery, or breaks the strength of pain when it seizes him with convulsive grasp. No friends relieve each other in solacing the weariness of protracted disease. No assiduous affection guards the avenues of approaching disquietude. He is alike removed from all the occupations of health, and from all the attentions everywhere but within his homeless abode bestowed upon sickness. The solitary cell, the noisome atmosphere, the unmitigated cold and the untempered heat, are of themselves sufficient soon to derange every vital function of the body, and this only aggravates the derangement of his mind. On every side is raised up an insurmountable barrier against his recovery. Cut off from all the charities of life, endued with quickened sensibilities to pain, and perpetually stung by annoyances which, though individually small, rise by constant accumulation to agonies almost beyond the power of mortal sufferance; if his exiled mind in its devious wanderings ever approach the light by which it was once cheered and directed, it sees everything unwelcoming, everything repulsive and hostile, and is driven away into returnless banishment."[18] The investigation conducted by this committee led to the establishment of the Worcester Lunatic Hospital, later the Worcester State Hospital, opened on January 19, 1833. The original building was designed to care for one hundred and twenty patients. After many years of agitation on the part of the public, the hospital was removed to a site overlooking Lake Quinsigamond in the outskirts of Worcester in 1877. It was soon found that it was impracticable to dispense with the use of the old building on Summer Street and it became the Worcester Insane Asylum, later the Worcester State Asylum, and finally the Grafton State Hospital. In 1919 it again became a part of the Worcester State Hospital. The original building is in excellent condition today and promises an indefinite continuation of an unusual career of usefulness. Many men destined to occupy positions of importance in the psychiatric world were trained within its walls.

The death of a prominent politician in 1806 is said to have led indirectly to the establishment of the first hospital for mental diseases in Vermont.[19] His medical advisers treated him for some form of mental alienation by submerging him in water until he became unconscious. It was thought that this "would divert his mind and, by breaking the chain of unhappy associations, thus remove the cause of his disease." As this plan failed he was given opium as "the proper agent for the stupefaction of the life forces." In spite of this vigorous treatment he died. The immediate event which made possible the incorporation of the Vermont Asylum for the Insane in 1835 was a legacy of ten thousand dollars rendered available for this purpose by the will of Mrs. Anna Marsh of Hinsdale. The hospital was opened in Brattleboro in 1836 and became the Brattleboro Retreat after the establishment of the State Hospital at Waterbury. The state care of mental diseases began in Ohio with the establishment of the Columbus State Hospital, which was opened on November 30, 1838. This was the first of a number of institutions now under the supervision of the Ohio Board of Administration.

The study of the development of the state hospital system of care now takes us back to Massachusetts. Notwithstanding the fact that the state already had two institutions for mental cases, McLean and the Worcester Lunatic Hospital, further accommodations were urgently indicated. This was largely on account of the needs of the metropolitan population centering in the city of Boston. To meet this situation the city established a hospital of its own in South Boston in 1839,—the first municipal institution for this exclusive purpose in America. Originally known as the Boston Lunatic Hospital and afterwards as the Boston Insane Hospital, it finally became the Boston State Hospital in December, 1908. Charles Dickens on the occasion of his visit to America was very profoundly impressed by the hospital and made the following references to it in 1842[20]:—"At South Boston, as it is called, in a situation excellently adapted for the purpose, several charitable institutions are clustered together. One of these is the hospital for the insane; admirably conducted on those enlightened principles of conciliation and kindness which 20 years ago would have been worse than heretical, and which have been acted upon with so much success in our own pauper asylum at Hanwell...." "At every meal, moral influence alone restrains the more violent among them from cutting the throats of the rest; but the effect of that influence is reduced to an absolute certainty, and is found, even as a measure of restraint, to say nothing of it as a means of cure, a hundred times more efficacious than all the straight waistcoats, fetters and handcuffs that ignorance, prejudice and cruelty have manufactured since the creation of the world." ... "In the labor department every patient is as freely trusted with the tools of his trade as if he were a sane man. In the garden and on the farm they work with spades, rakes and hoes. For amusement they walk, run, fish, paint, read, and ride out to take the air in carriages provided for the purpose. They have among themselves a sewing society to make clothes for the poor, which holds meetings, passes resolutions, never comes to fisticuffs or bowie-knives as sane assemblies have been known to do elsewhere; and conducts all its proceedings with the greatest decorum. The irritability which would otherwise be expended on their own flesh, clothes and furniture is dissipated in these pursuits. They are cheerful, tranquil and healthy." ... "It is obvious that one great feature of this system is the inculcation and encouragement, even among such unhappy persons, of a decent self-respect." The institution was removed to the Dorchester district of Boston in 1895, where it now houses in the neighborhood of two thousand patients. The Boston State Hospital was the first institution of its kind in the United States to establish a separate psychopathic department, which was opened in 1912.

Influenced doubtless by the attention given to this subject in other states, Maine opened its first state hospital at Augusta in 1840. There were between two and three hundred mental cases in the state at that time. A second hospital was opened at Bangor in 1889. This humanitarian movement naturally extended to New Hampshire. Governor Dinsmore in 1832[21] called attention to the condition of the insane, seventy-six of whom were in confinement. Of this number seven were in cells or cages, six in chains and irons and four in jail. Of those not in confinement at the time, some had been handcuffed previously, while others had been in cells or chained. After much unavoidable delay the New Hampshire State Hospital was opened at Concord on October 29, 1842. The next hospital development appeared in Georgia. After an active campaign inaugurated by the physicians of the state and continued for several years, the Georgia State Sanitarium was opened in Milledgeville in December, 1842. It now houses over four thousand patients.

By this time it became evident that further procedures on behalf of the persons requiring treatment for mental diseases in New York were imperative. The Bloomingdale Hospital, although taxed to its utmost capacity, was not able to meet the needs of the situation. In 1830 the population of the state had increased to nearly two million. The report of a legislative committee showed that there were 2,695 insane persons in the state in 1830, with hospital accommodations at Bloomingdale and one other private hospital at Hudson for only two hundred and fifty of these cases. An extensive system of state care was inaugurated by the opening of the Utica State Hospital on January 16, 1843. In addition to numerous other industries and occupations, a printing office was established in the hospital and the publication of the "American Journal of Insanity" was undertaken in 1844. This was the first journal in the world to be devoted exclusively to the subject of mental diseases. "The Opal," edited, published and printed by the patients of the hospital, was started at the same time. In the early days, strong rooms, padded cells and mechanical restraint of all kinds were used extensively. The "Utica Crib" has received a great deal of attention. This consisted of an ordinary ward bed enclosed in wooden slats, making it impossible for the patient to escape. These were eliminated for all time by Dr. G. Alder Blumer in 1887. Attendants were first required to wear uniforms in 1887. During the following year female nurses were assigned for the first time to male wards. Annual field day exercises for the benefit of the patients have been held since 1887. Baseball games, steamboat excursions, Fourth of July celebrations and Christmas entertainments have been in vogue since 1888. With the development of a large department on the "Marcy" site, nine miles from the city, the Utica State Hospital promises to add new accomplishments to an already dignified history.

The early care of mental cases in Rhode Island, as shown by a report to the legislature by Thomas R. Hazard in 1851, was perhaps no worse than that of other states, although the conditions he described so graphically have not been attributed to other New England communities by historians. The following extract from a codicil to the will of Nicholas Brown, who died in 1843, is proof of the fact that this unfortunate state of affairs had not entirely escaped notice[22]:—"And whereas it has long been deeply impressed on my mind that an insane or lunatic hospital or retreat for the insane should be established upon a firm and permanent basis, under an act of the Legislature, where that unhappy portion of our fellow beings who are, by the visitation of Providence, deprived of their reason, may find a safe retreat and be provided with whatever may be most conducive to their comfort and to their restoration to a sound state of mind: Therefore, for the purpose of aiding an object so desirable and in the hope that such an establishment may soon be commenced, I do hereby set apart and give and bequeath the sum of $30,000 towards the erection or endowment of an insane or lunatic hospital or retreat for the insane, or by whatever other name it may be called, to be located in Providence or its vicinity." Supplemental contributions by Cyrus Butler made it possible for the incorporators to found the Butler Hospital in Providence. The first patients were received on December 1, 1847.

More than any other one person, Miss Dorothea L. Dix of Massachusetts was undoubtedly directly responsible for the inauguration of the state care of mental diseases in this country. She is credited with having memorialized twenty-two different state legislatures on this subject. One of her first accomplishments consisted in inducing the New Jersey legislature to make an appropriation for the establishment of the state hospital at Trenton. This institution was opened in 1848, after some of the hardest campaigning that Miss Dix conducted. The last years of her life were spent as an honored guest of the hospital and she died there in 1887 at the advanced age of eighty-five.

Indiana inaugurated a system of state care by the establishment of the Central Hospital for the Insane in 1848. The East Louisiana Hospital at Jackson was opened in the same year. Missouri made its first provision for mental cases by opening a hospital at Fulton in 1852. Notwithstanding the fact that the first hospitals for mental diseases in this country were located in Philadelphia, the Commonwealth of Pennsylvania did not make any provision for a state institution until the State Hospital at Harrisburg was opened in 1851. This was only undertaken after a vigorous campaign on the part of Dorothea Dix had made some legislative action almost imperative. This is probably the only hospital in the country which has found it necessary to demolish all of the original buildings and replace them by others. In 1847 Miss Dix visited Tennessee and started a movement which resulted in the opening of The Central Hospital for the Insane at Nashville, the first institution of the kind in the state. California entered the state hospital field in 1853 with the establishment of an institution at Stockton. The St. Elizabeths Hospital in Washington, D.C., the first federal institution for mental diseases, was opened for patients in 1855. It receives cases from the United States Government Services and from the District of Columbia. Dorothea Dix was largely instrumental in its origin. The St. Elizabeths Hospital was an early invader of the field of scientific research. A pathologist was appointed in 1883. It was one of the first institutions to use hydrotherapy extensively. It now cares for nearly four thousand patients. Mississippi established its first state hospital for mental diseases in 1856, North Carolina in 1856, West Virginia in 1859, Michigan in 1859, Wisconsin in 1860, Texas in 1861, Kansas in 1866, Minnesota in 1866, Connecticut in 1868, Rhode Island in 1870 and Vermont in 1891. The Sheppard and Enoch Pratt Hospital, a well known private institution in Baltimore, was also opened in 1891.

It is hardly worth while at this time to emphasize the fact that the necessity of providing adequate facilities for the care and treatment of mental diseases, a problem which received little consideration of any kind for many years, gradually led to the elaboration of an extensive system of state hospitals. These are to be found now in every part of the country. They have long since passed through the purely custodial stage and have developed into highly specialized modern hospitals of most advanced type. Their function is to provide proper treatment for persons who cannot for financial or other reasons be cared for in the private hospitals which are to be found in almost all localities. These institutions, originating in Virginia in 1773, now represent one of the most important activities conducted by any state government. The extent of the field which they cover is illustrated by the fact that Kansas, Kentucky, Nebraska, North Carolina, Oklahoma, Tennessee, Texas, Washington, West Virginia and Wisconsin each maintain three state hospitals for mental diseases; Iowa, Maryland, Missouri and Virginia each have four institutions of this type, Minnesota five, California, Indiana and Michigan six, Pennsylvania seven, Ohio and Illinois nine, Massachusetts twelve and New York fifteen. In addition to this eight other states have two hospitals each and seventeen find one such institution sufficient for their needs. It is worthy of note that every state without any exception has now recognized the necessity of making provision for the care and treatment of mental diseases.