Mad Among Us

Gerald N. Grob

• Publisher: Free Press
• Year: 1994
• ISBN:
  9781439105719
• Topic: History
• Subtopic: World History
• Index: History

In the first comprehensive one-volume history of the treatment of the mentally ill, the foremost historian in the field compellingly recounts our various attempts to solve this ever-present dilemma from colonial times to the present.Gerald Grob charts the growth of mental hospitals in response to the escalating numbers of the severely and persistently mentally ill and the deterioration of these hospitals under the pressure of too many patients and too few resources. Mounting criticism of psychiatric techniques such as shock therapies, drugs, and lobotomies and of mental institutions as inhumane places led to a new emphasis on community care and treatment. While some patients benefited from the new community policies, they were ineffective for many mentally ill substance abusers. Grob's definitive history points the way to new solutions. It is at once an indispensable reference and a call for a humane and balanced policy in the future.

1 Caring for the Insane in Colonial America

In modern America the mentally ill are highly visible and therefore of public concern. In the seventeenth and eighteenth centuries, by contrast, mentally ill—or, to use the terminology of that age, “distracted” or “lunatick”—persons aroused far less interest. Society was predominantly rural and agricultural, and communities were small and scattered. Mental illnesses were perceived to be an individual rather than a social problem, to be handled by the family of the disordered person and not by the state. The very concept of social policy—the conscious creation of public policies and institutions to deal with dependency and distress—was virtually unknown.

The absence of systematic policies did not imply that insanity^I was of no significance. On the contrary, the presence of mentally ill persons was of serious concern to both families and neighbors. The behavior of “distracted” persons might prove a threat to their own safety or that of others, and the inability to work meant that others would have to assume responsibility for their survival. Nevertheless, the proportionately small number of “distracted” persons did not warrant the creation of special facilities. Nor had insanity come under medical jurisdiction; concepts of insanity in that period were fluid and largely arose from cultural, popular, and intellectual sources. Mentally disordered persons, therefore, were cared for on an ad hoc and informal basis either by the family or community. Insanity was an intensely human problem, and families and neighbors made whatever adjustments they deemed logical and necessary to mitigate its consequences to themselves and the community.

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Before the American Revolution mental illnesses posed social and economic rather than medical problems. The care of the insane remained a family responsibility; so long as its members could provide the basic necessities of life for afflicted relatives, no other arrangements were required. Yet in many instances the effects of the illness spilled outside the family and into the community. Sometimes the behavior of “lunatics” or “distracted persons” threatened the safety and security of others. James Otis, Jr., an important eighteenth-century Massachusetts politician, went berserk and began “madly firing the guns outside of his window.” For the remainder of his life he alternated between lucidity and bizarre behavior. Sometimes afflicted individuals were unable to work and earn enough for sustenance. In other cases the absence of a family required the community to make some provision for care or for guardianship. When one “distracted” person wandered into a Massachusetts town “in most distressed circumstances in most severe weather,” local officials insisted that “humanity required [that] care should be taken to prevent her from perishing.” She was placed with a local family and provided with the basic necessities of life at public expense while an effort was begun to discover her original place of residence.¹

Throughout the seventeenth and eighteenth centuries most cases involving the insane arose out of this inability to support themselves. Illnesses, particularly those that were protracted, created unemployment, which in turn had a disastrous impact upon the individual as well as the immediate family. If either the husband or wife was affected, the remainder of the family, including dependent children, faced dire economic consequences. Under such circumstances the community was required to assist the insane person and his or her family.

Early colonial laws were based on the English principle that society had a corporate responsibility for the poor and dependent. As in England, most colonies required local communities to make provision for various classes of dependent persons. Since illness and dependency were intimately related, the care of the mentally ill fell under the jurisdiction of the local community. Various codes and laws enacted in Massachusetts, for example, touched upon the care of the insane in one form or another. The first legal code, adopted in 1641, contained several references to “distracted” persons and idiots. One section authorized a “generall Court” to validate the transfer of property made by such persons. Another provision stipulated that “Children, Idiots, Distracted persons, and all that are strangers, or new commers to our plantation, shall have such allowances and dispensations in any Cause whether Criminall or other as religion and reason require.” By 1676 the legislature, noting the rise in the number of “distracted persons” and the resulting behavioral problems, ordered town selectmen to care for such persons in order that “they doe not Damnify others.” Another statute in 1694 made all insane persons without families the legal responsibility of the community. Its officials were enjoined “to take effectual care and make necessary provision for the relief, support and safety of such impotent or distracted person.” If the individual was destitute, the town was required to assume financial responsibility.² Other colonies, including Connecticut, New York, Rhode Island, and Vermont followed suit and often copied Bay Colony statutes outright. Even Virginia, which had laws dealing only with the property and status of the insane, cared for them under a poor law system modeled after that of England.³

Virtually none of this legislation referred to the medical treatment of the insane; the emphasis was strictly upon the social and economic consequences of mental disorders. This omission was not an oversight. To the limited extent that contemporary medical literature even discussed insanity, the concern was focused largely on the nature rather than treatment of mental disorders. Indeed, specific therapies were rarely mentioned before 1800. The frequent use of bleeding and purging reflected the influence of the Galenic humoral tradition. Disease, according to this tradition, was general rather than specific; it followed an excess in the production of any one of the four humors (blood, yellow bile, black bile, and phlegm). The physiological imbalances that resulted were treated by general nonspecific therapies, of which bleeding and purging were the most common. The distinction between mental and physical diseases, therefore, was tenuous at best. The relatively small numbers of trained physicians militated against medicalization as well. Sick individuals were often treated by ministers and women rather than doctors.

Although insanity was not yet defined exclusively in secular and medical terms, explanations about its origins or manifestations abounded. Most individuals who migrated to the New World brought with them the beliefs, traditions, and practices common in England as well as on the continent. Madness in early modern England was a term that conjured up supernatural, religious, astrological, scientific, and medical elements. The boundaries between magic, religion, medicine, and science were virtually nonexistent, and those who wrote about madness could integrate themes and explanations from all to explain mysterious phenomena.

The life of Richard Napier, an early seventeenth-century astrological physician, is illustrative. Napier treated five to fifteen patients per day between 1597 and 1634. During his career thousands of patients consulted him, of whom more than two thousand were either mad or deeply troubled. Like others of his generation, Napier believed that mental disorders could flow from both natural and supernatural sources. Stress, for example, could lead to either physical or mental disturbances. But mental disorders could also follow from the intervention of God as well as the Devil. Napier employed medicaments, psychology, environmental manipulation, and astrology in his armamentarium. He also exorcised those patients he believed to be possessed. When Edmund Francklin was brought before him, Napier ended with the following incantation:

Behold, I God’s most unworthy minister and servant, I do charge and command thee, thou cruel beast, with all thy associates and all other malignant spirits in case that any of you have your being in the body of this creature, Mr. E. Fr[ancklin], and have distempered his brain with melancholy and have also deprived his body and limbs of their natural use, I charge and command you speedily to depart from this creature and servant of God, Mr. E. F[rancklin], regenerated by the laver of the holy baptism and redeemed by the precious blood of our Lord Jesus Christ, I charge you to depart from him and every part of his body, really, personally.⁴

Napier’s therapeutic and theoretical eclecticism was by no means unique. Robert Burton’s famous Anatomy of Melancholy, published in 1621, was a compendium that incorporated beliefs and concepts drawn from a millennium of experience. The category of melancholia dated from antiquity, and its symptoms included depression, suspiciousness, weeping, muteness, and death wishes. Burton’s interest in melancholy grew out of his own sufferings, and he wrote his classic text both to assist others and to rid himself of its debilitating symptoms. Melancholy could arise from a wide range of causes, including (but not limited to) faulty education, stress, childhood experiences, and heredity. Secular explanations, however, did not imply the absence of supernatural elements. To Burton and many of his contemporaries the Devil was a reality. Religious melancholy, therefore, symbolized ensnarement by Satan and was but a measure of human mortality. Indeed, the line between sanity and insanity was at best murky; the presence of melancholy was but a reaffirmation of human fallibility. Similarly, therapy for ordinary melancholy could include music (“a tonick to the saddened soul”), avoidance of solitude and idleness, and pharmaceuticals. One treatment consisted of a decapitated head of a ram (“that never meddled with an Ewe”) boiled with cinnamon, ginger, nutmeg, mace, and cloves. For three days the concoction was to be given to “the patient fasting, so that he fast two hours after it…. For fourteen days let him use this diet, drink no wine, &c.” Religious melancholy, on the other hand, could not be expelled by “physick,” but required instead faith and a willingness to seek divine forgiveness.⁵

Those who settled in America were the heirs of Elizabethan thought, and brought with them the intellectual and cultural perceptions of the homeland. The rigors of creating a society in a radically different environment left little time to produce elaborate and original treatises on madness comparable to those published in England. Yet colonial perceptions of madness did not differ in fundamental ways from those of the mother country. Like their English brethren, colonial Americans integrated religious and secular themes in an effort to render insanity intelligible.

Few individuals devoted as much time and thought to the problems posed by madness as Cotton Mather. An eminent Puritan minister who played an important role in late seventeenth- and early eighteenth-century Massachusetts, he straddled the two worlds of the natural and supernatural. As a minister, Mather emphasized that Satan could tempt individuals into madness by exploiting their moral weaknesses. Sin, after all, was at the heart of the human condition, and one of its more obvious consequences was madness. But even saints could be smitten by divine intervention, for the will of the Almighty was beyond human comprehension. In Magnolia Christi Americana, published in 1702, he recounted the travail of John Warham, a pious man whom Satan “threw into the deadly pangs of melancholy” and whose “terrible temptations and buffetings” were relieved only by death.⁶

Nevertheless, by the 1720s Mather’s religious explanations of insanity had begun to be modified to include naturalistic and biological elements. His treatise, The Angel of Bethesda (written in 1724 but not published until the twentieth century), was indicative of this shift. In it, he supported inoculation, a technique whereby a healthy person was exposed to the smallpox virus. This controversial intervention followed the observation that naturally occurring cases of smallpox had far higher mortality rates than induced cases. When strong opposition to inoculation threatened to divide the Boston community, Mather denounced speculative thinking and argued in favor of experience. “A few Empirics here,” he added, “are worth all our Dogmatists.”⁷

The Angel of Bethesda included as well a discussion of insanity even though the bulk of the text was devoted to other physical illnesses. Mather continued to affirm that madness was of divine origin, and therefore required repentance and the confession of guilt and unworthiness. But he linked mania (a category that included disturbed reasoning, excited and agitated behavior, and general irritability) to “Animal Spirits inflamed” and melancholia to “Flatulencies in the Region of the Hypochondria.” He also accepted naturalistic therapies derived from traditional folk medicine, including “Living Swallows, cut in two, and laid reeking hott unto the shaved Head” as well as the “Blood of an Ass drawn from behind his Ear.” Mather was also aware of the burdens caused by such illnesses. “These Melancholicks” he observed,

do sufficiently Afflict themselves, and are Enough their own Tormentors. As if this present Evil World, would not Really afford Sad Things Enough, they create a World of Imaginary Ones, and by Mediating Terror, they make themselves as Miserable, as they could be from the most Real Miseries.

But this is not all; They Afflict others as well as Themselves, and often make themselves Insupportable Burdens to all about them.

In this Case, we must Bear one anothers Burdens, or, the Burdens which we make for One another.⁸

Like other Puritan divines, Mather was both articulate and prolific. Whether or not his views were representative is problematic. The similarities between his ideas and those of his ministerial brethren as well as his English contemporaries, however, suggest that his were by no means idiosyncratic. The shift in the nature of Mather’s thinking was reflective of a more general decline in supernatural explanations of most phenomena during the eighteenth century. Enlightenment thought had led to more naturalistic ways of explaining human behavior. God and Satan, hitherto central elements in popular perceptions of madness, were now relegated to a more remote position. A naturalistic interpretation of insanity merged with a moral component. Insanity no longer followed divine intervention, but rather was a penalty for the willful violation of natural law. Admittedly, natural law was of divine origin, but not beyond human comprehension. All individuals, precisely because they were endowed with rational minds and free will, could understand the moral imperative that constituted its central core.

Slowly but surely the traditional distinction between supernatural and secular interpretations of madness began to disappear. If moral irregularities and excessive passions hastened the onset of insanity, then at the very least the illness was amenable to human intervention. Human beings were no longer passive pawns in the hands of an inscrutable and mysterious Deity whose actions defied human comprehension. Eighteenth-century explanations of insanity, therefore, were less likely to employ the language of faith and theology. Even in Massachusetts—a colony in which religion continued to play a vital role—the clergy stressed not the inscrutable will of God, but rather the personal responsibility of the individual. In a sermon delivered at the burial of an individual who had committed suicide in 1740, Solomon Williams emphasized how “the ignorance and perverse desires of the Mind” ultimately gave rise to bodily illness, which in turn reacted back upon the mind to weaken the power of reason. Madness thus involved an interaction of moral excesses and physical illnesses.⁹

As supernatural explanations receded, popular perceptions of insanity and a long-standing medical tradition dating from Hippocrates that emphasized biological and psychological elements began to converge. Lay and medical explanations of madness as well as somatic illnesses, to be sure, tended to be eclectic. Yet they all shared a holistic pathology that eschewed any effort to define the precise relationship between body and mind. The focus was rather on the interaction between body and mind, between the body and external environment, and between emotions and physiological processes. The body and the mind were seen as mutually interdependent; both played a vital role in maintaining the balance that was so necessary for good health. A disturbance in the digestive tract or other organs could affect the brain and cause mental disturbance, just as morbid or perverse thoughts could lead to adverse physiological consequences. Insanity could either follow misfortune beyond the control of individuals or result from the willful and purposeful violation of moral norms.¹⁰

Indicative of the growing significance of naturalistic interpretations of insanity was William Buchan’s famous Domestic Medicine. From its initial publication in Edinburgh in 1769, Buchan’s manual enjoyed phenomenal popularity in America. An American edition appeared in 1772, and the book remained in print for nearly a century. Like most of his contemporaries, Buchan believed that the human body functioned as an equilibrium system. Diet and climate shaped intake; behavior and clothing affected process; and urine and feces represented an effort to rid the body of potentially harmful wastes. Any imbalance would lead to illness; hea...

Table of contents

• Cover
• Title Page
• Dedication
• List of Illustrations
• Preface
• Abbreviations Used in Text
• Prologue
• Chapter 1: Caring for the Insane in Colonial America
• Chapter 2: Inventing the Asylum
• Chapter 3: The Emergence of American Psychiatry
• Chapter 4: Realities of Asylum Life
• Chapter 5: The Problem of Chronic Mental Illnesses, 1860-1940
• Chapter 6: A New Psychiatry
• Chapter 7: Depression, War, and the Crisis of Care
• Chapter 8: World War II and New Models of Mental Illnesses
• Chapter 9: The Foundations of Change in Postwar America
• Chapter 10: The New Frontier and the Promise of Community Mental Health
• Chapter 11: Confronting the Mad Among Us in Contemporary America
• Photographs
• About the Author
• Notes
• Index
• Copyright