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' and the Politician

A History of Public Mental Health Care in Pennsylvania

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Ernest Morrison

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The Physician, the Philanthropist,

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■5 A History of Public Mental Health Care

in Pennsylvania

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Ernest Morrison

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1 2 Commonwealth of Pennsylvania *. ^1 Pennsylvania Historical and Museum Commission fl for j The Historical Committee of the Harrisburg State Hospital , I 2001 i I i fe a . •;? V.. .• JS Commonwealth of Pennsylvania Tom Ridge, Governor

Pennsylvania Department of Public Welfare Feather Houstoun. Secretary

Pennsylvania Historical and Museum Commission Janet S. Klein, Chairman < Brent D. Glass, Executive Director c <

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C The Historical Committee of the Harrisburg State Hospital was established in X June 1982 to collect and preserve the records , artifacts and story of <; Pennsylvania ’s first State Hospital , which first opened in 1851 in Harrisburg . <

Today the committee seeks to promote a better understanding of the state hospital « system and its role in providing for the Commonwealth ’s mentally ill. This book < has been written as part of the committee ’s efforts to commemorate the one hun­ dred fiftieth anniversary of the establishment of the state ’s first mental hospital at Harrisburg .

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t © 2001 Historical Committee of the Harrisburg State Hospital

Printed in the United States of America c c Published and distributed by < The Historical Commttee of the Harrisburg State Hospital * P. O. Box 61260 Harrisburg, PA 17106-1260 ISBN 0-89271-101-9 i <4 a —

■ . A to lift the curtain of popular misconception which unfortunately long has existed with regard to mental institutions.

Sophia M. R. O’Hara

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i., vv -v i. i Table of Contents

Foreword .Vll

Colonial America 1

William Penn’s Great Law .... 1 Madness in Colonial America 1 Pennsylvania Hospital ...... 1 Benjamin Rush ...... 3

The Asylum Building Era 5

The Frankford Asylum and “Moral ” Treatment ...... 5 Thomas S. Kirkbride...... 6 A Kirkbride Asylum...... 8 The Legislative Sessions of 1838 and 1841 ...... 10 Thomas Pym Cope ...... 11 Dorothea Lynde Dix ’s Memorial ...... 12 Dorothea L. Dix ...... 14 Founding of the American Psychiatric Association ...... 15 Construction of the First Pennsylvania Asylum...... 16 Joseph Konigmacher ...... 16 Asylum Life...... 17 Restraints and Therapies ...... 19 John Curwen...... 20 Dixmont ...... 22 Origins of Insanity...... 24 The Civil War...... ,25 Danville ...... ,27 Habeas Corpus ...... 30 Asylum Architects...... 30 The Board of Public Charities ...... 33 “Insane Asylum Warfare” ...... 36 “Life Among the Insane”—The Story of Adriana Brinckle 38

The Cottage Plan .44

Norristown State Hospital ...... ,44 Hiram Corson ...... 46 Search for New Measures...... ,48 Warren State Hospital ...... ,48 Asylum Afflictions: Fire and Disease 50 Wernersville State Hospital ...... 52 Blacks and the Asylum...... 55 Poor Farms...... 57 vi The Twentieth Century 59

Allentown and Farview State Hospitals 59 The Mental Hygiene Movement ...... 60 The Haviland Survey ...... 61 Torrance ...... 66 The Department of Welfare ...... 67 Wernersville and Act 272 ...... 68 First Pennsylvania Mental Health Act . 69 Western State Psychiatric Hospital ...... 70 Shock Therapy...... 70

“Full State Care ” 74

Byberry and the “Full State Care” Act...... 74 Mayview and Retreat ...... 75 State Hospital System at Its Peak...... 77 The Philadelphia Mental Health Survey Report. 78 “Crazy Harry” ...... 78 American Psychiatric Association Study of 1955 79 Citizen’s Mental Health Groups ...... 81 Return to the Commnity ...... 82 Staff Needs...... 83 Arthur P. Noyes: “Mr. Psychiatry”...... 84

Community Mental Health 86

The Scranton Administration and Mental Health 86 The Unit System...... 88 Psychiatric Nursing ...... 89 Wyatt vs. Stickney...... 91 The State Hospital as “City”...... 92 Vecchione vs. Wohlgemuth ...... 95 Patient Abuse...... 95 Mental Health Plans...... 96 Closing of Byberry...... 98 The Schizophrenic Mind...... 100 Not Guilty by Reason of Insanity...... 102 A New Century ...... 103

Appendices 106

Mental Health Care Acts of the Pennsylvania General Assembly 106 State Hospital System at its peak—1947 ...... 110 Bibliography ...... 111

- Foreword Moreover, the volume of legislative vii acts in the 150 years since 1851 —which Around a chandelier in the main read­ number in the hundreds—is evidence of ing room of the Pennsylvania State the concern for and the commitment of the Library in Harrisburg a motto is inscribed legislature to providing for the mentally that reads: “Thought never ripens into ill. truth except through action. ” Although it The reader should keep two points in is Emersonian in character, it is accompa ­ mind throughout. Regardless of the past nied by no attribution. And search as I shifts in public mental-health policy — may, I have never found it in any diction ­ whether at a given moment a community, ary of quotations, although there are county, or state system was preferred—the dozens of quotations that convey the same concern was always for the indigent, not basic idea. those who could afford to pay. The latter Thought and action do go together usually went to private hospitals or were (despite a widespread belief that individu­ cared for at home. This was true even als are either thinking or acting, but sel­ though many of the state facilities admit­ dom both), and significant actions are ted some paying patients during much of invariably preceded by thoughts. their history. The policy behind establish­ As much as the actions themselves, ing and maintaining both the county and the ideas are what this book is about — the state schemes was to provide for the ideas that led to the acts of the legislature, poor. the erection of buildings, and the evolution Second, the choice of which type of in Pennsylvania’s treatment of the mental­ facility—community, county, or state—was ly ill. Its underlying theme, then, traces in favor at any point was determined not the shifts in “public policy ” in Pennsyl­ only by the perceived quality of the care vania’s treatment of its mentally ill that the mentally ill might receive in one or the grew out of this thinking. other class of institution, but also by who Each act of the legislature, the erec­ should pay for the indigent ’s care. tion of each new hospital building, the Today, regardless of whether an indi­ implementation of each improvement in vidual stays in a state or a community medical regimen came about as the result mental health center, those who can pay of some new idea, which often emerged invariably do so with insurance reim­ from or led to changes in the public ’s per­ bursements, while the indigent are largely ception —the “public policy ” climate—of provided for with federal funds (Medicare the manner in which the Commonwealth or Medicaid). The state, of course, furnish­ should provide for its less fortunate citi­ es facilities, staff, and training at the state zens, including its mentally ill. hospitals it continues to maintain. This trend is quite apparent, for exam ­ While a people ’s greatness is usually ple, in the acts of the legislature. Between measured by the wars it wages, the 1868 and 1873 the acts that established notable cities it erects and the wealth it state hospitals at Danville and Warren amasses, the compassion it evidences for directed that they be of Kirkbride design. its less fortunate citizens—especially those When the legislature committed to build­ beyond the pale of known treatments or ing Norristown a few years later, it speci­ the ability to care for themselves—should fied that it be of cottage design; and then also he weighed in making that assess­ in 1901 when Allentown State Hospital ment. was authorized the act directed that it be The story of Pennsylvania’s role in a “homeopathic ” facility. caring for its less fortunate citizens is an

■ >- ^ A-' ’ viii extensive one stretching from William compassionate enough. My intent, howev ­ Penn’s time to the present. It touches on er, is to tell what I believe is a compelling areas all across the state, and is as diverse story, and to leave the judgments on the as the many ethnic groups who settled actions of, or neglect by, those who played each of the state’s regions. While, in some a part in it to those readers who wish to instances, there were similarities, many of make them. the state’s mental health ventures fol ­ A word, too, on words. I have tended lowed divergent paths and had unique throughout the text to use terms such as characteristics. Consequently, rather than asylum, lunatic, insanity, and mental ill­ try to construct a story along a single, ness in their historical contexts without broad continuous plan, I have provided the intending any pejorative connotations. reader with a cinematographic approach There is no other area, however, to its manifold events and parts. The indi­ where words have become freighted with vidual scenes may be read separately, but so much stigma as in that of mental ill­ together I hope they provide those who ness. Historically those so afflicted have examine them with a sense of the rich tex ­ been called first lunatics, then insane or ture of their diversity. crazy, later patients, now mentally ill, and Two of the chapters included here— the places they have been kept first asy­ “Life Among the Insane” and the lums, then hospitals, and now mental “Haviland Survey”—are long. They pro ­ health centers. As soon as one term vide, however, a first-hand, inside look at became a slur through usage, a new one life in an asylum and county poorhouse, was devised. Gradually with the use of the permitting us to see views that are more word as an adjective—“He is mental.”— revealing than those of other reports or someday even mental may become narratives. shunned as lunatic now is. This is not a happy story; nor is it one To paraphrase Hamlet, “The stigma with a satisfactory ending. It is a survey of lies not in the words, dear reader, but with a history marked by struggle, by shifting ourselves. ” As long as we believe that currents, by charge and counter-charge. In those who suffer from diseases such as the past 150 years there have been a few schizophrenia are somehow disgraced individual successes, but no triumphant (regardless of whether we ascribe the feel­ campaigns, no heroes acclaimed. It was a ings of disgrace to others or to ourselves), time in which each new facility, each new whatever term we apply to those who have treatment methodology, each new agency “lost their reason ” will in time become a reorganization, each new appointee, was disgraced term. viewed with hope for future success—a Likewise at one time it was the prac­ future that only led to yet another facility, tice when taking photographs of those treatment regimen, agency reorganization, housed in the state hospitals to block out or new appointee. their faces when printing the pictures. I Hospitals —especially those for the have always thought that rather than pro ­ mentally ill—are seldom thought of as tecting the identity of the patients, we are friendly or even “hospitable ” places, and heaping a final indignity on them. Their history has shown that in some instances minds are impaired so we strip them of “bad” things have happened in them. They their countenance, thus stealing from are, however, by their very existence evi­ them the last shred of their humanity. dence of the state’s benevolent attitude, its This, like the avoidance of words, is concern for its less fortunate citizens. done more out of fear of offending others Some readers may think this book is than out of benevolence toward patients. not tough enough, others that it is not Experience has shown that, at a chance

. .V.«2£w, ■ ...... meeting, it is as often we, as they, who There are several biographies of ix avert eyes or turn away faces. With an Dorothea Dix from which the reader may almost child-like guilelessness, they do not choose ranging from the popular to the feel the embarrassment or the shame that scholarly. And there are at least two on we do. Thomas Kirkbride—Nancy Tomes ’s A I was pleased to discover late in my Generous Confidence and Earl D. Bond ’s research that eventually the management Dr. Kirkbride and His Mental Hospital. of the Philadelphia State Hospital also Copies of Thomas Cope ’s Diary are also reversed its position on this practice for available. Full-length biographies of the the same reason. other principals have yet to be written, Although the title refers mainly to the although Patricia Davis’s A Family three individuals who were instrumental Tapestry, Five Generations of the Curwens in the establishment in 1851 of the first of Walnut Hill includes a substantial Pennsylvania mental hospital at amount of material on John Curwen. And, Harrisburg —the Philadelphia physician of course, there are numerous books deal­ Thomas Story Kirkbride, the Boston phi­ ing with the various types of mental ill­ lanthropist Dorothea L. Dix, and the ness: schizophrenia, depression, epilepsy, Ephrata politician Joseph Konigmacher — autism, senile dementia, etc. the book deals with and is dedicated to a In closing it seems, however, that a succession of physicians, philanthropists, note of hope may be in order. Recent and politicians and the impact they have developments in drug therapies and in had on the Commonwealth ’s treatment of studies of the brain and mind point to, if its mentally ill. not identification of the causes of diseases As this book was intended for a gener ­ (Manfred Spitzer ’s The Mind Within the al audience, it was decided not to include Net provides special insights into the the usual academic paraphernalia of end- mind, its functioning and disorders) such notes. However, a few citations have been as schizophrenia, or a “cure,” or at least a inserted in the text. It also seemed appro ­ “restoration ”—as the early alienists called priate to include some references for fur­ it—to full productivity and potential for ther reading on the more important topics most sufferers. covered in this book, so a brief bibliogra ­ Finally, just as it was Secretary of phy is included. Welfare Sophia M. R. O’Hara’s expectation There is no other general history of for her 1947 report to Governor Edward state mental health care in Pennsylvania, M. Martin on the state mental health sys­ although there are countless books cover ­ tem, it is mine that this book might help ing both the asylum and the community to lift the curtain of popular mis­ mental-health eras in the United States. conception which ... long has There are individual histories, however, of existed with regard to mental two of Pennsylvania’s state hospitals: Fred institutions. R. Hartz and Arthur Y. Hoshino ’s Warren State Hospital, 1880-1980 and Ernest Ernest Morrison Morrison ’s The City on the Hill about the Harrisburg State Hospital. /- Acknowledgments

The Historical Committee of the Harrisburg State Hospital would like to thank the fol ­ lowing organizations for their generous contributions in support of the production of this book.

AstraZeneca Office of Mental Health and Substance Abuse Services Department of Public Welfare

The Committee would also like to acknowledge the kind assistance of the following indi­ viduals in supplying historical and photographic materials for its use in the finished book.

David Jones of Mayview State Hospital Gregory M. Smith of the Allentown State Hospital Ron Fisk of Wernersville State Hospital Carmen M. Ferranto of Warren State Hospital Alden Altenor, Ph.D. of Norristown State Hospital Louise Miller and John Bizell of Danville State Hospital Tracy Ferguson of the Ben Avon Area Historical Association

Many individuals provided the author with advice and help during his research and preparation of the manuscript. Without their assistance, suggestions, and support, the book would have been the poorer. Those who deserve special mention are: Joan Leopold, Bruce S. Darney, Kenneth C. Wolensky, Ph.D., Allen Kirk, M.D., John Logan, M.D., Max Leopold, Edith Krohn, Ph.D., and Ford Thompson. Special thanks to the Publications Division of the Pennsylvania Historical and Museum Commission for the production of this book. Their editorial assistance, the attractive layout and design of this publication, and their print mangement were invaluable in bringing the book to fruition.

.-.i Colonial America methods were in place in New England to 1 handle the mentally ill. The more violent William Penn’s Great Law individuals were treated as criminals—the jail, the pillory, the whipping post, or the When he arrived at Philadelphia in gallows was their fate. The “harmless” October 1682, William Penn, as proprietor, ones were usually housed in kennel-like issued a set of laws for his colony that structures in the town square or “sold off ’ came to he called the Great Law. to the lowest bidder who was to provide The Great Law gave Pennsylvanians for their care and whatever work the the most humane legal code of any buyer could wrest from the individual. The American colony. While, for example, the term of servitude was usually one year, English code listed two hundred capital when the unfortunates would be resold. offenses, Penn’s prescribed death only for If there were no bidders, the insane first-degree murder. were often “dumped ” on another town. The In addition to provisions for a humani­ individual would be spirited late at night tarian prison system, the law specified to a distant community, left standing in that if any person or persons fall the town square, confused, unable the into decay [author ’s italics] or next morning to recall where he came poverty, and not able to maintain themselves and their children with from. The point of “selling off ’ or “dump­ their honest endeavors, or shall ing ” was to relieve the community of the die and leave poor orphans, that cost of maintaining those who could not do upon complaint made to the next productive work. Justices of the Peace of the same Although, following William Penn’s County, the said Justices, finding lead, Pennsylvania’s mentally ill were sel­ the complaint to be true, shall make provision for them, in such a dom abused in these manners, even at the way as they shall see convenient, Pennsylvania Hospital in Philadelphia, till the next County Court, and which had an insane department, it was that then care be taken for their the practice in the late eighteenth and future comfortable subsistence. early nineteenth centuries to exhibit the “lunatics” for a fee. Philadelphians com ­ Madness in Colonial America monly used it as a Sunday afternoon pas­ time for entertaining out-of-town guests. Many of the colonists brought with Jeers and taunts would be directed at the them all the awe, the fears, and the super­ patients in the hope that like caged ani­ stitions about insanity that had prevailed mals they could be goaded into a rage for in Europe from the time of the Middle the amusement of the visitors. Ages. The common explanation was demo ­ niacal possession, which from 1487 in the time of Pope Innocent had official, theolog ­ Pennsylvania Hospital ical justification for various proceedings Benjamin Franklin laid the corner ­ and methods for purging evil from the stone for the Pennsylvania Hospital in body, including the burning of the afflicted 1755. The idea for the hospital was not at the stake. Much of this abuse was his, however, but that of a young directed at deluded females who it was Philadelphia physician, Thomas Bond. believed infected men with disease and If not substantial, Franklin’s role was death through their witchcraft. an important one. In 1751 Bond, who The witchcraft trials of colonial New : according to Franklin was “zealous and England were based in part on this pre­ active” in attempting to raise subscrip ­ sumption. And a wide variety of other tions for his hospital idea, turned to ■ y"

2 Franklin when his efforts met with little effects. As the first such effort, it set the success. As Franklin tells the story in his precedent for two hundred years of public Autobiography support of the mentally ill by the he came to me with the compli ­ Commonwealth. Hundreds of acts by the ment that he found there was no legislature during the years following that such thing as carrying a public- original act appropriated money to build spirited project through without asylums as well as to support private hos ­ my being concern ’d in it. “For, ” pitals for their care. says he, “I am often ask’d by those to whom I propose subscribing, From the beginning, the Pennsylvania Have you consulted Franklin upon Hospital made care of the insane an inte­ this business? And what does he gral part of its mission. Bond and think of it? Franklin’s petition to the Assembly specifi­ Franklin first “prepared the cally mentioned the large number of minds of the people ” by writing lunatics in the colony and the problems articles in the Gazette, as was “his associated with them as part of the justifi­ usual custom in such cases.” The cation for the hospital. “Going at large subscriptions picked up, but when [they] are a Terror to their Neighbors, who after a while they began “to flag, ” Franklin came up with the scheme are apprehensive of the Violences they of seeking assistance from the may commit. ” Provincial Assembly. When the According to Thomas Kirkbride biog ­ members from the country object ­ rapher Nancy Tomes (A Generous ed that the citizens of Philadelphia Confidence), the hospital took only the should provide the expense, he told more dangerous and disruptive lunatics them that the proposal “met with such approbation as to leave no because of its limited space. The nonvio ­ doubt of our being able to raise lent cases were usually consigned to the two thousand pounds by voluntary almshouse. In most instances then, the donations. ” Pennsylvania Hospital ’s insane patients The members of the Assembly were so were in need of restraint with chains, certain this was “utterly impossible, ” they manacles, and straitjackets. They were agreed to support Franklin’s bill for a housed in the basement and only occasion ­ “capital stock ” appropriation if he was able ally were permitted out of their cells and to raise the two thousand pounds. into the “crazy yard,” a secure area on the Franklin claimed the members, who had hospital grounds where they could get opposed the grant, “now conceiv ’d they fresh air and some exercise might have the credit of being charitable Such accommodations as barred base­ without the expence. ” ment cells and heavy shackles of chains When Bond and Franklin told the were not considered inhumane in the late subscribers the Assembly would match eighteenth century. As Tomes writes: their subscriptions pound for pound, they “Even the most enlightened of the early easily raised the two thousand pounds. [hospital] managers and physicians Franklin wrote of his involvement “I do believed that the insane, by virtue of los ­ not remember any of my political manoeu ­ ing their reason, had reverted to a brutish vres, the success of which gave me at the state.” And the Pennsylvania Hospital time more pleasure, or, after thinking of it, apparently subscribed to this principle. As I more easily excus ’d myself for having one hospital physician wrote in 1794, made some use of cunning. ” “madmen, if suffered to have their liberty, Franklin’s cunning in securing the resemble beasts rather than men.” : support of the Assembly had far-reaching Within fifteen years of the hospital ’s

J opening, the insane made up nearly half of women, and common schools for children. 3 its patients. By the 1790s overcrowding Rush supported the cause of freedom from had forced the managers to construct for England from the outset of the Revolution. them a separate wing or “department ” as He served in the Continental Congress it came to be known. Removed from their and was a signer of the Declaration of basement cells into vastly improved new Independence. surroundings, their lives took on aspects of Benjamin Rush was the first normalcy. Although some patients still sat American physician to attempt an original in their rooms, other wrote poems, told theoretical systematization of the causes their life stories to the matron, worked at and treatment of mental illness, the first various crafts, or learned to play musical to institute a program of university-level instruments. study in mental disease, and the first to Finally in 1831, the hospital man­ write a general treatise, Medical Inquiries agers decided to construct a separate and Observations upon the Diseases of the building west of the Schuylkill River Mind, on insanity. Because he paid signifi ­ devoted to the insane. When it opened in cant attention to the problems of the 1840, Thomas S. Kirkbride, a young physi­ insane before any of his fellow physicians, cian who had specialized in their care at Benjamin Rush is sometimes called “The the center-city facility, became the manag ­ Father of American Psychiatry.” er of the new hospital. It was at the In spite, however, of his interest in Pennsylvania Hospital for the Insane, and sympathy toward the insane, his con ­ that—in spite of his reluctance to accept clusions concerning the disease and his the position rather than wait for a more treatment methodologies were more akin desirable one as a surgeon —he developed to those of the eighteenth than the nine­ the ideas on hospital construction and the teenth century. In what is probably a care of the mentally ill that were to domi ­ rather charitable description, Albert nate the field for the next half-century. Deutsch calls his conclusions “unsteady.” Because of the typical patient ’s “excitement, ” Rush believed insanity was Benjamin Rush caused by hypertension in the arteries of Benjamin Rush was born in the brain. He, therefore, employed purga ­ Philadelphia in 1746 of Quaker parentage. tives and emetics as well as such practices Rush was precocious. He graduated from as blood letting to reduce the blood pres­ New Jersey College (later Princeton) at sure in the brain. Obviously after enough age fifteen, did six years of medical blood was drawn the agitation of the apprenticeship, then journeyed to patient lessened. Deutsch describes Rush’s Edinburgh for advanced study. He treatment methodologies as in some received a Doctor of Medicine degree there respects “more harmful” than “curative,” in 1768. Following a year’s further stay in but credits him with providing more impe­ Europe, he returned to Philadelphia, tus to medical progress than any of his where he set up practice. He soon rose to contemporaries. eminence in the city and eventually Rush also invented several devices for became the most celebrated physician in treating the insane. One of these was a Revolutionary America. chair he called the “tranquilizer. ” In an Along with his fellow Philadelphian effort to reduce a patient ’s pulse rate, an Benjamin Franklin, Rush was a reformer agitated man or woman was tightly of prodigious energy. He participated in all strapped in this contrivance until all his manner of causes including prison reform, or her muscular activity had been immobi ­ the abolition of slavery, education for lized. Another of his machines Rush called 4 the “gyrator. ” The intent of this machine with an equal willingness to publicize was the opposite of the tranquilizer. By them. To him has been credited the idea of rapidly rotating a patient in the gyrator, the physician as “autocrat ” and the patient the blood rushed to the individual’s head, as completely subservient. It became a fun­ in the hope of rousing a patient out of his damental principle of asylum superintend­ “torpid madness.” ents during the nineteenth century. Rush was a man of strong opinions

j The Asylum Building Era chains and began ministering to them 5 with kindness and sympathy. It was his The Frankford Asylum and “Moral ” belief that not enough importance was Treatment placed on the emotional causes of mental disease. By use of the word “moral, ” he to fetter strong madness in a silken thread attempted to convey the importance he The Friends Asylum at Frankford, five accorded to the emotions as motivators of miles north of Philadelphia, was the first human behavior. hospital in America designed to care for Although Pinel’s ideas astounded the mentally ill as a moral treatment facil­ Robespierre, the latter was too busy at the ity. It was opened in 1817 on a fifty-acre height of the Revolution to give them country site selected for its peaceful much attention and gave responsibility for nature. The three-story building with two- Paris’s insane over to Pinel. By 1792, story wings could accommodate forty Philippe Pinel had formalized the patients. At first, only Quakers (members method ’s principles, systematized its prac­ of the Society of Friends) were admitted tices, and dramatized its results. but in 1834 the hospital was turned into a At the same time that Pinel was nonsectarian institution. working to improve conditions in France, “Moral ” treatment was first practiced William Tuke was attempting to convince in France and then in England. It consist ­ the Yorkshire Quakers in England to build ed of removing patients from their homes an asylum for members of the Society of to an asylum (preferably a calm retreat in Friends. Although there was great opposi ­ the country) that provided the patient tion to his plans, “The Retreat” was finally with an intimate family atmosphere. erected in 1796. William Tuke’s principal Coercion by blows and the use of bars and objectives were to provide a family-like chains were replaced with a system of 1 environment in noninstitutional-looking humane vigilance. buildings and surroundings, to emphasize Under moral treatment a gentler exercise and employment as conducive to medical regimen was substituted for the mental health, and to treat the patients as previous practices of bloodletting and guests rather than inmates. According to purgings. The objective was to “rebuild” Albert Deutsch (The Mentally III in the brain into a healthy one using appro ­ America), “Kindness and consideration priate mental exercises. The attendants formed the keystone of the whole theoreti ­ were instructed to act as if they were ser­ cal structure [of moral treatment]. Chains vants. Noisy patients were to be tolerated. were absolutely forbidden, along with The convalescing were allowed access to those resorts to terrorization that were books, music, and entertainment, and still being advocated in varying degrees by were given at least limited freedom of eminent medical men.” movement. The primary role of the institu­ The ideas of Philippe Pinel and tion was to help the patient “minister to William Tuke not only transformed the himself.” treatment of Europe ’s mentally ill but also Philippe Pinel, a French village doctor swept over the United States. They were who first began treating the inmates in the primary impetus behind the design the asylums of Paris during the French and construction of hospitals such as the Revolution, devised the term “moral ” for Frankford Asylum (which was patterned this form of treatment. Before Pinel’s after Tuke’s “The Retreat”) and those the arrival the inmates had been kept chained Commonwealth of Pennsylvania erected in irons and were treated like desperate, between 1850 and 1870. They also provid ­ dangerous animals. Pinel removed their ed the principal therapeutic regimen 6

I

The new administration building erected at Harrisburg in 1895 (left) with the old Kirkbride Building —the first Pennsylvania State Hospital which opened in 1851—in the background.

employed in asylums until the end of the minds, and . . . facilitate their restoration. ” nineteenth century. The Friends’ ideal was “to fetter It was at the 1811 Spring Quarterly strong madness in a silken thread.” I Meeting of the Philadelphia Society of Friends that the proposal to erect a moral- Thomas S. Kirkbride treatment asylum “for such of our mem­ bers as may be deprived of their reason ” Among nineteenth century American was first presented. A constitution was “alienists—a doctor who treats those drawn up and a subscription campaign whose minds have been “alienated”—none launched. An important feature of the had a wider reputation than Thomas Story campaign was the circulation of Samuel Kirkbride. He was born in Bucks County, Tuke’s Description of the Retreat near Pennsylvania, in 1809, a descendant of York. Quakers who had accompanied William

The ideas of Tuke and Pinel on treat­ Penn on his initial voyage to Pennsyl­ I ment were closely followed at Frankford. vania. Kirkbride first studied medicine Patients were not considered as subhu­ with a physician who had come from mans or social pariahs, but as “men and France with Lafayette during the brothers. ” The upper stories of the build­ Revolution. Then Thomas attended the ing were reserved for the mild and conva ­ University of Pennsylvania from which he lescent cases; the lower for the noisy and received a Doctor of Medicine degree in incurable. The facility’s constitution stated 1832. that the asylum “is intended to furnish, Kirkbride did a year’s apprenticeship beside the requisite medical aid, such ten­ at the Friends’ Asylum at Frankfort, and der sympathetic attention and religious then was named resident physician at the « oversight, as may soothe their agitated Pennsylvania Hospital. He practiced sur-

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\ Hr- J gery there for several years until he was a volume titled On the Construction, 7 appointed physician-in-chief of the new Organization, and General Arrangements Pennsylvania Hospital for the Insane in of Hospitals for the Insane. It was the 1840. His hospital was a model institution standard work in the field for the next in the treatment of mental illness. Sidney forty years. During that period asylums George Fisher, a Philadelphian whose for the insane were erected, internal hos ­ brother-in-law had spent thirty-five years pital facilities were organized, and the in Kirkbride’s hospital, wrote in his diary mentally ill were treated following the of an 1862 trip to visit his wife’s brother. ideas, theories and plans that Kirkbride He described the facility as situated laid down in his book. As Albert Deutsch, [in a] beautiful, richly cultivated wrote in The Mentally III in America, and wooded country, glowing in Kirkbride’s “word on hospital construction autumn colors. We drove first to was accepted as law in America.” the house of Dr. Kirkbride. He is Thomas Kirkbride was one of the thir­ highly respectable and has man­ teen founding members of the American aged this admirable institution for more than 20 years with signal Psychiatric Association and served ability and success. . . . The build­ admirably on the boards of other institu­ ings and grounds are extensive tions including the first Pennsylvania and kept in perfect order. He Lunatic Asylum at Harrisburg. Although received us very kindly and gave his influence on hospital construction us a note to the superintendent of began to wane late in the nineteenth cen­ the enclosure where Alexander lives. tury, no one ever personally assailed him Dr. Kirkbride was an early exponent of or his professional reputation. “moral treatment.” He made a point of vis­ Earl D. Bond, in his biography of iting his patients each day, of inviting Kirkbride, describes him as being “gentle them to his afternoon staff teas, and in as a woman, ” but “firm as adamant.” He making art, music and education readily was so well known in Philadelphia that a available. He believed in “free and friendly prominent British psychiatrist told the conversation on any subject in which the patient is interested.” His treatment meth­ story of a streetcar conductor who could ods stressed “earnest sympathy,” “gentle not tell him where the Pennsylvania attentions, ” and “judicious counsel. ” Hospital for the Insane was, but readily In 1847 Thomas Kirkbride published directed him to “Kirkbride’s.”

PLATE X.

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PLAN OP PRINCIPAL STORY OF IMPROVED LINEAR FORM OF HOSPITAL.

A plan from Thomas Kirkbride's classic book on mental hospital construction. W' '

8 A Kirkbride Asylum months, and during the mild weather of spring and autumn, one to “first relieve a patient of all his series of pipes will be sufficient. responsibilities and then give them With the ordinary winter weather, back one by one. ” two will be required, and when the In 1854, Thomas Kirkbride revised temperature is very low, . . . the and enlarged On the Construction, whole of the three ranges, . . . must be put in operation. Organization, and General Arrangements of Hospitals for the Insane. This revised A Kirkbride hospital was to be built work covered much more, however, than linearly, with two eight-ward wings ema simply the design of buildings. Among the subjects Kirkbride discussed were site VERTICAL SECTION OF WATER • ARRANGEMENTS. selection and preparation, drainage and water supply, heating and ventilation, lay­ PLATE IXt. out of the surrounding “pleasure grounds, ” the detailed appointments of patients ’ rooms, the height of the rooms ’ ceilings, the location of the kitchen, chapel and staff quarters, the daily duties of each employee, even the number of pigs in the piggery. Every subject, every point that Kirkbride covered was dictated from the consideration of its impact on the treat­ ment of his patients, not from any arbi­ trary architectural or aesthetic point of view. The following short passage from his long chapter on “Heating and Ventilation ” will give some idea of Kirkbride’s attention to details: The steam is to be conveyed from the boilers through an eight- inch iron pipe, till it reaches the air chambers under or near the centre building, and from this point a smaller pipe diverges to each extremity of the hospital. . . . The radiating surfaces may be either made of large cast iron or of small wrought iron pipes. Of the two, the latter are to be preferred on account of the greater facility with which they can be taken down or put up, turned at corners, and repaired in every way, while their cost is no greater. The radiating pipes should be PLAN AND VERTICAL SECTION OF WATER ARRANGEMENTS, AND prepared in two or three distinct THEIR VENTILATION. sets, one or all of which, can be Vertical Section of Water Arrangements from used at pleasure. In the cool morn ­ Thomas Kirkbride's book on the construction of ings and evenings which occasion­ insane asylums. ally occur even in the summer

Trr— .... . The patients were “classified” 9 VERTICAL SECTION" OF FIRE-PROOF STAIRWAY. (arranged) with the most seriously dis­ turbed at the far end of each wing (in the Eighth Ward), with progressively less dis­ PLATE XVII. turbed patients housed closer to the cen­ tral building. The attendants and nurses ill— for each ward lived in the basement of ■nNWIIRfflPm : :i ■ their respective structures, so they were immediately available. Calling tubes were provided from the upper floors to the base­ ment. As patients got better they were moved or “promoted ” from ward to ward closer to the center of the hospital. In the words of Earl Bond a Kirkbride hospital was intended to “first relieve a patient of all his responsibilities and then hopefully £«, if a give them back one by one. ” mum Patient admission and classification 1 •A.: □ □ - ' was done in the center or main building. a □ 0 I The kitchen and dining facilities (for the □□ staff) were found there, as well as a Qfi HI chapel. The superintendent and his family lived on the upper floors. VERTICAL SECTION OF FIREPROOF STAIRWAY. It was Thomas Kirkbride’s intention that a mental-hospital building should result from a close cooperation between a professional architect and a physician. He visualized it as a collaboration of distinguished and skillful archi­ tects and physicians who have had a large practical experience with mental patients, who are thor ­ oughly familiar with all details of their treatment, and who know the advantages and defects of existing hospitals.

PLAN OF FIREPROOF STAIRWAY. Accordingly, his On the Construction, Verticle section and plan for a fireproof stairway of Organization, and General Arrangements a Kirkbridge asylum. of Hospitals for the Insane contained numerous plates illustrating in detail such parts of a Kirkbride structure as a nating from a central building. Each of the “Longitudinal Section of an Infirmary wings consisted of four buildings (two Ward,” the “Plan of a Cellar of a wards to each structure). Each of the four Supplementary Ward,” a “Vertical Section was attached but set off from its adjacent of a Fire-Proof Stairway,” an “Elevation members to permit maximum entry of and Plan of a Kitchen,” and a “Vertical sunlight and fresh air as well as provide Section of Water Arrangements and Their separation from the other buildings. Ventilation ” [for bathing and toilets]. 10 Following the tenets of moral treat­ Pennsylvania—at Danville and Warren— ment, a Kirkbride institution was intend­ are still hospitals for the mentally ill. ed to impress its patients as cheerful and comfortable, and was always to be sur­ The Legislative Sessions of 1838 and rounded by attractive grounds for walking 1841 and socializing with other patients. Many In 1835 Thomas P. Cope, a wealthy of the “pleasure ” grounds at the early asy­ Philadelphia merchant and philanthropist, lums were covered with an abundant vari­ was appointed chairman of an association ety of vegetation and stocked with of Philadelphia residents interested in wildlife—turkeys and deer. “procuring for the pauper and indigent According to Kirkbride there must insane, the benefits of curative treatment always be “at least one nurse or attendant and hospital protection. ” The Cope for every eight patients. ” The nurses and Committee conducted surveys of condi ­ attendants were required to possess “tact, tions in the state and prepared a petition pleasantness, patience, a real interest in to the legislature to establish an institu­ the work, a sympathy that cannot be ques ­ tion for the insane. tioned, a sound moral character.” And, of On January 10, 1838, the Pennsyl­ course, with a superintendent who had vania House referred Cope ’s petition to a complete and exclusive authority over the committee headed by Joseph Konigmacher facility, any who did not possess these for study and report. Two months later, attributes were promptly dismissed Konigmacher submitted a lengthy report By the end of the nineteenth century favoring the establishment of an “asylum as many as thirty hospitals had been for the insane poor of this commonwealth. ” erected around the world following the Konigmacher ’s committee had gath ­ guidelines that Thomas Kirkbride laid ered data from nearly half the counties in down in his book. A few of them are still the state and concluded that there were standing. At least two of them in

A print of the architect's sketch for the Western Pennsylvania Hospital for the Insane at Dixmont. %

2,300 insane persons out of a population of be severally chargeable with the expenses 11 800,000. The report opened with a of the care and maintenance of such pau ­ heartrending appeal: pers. ” Poverty itself, when abject and The act also directed the hospital hopeless enough to seek relief from trustees to apply “to the maintenance of public charity, is a bitter portion, insane persons in, or to the general use of ... to be miserably poor and to be the asylum any grant of land, any dona ­ shut out from every pleasant and tion or bequest of money or other personal cheerful prospect, and to be deined the alleviation of sympathy and property ” that they received. But this hope, is an intense aggravation. money would not have been enough to run But to have the mind diseased, a large hospital. In all probability the leg ­ distracted and tormented; and to islature expected the trustees to be private endure, beyond all this neglect, fundraisers—a practice commonly used in abuse and cruelty, without the supporting private hospitals and poor power of resistance, . . . presents a picture of human woe, which few houses of the day. can contemplate without a tear of The project ’s managers bought land pity. outside of Philadelphia, secured the Governor David R. Porter vetoed the renowned architect William Strickland to bill, however, which the committee had design the structure, and laid the build­ attached to its report, not because of a ing ’s foundation. The group, however, ran lack of sympathy for the cause, but into political and financial difficulties. because of the “financial embarrassment” Cope blamed the failure of the effort that Porter found the state in when he on political interference; that the assign ­ took office. ment of “the carrying out of it to party Then in the 1841 legislative session, men, more intent on making jobs for them­ Cope and Konigmacher pushed through selves and their political friends” had another bill for the same purpose. During killed its chances. Cope wrote in his diary: this session the legislature was especially “[A] lot was contracted for at an extrava ­ busy writing philanthropic acts: to estab­ gant price and another agreement made lish poorhouses in several counties, to pro ­ with an unprincipled demagogue to fur­ vide pensions to Revolutionary War veter­ nish the materials for the building, who ans, and to establish an “Asylum for the afterwards ran away to escape punish ­ Insane of this Commonwealth. ” For the ment—and the whole thing was aban­ several poorhouses, the legislators elected doned. ” to pass the costs back to the counties. For the asylum, provided for in Act 34—which Thomas Pym Cope was signed by Governor Porter on March Thomas P. Cope was one of the 31, 1841 —they furnished $50,000 “seed” wealthier nineteenth-century residents of money to buy land and construct a build­ Philadelphia. He was born in Lancaster, ing, but nothing for its continued mainte­ Pennsylvania, in 1768 to a plasterer and nance. town burgess. While still a boy, Thomas The act did not completely overlook walked to Philadelphia “without, ” as he the issue—it did specify that the “authori ­ wrote in his diary, “a dollar either of my ties having care and charge of the poor in own or of any other person. ” He first the counties, districts and townships of became a lowly merchant’s apprentice, this Commonwealth, shall send to the asy­ but by the time he was a young man, he lum such insane paupers under their had made a fortune sending ships to charge . . . and they [the authorities] shall Europe and the Orient. *s?ififcy ~ ryf^rr■■- ■•?--.

12 By 1838 when he helped Joseph Konigmacher author the first state act for the establishment of a hospital for the mentally ill, Thomas Cope had become one of Philadelphia ’s leading philanthrop ­ ic citizens. He was involved in a wide variety of civic and charitable projects, including hospitals, poor houses, the city’s first public water supply, and the purchase of land that led to the establish­ ment of Fairmont Park. He shared the concerns of many of his fellow Quakers, devoting time and money to the poor and insane, the abolition of slavery, and Haverford College. Although Cope was a successful mer­ chant, he seemed to enjoy his political and philanthropic activities even more than making money. He maintained a Dorothea Lynde Dix, early advocate for the life-long interest in scientific matters, mentally ill. which resulted in a membership in the American Philosophical Society. forest she disarmed a highwayman (with

Dorothea Lynde Dix’s Memorial words) —the difficulties she had traveling and the conditions she found in the state’s During 1842 and 1843, when travel to jails and poorhouses were just as shock ­ parts of Pennsylvania beyond the ing. Appalachian Plateau was primitive, In the poorhouse at Gettysburg there Dorothea Dix, a Boston philanthropist and were eleven patients chained in a damp advocate for the humane treatment of the unventilated basement “crazy room ” eight nation ’s insane, visited the counties in the by eight by eight feet high. Several of state one by one. She systematically them had been there for years with noth ­ sought out and went through each jail and ing to sit or lie on. In the nearby Adams poorhouse in the Commonwealth in search County jail, which she described as in of the “idiotic ” and “insane.” “miserable condition, ” she found one man No jailer or poorhouse keeper was whose mental faculties had been defective able to deny her entry. Her bearing, tall from birth. He was loaded with chains—a and straight with a face of strong but deli­ ring about the ankle, connected by a sort cate, patrician features; her raven black of hinge, to a long, stout iron bar, reached hair, combed back and then knotted; her above the hips, and to this the iron determination; her firm and unyielding wristlets were attached. manner warranted to all her right to be After traveling from Gettysburg to there. Chambersburg where she visited the jail, Although her travels in Pennsylvania Dix headed west over the Allegheny were not filled with quite the difficulties Mountains. The first leg of the trip by and dangers that some of her surveys in stagecoach left Chambersburg at mid­ other states had been—in Massachusetts night. It was a nonstop thirteen-and-a-half her claims first were denounced as false, hour “hard ride” over the mountains to and then in a “dismal-looking ” Michigan Bedford. (She pitied the poor horse.) The

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rest of the trip was by a combination of apparently demented, standing 13 wagon and stage journeys. At the jail in upon a sack of straw. At first, I Allegheny County children and adults, thought there was no other occu ­ pant; but a little to the right, ... I men and women, sane and insane all discovered a woman of middle age shared common facilities. Dix wrote: seated on some straw in a packing If it had been the deliberate box —in a state of entire nudity. On purpose of the citizens of the opposite side of the room, stood Allegheny County to establish a a similar box, which at first, I sup­ school for the inculcation of vice, posed to be empty; but the sound and obliteration of every virtue, I of voices roused a female. She lay cannot conceive that any means coiled up. I cannot imagine how they could have devised, would she could have contracted herself more certainly have secured these into so small a space. Some straw, results, than those I found in full too, was in this box, and excepting operation last August. that, she had neither clothing nor covering of any sort. . . . And this Pittsburgh residents were shocked at is where, in 1839 (following the her recital of conditions. The Pittsburgh Konigmacher Committee ’s survey), Daily Gazette and Advertiser called for an it was officially announced, “that investigation and the mayor scheduled a the insane of this county are so public meeting and established commit ­ well provided for, that a state hos ­ tees to study the problem. pital would be useless.” For Dorothea Dix to get to her next Shortly before Dix ’s visit to Pennsylvania stop, Warren in the north ­ Montgomery County in eastern Pennsyl- west corner of the state, it was necessary sylvania, the county had built a new hos ­ for her to go first to Jamestown, New York pital at considerable cost, and although it via Ohio and then turn south back into was “well planned, ” the insane were Pennsylvania. The last leg of her journey placed in the basement. Dix condemned down the Allegheny River to Warren was a both the construction and the wretched nineteen-hour ride with an “old waterman condition to which the inmates were aban­ astride a drift log half under water.” doned. Moreover, she found that “these At Warren as in many counties, miseries are augmented by the entire including Bradford, Columbia, and incapacity of those who have the immedi­ Lycoming, Dix found that the paupers, ate care of this department. ” including the insane, were not in the jails The result of Dorothea Dix ’s travels but were “set off yearly to those who bid across Pennsylvania by buggy, canal boat, cheapest for their services.” In talking to and wagon was a fifty-five-page Memorial physicians in those counties, she was told, to the state legislature. Her detailed, “Some are well dealt by, and others suffer county-by-county study opened: great hardships. ” I come to represent to you the In the Washington County almshouse condition of a numerous and in the southwestern part of the state, unhappy class of sufferers, who fill Dorothea Dix found seventy paupers, seven the cells and dungeons of the poor- houses, and the prisons of your of who were insane. Dix wrote of her visit: state. I refer to the pauper and > In a large yard, common to all indigent insane, epileptics and the inmates, was a small building, idiots of Pennsylvania. I come to consisting of a single room, per­ urge their claims upon the com ­ haps twelve by fourteen feet. It monwealth for protection and sup­ being a hot day, two windows were port, such protection and support I opened. I looked in, as requested, as is only to be found in a well con ­ and saw first, a young woman ducted Lunatic Asylum.

v. A. 14 I must ask you, ... to exam ­ part of the Massachusetts frontier. ine with patient care the condition Although her father was there managing of this suffering, dependent multi­ her grandfather ’s land holdings, he appar ­ tude which are gathered to your ently spent much of his time as an itiner­ alms-houses and your prisons, and scattered under adverse circum­ ant Methodist lay minister. For some rea­ stances in indigent families; weigh son —perhaps because of her father’s the iron chains, and shackles, and inability to provide adequately for his fam­ balls, and ring-bolts, and bars, and ily—the first written record finds manacles, breathe the foul atmos ­ Dorothea at age fourteen living in Boston phere of those cells and dens . . . with her seventy-year-old grandmother. examine the furniture of these dreary abodes, some for a bed have Dorothea grew up with an elderly the luxury of a truss of straw . . . woman who “was a typical example of the Examine their apparel. The air of New England Puritan gentlewoman of the heaven is their only vesture. period —dignified, precise, inflexibly con ­ Do your startled perceptions scientious, . . . and with little trace of emo ­ refuse to admit these truths? They tional glow or charm.” It was an age, too, exists still; the proof and the con ­ dition alike; neither have passed of training the young “to habits of rigid away . . . Gentlemen, it is just, not industry, of exacting iron diligence over generous action, I ask at your school lessons, and of inculcating the dog ­ hands. mas of the catechism.” Dorothea Dix ’s Memorial was read in From the very beginning Dorothea the Pennsylvania House of Represen ­ Dix was drawn to the disadvantaged. After tatives on February 3, 1845. James tutoring the children of William Ellery Burnside, a representative from Centre Channing, the Unitarian minister, she and Clearfield Counties, moved that two opened a school for young women since the thousand copies of it be printed in English only Boston schools were for hoys. One of and five hundred in German for distribu­ her students wrote to a friend that Dix tion “so that it could be better and more was “tall and dignified . . . and very shy in widely studied.” (Until 1846 all Legislative her manners. . . . She was strict and Journals, executive documents, and laws inflexible in her discipline. . . . Fixed as in Pennsylvania were printed in both fate we considered her.” English and German.) For several years Dix taught, trav­ On March 8, 1845, the “select commit ­ eled, and wrote books for children. Then in tee” to which the Memorial had been 1841 she was approached to teach Sunday referred reported out a bill, No. 493, enti­ school to the women in the Cambridge jail. tled “An Act to establish an asylum for the When she discovered several insane insane poor of the Commonwealth [to be] women among the drunkards, thieves, called the Pennsylvania State Lunatic prostitutes, and vagrants, she was Hospital and Union Asylum for the launched on her lifetime work. Insane.” The House passed the bill on She traveled over Massachusetts vis­ March 29, the Senate on April 11, and iting jails and prepared a memorial to the three days later Governor Francis Rawn state legislature. After describing all the Shunk signed it into law. horrible details she told them: “You would i not treat your lowest dumb animals with such disregard to decency.” She closed her Dorothea L. Dix memorial with an impassioned plea: Little is known of Dorothea Dix ’s Men of Massachusetts, I beg, I childhood other than that she was born on implore, I demand, pity and pro ­ April 4, 1802 in Maine, when it was still tection for these of my suffering, ► outraged sex. Fathers, husbands, Among the other distinguished mem­ 15 brothers, I would supplicate you bers of the original thirteen were Isaac for this boon. . . . put away the Ray of Augusta, Maine, Luther V. Bell, of ► cold, calculating spirit of selfish­ the McLean Asylum at Somerville, 6 ness and self-seeking, lay off the armor of local strife and political Massachusetts, Pliny Earle of opposition; . . .consecrate [these Bloomingdale Asylum, New York, and halls] with one heart and one mind William M. Awl, of the Ohio Lunatic to the works of righteousness and Asylum, Columbus. just judgment. . . . Gentlemen, I William Maclay Awl, a native of commit you to this sacred cause. Harrisburg, Pennsylvania, was a product 1 Although there were outraged cries of of the apprentice system, although he disbelief, eventually with the help of attended one course of lectures at the i William Channing, Horace Mann, and University of Pennsylvania. He, however, others she was able to persuade the along with Thomas Kirkbride and Samuel i Massachusetts legislators that her catalog Woodward, were considered to be eminent f of horror was true. Rhode Island was her in the field. As early as 1827, Awl reported next state, followed by Pennsylvania and completing a difficult surgical operation — r New Jersey. The hospitals at Trenton and the removal of a tumor, with ligation of the one at Harrisburg were the first ones, the left carotid artery. however, actually to be built in response to % * At that first meeting the group of her memorials. Both were completed at superintendents appointed committees to \ about the same time. prepare reports on sixteen subjects, Dorothea Dix called them her “first including Restraint and Restraining born. ” As a result of her efforts, by the time Apparatus, the Construction of Hospitals, of her death in 1887, more than thirty such the Jurisprudence of Insanity, the institutions had been built throughout the Prevention of Suicide, Provisions for world. Although she was not a philanthro ­ Insane Prisoners, and the Causes and pist in the sense of having endowed institu­ Prevention of Insanity. l tions with large sums of money, she had The superintendents adopted a reso ­ sufficient income that freed her to devote lution that the abandonment of “personal i all her time and energies to the disadvan­ restraint is not sanctioned by the true \ taged, especially the mentally ill. interests of the insane” and also agreed that “mental occupation ” of patients was Founding of the American Psychiatric to be recommended. r Association Thomas Kirkbride served as president \ In October 1844 the Superintendents of the association from 1862 to 1870. He of American Institutions for the Insane, as attributed “the real progress that was r they called their organization, gathered at made in the provision for the treatment of the Jones Hotel on Philadelphia ’s Chestnut insanity” in the second half of the nine­ teenth century to the organization. i Street. The thirteen men in attendance selected Samuel Woodward of the Among the tenets the group developed Worcester, Massachusetts, Asylum as pres­ during this period were the following: t ident, Samuel White of the Hudson, New That insanity is a disorder of York, Asylum as vice president, and the brain, to which everyone is liable. ) Thomas Kirkbride of Philadelphia as secre­ That properly and promptly tary and treasurer of the organization that treated, it is as curable as most later became the American Psychiatric other serious diseases. I Association. That in most cases, it is better f ~w"t • ■

16 and more successfully treated in a of 1812, set up practice in Harrisburg. He 1 well-organized institution, than at soon became the most popular doctor in ' home. town. Although he was more interested in ! The insane should never be the professional life, he did agree to stand kept in almshouses nor in penal institutions. for election and served one term in the ■< i That the superintendent, a Twenty-fifth Congress. medical officer, should have com- * It was not until July of 1848, howev ­ i plete charge of medical, moral and er, that the building commissioners chose < dietetic treatment of the patients, the land, hired a contractor, and began and the unrestricted power of excavation. John Haviland of appointment and discharge of all persons employed in their care. Philadelphia, who had a considerable rep­ utation, was selected as architect. Haviland’s designs included the Walnut Construction of the First Street Theater and the Franklin Institute, Pennsylvania Asylum as well as a number of city churches. He According to Thomas Cope, the major was best known, however, for his innova ­ defect in the bill of 1841 to establish a tive design for the penitentiary at state asylum had been the “political inter­ Pittsburgh and the Eastern State ference” that surrounded the construction Penitentiary at Philadelphia. The Eastern of the hospital. The House managers in State Penitentiary, which incorporated the the 1845 effort were able to beat down, results of a generation of experiments in however, any efforts to politicize the bill. penal reform, was one of the most famous The most serious of these was an attempt American structures of the day. by Jeremiah M. Burrell to have the bill The Pennsylvania State Lunatic amended to include a provision that the Hospital finally opened in October 1851 state purchase one hundred acres of land with John Curwen, a former medical stu­ within five miles of Greensburg in dent of Dr. Kirkbride, as superintendent. Westmoreland County and that five men And it was probably at Dix ’s suggestion from Westmoreland be appointed commis ­ that, as the building was nearing comple ­ sioners. The motion was defeated fifty-two tion and the trustees to run the new hospi ­ to twenty-seven. tal were designated, Dr. Kirkbride was The final version of the bill named six added to the names of the building com ­ highly respected, responsible advocates for missioners as a trustee. the mentally ill as “building commission ­ ers”: two physicians, Luther Reiley and Joseph Konigmacher Hugh Campbell; two lawmakers, Joseph Joseph Konigmacher of Ephrata was Konigmacher and Charles B. Trego; and an influential state figure between the two businessmen, Jacob Haldeman and years of 1837 and 1855. He first came to James Lesley. Later three additional men prominence as a member of the Reform were added: a lawyer and two bankers, Convention, which was responsible for apparently to provide expertise that the revising the Pennsylvania Constitution in original group of men lacked. Dorothea 1837-1838. He was elected a state repre­ Dix was in Harrisburg to assist the com ­ sentative in 1838 and a senator ten years missioners in their early deliberations. later. It was Konigmacher who authored Reiley, who was born in Lebanon the three acts to establish a state mental County, was elected president of the hospital in Pennsylvania. Later as a mem­ group. He, like most country doctors, had ber of the Senate Appropriations studied with a practicing physician and Committee for a number of years, he then, after a term as a soldier in the War helped to push through John Curwen’s The attendants would wake the 17 annual appropriation requests for the hos ­ patients and see that they were washed, pital at Harrisburg. their hair combed, and that they were Konigmacher was, in spite of his per­ properly dressec for the day. The oedding sonal wealth, always strongly identified had to be aired each morning —replaced if and popular with the working class. Even soiled —and the 3oors carefully swept. his name, which meant awning maker, Whenever required (when a patient made helped to endear him with the Penn­ messes on them! the walls and windows sylvania Germans he represented. A short also were washsi The beds were to be heavyset man, he was of a kind, amiable ready for inspection by 10 am . The rule disposition. At one time he owned great was “nothing can ";e considered clean that amounts of property in Ephrata, including can be made ary deaner.” [Hartz and a farm, a hotel, and a tannery and was Hoshino, Warren State Hospital, 82] president of the Reading and Columbia The assistants helped with these Railroad. chores as well as setting the tables in the Joseph Konigmacher died broke, how ­ two dining rooms (the men and women ate ever, in 1861. He made out his will the day in separate rooms in the center building) before his death in a rundown Lancaster Meanwhile, the matron was busy in the hotel, but when his estate was settled his kitchen and the d.ning rooms overseeing liabilities exceeded his assets and his the preparations for breakfast. heirs were left with nothing. It was a “bit­ Two attendants were always cn duty ter portion ” for the man who had champi­ in each dining room. Their responsibilities oned the poor and the weak. His wife had included carving the meat, seeing that died the year before; their son became a each patient received an appropriate por ­ ward of her brother. tion, and then cleaning the room after the » patients left. They also had to ensure that Asylum Life One visitor to an early nineteenth- century asylum described the sound coming from the building as he approached it as that of “a hive of buzzing bees.” This never-ending din, of course, was what led to Kirkbride’s linear design with the more disturbed patients housed at the extreme ends of the building ’s wings; it also meant that quieting the patients at night so that those who were able to sleep could was a crucial part of the duties of the nurs­ es and attendants, who were on call day and night. The day in a state asylum fol ­ i lowed an unvarying pattern. The hos ­ pital steward rang the morning wake- up bell at 5 AM. The attendants and > assistants were expected to rise imme­ Patients workirg trader the supervision cftwo attendarts in the diately and start work within the half fields at Werne'sv'de State Hospital. hour. f 18 no patient removed a knife or fork from restless and excited, promotes a the room —the utensils were counted fol ­ good appetite and a comfortable lowing each meal. digestion, and gives sound and refreshing sleep to many who In walking those patients who had would, without it, pass wakeful permission to be on the grounds, the nights. attendants were directed to keep together Kirkbride then described the types of those they took out and to prevent any work he believed were appropriate. These straggling. Twice weekly, on Wednesdays consisted mainly of the farm or the garden and Saturdays, the attendants shaved the for the men and laundry and sewing for male patients. the women. He proposed, too, “systematic The hospital was “closed at half-past courses of instruction in well furnished nine” each night. Before shutting the door schoolrooms, ” the availability of “well to a patient ’s room the attendant had to be selected libraries” and of lectures, the certain the patient was in the room, wish playing of various games including ten­ him or her a “good night, ” and then close pins, the inspection of pictures and of “col ­ and bolt the door. All the lights in the lections of curiosities, ” the playing of wards were then extinguished and the musical instruments, and, of course, liber­ attendants and other employees of the al amounts of exercise —either in walks hospital went to their rooms. By ten around the “pleasure grounds ” or in use of o ’clock all lights in their rooms were also a gymnasium where available. to be out. These ideas on work, education, recre­ The steward, who had the most ation, and exercise were embraced by all responsible nonmedical position in the of the early hospital superintendents. For hospital, took care of all the buying example, in the 1880s at Danville picnics (including furniture, implements, and were a frequent part of patient life. Large even farm stock) and the accounts (includ­ groups of patients—numbering anywhere ing patient charges) and also saw to the from fifty to eighty would spend an entire opening and closing of the house each day, afternoon in the woods. its security, as well as its cleanliness, They would play games, listen to warmth, and ventilation. It was he, more ­ talks, or look at unusual objects or wildlife over, who was “to receive visitors, give in the woods. Refreshments were liberally them suitable information and accompany supplied. A typical spread might consist of them to such parts of the building and beef and ham sandwiches, rolls, butter, grounds as are open for examination. ” fruit spreads, pickles, peanuts, coffee, ice While the patients spent much of cream, and cake. According to one of the their waking hours simply sitting in the superintendent ’s reports, after everyone hallways or in the day areas when such had finished eating, the attendants would were available, there were respites from pass out “cigars for the men and a pinch of this sedentary life. The idea of work as snuff for the old ladies.” therapy was an essential part of the The use of patient labor was also Kirkbride plan for patient “restoration. ” highly acceptable to the state legislature. He wrote in On Construction: Many of the state hospitals became largely Labor, judiciously used, is one self-sufficient by producing most of their of our best remedies; it is as useful in improving the health of the produce and meat and making or repair­ insane, as in maintaining that of ing materials such as bedding and cloth ­ the sane. It is one of the best ano ­ ing. The male patients also shoveled snow dynes for the nervous; it often — and mowed lawns. In some instances they I but not always—composes the were even used to construct outbuildings 19

Hydrotherapy treatment at Mayview State Hospital during the mid-1940s. Straps were used to prevent the patient from slipping down into the water to commit suicide. >

and dig sewer lines, although Kirkbride Martha Elmer, for example, donated a would probably have objected that such stained glass window and Dorothea Dix heavy labor was of questionable value as induced the Society of Friends to donate a therapy. large, handsome Bible for the chapel at All this work, of course, meant that Harrisburg. the state’s appropriations for “running ” In later years, especially under the the hospitals could be kept to a fraction of influence of the cottage plan, the trustees the total cost of their operation. This also and superintendents began to erect sepa­ meant that the superintendent was as rate buildings as chapels. Several of these much a “manager ” of a large-scale busi­ were substantial, if not lavish. Among ness as a physician. them, the building architect John From the beginning, chapels and Dempwolf erected at Harrisburg is most church services were invariably a part of impressive. asylum life. In the first several hospitals, the chapels were set aside in the main Restraints and Therapies building, usually on the top floor. More Reading the narratives in the early than simply a room, they often had a stage asylum superintendent ’s annual reports — at one end and doubled as a place for which were designed for review by the patient gatherings, dances, and parties. governor and the legislature —often con ­ At Christmas the chapels would be veys a scene of pastoral even idyllic decorated and a typical celebration and patient life. Picnics, access to books and church service held. During the early pictures, walks and carriage rides around years at Harrisburg, the governor usually the “pleasure grounds, ” along with the came to greet the patients and help pass opportunity to view magic lantern slide out oranges to them. shows, to attend readings or dramatic Although these early chapels were > entertainments, or to participate in teas bare by modern standards, they did have with the superintendent were all reserved some appointments. John Curwen’s wife

... 20 most likely for those patients who lived in chases of restraining devices (cuffs, jack­ the first or second wards of the hospitals. ets, bed straps, wet packs, cribs); and Those who were housed in the outer check for the dismissal of attendants for wards—especially the “dreaded” seventh abuse of patients as well as for incompe ­ or eight wards, as one of Thomas tence. Kirkbride’s patients described them—led a Only then do we begin to comprehend quite difference existence. With little in the nature of this other life, to realize that the way of genuine therapeutic techniques hospital chairs were made of the heaviest available for their physician to use in materials (to prevent patients from throw ­ soothing their troubled minds, they passed ing them at each other or attendants); their days mainly in seclusion and in that patients were locked in their rooms at restraint, their nights locked in their cells night (to prevent them from harming oth ­ along with the howling and wailing of ers); that the walls of their rooms were their neighbors. scrutinized each morning (because We have to read between the lines on patients often smeared feces on them); the pages of the annual reports, to review that the silverware had to be accounted the attached statistical charts, and to scan for after each meal because a knife or fork the steward’s procurement ledgers in order might be used as a weapon; and that to catch a glimpse of this other side of asy­ patients ’ clothing was sometimes taken lum life. The careful reader will look for from them to prevent them from ripping it the statistics about those who died; pause apart. With these insights we finally real­ < at how the estimates of those who were ize that asylum life was at times violent, considered incurable overwhelm the count patient behavior frequently revolting, and ■ of those the superintendents believed a nurse or attendant’s life difficult. were curable; seek out the hidden pur ­ Therapies, too, were rudimentary by today 5s standards. The drug arsenal of asylum physicians consisted mainly of alcohol, opium (along with its many deriv­ atives, especially morphine, which was a favorite of Kirkbride’s), and bromide of sodium, then later in the nineteenth cen­ tury, of “sedative cocktails ” such as scopo ­ i lamine. Other than drugs, the most com ­ mon therapeutic techniques relied on < hydrotherapy, consisting of various types of baths and showers, wraps and packs— hot (to stimulate) and cold (to quiet). 1

John Curwen John Curwen was born at Walnut Hill outside of Philadelphia in 1812. Following a secondary education at the Newburgh Academy at Newburgh, New Jersey he i entered Yale University. At Yale he studied Latin, Greek, philosophy, and mathemat­ Betty Williams of St Francis Hospital administering a spray water treatment at Mayview State Hospital in 1946. Note the intravenous packs on the table. ics. This was supplemented by occasional lessons in chemistry, pharmacy, mineralo ­ gy, geology, rhetoric, and astronomy. After he graduated from Yale in 1841, Curwen ation or interest in even the simplest of 21 went to the University of Pennsylvania social or political maneuvering. At one where he got a medical degree in 1844. point he wrote Kirkbride: From then on he was known as “Dr. John ” I learned this afternoon one to his family and close friends. cause of the feelings on the part of He practiced for a time with a cousin certain members of the Board and then won an appointment as the toward me; that I have not made it a point to call on them at their assistant physician at the Wills Eye houses, . . . which I think is a Hospital in Philadelphia. In 1846 he rather lame reason hut as their joined Thomas Kirkbride in the Mental vanity has been touched, I will and Nervous Department of the Penn­ endeavor hereafter to apply to the sylvania Hospital. He remained there five wound the application needed. years, eventually becoming Kirkbride’s John Curwen also seems to have been assistant. a very cautious, careful physician. In this capacity, Curwen made the Although the law required that two per­ rounds each morning with Kirkbride, sons certify to a patient ’s condition before assisting the senior physician in adminis­ admission, Curwen insisted on three tering the patient ’s medical and moral before he would admit them to the treatment. Although he was seldom per­ Pennsylvania Lunatic Hospital. His mitted to make treatment decisions on his favorite, often-stated expression was: “I own, John was expected to know each cannot afford to take chances.” patient ’s condition intimately and to He was a man of conviction as well as observe Kirkbride’s manner with the resolve. When his first steward, Will patients—those he disciplined by remov ­ Slaymaker, did not work out, he fired him ing from a more to a less favored ward; without hesitation. And when, as a newly r and those he encouraged by invitations to appointed commissioner for the construc ­ the afternoon teas. tion of a new state hospital at Werners- John Curwen had been seeking a ville, he first saw the site, he exclaimed, i superintendent ’s position unsuccessfully ‘You are not thinking of putting a hospital \ for some time and was about to go into here in this hole? ” When it turned out private practice when the offer at they were, and for what he believed were Harrisburg was made. He accepted the political reasons, he resigned immediately. appointment, as he told Dorothea Dix, so At Harrisburg, John Curwen contin ­ that he would be able to marry, not ued many of the practices he had learned because he particularly wanted the posi ­ at the Pennsylvania Hospital. He regular ­ i tion. Its rural location struck him as being ly advised each patient ’s family how its i far removed from the amenities to which relative was doing. And he seems to have * he was accustomed. had the welfare of his patients uppermost Curwen was crisp and businesslike, in his mind. Even when years later he although in later years he sported large came under fire for administrative prob ­ mutton-chop sideburns that hung beneath lems at the hospital, there were never any his lower jaw. Even when he visited the claims against his reputation as a doctor. I governor ’s mansion Curwen was anxious Curwen was the only protege of 1 to conduct his business and leave. After Kirkbride’s to manage a large public men­ one visit to Governor William F. Johnston, tal hospital. He wrote numerous papers he wrote that the governor wasted “some and books on insanity and served for I useless breath” in discussing a recent many years as the secretary and eventual­ storm. As a hospital superintendent, John ly as the president of the American Curwen also apparently had little appreci ­ t •■rr-w

22 Medico-Psychological Association (formerly estate, with the view to the foundation the Association of Medical Superinten­ and endowment of a public hospital for the dents of American Institutions for the reception and care of the insane and Insane and now the American Psychiatric afflicted, as well as the sick, helpless and Association). In 1881 he became the super­ infirm.” intendent at Warren State Hospital. By the end of 1853, the first year the John Curwen’s departure from hospital was in operation, it was clear that Harrisburg was abrupt. Speculation has there were a great many more patients in 1 attributed this to several possible factors: the almshouses and jails than the twenty - his reluctance to appoint a female physi­ six beds that had been provided for the cian; his numerous, long absences from area’s insane. I the hospital (he helped select other hospi ­ Two years later, with the help of a tal sites, was frequently called on to exam ­ $10,000 appropriation from the state legis ­ ine criminals around the state who were lature, the local managers of the Western believed insane, and was sent by the gov ­ Pennsylvania Hospital bought a 177-acre ernor on various fact-finding trips); and farm overlooking the Ohio River south of discrepancies in accounting for funds that Pittsburgh. Although the board of man­ had been appropriated by the legislature. agers had first proposed building in He was never formally charged; the board Pittsburgh, Dorothea Dix rejected the idea of trustees simply refused to renew his and picked a site eight miles down the appointment in 1880, and placed Jerome Ohio River from the city. The Board of Gerhard, his first assistant, in charge. Managers proposed calling the new facility Dixmont, but according to Dix biographer, Dixmont Dorothy Clarke Wilson, the philanthropist The Pennsylvania legislature not only permitted it to carry the family name, not expected the trustees of its asylums for in her honor, but in memory of her grand ­ the insane to raise funds to supplement father. those it appropriated to erect and main­ The cornerstone laying ceremonies on tain the hospitals, it also encouraged local July 19, 1859 was turned into an elaborate groups to build private facilities by agree ­ affair. A special train made up of “elegant ing to “charter” them. With the authority cars” was run to the site from Pittsburgh ’s of the Commonwealth behind them, this Liberty Street Station. According to the turned them into quasi-state retreats; Pittsburgh Gazette, the two hundred ladies enjoying a reputation and preferred status and gentlemen who set out from not enjoyed by county institutions. The Pittsburgh on the train at 10 AM were 1 earliest of these charters was for Dixmont joined by others along the line until the in Western Pennsylvania. excursion arrived an hour later at Kilback Station. The crowd then assembled in a In March 1848 the legislature granted “delightful grove ” protected by the trees articles of incorporation to the Western from the glare of the noonday sun. i Pennsylvania Hospital at Pittsburgh, in After the placing of numerous objects which one ward was to be designated for in a jar, including a letter from Dorothea the care of insane patients. According to Dix (who was unable to attend) along with the act, a number of the citizens of the a copy of her 1845 Memorial to the legisla ­ area “actuated by a sense of religious duty, ture, the jar was sealed and set in an and the benevolent disposition to extend aperture in the stone. Then the speech­ aid, comfort and relief to indigent and making began. Finally following a number afflicted humanity, have made large volun ­ of short speeches and several lengthy “ora- tary contributions in money and real *: Dixmont opened on November 11, 23 I 1862, with another special train from Pittsburgh. On that occasion the Pittsburgh, Fort Wayne and Chicago Railroad provided enough cars to trans­ port the entire household of 111 patients along with all their attendants and other members of the staff from the Western Pennsylvania Hospital. The building at Dixmont was a typical Kirkbride structure with accommodations for seventy beds in each wing. It was lighted with gaslights and heated with a central hot air system. According to Dorothea Dix, the ventilation in the build­ ing was “excellent ” and there was an “abundance” of fresh water from the Ohio. The west wing of the building was not completed and occupied until 1868, at which time construction on the east wing began. Superintendent Henry A. Hutchinson, M.D. standing in front of As was typical of nineteenth-century a three-story wing of Dixmont. Hutchinson, the second hospi­ tal head, served in that position from 1884 until 1945. asylums, most of the food was produced on the hospital grounds. The farm not only tions ”—the Gazette called them the “intel­ provided vegetables but also extensive lectual feast for the day”—everyone “took dairy and poultry products. There was a to the baskets.” When the crowd fin­ ished eating the food that the hospi ­ tal’s board of managers had provided, they went to look over the site of the future hospital. Although the river was narrow at that spot, the site Dorothea Dix had selected was described as a “garden, smiling with whatever is beautiful.” The surrounding hillsides were cov ­ ered with tall elms, the broad fields “waved” their “burdens of corn and grain ” in the breeze, and trim hedgerows divided the meadows into neat squares. In the distance the smoke rising over the river and the “scream” of steamboat whistles reminded the gathering of “commerce and its dependencies in the far off world. ” With the fleecy clouds in the sky it was a picture, according to the Gazette, to which the painter “Turner Formal gardens on the south lawn, Dixmont. alone could do justice.” 24 large orchard that contained apple, sweet Hippocrates was perhaps the first and sour cherry, pear, quince, peach, and doctor to reject the supernatural trappings plum trees from which the patients picked that most early physicians accorded men­ and canned the fruit. There was also a tal illness. In writing of epilepsy, known bakery that supplied much of the bread, by the Greeks as the “sacred disease,” he rolls, cakes, doughnuts, and pies con ­ declared, “The Sacred disease seems to me sumed by the patients and staff. A green ­ to be no more divine and no more sacred house provided flowers for the wards, din­ than other diseases; but springs from nat­ ing room, and grounds. ural causes like other diseases.” At the i Dixmont continued to be associated same time Hippocrates claimed “Men with the Western Pennsylvania Hospital ought to know that from the brain, and as a “department ” for the mentally ill until from the brain only, arise our pleasures, as 1907, when it became a separate entity well as our sorrows, pain and grief . . . and known as the Dixmont Hospital for the by the brain, too, we become mad or deliri­ Insane. In 1945, it was taken over by the ous, and filled with fears and terrors . . .” Commonwealth and the name changed to But Hippocrates was the exception. Dixmont State Hospital. Many Greek physicians and those who fol ­ lowed them over the next two thousand years shifted back and forth between belief in psychic and somatic origins for mental illness. Prior to the nineteenth century, however, which of the origins a physician believed in made little difference in the treatment accorded to his patients; it was seldom humane. Those who j ascribed somatic sources resorted to blood ­ letting and purging as means of therapy; those who believed in psychic origins resorted to chains, flogging, and the appli ­ cation of terror and torture to dispel the spirits inhabiting the individual. The objective of any of these treatments was to quiet the disturbed, their forced silence being about the only measure of a treat­ Portrait of despair —patient at Philadelphia State Hospital, ment’s “success.” probably taken in early 1960s. By the end of the eighteenth century which of the two views—the somatic or the Origins of Insanity psychic—was current at a given time Since the time of the ancient Greeks, depended largely on the understanding of physicians have debated the origins of the mind-body relationship prevalent at insanity—whether the condition was somat ­ the time. Frequently physicians ascribed a ic, the body was diseased and affected the mix of the two causes (the somatic and the mind causing the symptoms (the excite ­ psychic) in their treatment of patients. ment, delusions, or fits); or was psychic, Benjamin Rush, for example, believed that “outside of the body, ” with the mind causing the origins of insanity were somatic, the the bodily symptoms. Belief in the later, of result of an excitement of the blood vessels course, led to the reasoning that the men­ in the brain, and often resorted to blood tally ill are possessed of evil spirits. letting to relieve the “pressure ” on the

1; brain, but in general treated his patients heat stroke, and religious excitement. 25 along moral or psychic grounds. Although the catalog of activities ascribed Fifty years later when John Curwen as causes was lengthy and filled with addressed the crowd assembled in 1859 for unusual, sometimes exotic-sounding rea­ the cornerstone laying at Dixmont, he sons, “unknown ” or “not assigned ” were I summed up the thinking at mid-century cited for about half of the admissions to concerning insanity and the hospitals that the state’s hospitals well into the twenti­ the state had begun erecting for those who eth century. suffered from it: The idea that the complexity of life in There are even yet many prej­ an increasingly urbanized and industrial­ udices to be overcome in the public ized society leads to mental illness has mind in respect to the insane. May never been confirmed. Moreover, as early these friends here not be turned as 1848, Thomas Cope questioned this aside from their course by any senseless clamor. We can trace the widely-held assumption about the cause of spirit of opposition to these noble insanity. In March of that year he wrote in institutions back to the time when his diary: the insane were treated like We are apt to think the culti­ brutes, chained, whipped, and vator of the soil is more exempt caged. Things are now different. from mental anxieties than the We of the medical profession know Citizen. The annual Report of the how the impression goes abroad . . Pennsylvania Hospital, makes the . an impression that an asylum of following exhibit: Of 633 male this kind is a terrible place, a patients, 95 are farmers, 49 place of punishment and almost of labourers, 19 physicians, 40 clerks, disgrace. We wish, however, that it 28 carpenters, 21 shoemakers, 18 could be seen by all as we see it, seamen, 15 teachers. . . . Not one how necessary it is that as soon as merchant is named in this list of possible those showing symptoms the insane and yet the life of a of insanity should be sent to the merchant is a life of constant care asylum. Insanity is a disease of and anxiety. Can it be that imagi ­ the body affecting the mind, and nary evils are more injurious to we treat it as a disease, and we the mind than actual misfortunes? need the patient under our care in Although there have been many stud­ the early stages of his sickness. ies claiming to show a relationship between Although insanity had been common such events, for example, as economic hard to the Western experience since the times and an increase in the incidence of Middle Ages and there was a growing con ­ mental illness, these are seldom convinc ­ viction among the physicians during the ingly linked as true causes and effects. asylum era that it was of bodily origin, the Newspapers in Philadelphia (The Evening belief was still widespread among the pub ­ Star and the Press) questioned, for lic and some professionals that anxiety instance, whether or not the surge of new brought on by personal mishaps or by such admissions following the Panic of 1873 to general causes as industrialization the city’s almshouse and Blockley (its accounted for many of those who were insane ward) was legitimate, stating their afflicted. The reasons given in the early concern that the public was being swindled Pennsylvania asylum records (as diag ­ by those who wanted room and board. nosed at the time of admission) included: overexertion, grief, failure in business, The Civil War domestic trouble, financial difficulty, intemperance, excessive study, disordered The Pennsylvania State Lunatic menstruation, loss of job, use of drugs, Hospital at Harrisburg had been open

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Bands were poputar items at many of the state hospitals. They were often made up of both patients and attendants. Pictured here is the group at Harrisburg State Hospital in 1885.

V slightly less than a decade when the treat battle casualties was enormous. The nation exploded in civil war. The ground North alone sustained 275,000 wounded immediately across the Pennsylvania men during the four-year conflict and the Canal in front of the hospital became the soldiers who suffered from diseases such most important staging ground and train­ as dysentery and diarrhea (which killed ing camp in Pennsylvania for the Union more than 57,000) numbered in the hun­ Army. Life in the camp was primitive. dred thousands. Antisepsis was unknown, Laundry and bathing facilities were and anesthetics often unavailable. almost nonexistent. Hospitals were makeshift and equipment The hospital soon became an exten ­ primitive. (See Morrison, p. 624.) sion of the camp. Officers marched large Many of the nation ’s doctors had had groups of men up to the hospital to take little more than a few years of apprentice baths. And, according to Superintendent duty with a more “experienced ” physician John Curwen, the kitchens at the facility before they were thrown into field hospi ­ “cooked hundreds of pounds of beef and tals. Those who had graduated from med­ pork ” as well as prepared “thousands of ical colleges often had taken no more than gallons of coffee ” for the men. The soldiers a year or two of courses in medical sub­ reciprocated. Several regimental bands jects and then, with little practical experi ­ played for the asylum residents. ence, had begun treating patients. Of much greater importance, however, Whenever there were major battles, the Civil War was to have a profound hospitals were called upon to send doctors impact on the country ’s youthful medical to the scene of the conflict. Physicians profession. The demand for physicians to with surgical experience were particularly

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; a in demand. As John Curwen wrote in a neurologists, who treated nervous diseases 27 r letter to Dr. Kirkbride, “under the urgent and the psychiatrists who treated patients call of the Governor [Curtin] for medical with personality disorders, developed \ men to go to Gainesville [probably Gaines mutual feelings of suspicion and distrust. Mills] to attend to the wounded, I have Eventually the disagreements turned into * allowed Dr. Schultz to go with the party open hostility. The neurologists berated which will leave here at 1 AM tonight. ” the psychiatrists as being “hospital admin­ Solomon S. Shultz (later the superin­ istrators ” rather than physicians, while tendent at Danville State Hospital, 1868- the psychiatrists claimed the neurologists 1891) and J. A. Miller, two of Curwen’s were interfering in areas that were histor ­ assistant physicians, were also undoubted ­ ically the responsibility of psychiatrists. ly among the local doctors who from time to time were called on to examine incom ­ Danville ing recruits at nearby Camp Curtin. In addition to producing an abun­ Seventeen years after the opening of dance of trained surgeons as well as the Pennsylvania State Lunatic Hospital refinements in surgical practices and at Harrisburg, the General Assembly equipment, the Civil War led the medical passed legislation “to establish an addi­ profession to develop a new discipline, tional State hospital for the insane.” It neurology. The large number of soldiers was to relieve pressure on the Harrisburg i ' with damage to their nervous systems facility by covering the “northern district of the state” which included Monroe, 1 caused by gunshot wounds led to this new medical field. As the writer Albert Deutsch Carbon, Pike, Wayne, Susquehanna, . put it, “Neurology as a profession was Wyoming, Luzerne, Columbia, Montour, practically created by the Civil War.” Sullivan, Bradford, Lycoming, Tioga, (Deutsch, pp. 246, 276.) Clinton, Centre, Clearfield, Elk, Cameron, There was almost no demand during McKean, and Potter Counties. the war, however, for psychiatrists to treat Act 49 of April 13, 1868, provided for mentally ill soldiers. Several members of what was to become the Danville State the Association of Superintendents of Hospital. The legislature directed the Hospitals for the Insane, including building commissioners to erect a Thomas Kirkbride, did bring the problem Kirkbride building, by expressly stating in of insane soldiers being discharged with­ the act that it “shall be in strict accordance out any provisions for their safe return with the propositions on construction of home to Surgeon General Joseph Barnes’s hospitals for the insane adopted by the attention. Association of Medical Superintendents of Many of these men wandered about American Institutions for the Insane.” the country confused, destitute, and half John Curwen, one of the commission ­ naked until someone took them to a near­ ers charged with erecting the hospital, by asylum. In his reply to the superintend ­ made a preliminary survey of the district ents, the surgeon general pointed out that and recommended locations from which a all insane soldiers were to be sent to the site selection commission made the final Government Hospital for the Insane at choice. He gave them a long list from Washington (later St. Elizabeths), and which to choose. directed the superintendents to transfer The commissioners —probably the any such patients from their facilities most distinguished group of site selection there. The army’s practice, however, of dis­ individuals in the history of the charging them;untended continued. In the Commonwealth —included Governor John ► decades that following the Civil War the W. Geary, the Speaker of the House

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28 sioners unanimously concluded that a 250- acre farm lying on an extensive plateau 101 feet above the river at Danville was ideal. The farm was originally owned by Daniel Montgomery (founder of “Dan”- ville), whose son left it to his daughter, Recent photograph of the "Isaac Ray" Margaret. Margaret married W. W. building, the last Pinneo, who as executor of her estate con ­ ward on the male veyed it to the commissioners for the state ■ side of the Danville State Hospital. Note hospital. in the exposed sec ­ The Pinneo farm included a fine tion the original orchard, and adequate spring water for under-structure stone cooking and drinking. It lay on a branch of that was quarried on the grounds. the canal and railroad in the center of the hospital ’s district, and had extensive stone, brick-clay, and sand on the premises with sufficient lime for making cement located nearby. Moreover, it was situated in a rich agricultural district so that flour, grain, and articles of produce were “conve ­ niently available” at the “lowest price. ” The commissioners also judged that Danville could provide “such a population ” from which “may be draw[n] the majority of those who may be engaged for the vari­ ous positions in the Institution. ” Although in 1868 the population of Danville was only 3,600 and the area was Wilmer Worthington of Chester County, rural, there were iron mills, blast fur­ the senator from Allegheny County, naces, and rolling mills in full operation in Russell Errett (both legislators being the community. Iron ore was mined in the members of the Committee on Charitable hills west of town and brought on a nar­ Institutions), along with Thomas row gauge railroad down to the mills. Kirkbride, Dorothea Dix, Isaac Ray (a pro ­ Danville was also proud of its four ­ lific writer on medical issues, especially teen hundred-seat opera house, said to be insanity, and possibly the most brilliant of surpassed in elegance and comfort in the founding members of the Association Pennsylvania only by Philadelphia ’s of Medical Superintendents of American Academy of Music. The wealth and philan ­ Institutions for the Insane), John thropic spirit of the town can be noted by McArthur Jr. of Philadelphia, the architect the citizen’s backing of the project with a for the hospital, and Solomon S. Shultz, contribution of $16,123.12 toward the who had been appointed superintendent of $26,600 price the state paid for the land. the new facility. Governor Geary came back to Danville The commissioners visited farms in on August 26, 1869, for the cornerstone the neighborhoods of Williamsport, laying. The town was decorated that day Bloomsburg, Wilkes Barre, Towanda, Lock as a “vast concourse ” for the parade to the Haven, Tunkhannock, Athens, Bellefonte, hospital site. Isaac Ray delivered the and Danville. When they met in address. He told the gathering: Harrisburg on July 2, 1868, the commis- I r We come together to lay the A chapel was located on the top floor 29 foundation of an institution unlike of the center building. It doubled as a lec­ most of those that give rise to occa ­ ture and concert hall. At one end of the sions like this. The structure hall, a small gallery accommodated “the > whose massive walls are to rest on this spot is to commemorate no dissolving apparatus to which the gases r victory of war, no triumph of a required for illumination are brought by cause achieved by sacrifices of life iron pipe from a place convenient for their and property. It is designed to min­ manufacture in the cellar.” ister to the advancement and glory The hospital opened on October 18, of no sect or party. It is designed 1872. The first patient arrived three not even as a storehouse of the treasures of science and art. . . . weeks later. During the next year 210 No, my friends, it is nothing of the patients were admitted. Of these, forty- kind. four men and twenty women, who were The institution we now inau­ from the district Danville served, were gurate with solemn ceremonies . . . transferred from Harrisburg. springs from those common Although Schultz provided the usual instincts and virtues of our nature which have received from the civi­ statistical tables in his first annual report, lizing influences of our time a he explained that the “square cut figures scope and direction unknown to of tables . . . fail to teach,” that the causes the polished nations of antiquity. of insanity are seldom straightforward, To relieve suffering both of body and that even the professional has difficul­ and mind; to rescue helpless men ty eliciting them from the family or the and women; to lead back the wan­ dering mind out of the darkness patient. and mazes of disease into the As the superintendent wrote, “Among unclouded light of reason; ... to the sources of fallacy under this head, is I improve this ministry to the disor ­ also the giving of only one cause, when it dered mind by the intelligent would be difficult, if not impossible to 4 application of medical science— describe correctly which one out of half a such are the ends which it belongs to enterprises like this to fulfill. dozen was most potential. The last one of a series gets the credit of mischief which Solomon S. Schultz, the first superin ­ belongs equally to a number, any one of tendent at Danville, had served at which would have been lifted into promi ­ Harrisburg as a first assistant to John nence had it been the last to come into Curwen and as a surgeon at several Civil play.” War hospitals. His initial task at the new As a further illustration of statistical hospital was “to lay out, grade, and error, he cited the confusion over the rela­ Macadamize” the roads of approach and to tionship between alcohol and insanity. “In * the rear of the building, so that “all the other words whether a particular person materials could be drawn to the ground in shall be insane, or a drunkard may the easiest manner.” depend upon the merest accidental trifle, t The completed structure was 1,143 and drunkenness may be as much an evi­ feet long. The center building contained t dence or symptom of a disordered nervous seventy rooms for offices and apartments system as insanity, so that statistics are at for the superintendent, assistant medical fault if they always ascribe the insanity of ’ officers, steward, and matron; a dispensa ­ a drinking man to his intemperance. ” ry, library, sewing room, kitchens, and din­ Schultz also claimed that such infor ­ ing rooms; as well as storerooms for gro ­ mation as “duration of the disease before ceries, meat, medicines, and “tin and stone admission ” is frequently wrong as it is ware.” usually “dated only from the first uncon-

L 30 trolled outburst of excitement, ” while it it apparently had a restraining effect. was “generally recognized that well John Curwen, for example, proudly told a marked and decided insanity may exist newspaper reporter (Harrisburg Telegraph when the person still knows everybody October 10, 1902) that he had been sub­ and remembers everything. ” jected to only one habeas corpus request Solomon S. Schultz served as superin ­ during his career. i tendent at Danville for twenty-three years While an individual could be placed in and built an institution that Thomas an asylum by relatives or friends or legal Kirkbride would have been proud of. Not guardians, as a safeguard from capricious only was the structure itself of Kirkbride commitments, this could only be done on design, but Schultz’s “cheerful cordiality, the receipt of a sworn certificate by two or sympathy and a rare degree of tact, which, more “reputable physicians” following combined with a sense of humor, was their “personal examination ” of the man or effective ... to a notable degree ... in his woman. treatment of his patients, ” reflected This safeguard was not, of course, Kirkbride’s therapeutic methods. failsafe as in a few pages Adriana Through Schultz, Danville became the Brinckle’s tale, “Life Among the Insane” “type and example of what such institu­ will show. tions should be.” According to a biographic sketch in the Board of Public Charities Asylum Architects 1891 Annual Report, Dr. Shultz was not only “zealous and judicious in the treat­ John Haviland ment of the insane,” he also “properly and wisely applied . . . the vast sums of public In the early decades of the state’s asy­ money with which he was entrusted.” lum-building years, the architects were chosen from among those who had a solid reputation, especially for designing public Habeas Corpus buildings. The trend started with the Patients’ rights did not first become an selection of John Haviland, of Phila­ issue in the 1960s. The right of a patient delphia, to construct the first state hospi ­ to communicate with an attorney and to tal at Harrisburg. Haviland, who was an have a judge issue a writ of habeas corpus, English-trained architect, had opened his “commanding that the alleged lunatic be practice in 1816. Among the major struc­ brought before him for a pubic hearing, ” tures he had been credited with by 1848 was affirmed by an act of the General were Philadelphia ’s Walnut Street Assembly in 1869. Act 54 of April 20 that Theater, the Franklin Institute, and sever­ year made it unlawful “for any superin­ al city churches. tendent, officer, physician or other employ ­ Haviland was best known, however, ee of an asylum to intercept, delay or for his design of the Eastern State interfere with, in any manner whatsoever ” Penitentiary. This facility, which was such contact between a patient and his or renowned worldwide as a model peniten ­ her attorney. The act also guaranteed tiary, “gave every prisoner a separate cell patients the right to a trial by jury. (with its own exercise yard) arranged At any hearing of habeas corpus, the along corridors radiating from a central law specified, “the onus of proving the core —a scheme that offered maximum alleged lunatic to be insane shall rest surveillance with a minimum of superviso ­ upon such persons as are restraining him ry personnel. ” (George B. Tatum, article or her of his or her liberty.” The number of “John Haviland,” Macmillan Encyclopedia hearings under the act was not large, but of Architects) Rather than an extrava- gance, the separation of prisoners was 31 intended to “avoid contamination ” from other prisoners as well as to isolate them so they could reflect on their sins. In spite of Haviland’s reputation, f John Curwen began to complain about the building —both in his annual reports and correspondence —soon after he arrived in Harrisburg. His complaints, however, of '> doors not closing properly and of windows leaking air appear to have been the result of faulty construction rather than design. Then in 1881, when Jerome Gerhard replaced John Curwen at Harrisburg, and began calling for replacement of the hospi ­ tal building, he placed the blame for the building ’s problems squarely on its con ­ struction. The time has come, I most firmly believe, when it is our duty to press upon those in authority the necessity of reconstructing the entire institution. This hospital has served a good purpose for one generation, but the buildings have Contemporary photograph of the center building at Danville State always been unsatisfactory. They Hospital. Erected in 1869 from a design by John McArthur Jr. were badly constructed in the beginning, have been a constant Although City Hall has never been expense to keep in repair and can considered architecturally distinctive—one never be made secure against fire. writer calls it an “insult to taste” and And ten years later, in Gerhard’s final another proclaims that “its only claim to year as superintendent, when the legisla ­ distinction should be the marvelous man­ ture was still ignoring his pleas for a new ner in which it combines bulk with ster­ building, he made one last appeal by ling insignificance ”—today it immediately invoking the memory of Dorothea Dix. He signifies “Philadelphia” as does no other quoted her as having told him that she building. could not help but feel that “it would be a McArthur (May 2, 1823-January 18, good thing if it would burn to the ground, 1890) first came to prominence at age providing the patients and everybody were twenty-five when his design of a new safely out of the building. ” House of Refuge Building for Philadelphia received first prize. He went on in the John McArthur Jr. 1850s and 60s to design a number of major hotels for Philadelphia, including In 1869, the same year that John the La-Pierre, the Continental, and the McArthur Jr. had been chosen to design Girard House. The Girard House, on the Commonwealth ’s second state hospi ­ Chestnut at Ninth, had accommodations tal, which was to be located at Danville, for a thousand guests and boasted a mag ­ the Philadelphia-based architect also was nificent ironwork balcony. The Continental appointed the chief architect for Hotel, which stood across Chestnut from Philadelphia ’s City Hall. Kitchen in the old Kirkbride Building at Harrisburg, with cart being readied to transport food to one of the patient wing buildings, 1890s. the Girard, included an elevator among its the cost of putting up large buildings legis ­ attractions and was considered the town ’s late against them, public sentiment outstanding lodging place. demanded a more restrained approach. During the Civil War McArthur was The erection of hospital buildings such as put in charge of building U.S. hospitals at those at Danville and Warren, which took Annapolis, Philadelphia, and San years to complete, gave way to those that Francisco. He was also responsible for the were more economical and more quickly design of Philadelphia ’s Public Ledger erected. Building and several private residences, Coupled with this turn in public and most notably that of the journalist George political sentiment, the medical profession, W. Childs. too, began a spirited debate over the Although the cornerstone to nature of appropriate hospital design. The Philadelphia ’s City Hall was laid on July population of most mental hospitals had 4, 1874, the structure was not completed grown well beyond the expectations of until 1900. The building, which contains those who built them. This overcrowding more than six hundred rooms, cost $23 led to cries of patient “warehousing ” million. According to Fodor ’s tour guide of rather than treatment, and to suggestions the city it is the “largest city hall in the that a “cottage ” approach to hospital con ­ country and [without supporting steel] the struction was better suited than the old tallest masonry-bearing building in the Kirkbride monolithic, linear design. world. ” At the end of the nineteenth century, Joseph Wilson, Addison Hutton, and as the nation moved from the Victorian John Dempwolf Age into the modern period, the monu ­ mental and extravagant designs of the Well into the twentieth century—even earlier period gave way to more modest with a change in design criteria— and functional approaches. Not only did Pennsylvania continued to employ archi- tects who were known for their municipal 33 buildings to design its mental hospitals. Among them were Joseph Wilson and Addison Hutton of Philadelphia, and John Dempwolf of York (See “The Cottage I Plan”). Today, a century and a half after they were erected, the only remaining rep­ resentatives of the early asylum-building years in the state are the two that John McArthur Jr. built at Danville and Warren. Wernersville State Hospital, 1895. Located on the second floor of Building 12 over the dining hall, this seven-hundred-chair hall The Board of Public Charities was used for assemblies and religious services.

On April 24, 1869, Governor John W. thrown in the face) to quiet them, or who Geary signed a bill establishing a Board of used the “stomach pump, ” a rubber tube Public Charities. The resultant board, used to force-feed patients who were trying which consisted of five commissioners, was to starve themselves to death—had fueled to have “full powers, ... at all times to public and press criticism of asylums and look into and examine the condition of all led to requests for legislative action. charitable, reformatory or correctional Responsible newspapers such as the institutions within the state.” Philadelphia Evening Bulletin and Public The board ’s responsibilities not only Ledger and the Lancaster Express came to included all financial matters—which, at the defense of the hospital superintend ­ least, for the first few years predominated ents and their facilities. ‘Yellow ” journal ­ in their activities—but also the “govern ­ ists, however, played up habeas corpus i ment and management ” of hospital cases (almost all of which were overturned “inmates”; the “official conduct ” of by the courts) and wrote lurid, sensational trustees, directors, and other officers and articles including ones that fed the popu ­ employees, the “condition of the buildings, lar fear that sane people were being held grounds and other property ”; and “all in the asylums against their will. other matters” of their “usefulness and A few judges even began to believe good management. ” The commissioners that lay people were as capable as doctors were to have free access to the grounds, in determining who was sane and who was buildings, and all books and papers relat­ not. John Curwen wrote to Thomas ing to the institution. Kirkbride about a case he had had at Moreover, they were “authorized and Harrisburg in 1870 in which a man who required ” to visit all of the state’s charita­ was violent when drunk was released by a ble institutions at least once a year, the judge after witnesses testified they never county and city jails or prisons and alms had seen him under the influence of or poor houses at least once every two liquor. The night after the judge released years. him, the man got drunk and forcibly tried The General Assembly established the to enter the judge ’s house. “Ever since,” Board of Public Charities for a number of Curwen wrote, “the patient has been kept reasons. Habeas corpus suits by complain ­ safe in the hospital by order of that judge. ” ing inmates and newspaper articles that Even more important to the legisla ­ painted sensational pictures of asylum ture, however, the creation of the Board of life—of attendants who choked patients, or Public Charities eliminated the burden of used “douches ” (a bucket of cold water reviewing the large number of reports 34 being sent to the governor and the legisla ­ vate institutions ”—the “keeping of the ture and then of separately determining insane poor in jails and filthy apartment each facility’s appropriation. in county alms-houses, without proper Before the creation of the board, the care or medical attendance”—than trustees and superintendents of each hos ­ because of conditions in state facilities. pital (along with all other state charitable Although things changed in later years, facilities) had prepared lengthy annual the board ’s first report in 1871 actually reports addressed to the governor and the lauded Curwen’s facility: legislature. These were designed, at least The Board have made several in part, to support their statements of visits to this institution, and have need for additional staff, money for new been highly gratified with the buildings, repairs to existing facilities, or earnest and intelligent administra­ tion of its interest, under the wise new equipment. Asylum statistical data superintendence of the physician- such as that showing “cure rates,” percent in-chief, Dr. John Curwen, who of “restorations ” of the “number treated” has occupied this position since or of the “number admitted,” even the February 13, 1851. occupation and place of nativity of those 1 Eventually however, the board devel­ being treated, were aimed indirectly at : justifying a hospital ’s claim not only of oped an agenda of changes that ran counter treatment “successes,” but also of the to the asylum practices the hospital super­ great need remaining. intendents—following Kirkbride’s lead— Now the superintendent ’s reports had developed from early in the nineteenth went to the Board of Public Charities. It century. The main thrust of the board ’s ini­ was the report the board compiled from tial recommendations, more correctly those it received from around the state demands, pertained to the admittance of that was sent to the governor and legisla ­ paying patients at state run facilities, the ture. Moreover, the board now decided removal of the chronic insane to separate how much to ask for each institution (asy­ buildings, and the nature of the “authority ” lum, prison, orphanage, almshouse). This (and ability) of the superintendents. meant that the state’s asylums had to

compete, not only with each other, but also The board wanted state institutions to stop taking paying patients. They with all the other charitable groups for an believed that by following the superinten­ appropriation line in the board ’s budget request. dent’s vision of the asylum as a “multi­ class institution, ” the “State had been Many of the older superintendents drawn away from her clear duty [to the such as John Curwen at Harrisburg saw poor] , to enlist in a scheme of charity [for the board ’s establishment as an attack on those who could pay] which is never recog­ their authority within their institutions. nized as the proper function or duty of the (After several meetings with the board, state.” It was the board ’s position that this Curwen wrote to Thomas Kirkbride: “I was a form of personal patronage being found their charity towards me was limit­ dispensed by the superintendents to their ed. I think the word charity will not con ­ friends. The superintendents held that vey the true intentions of the actions of their admittance policy let them select that board. ”) paying patients to give a needed democrat ­ The Board of Public Charities had ic balance to their institutions by includ­ been established, however, more because ing those who were educated, genteel, and of the “bad conditions of the county poor curable and those who were not. houses and jails, and the abuses of the The board also recommended that the inmates of these and other public and pri-

II

.... ;>• , I: J state use the hospitals it had built for had to be a member of the bar and anoth ­ 35 treating those that were curable, and er a practicing physician, each of at least remove the chronic to separate, less ten years’ standing. expensive structures. This, they believed, Among the new powers the act gave would reduce the demand for building new the hoard and its new Committee on hospitals in the style of those already Lunacy were the right to license all

► erected. Such a two-tiered systems (with “places in which any person can be patients housed in inferior facilities) was detained as a lunatic, or of unsound exactly what Dorothea Dix and Thomas mind,” and, with the consent of the chief i Kirkbride had fought against earlier. justice of the Supreme Court and of the ► The board began to criticize Curwen attorney general, to establish rules and » i and his concept of an asylum, rather than regulations governing such places. » Thomas Kirkbride, according to Nancy Moreover, the Act of May 8, 1883, ► r Tomes, because of the latter’s eminence in named a large number of specific areas for the profession. which the committee was to prescribe reg ­ i Initially it was Curwen’s practice of ulations. The regulations were to “insure accepting paying patients rather than only the proper treatment of persons detained”; . the indigent insane that was challenged, to “guard against improper or unnecessary but later the board began attacking his detention of such persons, ” to “establish \ “authority ” within the hospital. The Board the forms to be observed warranting the believed that asylums “should be subject commitment, transfer of custody ” of to the supervision of some party not con ­ patients; to “specify the reports and infor ­ nected with their immediate manage ­ mation ” to be furnished by the superin ­ ment,” then later went so far as to claim tendents; to appoint inspection boards in * \ that the “Authority of experts is limited.” every county; to “insure” that all “proper Ultimately, the Board of Charities visitors, members of the family, personal t began asserting its own authority by pro ­ friends, or attorneys ” were given admis­ * posing several changes in asylum practice. sion to patients; and to withdraw the ) The board first recommended moving the license of any house or place for violations criminally insane from the penitentiaries of the act or the rules that the committee to state hospitals. The superintendents, established. believing that a secure hospital wing for It further specified that each estab­ convicts would further increase the “moral lishment which was subject to the act had odium ” attached to insanity and to their to keep the following “books” : An admis­ institutions by blurring the “distinction sion hook, a discharge book, a case book in between virtue and vice,” prepared a which the hospital regularly entered all “memorial ” in February 1874 to the legis ­ the facts bearing on each patient and his lature requesting that the board ’s proposal or her case, and a medical journal in be rejected. Kirkbride, Curwen, Isaac Ray, which, at least once a week, a statement S. S. Shultz of Danville, and J. A. Reed of was “written of all matters which are of Dixmont signed the memorial. special importance bearing on the treat­ 9 Although the memorial was success­ ment and condition of the patient. ” The ful, the legislature eventually backed the act also mandated that a person had to be board it had established. Nine years later examined and the “results of the examina ­ the legislature increased the powers of the tion reduced to writing ” within twenty- Board of Charities as well as its size. The four hours after an individual was admit­ 1883 act directed that the “board shall ted. appoint a committee of five to act as the By the end of the nineteenth century, committee on lunacy.” One of the members the Kirkbride model of an asylum had fall- • i •

:: 36 en from its pedestal—both his arrange ­ to get legislation providing for housing the ments for a hospital building and his criminally insane at Danville, the board method of ministering to the mentally ill. did win a partial victory in its campaign to Attacks by the Board of Public Charities have separate facilities constructed for the on the authority of the superintendents, chronic ill. and by younger physicians anxious to The superintendents, especially establish their own credibility in the treat­ Curwen and Kirkbride, also vigorously f ment of the insane ultimately led to its contested that plan. In the superinten­ downfall. dent’s memorial to the legislature, Curwen wrote that separate asylums for the chron ­ “Insane Asylum Warfare ” ic ill meant that they would degenerate The success of the asylum superin­ into “receptacles for the safe-keeping of an afflicted class . . . rather than [serve as] a tendents in thwarting the Board of Public curative institution. ” According to Curwen, Charities’ efforts to establish a department to make real progress the state must build for the criminally insane at Danville made enough asylums for all the indigent insane. the board and its president, George While separate chronic buildings were Harrison, even more determined to assert their authority over the management of not erected until several decades later, the board was successful, in getting Curwen’s the state hospitals. subsequent appropriation bills amended to The struggle between the two groups prevent him from taking any paying as well as within the medical profession patients as long as there were indigents unleashed what one superintendent called seeking care. Then later (in 1893), rather “insane asylum warfare.” than separate buildings for the chronic ill For some reason, in spite of its benign on existing hospital grounds, the board country-doctor image, medicine historical ­ J was able to get the legislature to erect an ly has been blistered by discord. In the entire hospital, Wernersville, for them. mid-twentieth century it was the struggle Controlling his admittance policy, of over the advent of health insurance and course, weakened Curwen’s ability to mold fear of a “socialization ” of medicine. In the the character of his institution. Moreover, late nineteenth century it was over the in having demonstrated its power with the nature of providing for the indigent legislature, the board gained significant insane. ground in the struggle to establish its The nineteenth-century debate of lay authority over the superintendents. versus professional control over the deci­ By the 1880s, the clash between the sion-making process in ministering to the superintendents and the neurologists not insane was aggravated by several addi­ only had come into the open, it had tional factors: the elitism among the vari­ become rancorous. The neurologists ous professional disciplines, (e.g., the neu­ averred that although the superintendents rologists versus the psychiatrists); the his­ might have started as physicians they had toric argument over treatment methodolo ­ I gies (whether it was the body or the mind become largely administrators. Medicine had changed greatly since that needed curing); and whether the the first decades of the nineteenth century, proper treatment should be aggressive or when doctors, including most of the asy­ less assertive. With the insane, of course, lum superintendents, had taken a few such side issues as whether and when to courses in medicine as part of a two-year use restraints added yet another layer to program and then gone into practice. the controversy. The new generation of physicians— Having been blocked in their efforts the neurologists and the younger psychia- trists (the “young Turks” as they came to Although his report was scathing, 37 be known) —were anxious to assert them­ Mitchell made several recommendations selves and their ideas on treating the that in time began to bear fruit. He sug ­ insane. Paramount among their proposi ­ gested revision in patient employment, tions was the rejection of Kirkbride’s lin­ which he claimed was poorly planned; he ear building and his ideas of moral treat­ recommended increasing recreational and ment. The new generation of doctors was exercise facilities, more variety in diet, interested in employing a dispersed “cot ­ and a lessened use of mechanical tage plan ” rather than a single monolithic restraints. All these he asserted would hospital structure for ministering to the reduce the appearance of the asylum as a insane, and in treating their patients ’ prison. He also suggested educating the somatic symptoms rather than their psy­ public in newspapers and lay journals to chic condition. change the public ’s impression of insanity Along with the Board of Public as always dangerous. And he recommend ­ Charities, the young Turks believed that ed placing greater emphasis on treating S the chronically ill should be isolated to patients outside of the confines of the asy­ permit the professionals to concentrate on lum. those who were deemed curable. They also In time, many of Mitchell’s recom ­ condemned the current asylum arrange ­ mendations came to pass, some not until ment on the ground that it failed to pro ­ well into the twentieth century. Others, duce substantial research capability and however, were implemented soon after he \ certainly no results. made them. Training schools for asylum In an 1894 talk to the American nurses and attendants began to appear at Medico-Psychiatric Association (the name hospitals around the country, women the Association of Medical Superin­ ' ! physicians began to treat female patients, : tendents of American Institutions for the and medical schools, which previously Insane had given itself the year before), S. were indifferent to courses on mental dis­ Weir Mitchell, the eminent neurologist of ease, began added such material to their his day, leveled these charges against the curriculum. asylum superintendents directly. He was Benjamin Rush’s Medical Inquiries sharp in his criticism, especially of their and Observations upon the Diseases of the isolation from general medical practice: Mind, the only text on mental illness for Yo u were the first of the spe­ seventy years, was soon replaced by newer cialists and you have never come works; the first two, as Deutsch (The back into line. . . . You . . . live Mentally III in America ) pointedly apart. . . . Your hospitals are not our hospitals; your ways are not observes, being written by neurologists. our ways .... You live out of In the ensuing decades the power of range of critical shot; you are not the Pennsylvania Board of Public preceded or followed in your ward Charities continued to grow, that of the work by clever rivals, or watched superintendents of the asylums declined. by able residents fresh with the In 1923 the Commonwealth adopted its learning of the school. [Your annu­ al reports are filled with] too com ­ first Administrative Code, which reorgan ­ fortable assurance of satisfaction. ized the structure of state government and [Your practices show] too many specified the basic powers and duties of signs of contented calm born of iso ­ the executive departments, boards, and lation from the active living strug ­ commissions. gle for intellectual light and air in Previously, in each statute authoriz ­ which the best of us live. ing an institution, the legislature had 38 declared the board the governor was to story Howard K. Petry’s son Robert tells appoint to be a “body politic and corpo ­ about his father, who was the superintend ­ rate.” The new code made these boards ent at Harrisburg State Hospital from administrative bodies in the Board of 1934 to 1954. Whenever the father, a Public Charities, which two years earlier physician, drove his son through the hos ­ ' had become the Department of Welfare. In pital gates after a trip “downtown ” to visit t 1955, a further change was made making an administrator at the Department of the role of the boards of mental health Public Welfare, Robert remembers him institutions “advisory ” in place of “admin­ saying, “It sure is good to get back home, istrative.” where we know who the crazy ones are.” The debate over lay versus profession ­ Today the state hospital superintend­ al control continued —if not to rage —to ents are not required to be physicians, but 4 simmer for more than a century. are often managers appointed to their posi ­ d Symptomatic of its perseverance is the tions by the Department of Public Welfare.

44 Life Among the Insane” it is also nearly impossible to believe that John Curwen did not know of her ; The Story of Adriana Brinckle situation, and still acquiesced in keep ­ In 1885 the Lunacy Committee of ing her. the Board of Public Charities ordered — In his admittance book he left the in a unanimous opinion —the release of columns under her name for “Apparent Adriana P. Brinckle from the Asylum Cause of Insanity” and “Occupation ” for the Insane at Harrisburg. She had blank, and wrote “friends” in the one been there for twenty-seven years. Two for “Committed By.” Rarely did he miss years later her story appeared in the entering some diagnosis for cause of North American Review. insanity and wrote under occupation Adriana’s story—with its Ibsenian for other female patients “daughter of overtones of a strong-willed young farmer, physician, etc.” woman, determined to make her own He certainly released other way, and a weak man fearful of a loss patients—even when first admitted— of family “honor" —unfolded twenty that he declared were not insane. But years before Ibsen’s A Doll ’s House men (and women) in powerful positions appeared. are sometimes guilty of irresolute As tragic as her story may appear actions. we should remember that the middle of Adriana’s story is included here, the nineteenth century was an age of however, more for the picture it paints rigid ideals, a time when prison was a of life in a nineteenth-century frequent outcome for indebtedness or Pennsylvania asylum. And, of course, theft (conversion) of someone else’s the actions of the Board of Public property. Moreover, honor —one ’s name, Charities and its Lunacy Committee do even one ’s signature —was given much deserve to be characterized as com ­ greater currency than today. mendable. As small an act as it was, Still, knowing this, it is hard to the posting, that Adriana mentions, of believe that a Judge of the Pennsyl­ a notice that grievances could be freely vania Supreme Court would have par ­ sent to the committee indicates that ticipated in such a shameful affair, and the men of the committee were sincere ?

39 in their efforts to reach out to and help tion was by no means neglected; for I those who were incarcerated in asy­ received a thorough training in the ? lums. The men of the committee must ordinary English branches, became have suffered through countless frivo ­ quite familiar with the French lan ­ lous letters to find the few that guage, and acquired a thorough knowl ­ deserved their attention. edge of music. : Regardless of which of the three I was naturally of a gay tempera ­ insane-asylum-warfare principals ’ posi ­ ment and inclined to extravagance, and tions we may feel was the more just, I knew that I had my father to help me each of the warring factions —the out of possible financial straits. In the superintendents, the lay Board of year in which I was placed in the asy ­ Public Charities, and the “young Turk” lum there was a general panic and my -■ neurologists —did have the best inter­ father was unable to pay my debts. ests of the indigent mentally ill at The particular difficulty in which I heart. became involved was that of buying fur ­ niture on part credit, for a parlor which Adriana’s story, condensed, but in her I had rented in the home of two old own words ladies. Their house was small and I I do not think any woman in had no room for a piano. I therefore America is better qualified than I to moved to a large house securing fur ­ supply the material for a good sermon nished parlors. Having no use for the t on insane asylums —for I was locked up furniture which I had purchased, I sold in one for twenty-eight years. During it. This proceeding came to the knowl ­ I those years I never lost my reason —it is edge of the dealer from whom it had i k i a wonder I did not —and so what I say been purchased, and he prosecuted me. I ! may be relied upon as being truthful. Before the time came for my appearance My story is simple. I was put in the in court I was placed in the asylum. asylum for two reasons: the first was My father was advised to take this i- course by the late Judge George W. ; that I was extravagant and too fond of : dress. The other that my family wanted Woodward, then of the Supreme Court me relieved of the disgrace of being of Pennsylvania. Judge Woodward, who accompa ­ publicly accused of obtaining goods -i under false representations, by resort ­ nied me [to Harrisburg], represented A ing to the insanity defense. that it was better than being impris­ My father was William Draper oned in a jail, and that insanity was Brinckle, a physician, who lived in after all the bluntest horn of the dilem ­ Girard Row, Philadelphia. My mother ma, because it preserved family honor. I died while I was young. was led into the presence of Dr. John I was placed in the State Hospital Curwen and Mrs. Cole, the matron. To for the Insane at Harrisburg, Penn., on these people Judge Woodward, in my July 14, 1857 (hospital records show presence, spoke of my extravagant ten­ her admittance date as July 13, 1858), dencies; what he said when my back on the commitment of two physicians, was turned I do not know. He wished one my father, the other a stranger to me good-bye rather sorrowfully, and I me. My father, occupied with his profes ­ think when he left it was with a little sional duties, was of course, much away remorse at what he had done. from home, so that I grew up, wander- Everything in the institution was ins at my own pleasure. Yet my educa- strange to me. They put me in the best

Vl-j-JivS'. 40 ...... ward at first. I found life insupportable but it seems his family thought the hos­ dull. The only things that made exis­ pital would be a good prescription to tence tolerable were music, which I cure a certain intemperate disposition loved passionately, and fancy work, with which he was afflicted. He was which I liked less because of its monoto ­ addicted to the use of wine. My father ny. It was change, however, from the and Judge Woodward wrote to Dr. sameness of idling. Curwen, asking him to put a stop to our My nurses were Susan Spiegelmyer meeting. and Ruth Noble. At the end of a year in For seven years, however, we wrote the asylum, under the kindly care of letters to each other, and we were all these nurses, an attack of dyspepsia, along determined that I should become from which I suffered prior to my incar ­ his wife. It was the knowledge of his ceration, disappeared. I think the regu ­ being near me that made me less active lar way of living and the plain food in my efforts to escape. At the end of the effected that cure. seven years of which I have spoken, my In my observation [however] the friend was removed from the asylum, I nurses at the Harrisburg Hospital, for think to the Pennsylvania Hospital for some reason or other, were not all the Insane in Philadelphia. I have com ­ rational beings. Perhaps it was the con ­ pletely lost trace of him. tact with mad women, Perhaps the fact Untrained nurses in a hospital for that some were promoted to be nurses, the insane know no more about treating first having been patients, made this insane people than I know about pre­ seem to me true. scribing for a case of fever. The secret of In June 1858, my father came to proper conduct toward the insane is see me for the first time, and compli ­ management. It requires tact. The ex­ mented me on my rosy cheeks and gen ­ laundry-woman or factory girl who erally healthy look. That was all very becomes a nurse cannot understand well, but I wanted to get out, and I told such a problem as the mind, and when him so. He promised me that if I would the patient is refractory [stubborn] she wait until the troubles caused by my can only meet it with brutality. Those debts had blown over he would have me who are deprived of reason cannot released. Then he went away. I never understand violence, nor has it any saw him again, and he died four years good effect on them. I have seen a later. He wrote to me, however, and gave patient who had been struck look in me the impression that my release surprise at the nurse who struck her, would be a more difficult matter than and ask, “Why do you do that? What anticipated. The man who can be said have I done? ” We may just as well to have managed my detention was thrash a cripple for limping, or vent our Judge Woodward, whose visits to me malice upon a blind man because he were frequent. cannot see. Soon after my arrival at the asy ­ The only way in which patients lum, I met at a picnic given to all the can get on the right side of sane nurses patients a young inmate of good family. is by doing their work for them. They He was a son of a judge of one of the are often expected to help to sweep and upper counties of Pennsylvania, well clean up. I saw a harmless patient who bred and entertaining. After meeting was sitting listlessly on a heating regis ­ several times we became engaged to be ter attacked and beaten because she married. He was not considered insane, would not work. One nurse knocked her Interior of the old laundry at Harrisburg State Hospital, 1910.

down and then called another nurse to I am happy to certify that during her assistance. Together they got a the entire period of my incarceration I patient afflicted with homicidal mania personally received mild and courteous treatment from the superior officers of t to join them and the three pounded the unfortunate creature until she was the institution, as well as from the black and blue. attendants. [The circumstances of ) One of the patients in a ward Adriana’s confinement probably were adjoining mine was found one morning well known throughout the hospital.] ► hanging with her head wedged between When I was playing a melodeon or ' > the transom and the doorframe. She doing embroidery, I watched the peculi­ r was quite dead. How she had even got arities of those around me. Mary, a in that position was a mystery. patient from Carlisle, who was admired * Probably one of her associates helped for her self-possession, smiling face, her up with a chair and then removed and quiet demeanor, took up a. chair, \ it. one morning, and attacked an atten ­ t Altercations with patients are, of dant with it. The latter eluded her, and \ course, frequent from the very nature of the chair went against the wall with so their maladies, and the position of a much force as to break the plaster. \ nurse or attendant in an insane asylum Some lunatics seem to live in a is a very trying one. It requires great world of their own. An old lady once ) patience and force of character, accom ­ astonished and amused us by exclaim ­ panied by a high order of intelligence. ing, without any warning or provoca ­ r No two cases are alike. tion, “Two cats and the bird of paradise ¥

42 are waiting to convey you to your heav­ pital in full chase after him. He eluded enly home, and you are to sit for nine them, pawned his watch to raise money, days between the cats and the bird of rallied his friends around him, and paradise. ” Then she stopped, and forgot shortly afterward returned to the insti ­ that she had said anything. Another tution for his clothes—a free man. He patient lived in the bathroom, and had never been insane but was commit ­ lr* made friends with the rats (they were ted to the hospital, through some con ­ numerous). Some one else thought she spiracy, on the certificate of irresponsi ­ was the wife of President Buchanan, ble physicians. C and had the hallucination that her hus­ band frequently ran a locomotive i- The story of Adriana ’s release through Washington Avenue, Philadelphia, with a big bonnet in front In the fall of 1884 a notice, which of it, to remind her of the annoying fact the new law required, was posted in our that in her young days she had been a ward, telling us that if we had any milliner. And another woman [with grievances, we could write freely about delusions] frequently mentioned that them to the Committee of Lunacy of the she had enjoyed herself in previous Board of Public Charities. Before I had years riding on the back of a dolphin at time to avail myself of the opportunity Cape May of getting a hearing, I was taken very ill My observing powers were concen ­ and was too weak to do anything. When trated during my stay on such persons I recovered I found that the patients as these: One man who had cut his had torn down and destroyed the print throat; a murderess of her own child; a law the committee had posted, and I 4 woman who had been a nurse and who did not remember the name of any gen ­ i killed an infant, under her care; a tleman upon it. woman who had severed her child’s Fortunately, Miss Annie Drinker, a jugular vein; another who had killed convalescent, recalled the name of the medical member of the committee and her husband; one who became insane 4 through accidentally killing her child, wrote to him. Dr. A. J. Ourt, secretary and any number of patients with suici­ of the committee, Dr. Morton and Mr. i A dal mania. Philip C. Garrett, chairman of the com ­ mittee visited me shortly afterwards. 5 * Others who apparently were Soon after this the committee fully not insane investigated my case and ordered my immediate release. A victim like myself was a Mrs. Z I do not think my story can create I ------, who with her baby, was in the in the mind of the reader any but the 1 hospital. I knew her well and was cer­ one impression —that I am a wronged tain that she was not insane. Her hus­ woman. No one, it appears, is now band was thriftless, she sued him for - responsible for my incarceration. My support, and he, out of revenge, put her counsel informs me that an action will in the asylum. Her friends soon applied not lie against the State or the hospital to the court and she was liberated. authorities, as my commitment was i One man who was wrongfully •• made in due form of law. [Adriana’s placed in the asylum got out. He father and another physician had certi­ crossed the Susquehanna River far fied to her insanity.] Apart from this, ahead of his pursuers, who left the hos- all those who procured my incarcera-

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... . A I 43 I tion have since died. My release came last years of her life in the about solely under the operation of the Convalescent ’s Retreat at Glen Mills. new lunacy law of Pennsylvania, and Unlike Ibsen’s Nora, when Adriana f the zealous efforts of the gentlemen left the Pennsylvania State Lunatic whose duty it is to carry the law into Asylum, there was no one on which to r effect. slam the door. Her father and Judge :r Adriana had been one of John Woodward were dead, and John Curwen’s "paying ” patients. Since her Curwen had moved from Harrisburg to i father’s death, twenty-four years the superintendency at Warren. Nine before her release, his estate had years later Curwen was elected presi­ maintained her in the hospital. As she dent of the American Medico- only had limited funds left and “didn't Psychiatric Association. know what to do, ” Adriana spent the —i

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44 thought of them that way, opponents started to call them “palaces. ” As one nineteenth-century history described it, the cottage plan corrected “the Civil War General John lamentable inconsistency of caring Frederick Hartranft for a portion of the indigent insane * served two terms as gov­ in palaces, while an equally ernor of Pennsylvania starting in 1873. After deserving number of them are leaving office, Hartranft lying in squalor in the almshous- became the president of es.” the board of trustees of Norristown State Act 89 of May 5, 1876, to f: Hospital. He served in establish a state hospital for the k this position from 1880- insane for the city and county of 1889. Philadelphia and the counties of Bucks, Montgomery, Delaware, Chester, Northampton and Lehigh con­ tained no language —as had previous acts—directing that the building commis ­ sioners follow the plans “adopted by the Association of Medical Superintendents of American Institutions for the Insane.” It said that the plan for the new The Cottage Plan hospital “shall be in accordance with the best design for the construction of such Norristown State Hospital institutions; shall be well and securely built without expensive architectural By the beginning of the last quarter of the adornments or unduly large or costly nineteenth century, Kirkbride’s ideas on administrative accommodations. ” The act hospital construction were beginning to be went on to direct that “its general charac­ questioned. Experiments in Gheel, ter” was to be subject to the approval of Belgium with a “cottage ” arrangement in the governor and the Board of Public place of the individual “wing ” buildings of Charities. a monolithic Kirkbride structure provided After reducing the field to five archi­ greater separation of the various “classes” tects, who were invited to make detailed of patients so that the more agitated could presentations before them, the Norristown be widely dispersed from those who were building commissioners selected the recovering or less disturbed. The new Philadelphia firm of Wilson Brothers & structural arrangement (sometimes called Company to design the hospital. Joseph a segregate or detached system) also sig ­ M. Wilson, as did his brothers John nificantly reduced the likelihood that a Allston and Frederick Thorn, had a con­ fire could destroy an entire hospital. siderable reputation as both a building There were problems of perception, and bridge designer. Although Joseph too, with a Kirkbride hospital. Because of began work after graduation from their size, critics—both within the politi ­ Rensselaer Polytechnic Institute as an cal arena and the medical profession — architect and engineer for the eventually began describing such build­ Pennsylvania Railroad in charge of ings as philanthropic and bureaucratic bridges and buildings along Philadelphia ’s white elephants. Although those who lived Main Line, he first came to prominence packed in them would hardly have when he was selected to oversee the design and construction of the main exhi ­ however, Norristown can best be described 45 bition building and Memorial Hall for the as consisting of a U-shaped arrangement Centennial Exhibition in Philadelphia in of a series of dispersed mini-Kirkbride 1576. structures—each with a small center f Although the firm of Wilson Brothers building and short wings of “cottages ” on P continued the railroad design and engi ­ each side—all fronted by an administra­ neering work with which all three broth ­ tion building. Construction of the hospital ers got their start (they were responsible began in March 1878 and was completed for the Reading Terminal in Philadelphia, in February two years later. the Chesapeake & Ohio Railroad ’s Union A far more representative copy of the Station in Richmond, Virginia, and the Gheel cottage plan, however, was that Broad Street Station in Baltimore), the undertaken in the rebuilding of the first r firm erected many residences, churches, state asylum at Harrisburg by the super­ factories, and other commercial structures, intendent Henry Orth. Commencing in as well as medical facilities. 1891 Orth, who that year had followed Through the patronage of the Drexel Jerome Gerhard at Harrisburg, began a family in Philadelphia, the brothers campaign to do a complete overhaul of the designed office buildings, including the facilities at the site. Orth’s first annual Drexel Office Building (Philadelphia ’s first report was short —only five pages —but 80 skyscraper) and the Drexel Institute at percent of his annual reports were devoted 32nd and Market Streets. to the “deplorable and almost uninhabit­ The State Insane Asylum at Norris ­ able conditions of the building ” he had town was the first hospital to follow the inherited. He claimed, “the sure but grad ­ “cottage ” plan that the Commonwealth ual deterioration of the inferior materials erected for its mentally ill. Rather than a in the house has been going on for years, true cottage plan with separate buildings, and cannot be retarded.” In 1893 Orth convinced the legisla ­ ture to appropriate $100,000 to rebuild the administration portion of the old Kirkbride Building. He hired Addison Hutton of Philadelphia to design the new structure. Orth’s long-range plans—which were carried out over the next twenty years, included a central building and four cottages on each side, all connected with underground corridors. His scheme also included separate buildings for a bakery, congregate dining room, chapel, amuse­ ment hall, and a dormitory for nurses. Hutton designed the Administration Building and one for the chronic ill along with the overall plans for the site, the remaining cottages by John A. Dempwolf of York. Addison Hutton was born near Pittsburgh in 1834. In 1857 he became an Hiram Corson early advocate of female doctors to treat women patients in state hospitals. apprentice to Samuel Sloan, the well- known Philadelphia architect. Within two years, Sloan was sending Hutton south to w

46 North Carolina and Mississippi to oversee railroads and high buildings. The the building of Sloan designs for private twentieth century, with the grow ­ homes. By 1862 Hutton was receiving ing tendency of the strong to help the weak and the unfortunate . . . independent architectural commission may prove to be an age of scientific such as the one for Henry Morris ’s “cot ­ healing and more universal, 1 tage ” at Newport, Rhode Island. That enlightened, and charitable work same year he opened his own office in than has ever before been seen in Philadelphia. the world. Among the many commissions he Hutton abandoned the more severe completed —some in partnership with classical design of a Kirkbride Building Sloan —were ones for the State Hospital at and adopted what he called the “Colonial ” Middletown, Connecticut; the Third style. In this he followed the same think­ Presbyterian Church in Pittsburgh; the ing that was exhibited in some of the old 1 Ridgway Library, the Philadelphia Saving mansions he built in and around Fund Society and the Women ’s Medical Philadelphia. Hutton designed the new College in Philadelphia; and Parrish Hall, Administration Building at Harrisburg the first building of Swarthmore College. and one for the Chronic Ill. (The remain­ Hutton also designed a number of impor ­ ing “cottages ” that completed Orth’s plan tant private residences in the Philadelphia for the site were the work of John A. area, especially many of the fine Main Dempwolf.) Line homes. He served as the architect for The most original building design Haverford and Bryn Mawr Colleges. Many that Hutton produced for Orth was done of the dormitories and lecture halls on in 1900. The Chronic Ill Building, which both campuses were designed and con ­ stands at the opposite end of the site from structed by him. Packer Hall at Lehigh the Administration Building, is really two University was another of his college buildings in one. Each structure, one for buildings. the men and the other for the women, was According to his granddaughter and rotated 45 degrees so that the corners biographer, Elizabeth Biddle Yarnall, were to the front, back, and sides. Hutton Hutton had “little tolerance for the overly joined the two together with a large rec­ ornate, ” although he was “fond of finely tangular dining room to be used by the executed work. ” The Philadelphia archi­ occupants of both buildings. tect had a special affection for designing Each of the structure’s two dormitory hospitals. “I plead, ” he wrote, “that the buildings opened in the center to a large skill of an architect can modify the “airing court. ” The whole structure thus appearance of almost any thing ... so as provided maximum ventilation and sun­ to render it a thing inoffensive and, with light for the patients but afforded ade­ perhaps a slight addition to the expense, a quate separation of the men and women thing of beauty.” as well as privacy. It admirably fulfilled At a lecture Hutton gave to the archi­ Hutton ’s hope that “on every day of the tectural students at the University of year in which the sun shines, at least Pennsylvania in 1894 titled, “The three walls will be bathed in sunshine.” Planning of Hospitals, ” he summarized his views on the connection between architec­ Hiram Corson ture and responsibility for the less fortu ­ nate: Norristown and Montgomery County The Middle Ages were the were the focal points for numerous protest cathedral building centuries. The movements and activities during the last nineteenth century is the era of half of the nineteenth century.

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: A country physician, Hiram Corson, John Curwen (the superintendent at 47 was at the center of many of these. In the Harrisburg) must have considered Corson 1 , late 1850s and early 1860s, Hiram and his a troublesome agitator, as did many other 1 brother William were staunch abolition ­ physicians, rather than a constructive co ­ professional. It was Corson ’s opinion, for t ists. They were responsible for helping to engineer many escapes along the example, that the superintendents of pub ­ ' I Montgomery County Underground Rail­ lic and private mental hospitals were way. And as soon as Hiram had graduated “tyrants” over their patients as well as r 1 from the two-year medical program at the “bad managers of their facilities,” and University of Pennsylvania and entered although Curwen was never accused of i’ practice as a country doctor, he began to being despotic, he certainly believed in take up numerous “radical” causes associ ­ Thomas Kirkbride’s idea of the superin­ ated with the profession. tendent as an autocrat. - The first of these had to do with the Of all the practices in the manage ­ 1 common practice among physicians of the ment of the insane, however, Hiram i day of prescribing alcohol for medicinal Corson “deplored ” none more than the ! purposes. One biographic sketch (Theodore practice of male physicians treating Bean, History of Montgomery County, Vol. female patients. It was his belief that 1) describes how Corson approached the women were as capable physicians as issue. “No sooner had he begun his profes ­ men, moreover, that they alone should be sional routine, than he threw himself treating females. f against the whole system with the deci­ Largely as a result of Corson ’s efforts i sion of a quick mind and the cool intrepid­ the first two female physicians were hired ity of a hero. ” Hiram Corson began lectur­ at state hospitals —Margaret A. Cleaves at t ing and writing papers condemning the Harrisburg (after Curwen departed) and practice and regularly presented resolu ­ Alice Bennett at Norristown. This was the tions at state and national medical society culmination of a nineteen-year-long fight meetings attempting to get them to do the by Corson (from 1860 to 1879) both pub ­ same. This later technique of introducing licly and within the Pennsylvania Medical ► resolutions year after year to medical soci ­ Society that initially rebuffed his efforts. eties of which he was a member became Only after Corson gained the support of > one of his standard “activist” approaches the Montgomery and Lancaster County for the causes he undertook. Medical Societies was he able to overcome Hiram Corson ’s next mission became a the domination by physicians from lifelong one —to improve the treatment of Philadelphia and get the state society ’s i the Commonwealth ’s mentally ill. In 1877 position changed. Finally in 1879, largely he wrote a series of newspaper articles through his efforts, the General Assembly ► about the ‘bad management of the insane passed an “Act for the Better Regulation of in the Montgomery County Almshouse. ” the Female Insane.” The act unfortunately The articles came to the attention of made the appointment of female physi­ Governor John F. Hartranft, who as a cians optional rather than mandatory, as result appointed Corson a trustee of the Corson had originally written it. State Hospital at Harrisburg. When We should not consider Hiram Corson made his first inspection as a new Corson, however, as simply a medical trustee, he immediately charged, ‘beside activist. He was the author of numerous the torturing appliances, pleasantly called papers, most notably several on scarlet ‘restraining measures,’ there are cells in fever and diphtheria, and was reported as which they [the patients] could be shut up the originator of the ice-treatment for for slight breaches of rules.” those diseases. Some of his other articles 48 included ones on “Pneumonia, ” “Diseases the increase (see “Wernersville and Act of Children,” “The Use of Opium in 272”). Nonetheless, the sense of a need for Obstetrics,” and “Meddlesome Midwifery,” wider individual control over the nation ’s which from the title we can assume he did political and business environment that not favor. His ice-treatment in treating grew out of the changing economic, politi ­ scarlet fever and diphtheria proved effec­ cal, and economic conditions certainly con ­ tive and eventually came into general use tributed to the conviction that the state throughout the United States. In spite of bore greater responsibility for the care of his radical views on various reform sub­ its less fortunate citizens. And this in turn jects, he was honored by medical societies led to a willingness on the part of policy and the profession at large. makers, especially those in state legisla ­ 1 tures, to provide for the nation ’s indigent Search for New Measures insane. The decades between the Civil War During the last half of the nineteenth ' and the turn-of-the-century were marked century most physicians, philanthropists, by significant changes in the nation ’s busi­ and politicians believed that, at least in ness, political, and social makeup. The part, the growing number of patients was failure of the North to impose its political a reflection of the nation ’s industrializa­ and business system on the South through tion and urbanization. Legislatures, Reconstruction, as well as the Panic of including Pennsylvania’s General 1873, which was brought on by excessive Assembly accepted the proposition that it railroad construction, and which led to six was the price that society paid for change lean years for the nation ’s economy, espe­ and thus the state should assume the bur­ cially that of its growing industrial might, den in providing facilities and care for created feelings of dissatisfaction with the those who unfortunately bore the direct * consequence of the nation ’s growth. economic and political, and to a lesser , degree, the social systems of the country. The final decades of the nineteenth At the same time, the period leading century marked, therefore, not only the to the twentieth century saw a shift from coming to maturity of the medical profes ­ a nation of “island communities ” with sion, including psychiatry, but also a their “personal, informal ways,” as the search by the legislature for the means to writer Robert H. Wiebe describes it, to one control as well as to provide for the grow ­ of an “urban-industrial life” with its “regu ­ ing numbers of the state’s poor mentally lative, hierarchical needs.” ill. It is difficult, of course, to trace any direct connection between these changes Warren State Hospital and the increased number of those being By the Act of August 14, 1873, treated for mental illnesses. The growing Governor John F. Hartranft was author ­ number of patients in the state hospitals ized to appoint three commissioners to 1 might be attributed to an expanded popu ­ select a site and build a hospital for the 4 lation (Pennsylvania’s nearly tripled in the insane of the northwestern district of the < fifty years after the opening of the state state: the counties of Erie, Crawford, 4 hospital at Harrisburg), or to a greater Mercer, Venango, Warren, McKean, Elk, < receptivity to placing family members in Forest, Cameron, and Clarion. Governor such facilities, or to other causes, rather Hartranft appointed Dr. William Corson, I than to industrialization or urbanization. Dr. John Curwen, and General James A. i Edward Shorter, for example, believes Beaver (Pennsylvania governor, 1887- that neurosyphilis was the major cause for 1891). The commissioners were instructed t

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Construction of the hospital, designed by Philadelphia architect John McArthur Jr., began in 1874. It was not finished until 1882.

to select “good arable land, with an ade­ in accordance with the propositions of the quate supply of pure water, and large facil­ Association of Medical Superintendents of ities of drainage from the buildings, ” which American Institutions for the Insane. It lay “within convenient distance from some consisted of a main four-story center build­ town, and easy access by railroad. ” ing with three horizontal sections on After surveying more than seventy either side at right angles to the center farms in the several counties of the dis­ building. Each of the three wing struc­ trict, the commissioners purchased three tures was connected by transverse wings contiguous farms totaling 330 acres for parallel with the center. Although the $33,000 in the heart of rich farmland in structure was considered to be “fire-proof, ” Warren County near the mouth of the the floors were Georgian pine and the rest Conewango River, on lands that David of the woodwork, walnut, ash, and oak. f Rittenhouse of Philadelphia had originally The cornerstone laying ceremonies surveyed. The commissioners reported took place on September 10, 1874 before that the high ground in the rear of the an estimated crowd of five thousand peo ­ main property was “covered with wood, ” ple. After describing it as the “fourth edi­ ► and contained “sufficient stone for the fice of the kind within the Common ­ erection of the hospital building, of a good wealth” (the second, in Philadelphia, was quality, easily worked, and of a light not strictly speaking an asylum for the cheerful color. ” And they observed that at insane but a Training School for Idiotic the “base of this elevation ” were “ample and Feeble-Minded Children), the “fourth supplies of brick clay from which the brick great monument of her beneficence and can be made for the construction of the charity,” Governor Hartranft told them: interior walls.” Is there a more fitting channel The commissioners hired John through which the current of her McArthur Jr. as architect based on his bounty and benevolence could previous experience at Danville. The flow? No scientific or social prob ­ lem has been more perplexing building was planned as a Kirkbride struc­ than the treatment and care of the ► ture; it would be one of the last ones built insane and modern civilization has

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) 50 given no more striking and noble appropriations were often made piecemeal manifestation than the earnest­ from year to year as intermediate work ness with which the world was completed. In the fifth year of work on addresses itself to the solution of the building, the superintendent for con ­ this problem. struction, John Sunderland, reported the No part of the policy of the carpenter shop, which had been set up on \ State has reflected more honor the grounds to make the finished wood ­ upon her citizens than the omnis ­ work and furniture for the hospital, had cient provisions she has made for her insane, and it is a satisfaction produced 1,971 window frames and 1250 to know that the beneficence so doorframes. Moreover, according to creditable to her mind and heart, Sunderland, the finished building con ­ < < has not been misapplied, and that tained 1,465,643 pounds of iron beams and much and permanent good has 31,500 perches of stone. been accomplished by this charita­ ble work. The construction plan was unique. The wings were put up first in reverse order, In addition to copies of Governor from the extremities to the center building, Hartranft’s address and the Memorial of which was erected last. In this way the the Medical Society of Pennsylvania rec­ commissioners hoped to provide first for ommending building the hospital, the com ­ “the excited class of each sex, which are missioners placed a copy of the plans and always the first admitted” and then “By the specifications for the hospital along with a plan adopted, . . .[provide for] nearly two set of the paper currency and silver thirds of the whole number for which the coinage of the United States for 1874 in hospital is designed. ” the cornerstone. There was some grumbling by the Construction of the hospital that staff over this inverse construction plan; began in 1874 was not completed, howev ­ the building commissioners dismissed this er, until 1882, partly because of the size of by stating, “no one is properly calculated the task, but also because the legislature ’s to be an officer of a hospital for the insane, who is not willing for a time to suffer some personal inconvenience for the benefit of those entrusted to his charge. ” A year after the Warren State Hospital opened, John Curwen, who had 1 spent thirty years at Harrisburg as super ­ intendent, became the hoopital ’o hoad. He fillod his new position for nineteen years. 4 Asylum Afflictions. Flic and Disease It seems inappropriate to speak of psy­ chiatrists as having fears, but the two most dreaHeH events in nineteenth- and early twentieth century asylums wore fire and contagiouc diooaco. Asylum superin ­ tendents looked upon the prospect uf either with apprehension. ^ ' Birds-eye view of Warren State Hospital. Probably taken in the 1970s In the crowded conditions oi a hospi ­ after farming was discontinued. tal ward an infectious disease could quick ­ ly become nil

2 i , in a building with patients locked in their Harrisburg. While the outer portions of 51 rooms could have devastating results. stone were substantially undamaged, the Thomas Kirkbride had devoted con ­ restoration of the structure’s interior was siderable thought to the issue of fire. not completed for three years, at which [ Chapter XXXI of his On the Construction, time the women returned. Organization, and General Arrangements From that time on Danville State of Hospitals for the Insane was devoted to Hospital maintained a ready, well- ways to construct buildings so that fires equipped fire department of staff members i would be minimized and if started could who trained regularly. Periodic fire drills be contained at the point of origin. Roofs were also held for the patients and staff. were to be of tin or slate; side walls were In 1896 the hospital acquired “motorized i to be “arched” and “run up from the cellar equipment ” and, according to the Danville f to the roof ’; the buildings were to have Intelligencer, by 1934 had a modern chem­ “stone floors, and iron doors on one side” ical truck, hook and ladder truck, thou ­ . of each ward to prevent a fire commencing sands of feet of hose, and a full-time paid t in one section from spreading to any other. foreman —thirty members from the vari­ A Kirkbride hospital was to be heated by ous departments of the hospitals served as steam and the fires for generating the firemen. steam were to be in a detached, fireproof Other Kirkbride buildings suffered structure. In a subsequent chapter from fires, but apparently not significant Kirkbride covered the “Means of enough to cause a loss of life. In such Extinguishing Fire,” which recommended cases, the superintendents apparently the availability of iron tanks of water in chose not to mention them in their annual the attic and the maintenance of an effec­ reports. Adriana Brinckle states (see “Life tive “night-watch. ” Among the Insane”), that during her twen­ Notwithstanding the concerns and ty-eight years at Harrisburg there were attention given to preventing them, most five fires in the house, one of which was of the state hospitals suffered from fires, severe enough that it required the hurried some quite heavily. While these were usu­ evacuation of the building at night. r ally in the outbuildings —the barns, laun­ Perhaps the most tragic Pennsylvania dries, kitchens, and icehouses —at least asylum fire occurred not at a state institu­ * one fire virtually destroyed a main build­ tion but at Philadelphia ’s Blockley ing. On Saturday evening, March 5, 1881, Almshouse —a forerunner of Philadelphia a fire ravaged the center administration State Hospital. Ten male inmates, who building, all the female wards and a quar ­ were locked in their rooms and secured to ter of the male wards at Danville State their beds, died in the February 12, 1885, Hospital. The fire began in a closet on the conflagration that, according to the female side of the house. Philadelphia Inquirer, left “only the walls Fortunately most of the patients were of the insane wards standing. ” gathered for a program in the auditorium Just weeks before the disaster, a at the time the fire was discovered, so group of consulting physicians, including their removal to the outbuildings was car­ the distinguished S. Weir Mitchell, had ried out in an orderly fashion in spite of inspected the facility and cited it for the snow and slush on the ground. Several numerous fire hazards. Although they of the 220 male patients escaped, however, faulted the building as “highly com ­ in the confusion but were returned within bustible, ” it was the manner in which the a few days. The 172 female patients were patients were handled that received the cared for in the outbuildings until they greatest condemnation. The hospital ’s par ­ could be transferred to Warren and alytics—who would need individual assis- 52 tance to exit the building, were housed on Fire and disease then were the two the fourth floor. Inmates who were consid ­ most feared pestilences that beset asy­ 1 ered dangerous were cuffed to their beds lums; asylums crowded with patients, and then locked in individual cells on the many of whom were unable or unwilling to third floor, the locks requiring consider ­ escape their arrival. able effort to open due to their age. To get to the fire escape once released, such Wernersville State Hospital patients had to walk through three wards, each of which was secured from the next With the Act of June 22, 1891, the I by a lock that required a unique key. Pennsylvania legislature provided for the Moreover once unlocked, the doors swung construction of yet another hospital for the inward rather than out. insane. By 1890 the population of patients 1 Less dramatic than fires but much in the five state hospitals had increased to more frequent and the cause of greater 5,200. The condition of many of these, per­ losses of life was the occurrence of infec­ haps 85 percent, was considered to be tions that quickly turned into epidemics. chronic. Lacking any medical prognosis of One of the observations each hospital recovery, state officials foresaw little superintendent liked to make at the begin ­ chance, other than death, of the eventual ning of his annual report to the governor release of these patients who were begin ­ and the legislature was that the hospital ning to fill up their institutions. At the had been “free of infectious disease.” same time, these chronic insane required There were years, however, in which minimal medical treatment or even atten­ this could not be done. In 1890, for exam ­ tion. Considered as beyond cure, their only ple, Solomon S. Shultz of Danville had to need was for custodial care. state, “we were visited with an outbreak of The General Assembly presented dysentery which continued nearly three Governor Robert E. Pattison with two months, affected 12 per cent of the alternatives for the care of these chronic patients, and caused 12 deaths. Additional insane. One would return them to the city patients were affected with diarrhoeal and county almshouses, the other would troubles; of these two died.” authorize the construction of a new hospi ­ Schultz went on to make the point tal. The governor vetoed the first bill and * that “mortality would have been less had approved the second. not insane delusions in a considerable The hospital at Wernersville—the number interfered with and frustrated all result of the 1891 Act—was designated to efforts at treatment.” He also attributed relieve the pressure that housing these some of the deaths to “feeble and old per­ chronic ill placed on the existing facilities. sons, who succumb at the first onset of It was fully the legislature ’s intent, howev ­ every trifling affection. ” er, that the new hospital be self-sustain­ Periodically, each of the hospitals ing. The act specified that as soon as the reported outbreaks of other diseases such commissioners had acquired the land for as diphtheria or typhoid fever, usually the facility along with temporary quarters, with less impact than the 1890 dysentery they transfer twenty able-bodied harmless episode at Danville, but with deaths still chronic insane from each of the hospitals frequently resulting. Then later during for the insane, to the premises and farm World War I, influenza struck most of the provided, for said asylum to engage in state hospitals, in some cases with heavy farm work, grading, macadamizing, exca ­ losses. At Wernersville, for example, fifty- vating for buildings and such other three male patients and four employees employment as may be required. died during the epidemic. Accordingly in early July 1893, after 1

having selected property near Reading — and to do this the very best talent 53 ► known for its pure water and fresh air must be used in the attendance on spas—three of the five commissioners the patients. Governor Pattison had appointed to over ­ The Wernersville building commission ­ ► see site selection and construction person ­ ers selected the architectural firm of ally visited Danville, Norristown, and Rankin and Kellogg of Philadelphia to r Harrisburg and selected one hundred male design the hospital. John H. Rankin, the * and thirty female patients to work at the senior partner of one of the most success­ site. During the hospital construction, the ful Beaux-Arts firms in Philadelphia, had men were housed in an old mill and a been born in Lock Haven. He and Thomas barn and the women in a cottage that Kellogg were both graduates of the two- t came with the property. year architectural course at Massa­ While the women prepared meals in chusetts Institute of Technology (M.I.T.) » the kitchen of the cottage, the men began Rankin worked with Wilson Brothers and * * converting the pigpen adjacent to the mill Company following his graduation in 1889 into a bathroom. Pipes were connected to and Kellogg held a position with the lead­ ► the boiler in the mill. Women bathed on ing architectural firm in New York, i Thursdays and the men on Saturdays. McKim, Mead, and White, at the start of i One of the patients, a carpenter, added a his career. t room on the west of the washhouse for use Although Rankin and Kellogg had as a laundry drying room. He also made founded their own firm not too long before I tables, benches, and other furnishings their selection as the architects for the required for use in the dayrooms. While Wernersville State Asylum for the ► most of the male patients were busy fit­ Chronically Insane, the firm soon became ting out the barn as a dormitory, another, ► very successful at winning contracts to a stonemason, began building a stone wall design government buildings. (It is possi- at the pond inlet. u. At the cornerstone laying on f November 29, 1892, Governor Pattison told the assembled crowd that “The nineteenth century marks the dawn of the treatment of the insane. . . . The erection of insane hospitals has resulted in the greatest good to the entire people, for many lives had been rescued from dun­ geons. Through their efforts and treatment, there has been a decrease instead of increase in insanity among i the people. ” The governor then elabo ­ rated on his ideas of caring for the insane: In some of the institutions I a J 5 A have visited the very cheapest labor is used in the corridors at night. This is wrong. I would like to see even a more minute classi­ fication of the insane, with a view Wernersville Administration Building, about 1912. The bell in the Independence of effecting a cure, if possible, Hall look-alike tower was rung each evening as a signal for patients, field workers, and their attendants to return to the hospital. The tower was removed in 1961. 54 ble, of course, the men were recommended by Wilson Brothers and Company, Rankin’s former employer, who had built the state hospital at Norristown in 1876.) Among Rankin and Kellogg ’s commis ­ sions in the ensuing years were the U.S. Post Office and Federal Building in Indianapolis, Indiana, the U.S. 1 Department of Agriculture Building in Washington, D.C., and the U.S. Army Supply Depot in San Francisco. In the 1 Philadelphia area, the firm was responsi ­ ble for the Chestnut Hill Academy, the Provident Trust Company bank, the Elverson Office Building, the Camden (New Jersey) County Court House, and the Philadelphia Post Office, among oth ­ ers. They also erected numerous private residences, hotels, schools, libraries, and churches throughout Pennsylvania as well Wernersville Administration Building foyer in 1896. as the Homeopathic Hospital in Buffalo, New York. lar arrangement of a series of dispersed mini-Kirkbride-like structures each front ­ ed by an administration building. The patient-occupied buildings were constructed of steel and concrete with and roofed with 3late. The Administration Building was constructed of brick and wood. The dormitories are separated by open spaces from each other and the Administration Building, but are all inter­ connected with enclosed corridors. One unique design feature, however, of the 1 Administration Building was its close sim­ ilarity in appearance to Independence Hall The patients at Wernersville had to be “able-bodied, harmless, chronic insane.” Print shop at Wernersville State Hospital in 1920. This fully- They could only be admitted on transfer equipped letterpress-offset facility regularly printed nearly two from other state hospitals or county hundred different administrative and medical forms. almshouses, and they had to have been The hospital at Wernersville was sim­ insane for more than a year. They were ilar in design to the one at Norristown, employed in farm work, or in the orchards, t adding weight to the possibility of, if not gardens, kitchen, bakery, laundry, or the direct involvement of Wilson Brothers sewing rooms. In the first years there and Company in securing the contract for were seven mechanics, three tailors, five Rankin, the firm’s influence through him cobblers, four painters, eight carpenters, on the hospital ’s design. The Rankin- nine mule-team drivers, a blacksmith, a Kellogg structure consisted of a rectangu- mason, and a printer. The remaining male ft

* : Taking in the hay at By berry, 1932.

patients were laborers. The work of the pitals almost from the beginning —but we patients was “voluntary, ” although the ini­ do not know this from the voluminous sta­ tial act specified that: “Patients shall be tistics about their patients that hospital i assigned for labor by the superintendent superintendents began collecting in the ... in farm or ward work of other useful middle of the nineteenth century. Until labor, for the purpose of enabling said late in the century, no statistical record of inmates to contribute ... to the cost of their presence was kept. On occasion we I their maintenance.” find a passing mention of a black patient It was the attendant’s duty to “direct” in the text of a hospital annual report or a and “encourage ” patients in their assign ­ newspaper article, but nothing more. ► ments. Each attendant leaving the ward Blacks probably were more likely with patients became their foreman in the than whites to be assigned to county field. In September 1894, a “company ” sys­ almshouses rather than the state hospital. tem was organized along military lines. County officials probably objected to pay­ Each foreman had between fifteen and ing the state to take a black; moreover, twenty patients. Each of the twenty-five they also may have seen the labor they companies at Wernersville was identified performed on the local poor farm as a nec­ army-style as Company A, B, C, etc. essary exchange for the cost of keeping Over the years the hospital was self- them. Transporting them, too, from the supporting, manufacturing and planting urban areas to the first state facilities, everything needed for daily living. In gen ­ which had been erected in the middle of eral patients built all grounds improve ­ the Commonwealth, would have been con ­ ments—roads, bridges, stone curbing and sidered prohibitive. walks. One of the ten inmates who died in the 1885 fire at Philadelphia ’s Blockley Blacks and the Asylum Almshouse, for example, was identified as an African American by the Philadelphia The information available on African Inquirer. And Jerome Gerhard, who fol ­ Americans in the Pennsylvania state hos ­ pital system is sketchy. We know that lowed John Curwen as the superintendent at Harrisburg, noted in his 1887 annual there were such patients in the state hos- 56 report that he helped a black gain his free­ ness of the ward patients to admit them.”’ dom through a habeas corpus proceeding. While it is doubtful that the provisions The man, who had been sent to the hospi ­ of the AMSAII’s policy would have had any tal from the Eastern Penitentiary, “did not influence at rural hospitals such as show any symptoms of insanity.” Gerhard Danville, Warren, or Harrisburg, where wrote: the number of blacks was likely insignifi ­ He was industrious and anx ­ cant, it is possible that at facilities such as ious to make money. I allowed him Norristown, Wernersville, and later to work on the new building, and Philadelphia separate wards were main­ to keep all he could earn. After he tained for them. had saved thirty dollars, I applied A review of the annual reports at to court for an order to discharge ; him, which was granted and he Norristown shows that the first year that left the Hospital a happy man. African Americans were reported in the Much of the lack of information can be statistical charts for the hospital was 1886 when there were 17 out of a total popula ­ attributed at mid-nineteenth century to the small number of blacks (less than 2 tion of 708 patients. This number rose to percent of the total population) in the 29 in 1887, and 32 in 1888 and 1889; the Commonwealth. The superintendents population of whites showed a correspon ­ probably saw little need to collect data on ding increase in those same years. such a small sample of individuals. The Blacks were not reported as patients number of blacks in rural areas—where at Wernersville until 1901, but the size of the first state hospitals were erected—was the population that year—thirty-six out of probably even smaller. a total of eight hundred patients—would indicate that they probably had been in The superintendents were, of course, the hospital much earlier. That year, too, susceptible to the same biases as were Wernersville’s superintendent Samuel S. present in the general population. At an Hill specified that of the blacks, twenty- early meeting of the Association of Medical four were men and twelve were women. Superintendents of American Institutions By 1914 the population had risen to fifty - for the Insane (AMSAII), for example, it one blacks, of who thirty-nine were men was agreed that—although separate build­ and twelve were women. None was identi­ ings need not be constructed —it was desir­ ?! fied as a child, and no further breakdown able to keep blacks separated from the by type or cause of illness, county of ori ­ white population. Generally the doctors gin, employment status at time of hospital had no problem with mixing them, but entry, or length of stay was supplied. One they believed that it would cause anxiety might assume that the twelve women among their white patients. were chronic cases, but this is simply spec­ In northern states other than ulation. Pennsylvania, separate facilities were usu­ Grob summarizes the situation ally provided. This seldom meant separate regarding African Americans in mental buildings, but rather segregated wards. hospitals up through the mid-twentieth According to Gerald Grob (Mental century: Institutions in America), several states, Like the overwhelming majori ­ including Indiana and Ohio, simply ty of most white Americans, virtu­ refused to admit African Americans. At the ally no member of the psychiatric ;• Massachusetts General Hospital, Grob profession was willing to challenge quotes the trustees as being “confronted the dominate separate but equal with the ‘painful necessity’ of rejecting doctrine that was the basis of pub ­ *11 black applicants because of the ‘unwilling- lic policy. ... A few who might

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have been opposed took the posi ­ [their new] urban situations ” 57 I tion that their function was to pro ­ When John Logan arrived at vide care and treatment and not to Harrisburg State Hospital as a new physi­ educate the public on racial issues. cian following World War II, he encoun ­ . . . Concerned also that integrated T hospital wards might undermine tered no black patients at the facility. public and legislative support for There were also few blacks working there. their institutions, they followed Today they are there in significant num­ what appeared to be a reasonable N bers as both employees and patients. [ and logical policy. When the Department of Welfare took Poor Farms over the responsibility of data reporting Most of Pennsylvania’s counties and from the individual hospitals in the 1920s, ► large cities ran poor farms or poor hous ­ blacks were still less than 5 percent of the es—some like Blockley were called state’s population; however, beginning in almshouses. Along with the state’s jails, the 1940s their number began to grow at a I the poor farms were the primary source of pace faster than that of the general popu ­ material for Dorothea Dix ’s 1848 memorial lation. By 1960 they numbered 852,750 to the legislature. These facilities were statewide, which represented slightly used to house the aged poor, those the more than 7.5 percent. courts had found guilty of nonviolent In one of the few demographic studies crimes such as vagrancy or had been specifically targeting blacks and mental judged incapable of paying their debts, health in Pennsylvania, Robert J. Kleiner \ along with the community ’s indigent of the Philadelphia Region Commonwealth insane. The county poor farms were more Mental Health Center reviewed data (from jail than refuge. A man and woman usual­ an unidentified source) for the five-year ly were paid to run them with the hope period 1951 through 1955. He reported that some work could be gotten from those t that there were 2,013 new admissions of housed there in return for the county ’s blacks to all Pennsylvania mental hospi ­ cost of maintaining the farms. The pur ­ tals during those years. pose of many of these Dickensian facilities Kleiner’s study—which was designed I was more to get the individuals away from to review the impact of migration on men­ the general population than true humani­ tal health—disclosed that African tarian concern for the state’s less fortu ­ Americans who had moved from the South nate. to the North “clearly” were “under-repre­ One of the objectives of the 1848 act sented” when compared to blacks already providing for the Commonwealth ’s indi­ living in the North. However, black gent insane had been to remove them from “Southern females [who had moved to the the county ’s care to the state hospital, North] showed more mental illness than which was anticipated to have not only a [black] males [who had come north] ,” “curative” function, but also a uniformity while among Northern migrants [those in treatment which was lacking across the who moved between northern states], it various counties. was the male that was “over-represented Since the establishment in 1848 of the in the patient population. ” first state asylum, the policy pendulum of Kleiner’s tentative conclusion con ­ state vs. county care has swung back and cerning females was that Southern forth, the legislature insisting at one point migrant families being “matri-centered” that the mentally ill should be treated in placed a considerable burden of responsi ­ state hospitals, and then (when the state bility and stress on married females in facilities became too crowded) that the 58

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Patient snow removal crew at Byberry, 1935.

excess patients could be transferred back cians as medical superintendents, were to the counties. staffed by trained nurses, and gave care Since the counties had to “pay” for equal to that of the state hospitals, several each of their residents housed at a state counties openly converted their poor farms facility, they usually objected to the legis ­ into county mental hospitals. The state lation mandating state care, and then Board of Public Charities considered the stalled or even refused to transfer patients standards beyond the reach of most poor to the state hospitals because the cost of districts, so two years later the legislature keeping them on the poor farms was con ­ amended the law to require only that the sidered less than the state charged for board be satisfied with the equipment and them. And, although some state hospital care provided. superintendents objected when the coun ­ Soon after the Department of Welfare ' ties did not send them all their patients, was created in 1921, it closed seven when overcrowding became serious licensed and one unlicensed county “asy­ < enough at the superintendent ’s facility, he lum.” In 1934, however, there were still conveniently overlooked the laws directing thirteen county “mental hospitals ” caring the counties to send them to the state hos ­ for 14,361 patients 1 pital. Finally, by the act of September 29, « Eventually many of the poor farms 1938, the legislature assumed direct con ­ were closed by the counties, but in 1897, trol of eight of the county public mental when the General Assembly—in yet anoth ­ hospitals as state hospitals and closed the er policy reversal—authorized payment by remainder. This 1938 “State Care Act” pro ­ the state for the care of mental patients in hibited any county, city, or district from facilities built by poor districts, provided operating an institution for the care of these hospitals had experienced physi- mental patients.

i 1 The Twentieth Century pathic was to permit the Board of Public 59 Charities to transfer patients frcm any Allentown and Farview State other state hospital for the insane, or to Hospitals authorize the commitment of new- patients from any p art of the state “giving prefer­ In 1S01 the General Assembly passed ence to these whose family or friends acts that provided for two state hospitals desire their, to receive homeopathic treat­ for the insane, both to be erected in the ment.” northeast corner of the Commonwealth. Interest in homeopathic medicine (the The two, however, were to be of quite dif­ brainchild of a German physician, Samuel ferent character. Hahnemann), swept the United States in The legislation (there was an act in the late nineteenth century. Its main each of the years 1901, 1903, and 1905) tenets were two: that of administering that led to a new hospital at Allentown microdoses of medication in successively specifically directed that the facility be a larger amounts until it was determined “homeopathic ” hospital. The act of July 18, what quantity cured the patient; and that I 1901 —the most comprehensive of the “like cures like,” an idea closely related to three—stated, for example, that the com ­ the principle of immunization. The physi­ missioners were “to select a site and build cian, Emil von Behring, for example, who a hospital, to be conducted under homeo ­ first demonstrated that immunization was pathic management, for the care and a practical therapeutic procedure, oelieved treatment of the insane.” that Hahnemann should be credited as the It was a further stipulation of the f discoverer of this idea. 1901 act that the board of trustees “shall In contrast, the May 11, 1901, act appoint a competent and skillful physi­ that authorized erecting a hospital at cian, of tne homeopathic medical school Farview in Wayne County specified a func­ r and practice ” as superintendent. The pur ­ tion for that facility different from the one * pose in specifying the hospital as homeo- ►

An August 1935 view of the Pittsburgh City Horne and Hospital Administration Building at Meyview

3 60 to be erected at Allentown. It was unique The Mental Hygiene Movement among all the state asylums the legisla ­ { ture would build. “There is a hygiene of the personality Farview was established expressly to as well as of the body and its principles furnish both medical and custodial treat­ are those that promote an adjustment of ment to the criminally insane from across human beings to themselves and the the state. The building commissioners world at large. ” Thus Norristown State selected a site in Wayne County located on Hospital Superintendent Arthur Noyes the eastern plateau of the Moosic opened the “Mental Hygiene ” chapter of J Mountains that included more than 1,500 the 1940 edition of A Textbook of acres, of which the state purchased 669 Psychiatry. Noyes went on to explain that and the Delaware and Hudson Company Mental health implies much more than an absence of delusions, hallucinations, intellectual deterioration, or other symptoms that we associate with mental dis­ ease. Rather it is the near­ est approach to a state of mind through which we may achieve maximum efficiency and greatest happiness, unhampered by habits and attitudes towards life that lead to varying degrees of I failure. The Mental Hygiene Movement swept the United 1 States following the publication 1 in 1909 of the book A Mind That Dixmont post office with horse and buggy standing in front, about 1900. The postmaster and his family lived in an apartment on the second floor. Found Itself by Clifford Beers, a former mental hospital patient. Beer’s book attracted wide­ and the Hudson Coal Company donated i spread attention, including that of such 799. notables in the fields of psychiatry and By arranging its massive brick, psychology as Adolph Meyer and William Jacobean Revival style building to form James. restrictive inner courtyards, the structure With the support of such professionals was designed to be a “prison without plus a large segment of the public who had fences.” read A Mind That Found Itself, a National The hospital —which was built to Committee for Mental Hygiene was accept only males—admitted its first formed. The movement for mental hygiene patient in December 1912. In ten years, was hardly unique. The early decades of the population rose to nearly six hundred the twentieth century were, as Albert inmates. The attendants at Farview hold Deutsch wrote, “rich in the rise of reform job titles different from those at other movements —political, economic and state hospitals, where they were known as social. ” guards. The chief objectives of the National Committee for Mental Hygiene were to work for the protection of the mental health of the public; to help raise the standard of face, for him who works for social 61 t care for those in danger of developing betterment, for the sane and for mental disorders; to promote the study of the psychotic. It seeks to strength ­ en the personality equipment of mental diseases and disseminate knowl ­ the individual and to promote the edge concerning their causes, treatment oealth and happiness of the race. and prevention; and to combat the belief An understanding of the forces that mental disease carried, as an “incur­ underlying human behavior should able disease,” the stigma of disgrace. teach us hew and why people fail P It took a number of years for the m the process of adaptation, as well as why it behooves us not to movement to gain strength. The entrance be too captious of those who have of the United States into the First World not succeeded when called upon to War gave impetus, however, to both psy­ 1'aoe problems beyond their ability. chiatry and hygiene in many fields. The problems of the health of its citizens, while previously ignored, became urgent The Haviland Surrey matters of national public policy. From June 1 to December 1, 1914, r A great interest in mental hygiene and Clarence Floyd Haviland, the first assis­ ! social work was manifest following the tant physician at flings Park State war. In working with the problems of men­ Hospital, Long Island, traveled throughout tally disabled soldiers (“shell shocked ”), Pennsylvania examining all the institu­ the National Committee for Mental tions caring for the insane. His survey was Hygiene proposed establishing a training made for the Public Charities Association school for psychiatric social work. As a of Pennsylvania. The study was paid for result, a number of schools began to offer by Charles C. Harrison, the son of George courses in mental hygiene, and in the L. Harrison, first president of the Board cf r summer of 1918 a school for psychiatric Public Charhies. social work was opened at Smith College. Haviland visited eight state hospitals Although the bond between mental for comparison purposes, but his survey hygiene and social case work grew stronger over the next few years, the depression beginning in 1929 led to the belief that mental hygiene had been over emphasized, that other factors such as an individual’s physical and socio-economic condition needed to be considered along with the hygienic. While it is difficult to make a direct connection between the mental health movement and the Pennsylvania State Hospital system, the effect of what became a worldwide movement on behalf of the mentally ill profoundly influenced psychia­ trists and social workers everywhere. Arthur Noyes, for example, closed his chapter on “Mental Hygiene ” in the 1940 edition of his A Textbook of Psychiatry by writing: Or. Samuel S. Hill, second Wernersville Stcte Hospital superintendent (13S7- 1927), stands behind c seated Mrs. Hill, as c chauffeur ana Mrs. Hill's sister The message of mental hygiene pose in a Stanley Steamer in this early tv>emieth-anzury photo. is for all who have difficulties to

/ / 62 and report, which was published in April Most incredible, however, were 1915, was directed at three types of insti­ Haviland’s remarks on Blockley ’s fire pro ­ t tutions: those maintained by municipali ­ tection. Ten years after the disastrous ties, those by maintained counties, and 1893 fire, he still found much to improve. those that were unlicensed. Some of the stone stairways were enclosed Reviewing the report in its entirety in wooden towers and others led only to leaves the reader with the impression that the cellar. A number of iron fire escapes the situation had improved only slightly even had wooden platforms. from when Joseph Konigmacher and Although the medical work at 1 Dorothea Dix made their statewide sur­ Blockley appeared “fairly efficient”—which veys seventy years earlier. Haviland’s was unusual for most of the city institu­ report makes it clear, however, that the tions he visited—there were seventy-seven i improvement was superficial in most cases patients either in restraints or seclusion and that abysmal conditions still existed when he visited due to a lack of adequate all across the state. Virtually all the facili­ attendants. ties Haviland visited were overcrowded, At Philadelphia ’s Byberry (the city’s few provided any medical treatment for poor farm), Haviland found the patients 1 the insane, and the physical plants were living in old farmhouses that were “rather often “impossible. ” crude accommodations. ” Although Byberry Of the institutions maintained by was better than Blockley, its “parent ” municipalities, his general conclusion was institution, the chief defects he found were that “none have been properly performing an insufficient water supply, great fire their function as institutions for the treat­ risk, and unsanitary sewage disposal. ment and possible cure of insanity.” He Cesspools were used which were too close found it particularly regrettable that to the buildings including one adjacent to Political and secular interests the barn. Byberry was run by a “head 1 have apparently submerged the farmer” who reported to the superintend ­ medical spirit, and as a result it is ent at Blockley. < certain that many unfortunate At another urban facility, Pittsburgh ’s insane persons have failed of Marshalsea, Haviland found even worse i recovery through lack of proper medical facilities and treatment. conditions. The plant consisted of a gener ­ The conviction appears irresistible al hospital, almshouse, and tubercular that whatever may have been past colony. Tubercular patients mingled with policies the welfare of the commu ­ the others. The plant itself was “archaic.” nity would be best served by For the most part the wards were bare, removing these hospitals from lacked furniture, and were “desolate in municipal control. appearance. ” Haviland described some of He described Philadelphia ’s Blockley the wards as “equipped with concrete as an “ancient, monasterial structure.” The floors, with center drains, similar to a sta­ building for the insane formed part of gen ­ ble.” The exercise yard was especially eral plant housing an almshouse and a “objectionable. ” The grass was worn off, general hospital. Light and air were “defi­ and during the absence of the women from cient.” Overcrowding was of a “serious the yard, he counted eighteen large rats degree. ” In some places beds actually running about it in. touched each other. “Day space was so lim­ The situation of the care and medical ited,” he wrote, “that benches were placed work at Marshalsea was distressing. There in rows across the room to provide seating were two physicians to care for 324 insane accommodations. ” And basement bath­ patients and another 291 inmates in the rooms were “poorly lighted and ventilated.” almshouse, with but one attendant to twenty-three patients for day duty and der improvement or recovery, but 63 one to ninety for night duty. According to must necessarily result in actually Haviland, the most deplorable feature of hastening the terminal process of deterioration. the institution, however, was the political influences that operated in the selection of Amazingly, just as Dorothea Dix had employees, many of whom were incompe ­ singled out Adams County as grossly defi­ tent. cient, so did Haviland. In Gettysburg the ► One woman at the facility accidentally scalded herself to death. In spite of an order the year before by the Committee on Lunacy that a safety device be installed on k the hot water line, no action had been r taken. And while Haviland was visiting, an attendant laid a sick patient on the cold concrete floor to clean the man’s bed, whereupon the shock of such treatment caused him to collapse and die later the same afternoon. Haviland described Marshalsea as providing “only the most crude custodial care.” He condemned it by declaring: “The fact that no patients have been discharged as recovered for seven years tells the whole tale.” Haviland found the conditions slightly better—but far from ideal—at the nine­ teen licensed county institutions he visit­ First library at Philadelphia's Blockley Hospital, 1923. The worker near the window was a patient, Mary Fawlor. ed. The most striking feature he found was the “close association between the building for the insane was at the rear of institutions for the insane and almshous ­ the almshouse. The building was in good es,” in some instances both the insane and repair, but the halls were too narrow and paupers being cared for in the same build­ there was no regular dining room, a short ing, and in a few cases in the same ward. hall serving in its place. The food was The inevitable result of this arrangement brought in buckets from the almshouse. f was that the “care of the insane tends to The “cells” for seclusion had concrete floors. They did have electric lights, but f the almshouse standard.” ¥ He discovered that mechanical means the wiring was attached to the surface of ¥ of restraint and confinement were fre­ the walls making it accessible to the quently substituted for proper personal patients. Because of the lack of atten­ r treatment and attention. It was agreeable dants, seclusion was sometimes used for he noted that there was “little evidence of from six to eight weeks. \ actual physical abuse,” but he stated that There were only two wards for each it was “indisputable ” that “gross neglect sex —bare and without sufficient seating exists. ” Haviland summarized the county facilities—so that little classification of situation as follows: patients was possible. The visiting physi­ Dreary, desolate wards, lack of cian came once a week. He refused to pull recreation, or other means of excit ­ teeth. After listening to the all-night wail­ ing or maintaining active interest ing of one woman in pain, the farmer in t are alone sufficient not only to hin- charge pulled it for her. Fire protection 64 was insufficient. Sewage flowed untreated into an open ditch about 150 yards from the main building. Haviland observed that the ditch “was i absolutely stag ­ nant.” Women lived on the second floor, i but there were no locks on the stair 1 doors. Haviland found women patients doing housework in the Occupational therapy at Byberry in the 1930s. male wards, without any attendant pres­ ent. [syphilis] origin. ” Neither of these patients Patients were left alone much of the nor a tubercular patient were isolated, but time. Once locked in the exercise yard, for mingled freely with the others. Haviland example, they were left unattended. In wrote that one of the yards, Haviland saw “five con ­ A particularly reprehensible centric rings beaten in the earth about a practice in this community is the custom of committing insane tree by the ceaseless pacing of patients. patients to the State Hospital only He found one woman with an open, if they belong to one of the “better undressed cancer, and another with “ulcer­ families” or if they are particularly ations of the nose, apparently of luetic disturbed or troublesome.

At Woodville in Allegheny County he found some things to commend, such as the buildings and the availability of drink­ ing fountains. But sewage flowed untreat­ ed into a neighboring creek, tubercular patients were mixed with the insane, and fire protection needed improvement. He 1 found one third-floor dormitory with a ◄ hundred patients that had but a single exit to a stairway, although an outside iron fire escape had been installed. It was inaccessible, however, as iron bars covered the oval window that led to it. The building at Hollidaysburg in Blair County was satisfactorily fire­ proofed, although at times the pressure Male patients standing and lying idle in the yard at Philadelphia, 1947. was insufficient to take water to the sec­ ond floor. Whenever this occurred, it was

C.yl, ...

sf. carried up in pails. The hospital, however, the better families” to state hospital and 65 t was overcrowded with the result there was others to the “county custodial institu­ little day space. The men’s wards, more ­ tion, ” and declared it “should no longer be over, were bare, with only a few chairs. He tolerated. ” Then in a backhanded compli ­ claimed that the “custodial care at the ment he wrote: “The only results obtained facility was below even the usual standard in the State of Pennsylvania, which have of county institutions, ” and recommended been even approximately satisfactory, have ► “as a matter of humanity” that the been in the state hospitals. ” patients should be removed at the “earli­ Haviland closed his report by dis­ est possible moment. ” cussing the “relative merits of state and The third class of facilities surveyed county care.” He cited six arguments in was the unlicensed almshouses. favor of local facilities—ideas he apparent ­ Haviland’s summary of this group was ly had heard from county officials during I that, while the majority provided fair his tour: the possibility of patients who > material conditions for paupers, none had remained near home receiving more fre­ any proper means of caring for the insane. quent visitors, greater opportunity for None of the local authorities, moreover, occupation, the avoidance of “massing had “any idea as to what constitutes prop ­ together ” in large institutions, availability er treatment for the insane.” Haviland of more homelike surroundings, greater claimed, “there can be no doubt that many number of recoveries, and lower mainte­ ’ insane patients have failed of recovery . . . nance cost, especially for the chronic r by the barbarous treatment to which they insane. Haviland debunked all six. He ' have been subjected.” found that the “unvisited” rate for the In one of these institutions, he found state hospitals was 40.4 percent, while that five of the “defective women ” inmates that for the twenty-one city and county had borne children; one even had her child institutions was 39.9 percent. He admitted \ in the house with her. In another, he found that maintenance cost less in a county two “standing cells” used to quiet agitated hospital, because “proper facilities cost patients. They were “merely two small more than does their lack,” then curtly closets, just large enough for an adult to dismissed this point by saying: “It is stand erect in with the door closed. If a cheaper to die without medical attendance person once sank down, ” he wrote, “it than with it.” would thus be impossible to again assume In addition to proposing a “state care an erect posture. ” system” for Pennsylvania that removed Haviland’s report was a major indict­ the insane from the counties and munici­ ment. Little had changed in the thirty palities, Haviland also made several other years since the Pennsylvania Board of recommendations, among them the devel­ Public Charities had been given the opment of a state civil service and a uni­ responsibility for “all institutions ” in form method of commitment. l which insane patients were housed. It The year following the survey, C. would seem particularly alarming that he Floyd Haviland took charge of the was able to uncover nineteen unlicensed Connecticut State Hospital. While there institutions. he served as chairman of the executive Haviland’s general summary of the committee of the Connecticut Society for state was that although there was “little Mental Hygiene. Then in 1926 he became evidence of actual physical abuse, what superintendent of the Manhattan State may be even worse, there is the most utter Hospital in New York as well as president neglect. ” He called “un-American” the of the American Psychiatric Association. practice of sending patients “belonging to It was not until twenty-four years 66 after Haviland made his report, however, hosp.tal may be produced on said land.” that the Pennsylvania legislature finally The act stated that the plans and spec- passed a “State Care” act which took con ­ lficavbns for the building must accommo ­ trol of all county and municipal hospitals date at least one thousand patients. for the mentally ill. Furthermore, they must permit provisions for additional accommodations “without Torrance undue cost, from time to time.” Although Terrance was intended to * In 1915 the Pennsylvania Legislature serve as a relief valve for the system’s passed the next to last of its many acts to overcrowding, it soon reached and exceed ­ build a “State Hospital for the Insane.” ed its capacity. By the early 1940s it had a The June 18, 1915, act directed Governor population of 2,551 patients against a Martin G. Brumbaugh to appoint five citi­ raxed. capacity of 1,670. Moreover, it was zens as a Building Commission to erect estimated that to properly accommodate buildings to be known as the Western the mentally ill out of the million and a State Hospital for the Insane. half citizens of the eleven counties the The act specified that the land should hospital served, it would be necessary to 1< be on a site west of the Allegheny construct additional facilities to handle Mountains, reasonably near a railroad, another 800 patients. This would entail and containing not more than five hun­ capital expenditures of $7.6 million. dred acres And like most of the state hospitals, After indicating the necessity for a Torrance struggled with severe employee nearby source of potable water, the legisla ­ shortages as well as more patients than it ture directed that the property shall con ­ was designed to house. At the low point, in - sist of “arable land or land capable of December 1943 (with no more than 40 per­ being made arable, so that, as far as prac­ cent of the staff meeting the minimum ticable, the rood for the inmates of said standards for the hospital), the Depart- i

Hay new State Hospital patients playing softtcll ca 1940 as part of their physical therapy program, with the hospital building in the background. Note that the Krkb.idge idea of adjoining, but offset, ward build ­ ings is still visible in this 1940s view of the Hospital.

A ment of Welfare ordered the hospital to governor ’s legislative program had been 67 cease admissions. The needs of the service passed. area were so urgent, however, that it was Although the newspapers around the impossible to comply with the order. state reported the activities on page one, they did not seem too concerned over the The Department of Welfare mischief—the “rump ” session, as the Philadelphia Inquirer called it—in The Department of Welfare was born ► Harrisburg. Either they supported the in the most raucous legislative session governor ’s program, or else saw the situa­ ever held in the Pennsylvania House of tion in the legislature as business as * Representatives. For six months, com ­ usual. mencing in late 1920, administration sup­ The fight over the creation of the porters and an anti-Sproul faction within \ Department of Welfare was brought on, in Governor William C. Sproul ’s own party part, out of concern over the “power ” it had wrangled over legislative initiatives. would invest in the department ’s secre­ Once again on the night of April 25, tary. One member of the House charged 1921, the pro-Sproul forces found them­ that “The Czar of Russia and the Emperor selves blocked by an all-night filibuster. of Germany never had greater power ” Thoroughly frustrated, they waited until than the bill would confer on the head of House Speaker Robert S. Spangler the proposed department. adjourned the session at 12:10. At that The fear, of course, was for the point, in the words of one reporter, they patronage —not legislative or administra­ “kidnapped the organization of the House tive—power that would come with the new of Representatives and rescued the department. In the days before civil serv­ Governor ’s legislative program. ” ice, Pennsylvania’s executive departments * Following the departure of Spangler were filled with the faithful of the party of and many members of the anti-Sproul fac­ the governor in office. The governor dis­ * tion, the governor ’s friends locked the pensed department head positions to doors to the chamber, elected a speaker important party supporters who had pro tem and began passing Sproul ’s pro ­ helped get him elected, and then the gram. According to the Harrisburg Patriot, department heads dispensed hundreds of “One by one, the welfare department bill, lower-level jobs to party friends around the second class city, a non-partisan ballot the state. repealer, and other measures were Every time the governor ’s mansion f brought out of committee, where the oppo ­ changed party hands, virtually all of the sition thought they were buried, and bureaucrats in the executive branch were [were] passed. Any member who objected replaced. The proposed Department of r to the proceedings was ‘howled down. ’” Public Welfare was seen as the biggest As bills had to be “read” in two sepa­ patronage plum the legislature had ever } rate sessions before being voted on, the created. speaker pro tem adjourned for one minute The act itself—which Governor Sproul at 12:54, then called the members into ses­ signed on May 25, 1921 —made few sion again, appointed a chaplain pro-tem changes in the administration of the state to offer a short prayer, and presented each hospitals or the management of the state’s of the bills for a second consideration. By mentally ill. It abolished the Board of the time several senators —attempting to Public Charities, the Lunacy Committee, find out what had happened during the and the state Prison Labor Commission earlier House session —had broken the and combined their powers and responsi ­ locks and stormed into the chamber, the bilities in the new department. 68 All issues including the rules for com ­ when the microorganism which causes mitment, transfer, or release of patients this disease invades the brain.” Some ­ remained as before. Moreover, the licens­ where between ten and fifteen years fol ­ ing of facilities, the preparation of stan­ lowing infection, a chronic inflammation of dard forms to be used, and the need for the lining of the brain, the meninges, inspections of all houses holding the men­ begins. The nearly inevitable terminal tally ill stayed in force and were vested in stage, especially in males, is paresis or the Department of Welfare. paralysis. Among the early symptoms are The new agency had gargantuan jumbled speech, an irregular gait, delu­ responsibilities. They included, in addition sions of grandeur, and loss of rational to mental hospitals, all “county, city, bor ­ behavior —borrowing and spending, for ough, township, or poor district” prisons, example, large sums of money. During the hospitals and “houses which conducted the final stage, “progressive paralysis” as it is business of receiving, boarding, or keeping sometimes called; the patient dwindles I infant children.” into complete mental and physical decay. Over the years the issue of the The limbs, especially the lower ones, often department ’s size disappeared. In 1957 the become paralyzed, the patient is unable to General Assembly combined the depart­ raise their eyelids, and the mind borders ments of Welfare and Public Assistance in on idiocy. an even larger unit, the Department of From the very earliest, the annual Public Welfare. reports at Pennsylvania asylums included “syphilis” as a cause of admittance for a Wernersville and Act 272 few patients. But others who in much In his A History of Psychiatry, Edward greater numbers were recorded as having Shorter states that a “major component in died of paresis after spending time in the hospitals undoubtedly were also victims of the press of bodies ” into the nineteenth- 1 century asylum was a “genuine increase in the disease. By the end of the nineteenth the rate of mental illness.” And he goes on century it had become one of the major to assert that the psychiatric illness that problems at state asylums, although the

“most demonstrably increased” was neu­ disease was almost never mentioned in rosyphilis. Shorter contends that the the texts of the reports. “syphilitic infiltration of the central nerv­ In 1898, for example, the statistics in Harrisburg Superintendent Henry Orth’s ous system is of capital importance in the 1 history of psychiatry”—far more than all annual report show that eleven of his the “social constructions ” that have been twenty-eight decedents (39.3 percent) died claimed for the rise in mental illness dur­ of paresis that year. And that twenty-two ing the asylum period. (4.7 percent) of the male patients remain­ Syphilis—sometimes called in the ing in the hospital were suffering from the 1900s the “disease of the century”—was disease. A decade later the deaths from first detected in Europe in the late eigh ­ paresis at Harrisburg had risen to 48 per­ teenth century, but soon grew to epidemic cent, and of the males remaining, paresis proportions that swept first Europe and was recorded as the form of insanity for

then America. 15.8 percent. “Of all the infections which attack The epidemic in Pennsylvania became man,” wrote Arthur P. Noyes of serious enough that in 1921 the legisla ­ Norristown State Hospital in his Textbook ture decided it was a major public health of Psychiatry, “syphilis produces the most issue. On May 16 that year—over the devastating effect upon his mental life strenuous objections of the Wernersville superintendent and the hospital board —

W&Yt- . : the legislature passed Act 272. This The First Pennsylvania Mental Health 69 amendment to the original one establish­ Act r ing the hospital for the “chronic insane,” In 1923 the General Assembly placed provided for the reception, detention, care two laws affecting mental health on the and treatment at Wernersville, of persons books. The first of these, in June, adopted suffering with syphilis. the state’s first Administrative Code. It The act directed that “Any person reorganized the structure of state govern ­ afflicted with syphilis who is an inmate of ment and specified the basic powers and any State Hospital for the Insane or any duties of the executive departments, r almshouse or poorhouse, ” was, at the boards, and commissions. direction of the Board of Public Charities, The code modified the character of to be committed to Wernersville. Moreover, institutional boards of trustees including the commissioner of Health or any health those at state hospitals, changing them officer in any community was also author ­ from independent public corporations ized to send any person who was suffering responsible for making decisions concern ­ with syphilis to Wernersville. ing the management of the hospitals, The treatment of all individuals com ­ f including hiring and firing, to administra­ mitted to Wernersville under the act was tive bodies within the Department of under the “control and supervision ” of the Welfare. Although their powers were Commissioner of Health. At the same time somewhat curtailed by the 1923 act, it was the act specified that the hospital superin­ not until 1955 that they were stripped of tendent had responsibility for the supervi­ all authority by a change of their responsi ­ sion and the care of these individuals bilities to strictly “advisory. ” “except with regard to the supervision 1 Then in July 1923 the General over their medical treatment and dis­ Assembly passed the state’s first Mental charge. ” The Commissioner of Health was Health Act. It consisted of a codification t the only one who could discharge one of and update of all mental health statutes these quarantined patients. His certifi­ enacted since the 1845 act establishing the cate, moreover, had to specify that the per­ first state hospital at Harrisburg. This son was either “cured” or is “no longer a ► effort had been accomplished by a commis ­ menace to the health of the community. ” sion appointed in 1919. The new law By October 1922, 150 patients, all applied to all mental health facilities, pub ­ women, had been transferred to lic and voluntary. Wernersville from other institutions. The act established uniform hospital Eventually the number being treated for admission, commitment, transfer, and dis­ syphilis rose to 1,129, of which 375 were charge procedures. It also made provisions females—most probably prostitutes swept for handling of those convicted of crimes, off the streets and out of the jails of east­ spelled out the rights of patients, and ern Pennsylvania communities. assigned responsibilities for the cost of Although other such programs would caring for the mentally ill. The act also follow, this was probably the first instance changed Wernersville State Hospital ’s role of the Commonwealth using its state hos ­ from its original one of handling only the pitals in an attempt to solve a major chronic ill to that of the other state hospi ­ health problem, rather than merely treat­ tals. ing those with some form of mental ill­ Perhaps the most striking aspect of ness. the new law, however, was its establish­ ment of standard terminology and defini- 70 tions. Words like asylum, insane, and By 1955 undergraduate teaching to lunatic were eliminated in its language. medical students was taking part of the Mental illness, mental disease, mental dis­ time of all twenty-one full-time staff mem­ order, mental patient, and mental hospital bers. Clinical facilities for teaching the took their place. By this time, too, the students consisted of 150 beds. Integration names of each of the asylums had been between the psychiatric and the other \ changed officially to that of “state hospital. ” departments in the medical school was achieved by rotation of residents, a shar­ Western State Psychiatric Hospital ing program, mutual research, and consul ­ tation. On June 23, 1931, Governor Gifford In 1979 the legislature directed that Pinchot signed the General Assembly’s bill to accept a gift from the University of the institute be leased back to the univer­ sity under an arrangement whereby the Pittsburgh of a “suitable site for a Western State Psychiatric Hospital on the campus state would continue to make regular of or in the neighborhood of the University appropriations for its operation. ’ of Pittsburgh. ” At the start of the twenty-first centu­ Act 324 directed the Department of ry the University of Pittsburgh ’s health operations comprise an internationally Property and Supplies to conduct prelimi­ nary surveys, develop plans and provide renowned academic medical center provid ­ estimates for the construction of the hospi ­ ing full care services; a network of teach­ ing hospitals offering the latest tools for tal, which when completed would be turned over to the Department of Welfare. diagnosing and treating a wide variety of illnesses; and a research center involved The hospital was unique. It would not only provide treatment for psychiatric in extensive studies of both the mind and patients, but also would conduct research the body. The activities conducted in the research center include trials in gene ther­ into mental health issues and provide 1 training of medical and other personnel in apy; the development of revolutionary new “mental diseases, mental defects and their artificial hearts, lungs and kidneys; and complications. ” the use of new brain-imaging methods to i The Western State Psychiatric watch the mind in action, providing a win­ 4 Hospital (now known as the Western dow into how healthy brains work and Psychiatric Institute and Clinic) opened in leading, it is hoped, to the discovery of 1942. With the University of Pittsburgh new clues as to how behavioral afflictions can be treated. Medical School, the institute provides clin­ ical instruction in psychiatry and graduate work in psychiatric nursing and adminis­ Shock Therapy tration. From the time of Benjamin Rush until Among the objectives of the institute the twentieth century, therapy for the was the development of a strong program mentally ill consisted almost exclusively in of psychiatric education in all its phases, efforts to calm the excited and stimulate as well as an aggressive program of psy­ the depressed. Hydrotherapy was among chiatric research. To meet these objectives, the earliest therapeutic techniques applied the clinical director initially selected to mental patients in American asylums. patients individually from other hospitals It has a history, however, dating back to around the state. In this way it was possi ­ the Greeks. ble to ensure that a representative mix of the desired types of mental illness was Many of the early techniques were achieved. crude. The douche —a bucket of cold water 71 r

Mental patients at the Pittsburgh City Home and Hospital—later Mayview State Hospital—undergoing a f water pack treatment ca.1927. Nurses had to wrap the patient carefully in layers of ice-cold wet sheets and blankets, mummy fashion.

in the face—or the “bath of surprise ”— changed a patient ’s physiological state dropping a patient through a trap door began to appear. The three most promi ­ into an icy bath—was designed to shock nently used in Pennsylvania state hospi ­ the poor unfortunate into his senses. tals were insulin-coma, metrazol-convul- By the early twentieth century, how ­ sion, and then later electroshock. All three ever, physicians had developed more sub­ procedures were developed in Europe but tle applications of the various hydrothera ­ were quickly adopted by American hospi ­ pies. A variety of baths, douches, sprays, tals. and wet packs had come into vogue as In 1933 a Viennese physician, means of ministering to the mentally ill. Manfred Sakel, accidentally induced a These seldom had real curative value, but deep coma in a patient by injecting a high did provide some efficacy as a sedative or dose of insulin. After he recovered from stimulating agent with temporary bene­ the coma, the patient, who was psychotic fits. as well as a drug addict, appeared to There were “rain” and fully sub­ improve. Sakel began experimenting on merged baths, and fan, vapor, and Scotch animals with insulin. Soon favorable douches, as well as jet sprays. These were results from this insulin-coma procedure primarily used to calm the agitated, but began to be reported. By 1936 it was being also to “massage ” those who were in need widely used throughout the United States. of stimulation. The wrapping of patients The procedure is a complicated and in wet packs or wet sheets was principally lengthy one. The coma is induced by giv ­ used, however, to restrain the excited. ing increasingly larger doses of insulin on Wrapped securely around the patient, the successive days until the desired depth of wet sheet or pack would shrink as it dried unconsciousness is achieved. The depth and further restrict the patient. Abuses of and duration of the coma is varied based this technique were reported at times in on the experience and practice of the indi­ some Pennsylvania state hospitals. vidual therapist, although the textbook Then in the early decades of the twen­ average was given at about fifty hours. tieth century the first therapies that The patient does require close nursing 72 supervision for an extended period during It soon became the treatment of treatment. choice everywhere. At Philadelphia, for About the same time, a young example, nine thousand electroconvulsive Hungarian, Ladislas von Meduna, had treatments were logged in a two-year peri­ I begun examining the brains of former od in a single ward building. epileptic and schizophrenic patients and In the 1958 edition of his Modern concluded that there was a mutual antago ­ Clinical Psychiatry, Arthur Noyes wrote: nism between epilepsy and schizophrenia. “In the depressions of involutional melan­ This led him to the idea that if he induced cholia and of manic-depressive psychosis 1 convulsions in schizophrenics similar to the improvement following electroconvul ­ those in epileptics, it might lead to a cure. sive shock therapy is striking. In 80 per­ To achieve the desired convulsion, he began cent or more of these disorders five to ten injecting first camphor and then metrazol treatments are followed by full or social into his patients. Meduna claimed recovery recovery. Prior to the treatment. . . pro ­ in ten of his patients, good results in three tracted depression, sometimes lasting for and no change in thirteen. Interest in the years, was the rule.” method spread quickly. There is—especially over time—an Meduna’s method of inducing convul ­ apparent eroding of brain capability. With 1 sions was soon overtaken, however, by the each electroshock treatment a patient invention of electroconvulsive therapy, or loses some memory. While this is seldom ECT, by two Italian doctors, Lucio Bini permanent or significant following a single and Ugo Cerletti. Their work, which was series, a patient who must return for sev­ first reported in 1938, was introduced in eral treatments because of relapses, can the United States two years later. Its use appear eventually to lose a noticeable spread rapidly as it was much more con ­ amount of memory. (Latest studies, howev ­ venient to administer than either insulin er, fail to show any permanent cellular or metrazol. impairment.) Still this seems to be prefer­ An electroconvulsive treatment could able to having a schizophrenic fall into a ! be administered in a matter of minutes. permanent delusional state. The patient was simply stretched out on a Although it found favor in some table, his or her arms and legs held to pre­ schools of psychiatric thought, loboto- vent injury when the convulsion occurred, mies—the severing of selected nerves in f:. and the two electrodes applied to each the brain—were only performed occasion ­ temple. After approximately five minutes ally in Pennsylvania hospitals. Most facili­ of unconsciousness, the patient rouses ties either found the procedure objection ­ gradually over the next ten minutes. able or too risky to perform without expe ­ ECT was introduced at Pennsylvania rienced surgeons interested in doing such state hospitals in 1941. At Harrisburg operations. Lobotomies were performed, State Hospital this was done first in a however, at Philadelphia with some fre­ research mode. Five hundred sixty-six quency In the two-year period between patients were selected for treatment with­ 1950 and 1952, twenty-five patients were : out regard to their disorder. Of that num­ lobotomized in one building alone. Of ber, Superintendent Howard Petry, report ­ these five patients were reported as “much ed that about half showed enough improved, ” ten “slightly improved, ” and improvement that they could be returned ten as “unchanged. ” to their homes. By the end of the decade Wilbur M. Lutz, the clinical director at about six hundred of Petry’s patients were Wernersville also performed large num­ receiving an average of seventeen electro ­ bers of a modified version of the loboto- convulsive treatments each year. my—the transorbital leucotomy —during

A the late 1940s. In a transorbital leucotomy With the advent of the psychotropic 73 only a few of the frontal nerves were sev­ drugs, use of ECT and the other shock ered. Lutz claimed that his patients were treatments declined. Electroconvulsive ambulatory within a matter of hours, treatments are still employed, however, for required little or no nursing care, and that those patients who do not show improve ­ “the operation produced none of the unde­ ment from any of the available drug thera­ P sirable personality traits or intellectual pies. 1 deficits” of a traditional lobotomy.

9 ► l

► ► r 74 "Full State Care" George H. Earle convened in July of that year. “Care for the mentally ill and feeble­ -A Byberry and the “Full State Care” Act minded” was one of the subjects of this of 1938 special session. As a result of the legisla ­ tion, Blakely, Lancaster, Mercer, Ransom, Byberry, named for the Philadelphia and Schuylkill County mental hospitals neighborhood in which it resided, stood on were closed. Clarks Summit, Embreeville, a 1,100-acre site near the northeastern Hollidaysburg, Mayview, Retreat, boundary of the city. The facility began as Somerset, Woodville, and Philadelphia ’s the city’s poor farm in the mid-nineteenth 1 Byberry became state hospitals. century, and became a mental hospital in The township of Byberry dated to the 1906. Its location was chosen as the time of William Penn. The original settlers remotest possible spot from center city. in 1675 were Quakers. They would have Byberry became perhaps the most notori ­ been distressed greatly to know that the ous of the poor farms in Pennsylvania and beautiful, level lands that so pleased them certainly the most infamous of the state’s in 1675, with their abundance of good mental hospitals. water, would become known as the site of The state took control of Byberry in such notoriety two hundred and fifty years 1938, when—as part of its “Full State later. And in an even greater irony Care Act” of September 29 —the legisla ­ Byberry was the site of Benjamin Rush’s ture assumed responsibility for eight of birth in 1746. the thirteen existing county public mental The place was named Byberry in hospitals and closed the rest. The state honor of the settler’s native town, near took over all properties, equipment, and Bristol, England. In Old English By meant patients for which the counties and cities to build up. Berry meant town. As a com ­ had been responsible. By this act counties, pound it signifies a habitation or castle on cities, or institution districts were prohib ­ a hill. At the Byberry in England, Henry ited from operating a facility for the care VIII erected a royal palace and lived there of mental patients, although general hos ­ during a portion of his time, giving rise to pitals were authorized to provide tempo ­ the belief that that was the source of the rary inpatient psychiatric services. name, one that is unique in England. In what was yet another swing in the The state spent $8 million in the first pendulum of state versus local mental few years after the takeover at health care, Act 21 opened by declaring, Philadelphia on construction and renova ­ “Experience has proven that the care and tion, in addition to the facility’s annual maintenance of indigent mentally ill per­ operating cost of more than $2 million. As sons, mental defectives and epileptics a 1947 report to Governor Edward M. should be centralized in the State Martin stated, “this, however, has accom ­ Government in order to insure their prop ­ plished nothing but the most acutely nec­ er and uniform care, maintenance, cus­ essary repair, replacement, and expan ­ tody, safety and welfare.” Moreover the act sion. ” The institution reported it was short asserted, “Complete care for such persons of its personnel quota by 14 physicians, 47 in institutions operated exclusively by the nurses, and 299 attendants. Without ade­ State Government will effect great quate staff, restraint became a “necessary economies for municipal subdivisions. ” safeguard. ” In the month of May 1946 The “Full State Care” Act of 1938 was alone 49,609 hours of “restraint” were the result of an extraordinary session of logged in the male division. the General Assembly that Governor Mayview and Retreat was 164, while an additional 96 patients 75 were maintained at Dixmont. The state had little alternative follow ­ By 1890, however, the Carnegie Steel ing the enactment of the Full State Care Company ’s plant facilities were beginning Act in 1938 other than to take over to encroach on the property, so the city Philadelphia because of its sheer size. once again moved its poorhouse to a tract Among the remaining institutions the in Upper St. Clair Township in Allegheny Department of Welfare considered for County. The railroad station erected to incorporation into the system, Mayview r and Retreat were representative of the two classes of facilities (other than the state hospitals) in exis ­ tence at that time for treating the mentally ill. Mayview, near ► Pittsburgh, was a community- based almshouse and mental hos ­ pital of long standing; Retreat, along the Susquehanna River in the north central part of the state, which was dedicated exclusively to serving the mentally ill of Luzerne County, was of much more recent origin. By 1938, the Department of Welfare apparently had come to believe that enough of the prob ­ * lems had been corrected that C. HHcI r m Floyd Haviland had uncovered in 1914 at Mayview—then known as Patient picnic at Retreat State Hospital, July 28, 1964. Marshalsea—making the facility an appro ­ priate takeover candidate. r Mayview’s long history began in 1804. serve the almshouse was named The Overseers of the Poor in Pittsburgh Marshalsea after the debtors ’ prison where had maintained an almshouse in the city commencing in that year. In 1852 the Dorritt of Charles Dickens’s novel Little Dorritt lived with her pauper father. The ► Overseers relocated it out of the city to a name, which carried connotations of deri­ new site at Homestead along a pictur ­ sion and disgrace, was finally changed in esque bend in the Monongahela River. The overseers built a large brick home on ele­ 1916 to Mayview. f vated ground with an immense front As C. Floyd Haviland discovered dur­ lawn—embellished with trees, shrubbery ing his 1914 survey, the city made no and walks—that sloped down to the river. effort to provide other than custodial serv­ By 1870 the records of the facility, which ice for it mentally ill at Marshalsea. could accommodate three hundred individ­ Finally in 1923 —with the appointment the previous year of Mrs. Enoch Rauh as head uals, showed there were sixty mental inmates. They were all the mild-mannered of Pittsburgh ’s Department of Charities— Mayview began to treat its mentally ill for or chronic insane, the more excited or dif­ ficult cases being sent to Dixmont. By other than their physical illnesses. Under Rauh’s guidance occupational 1888 the census of insane at Homestead therapy, social service, and physical thera- f

76 1900 from Danville. By the following year, three hundred patients were being cared for. In addition to the patient build­ ing, which like a Kirkbride asylum contained separate 1 wings for men and women, the site also housed a kitchen, bakery, laundry, and boiler building. By * 1906 additional struc­ tures had been erect- I ed including an infir­ 1930s Mayview physical therapy program, cleaning vegetables from the garden. mary building —all ■ connected by covered py units were established within the corridors —thereby Mental Department of the hospital. By adding two hundred beds to the facility’s 1930, Mayview was employing various capacity. hydrotherapy techniques; in 1933 Both Mayview and Retreat had, how ­ insulin shock therapy was intro ­ ever, unique features of note. Standing duced; and early in the 1940s apart from the other buildings at Mayview hospital physicians began admin­ was the nursery. There were about ten istering electroshock and metra- births a year at the hospital. Until 1940, 1 zol convulsive treatments. unwed mothers were brought from In contrast to Mayview, Pittsburgh to Mayview. In the baptismal Retreat was established in 1898 registry at St. Agatha ’s in nearby Bridgeville the mothers of the hospital ’s 1 as an outgrowth of the problems of overcrowding in the state hos ­ newborns were listed as Mater Amentes pitals that had led to the “Dual (mentally ill) or Illegitimus. Other chil­ Care Act” of May 1897. dren in the nursery were there as the Previously, mental patients from result of having been deserted or abused. 1 Luzerne County had been com ­ The children were cared for by a live-in mitted to Danville State Hospital, attendant and an assistant. According to which by 1893 was so crowded an unpublished history of Mayview by that the trustees of the institu­ Father George T. De Ville, the children all 1 tion passed a resolution to stop romped in one central playroom during 1930s Mayview physical thereapy the day. program, broom making. taking patients. Following passage of the Retreat State Hospital, on the other Dual Care Act, the Luzerne hand, was noted for its inaccessibility. The County Poor District began to build its hospital property is located on the east own hospital on a 146-acre site along the bank of the Susquehanna south of Wilkes- Susquehanna River. Provision was made Barre in the shadow of a steep mountain. for four hundred acute mentally ill U.S. Route 11 lies across the river on the patients, the first of which arrived in June west bank. From the time of its opening until 1951— when the state finally built a

A bridge across the Susquehanna —Retreat 77 could only be reached by a flat-bottomed ferry. The ferry was often inoperative due to river conditions, sometimes for periods as long as three or four weeks. Floods, low water, or winter ice isolated the institution. If Retreat was separated on occasion from the outside, Mayview had no similar r concerns. It not only had the usual farm, garden, greenhouse, and electric power plant, it also had its own mine from which the coal to run the plant was taken.

The State Hospital System at its Peak By 1947, when Secretary of Welfare f Sophia M. R. O’Hara, made a report to Governor Martin, the system of state hos ­ pitals had reached maturity. As O’Hara reported, however, many of the twenty-one 1930s Mayview Physical Therapy Program. facilities were aging and most had prob ­ Chair caning and matmaking. lems of low budgets, overcrowding, lack of staff, poor care, and sometimes ineffective lines of patients queued up for dinner or management. naked to take a shower at Wernersville, According to O’Hara, she had pre­ outmoded plumbing and run-down cells for pared the report “to lift the curtain of pop ­ seclusion at Norristown, and congested r ular misconception which unfortunately dining, jammed shop, and crowded sleep­ long has existed with regard to mental ing areas at Hollidaysburg. institutions. ” In what was probably direct­ Although O’Hara’s report included ed more at the legislature than the gover ­ pictures of modern facilities and patients l nor, the secretary outlined a “ten-year pro ­ engaged in meaningful activities, it also gram of education, training, research and depicted ones showing extreme overcrowd ­ construction ” she hoped to embark on ing, large groups of listless patients, lack what would provide “new and expanded of professional attention, and ones of out ­ institutions of modern hospital design, ” all moded, deteriorating, unhealthy, under­ to be “supported by your informed and staffed facilities. As the caption for a pho ­ intelligent aid.” tograph of men lying on the floor and lean­ The report included pictures of dilapi­ ing against the wall of a hallway at dated showers at Dixmont, “cuffs” on the Norristown stated, it also often portrayed beds in lieu of nurses at Philadelphia, “studies in futility.” modernized but crowded conditions at In 1947 the annual operating cost for Harrisburg, patients in seclusion or seated the state hospital system was $18.4 mil­ side-by-side on rows of benches (waiting lion. This represented a Spartan per capi­ Godot-like) in a day room at Retreat, peel­ ta cost of $424 a year for the state to ing paint and cracked plaster in the house, feed and clothe each of its patient sleeping quarters at Somerset, a patients. (See Appendix B for details) woman wearing the “camisole ” and long 78 The Philadelphia Mental Health two-thousand-bed hospital at Embreeville Survey Report and two three-hundred-bed buildings at In June 1952 the committee that Philadelphia, one for medical and surgical Governor Fine had appointed to “make a patients and the other to be used for the complete study of the mental health needs reception of new patients. of the Philadelphia area” made its report. For the long term, the report recom ­ Leonard T. Beale, chairman of the commit ­ mended the augmentation of staff “at all tee, opened the report by telling the gover ­ levels” as well as increases in pay for nor: “Your Committee finds that the situa­ “qualified physicians, psychologists, social tion in the Philadelphia area is one of the workers and attendants,” and the con ­ most serious and potentially explosive struction of geriatric units at both public health emergencies in its modern Philadelphia and Embreeville. Most strik­ history. ” ing of the future recommendations, howev ­ er, was one to build a new hospital in The report stated that Philadelphia Delaware County with an initial capacity State Hospital with a bed capacity of 4,709 of two thousand beds. had a resident population of 6,300, and 1 was “restricting admissions to five male and five female cases per week.” The com ­ “Crazy” Harry 4 mittee reported that the situation at One of the more effective, and certain­ Philadelphia State Hospital is “in no way ly the most flamboyant, of the secretaries unique. ” It asserted: “All the state hospital of welfare was Harry Shapiro, a Phila­ facilities in the Philadelphia area are trag ­ delphia lawyer and former member of the ically overcrowded and in some wards to a Pennsylvania Senate. In recognition of his degree which is little short of revolting. ” exploits, the members of the Capitol Press After claiming that the deficiency in Corps called the wildest poker game they both the quantity and quality of personnel played “Crazy Harry.” Shapiro, along with 1 was due to “inadequate wages and housing Governor George M. Leader who had facilities, the report maintained that this appointed him secretary in January 1955, “tended to limit facilities for treatment were appalled at the conditions in many of with consequent longer residence of the the state hospitals and were determined to I patients, a lowered percentage of cure and take action to correct them. further refusal of admission to other ill Shapiro was especially knowledge ­ patients. ” Moreover, it asserted the “condi ­ able. He was credited with having tions described have handicapped research authored much of the state’s mental which is the principal means by which the health care legislation in the 1930s and growing magnitude of the problem of men­ 1940s while he was in the Senate, includ­ tal illness can be checked and the increas­ ing having spearheaded the fight for cen­ ing expense of institutional care ultimate­ tralized control in 1938. Shapiro also had ly lessened.” served as chairman of the Senate commit ­ The committee made recommenda ­ tee that looked into the problems at tions for both the short term and the Philadelphia State Hospital (Byberry). future. Among those for immediate imple ­ Once in this position —on being refused mentation, it suggested that patients be entry to inspect the facility—he climbed moved from Philadelphia to Embreeville over the fence at night to see the situation State Hospital, which apparently had firsthand. some excess capacity It also suggested Although Shapiro had initially been a giving urgency to the already planned Republican, he had some basic disagree ­ building construction at both facilities—a ments with his party, and so one day he

i simply stood up in the Senate chamber them to be living in state quarters while 79 and moved over to the Democratic side. He there was a shortage of space for patients. then was elected for two more terms as a Although some superintendents interpret­ Democrat. ed the order as giving them the discretion At first the new secretary of welfare to retain their medical staff on the hospi ­ attempted to clean up things by sending tal grounds in a permanent “on call” sta­ inspection teams to the worst of the hospi ­ tus, the secretary made it clear he wanted tals to make recommendations for improv ­ them out too. When some superintendents ing their management. Shapiro started balked, Shapiro simply held up the pay- r with hospitals known to have some of the checks of all those who had not left. They more intractable problems, those at soon departed. r Allentown and Philadelphia. By December The Department of Welfare was now 1955, when progress by this method had fully “in charge. ” The state hospital super ­ proved to be too slow, he and Governor intendents had become employees of the Leader pushed through the House a bill department, and the trustees, whose jobs that not only placed mental health person ­ were no longer political plums, were i nel under the merit system but also trans­ reduced to an advisory role. ferred the administrative powers of the individual state hospital boards of trustees American Psychiatric Association to the Department of Welfare. They were Study of 1955 divested of most of their responsibilities No sooner had Governor George M. and became largely advisory bodies for the Leader appointed Harry Shapiro secretary superintendents. of the Department of Welfare in 1955 than The changes that Harry Shapiro Shapiro hired the American Psychiatric implemented as secretary of welfare were Association (APA) to study the state’s administrative rather than medical; how ­ mental health program. r ever, any intrusion into the running of the The focus of the APA investigation, hospitals tended to be seen by the superin ­ which was completed in 1956, was more tendents and the trustees as interference on the side of the professional than the in decisions over the care of the mentally human dimension. Unlike the surveys of f ill by a nonmedical individual. Shapiro ’s Dorothea Dix in 1845 and Arthur “political ” behavior especially annoyed Haviland in 1914, it was not an expose of them. Each time he arrived at a facility it neglect and abuse. There was no mention, was with a large retinue of department for example, of the severe problems that employees as well as with a personal pho ­ Albert Deutsch found at Philadelphia in tographer. Picture taking always seemed 1948 (see the “Closing of Byberry”), to be a significant part of his travels. although they most certainly still existed Although he was attempting to force at the time the survey team visited. change by raising the public ’s awareness Instead the 1956 APA report por ­ of problems through publicity, within the trayed problems in terms of needed or hospitals he was seen as using the visits improved facilities, staff, and programs — as an opportunity for personal news mak­ all of the discussions of which were direct­ ing. ed toward an “ideal program ” for In May 1958, Shapiro ordered that all Pennsylvania. One of its important sec­ nonessential hospital employees living on tions, for example, was devoted to “New hospital property in state-owned buildings Ideas.” Among those the study concluded be moved out into the community. The sec­ would be helpful were branch hospitals, retary claimed it was inappropriate for half-way houses, sheltered workshops, 80 therapeutic farms, community mental verted from storage rooms, or in other health centers, and the establishment of available space. These makeshift arrange ­ psychiatric units in general hospitals. ments were too small to serve more than a These suggestions were directed, of course, handful of patients at a time. toward reducing the overcrowding in state In its building section, the report rec­ hospitals as well as improving patient ommended the construction of new admis- care. sions buildings, geriatric units, and recre­ In some respects, the study was even ational centers at all hospitals and stated laudatory in tone. It recounted the that the building situation was especially “unprecedented interest” in mental health bad at Allentown, Farview, Harrisburg that the survey team found throughout and Philadelphia. 1 the state, especially in citizens groups. It At Harrisburg beds were needed for described the General Assembly’s legisla ­ 930 patients; at Embreeville there were tion and appropriations as “forward-look ­ leaking roofs as well as one building that ing ” and of “record proportions. ” And it was a fire hazard and needed to be razed, called Harry Shapiro an “extraordinarily and although Philadelphia had the great ­ dynamic” secretary who has “exhibited a est shortage in number of beds, Farview determination to fight without let up. ” came in for even greater condemnation It acknowledged, however —after because of its “severe overcrowding. ” describing biennium appropriations for Of the fourteen hospitals rated as operating expenses as having risen from overcrowded, Farview was calculated as $30 million in 1943 to $110 million in 1953 62.5 percent, while Danville—with the and then to $193 million in 1955 (of which lowest rating —stood at 11.5 percent. $140 million was earmarked for mental Percentages, of course, are somewhat health), and of $42 million allocated in deceptive. Philadelphia was appraised at 1955 for new construction at mental hospi ­ 57.1 percent, not too far behind Farview’s \ tals and schools —that “except for scat­ rating, but in terms of real numbers this tered improvements in service, the same represented a shortage of nearly 2,400 amount of overcrowding and shortages beds for its total population of 6,567 still occur. ” patients. ( Much of the lack of improvements in There were also major shortages of service was attributed to the low per capi­ staff. Among psychiatrists, only five of the ta expenditures in Pennsylvania in com ­ seventeen state hospitals had half of their parison to other states. While Michigan quota, while twelve hospitals had a deficit was spending $4.08 per patient and New of over 60 percent, and five were “so inad­ York $3.38, the Commonwealth was equately staffed that little more than cus­ spending $3.02. There was also consider ­ todial care can be expected. ” The thirty- 1 able variation between the state’s hospi ­ eight psychologists in the state system tals. The per capita at Hollidaysburg was also represented a deficit of 62 percent of $4.15, while that at Philadelphia was those the APA recommended as required $2.73, the lowest in the state. for an adequate program. At the same time the demands on the According to the report, the reasons state’s mental hospital infrastructure was for the shortages lay in the “isolation of “running far ahead of the facilities provid ­ several of the institutions, ” the “connec ­ ed.” Virtually all of Pennsylvania’s hospi ­ tion between the care of mental patients tals were cited as being “especially short of and the indigent, ” “inadequate financing, ” day space for activity therapies. ” and the “operation of the spoils [patron ­ Frequently occupational therapy shops age] system.” From an historical perspec ­ had been set up in basement areas con- tive, however, the study attributed the long-term cause to the “lack of scientific vided strong, capable support for the 81 treatment techniques ” having “placed the American Psychiatric Association ’s 1955 whole program in a condition of essential study. hopelessness, which attracted few people. ” The organization ’s members designed Although the several hundred pages and then conducted a statewide inventory of the report had a positive ring through ­ of Pennsylvania mental hospital services, r out, those four words —condition of essen­ both their strengths and weaknesses. tial hopelessness —seemed to carry a Members across the state visited their ► weight out of all proportion to their num­ local state hospital and, using a standard ber and position in the middle of the questionnaire, gathered the information analysis, to expose a system with serious needed to shape the APA survey. In sum­ difficulties, one that, for all the report ’s marizing their findings they reported on hopeful stance, appeared to offer little real buildings as firetraps, patients sleeping on hope. the floor for lack of beds, and personnel ratios at less than half the minimum stan­ dards prescribed by the APA. Citizens Mental Health Groups With the initiatives of the APA study A significant element in the press to and presentations by the various citizens conduct the 1955 American Psychiatric organizations before the legislature, the Association study came from citizen General Assembly increased funding for groups around the state, especially from mental health, approved a new state hos ­ Harry Shapiro ’s fellow Philadelphians. pital building in Delaware County to Prominent among these organizations relieve overcrowding, and—although not was the Pennsylvania Citizens Association the separate cabinet-level position (PCA), a 1950 outgrowth of the desired—did approve establishment of a f Pennsylvania Charities Association, which mental health chief as a deputy secretary had been organized at Wilkes Barre in within the Department of Welfare. 1912. According to Max Silverstein (Vital The promising start in 1956 following ► Connections: Integrated Care for the the release of the APA study was soon suc­ Seriously Mentally III), the Pennsylvania ceeded in the 1957 legislative session, Citizens Association ’s mental health com ­ however, with deep cuts in funds for men­ mittee took on a corporate identity in 1952 tal health. As Silverstein puts it, from as Pennsylvania Mental Health, Inc. then on “a constant battle took place (PMH), and then associated itself with the between Pennsylvania Mental Health and 9 National Association for Mental Health. the political leadership of the Financial support for the fledgling organi ­ Commonwealth ” until 1963 when, under zation continued to come from PCA as well the impetus of President Kennedy, the as the Philadelphia United Fund, the U.S. Congress stepped into the mental v Pittsburgh United Fund, and other com ­ health picture. During that period, howev ­ munity groups around the state. er, the PMH was successful in getting the Just as earlier the Pennsylvania General Assembly to increase the per- Charities Association had played a major patient expenditure level from $2.60 in role in the legislative campaigns that led 1952 to $12 in 1962. in 1921 to creation of the Department of When federal funds for a planning Welfare and in 1949 of the General State study became available in 1962, PMH, the Authority (which initiated a $65 million Pennsylvania Association for Retarded building program for the “treatment and Children, the Pennsylvania Medical safe keeping of the wards of the state”), so, Society, the Pennsylvania Psychiatric too, Pennsylvania Mental Health, Inc. pro- Society, and members of the health and 82 welfare councils in the state developed a sonal and generally sympathetic meeting draft plan for the Office of Mental Health. between Dorothea Dix and President The final draft that the Office of Franklin Pierce, he vetoed the bill because Mental Health submitted to the National he believed it was constitutionally Institute of Mental Health was accepted unsound. immediately and a grant of $398,600 was It would be another hundred years provided to the state for development of a until the federal government finally comprehensive mental health planning entered the mental health field—with the study. passage of the National Mental Health Act I It was this plan, which was completed in 1946, and the establishment of the in December 1965 that led to the 1966 National Institute of Mental Health. The Pennsylvania Mental Health and Mental Second World War had created a “success” Retardation Act. At a ceremonial signing environment in the nation. If science could of the bill in the “old section ” of the split the atom and develop a vaccine for Pennsylvania Hospital in Philadelphia, polio, it seemed plausible that other areas Governor William W. Scranton called the such as mental health would benefit from bill, “a triumph for the citizen’s mental federal involvement and money. health movement. ” Prior to that time “the framework of mental health policy . . . with an extensive Return to the Community system of public mental hospitals whose 1 foundations had been laid in the early In the late 1840s and early 1850s nineteenth century . . . appeared stable,” Dorothea Dix waged the foremost struggle as Gerald Grob writes in From Asylum to of her career on behalf of the nation ’s indi­ Community. Although there were dis­ < gent insane. It was a fight that one biogra ­ agreements over the details,” according to pher calls the “most dramatic battle of her Grob, “there was little disposition to ques ­ life.” Believing that greater strides could 1 tion the concept that the mental hospital he made at the federal level than by press­ was the appropriate location for the care ing the individual states to action, Dix and treatment of the mentally ill.” began a years-long campaign to have The time was ripe following the war, i> Congress approve a “land bill.” f however, for a wave of public beneficence The federal government was being in regard to mental health. Advocacy besieged during that period by specula­ groups in support of a greater governmen ­ tors, the railroads, development compa ­ tal role —both within the profession and nies, and private adventurers, each hoping among the general public —sprang up and to secure free public lands for their indi­ began lobbying for greater federal involve ­ vidual enterprises, all promising some ment. While before no more than occasion ­ public good in exchange for the receipt of a al voices were raised questioning the “juicy plum ” of public land. nation ’s state asylum scheme, following Unlike the other claimants, Dorothea the war the floodgates of criticism, ques ­ Dix had no votes or bribes with which to i tions, and suggestions, and the condemna ­ enlist congressmen to her cause. She per­ tion of the one hundred-year-old system severed, however, until she had persuaded were opened wide. President Pierce’s enough senators and representatives to doubt over the constitutionality of the U.S. pass a bill that distributed 12.23 million government entering an area traditionally acres of land to the states for the construc ­ reserved for the states was ignored in the tion of asylums—the cost of the buildings calls for action. to be financed by the states through the resale of the excess land. In spite of a per- In 1955, at the suggestion of the chiatrists began to empty the “back 83 American Psychiatric Association and the wards” housing the nation ’s and the state’s mental health council of the American chronic mentally ill. Medical Association, Congress passed and Between 1965 and 1980, the number President Eisenhower signed a Mental of patients in Pennsylvania’s state hospi ­ Health Study Act. Five years later the tal dropped from 53,917 to 10,796, an 80 study group ’s report included a proposal to percent reduction. Still the new drugs did provide a mental health clinic in every not reach everyone. While one third of the community with more than 50,000 individ­ remaining patients had been hospitalized r uals. In 1963 President Kennedy took up under four years, 28 percent had been this idea when he presented a plan for a patients between three and twenty years, national program of mental health cen­ and 40 percent had been living in the ters. The president stated: “I believe that state system for more than twenty years. the abandonment of the mentally ill... to Schizophrenia was still the predominant the grim mercy of custodial institutions disorder among both chronic patients and f too often inflicts on them a needless cruel­ new admissions. ty which this Nation should not endure.” While few voices have been raised to President Kennedy signed the resulting suggest a return to the asylum-era sys­ legislation in October 1963. The act provid ­ tem, those in opposition to “deinstitution ­ f ed for community centers that would pro ­ alization, ” as it has come to be called, are vide services (i.e., emergency and outpa ­ many. Arguments abound asserting that tient care) designed to reduce the number the community centers are used primarily I of patients who would otherwise have been by the middle-class, that the indigent who i admitted to state hospitals. have been returned to the community The act was reauthorized in 1970 and have ended up on the streets rather than in 1975 the original list of “services” the in the care of a center, that without the r centers could offer was expanded. No daily oversight of a hospital staff member, more, however, than a third of the planned medication is often forgotten, that city centers were actually built. jails have once again become defacto men­ About the same time that the commu ­ tal institutions. r nity mental health center idea was born, After thirty years, however, the com ­ the discovery of the effects of tranquilizers munity mental health center idea is still on mental patients became known. While dominating the mental health picture and * previous therapies (metrazol convulsive, appears destined to continue doing so for electroshock, hypnosis, and insulin shock) the foreseeable future. had provided only occasional and frequent ­ ly no more than temporary relief, the new Staff Needs psychotropic drugs seemed to offer dra­ In October 1962, the Office of Mental matic and possibly permanent change. Health’s Program Research and Statistics Also, patients who had not previously group under Robert P. Wray prepared yet responded to any of the available treat­ another in the long succession of studies ments now seemed to exhibit remarkable and reports dating back to the nineteenth improvement. The drugs, moreover, century. This report again cited the lack of appeared to benefit large numbers of adequate staff for Pennsylvania’s state patients. hospitals. Using quotas established by the With the use of drugs such as tho- American Psychiatric Association, Wray’s razine, and the availability of community staff found that the state system was defi­ centers where patients with relapses could cient in every category of employee from go for short-term stays, state hospital psy- 84 physician and social worker to therapist American Psychiatric Association ’s stan­ and laboratory assistant. dard. There were only 172 vacant posi ­ There had been an increase of 466 tions across the whole system, and any full-time employees in the seventeen hos ­ requests for funds for additional personnel pitals from 1961 to 1962, including an would probably go unfilled. additional twenty-three psychologists and While the APA continued to set stan­ seventeen social workers. However, in no dards, its president, Harry Solomon told job category had the growth kept pace the group: i with the increase in number of patients. The large mental hospital is Moreover, they had fallen far short of the antiquated, outmoded, and rapidly American Psychiatric Association ’s stan­ becoming obsolete. We can still dards. Between 1956 and 1962, for exam ­ build them, but we cannot staff them; and, therefore, we cannot ple, the number of physicians had make true hospitals of them. After increased from 220 to 272, but this was 114 years of effort, . . . rarely has a still 121 short of the standard, while dur­ state hospital an adequate staff, . . ing the same period the figure for atten­ . and our standards represent a dants had increased from 5,584 to 6,352 compromise between what was that was 1,241 short. Wray’s report listed thought to be adequate and what it was thought had some possibili ­ u a far more striking statistic, however, ty of being realized. among registered nurses. Their numbers

actually had fallen between 1956 and 1962 I from 971 to 885. Moreover, nurses repre­ Arthur P. Noyes, “Mr. Psychiatry” sented the most striking deviation from John Curwen was probably the best < the standard. The known of the Pennsylvania state asylum American Psychiatric superintendents of the nineteenth century. Association estimated Like Curwen, the two most prominent * a total of 2,191 nurses twentieth-century psychiatrist-superin ­ were required to han­ tendents in the Commonwealth also dle Pennsylvania’s served as presidents of the American 4 patient population. Psychiatric Association. This left a whopping While Daniel Blain was hired at shortfall of more than Philadelphia State Hospital (in the hope 1,300. (These numbers he could turn the trouble-ridden facility were still better, how ­ around), both late in his career and follow ­ ever, than Thomas ing his presidency of the A.P.A., Arthur P. 1 Kirkbride’s one atten­ Noyes had a long as well as distinguished dant or nurse for each career at Norristown State Hospital before eight patients of a he headed the association. hundred years earli- Following Noyes ’ death in 1963, er.) Secretary of Welfare Arlin M. Adams Although by 1962 called him the “dean of state mental hospi ­ the number of full- tal psychiatrists,” and described him as a time employees stood “true champion of clinical research and at 12,174 for the sev­ study in the field of mental health.” Arthur P. Noyes, superintendent of Norristown State enteen hospitals, Noyes was not only a physician but Hospital from 1936-1959. Noyes, who served as the four- there was little hope also a respected author and teacher. teenth president of the American Psychiatric Association, 0f making Up any 0f During his twenty-seven-year service in was a distinguished writer on mental illness and organ­ ized an annual national research conference focusing on the gap between that Pennsylvania, Noyes contributed gener ­ the treatment of mental illness. level and the ously to medical and scientific publications If

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.. tm: and was the author of several books, Hospital, Noyes accepted appointment as 85 among them a Textbook of Psychiatry, a an instructor at the Harvard Medical Textbook of Psychiatric Nursing, and School, where be became the chief execu ­ Modern Clinical Psychiatry. The latter tive officer of the hospital. book went through at least six printings. In 1936 Noyes became superintendent It was widely used in the United States at Norristown State Hospital following a and was translated into several foreign similar appointment at the Rhode Island languages. State Hospital. He had the honor of hav­ ► Arthur Noyes was a native of Enfield, ing two institutions named for him—the New Hampshire. In 1899 he graduated at Arthur P. Noyes Neuropsychiatric the head of his class at Kimball Union Institute at New Hampshire State Academy and entered Dartmouth College Hospital and the Arthur P. Noyes on a scholarship. He graduated Phi Beta Research Foundation at Norristown State Kappa three years later. Following med­ Hospital. ical studies at the University of Penn­ Although he made substantial contri ­ sylvania, he accepted an internship in City butions in the field of mental health, I Hospital, Blackwell’s Island, New York. according to Secretary of Welfare Adams, After teaching at the University of Noyes ’s “astute wisdom was tempered by 1 Chattanooga Medical School, he returned the serenity of his gentle nature.” Adams to the University of Pennsylvania for grad ­ continued, “Beloved by thousands through ­ l uate study in psychiatry. Following a stay out the nation, he will always be ‘Mr. I on the staff at the Boston Psychopathic Psychiatry’ to those in the state system.” r 86 Community Mental Health causes. During his administration, Scranton put through the state’s first col ­ The Scranton Administration and lege loan program, several major conserva ­ Mental Health tion programs, a 50 percent increase in public school financial support, and estab­ The 1960s were a time of great civic lished geriatric centers, as well as a sys­ unrest across the nation. Unleashed in tem of community colleges. part by protests over the war in Vietnam, On a number of occasions, proposals the civil rights movement was perhaps the had been made for establishing and then most conspicuous of the public demonstra ­ -I for extending civil service in the state. For tions of the decade. Although the civil example, the need for civil service status rights movement is primarily associated for hospital employees had been the first with the emancipation of the nation ’s of several recommendations C. Floyd blacks, especially those in the South, it Haviland made in his 1914 report. also included numerous initiatives, princi­ Although some progress had been made in pally court actions, on behalf of the men­ the intervening years, state government tally ill. was still largely run by political I Court suit after court suit was under- appointees when George Leader became taken across the state and the nation: for governor in 1955. “unconstitutionally confining an appellant Governor Leader’s efforts at expand ­ after termination of sentence for original ing the limited civil service coverage then conviction ”; for transferring a patient from 3 in existence failed in the legislature, as Philadelphia State Hospital to Farview (a 1 had earlier such efforts. Leader was so maximum security facility) “without notice determined, however, to “professionalize ” and a hearing ”; for the right to treatment his administration that he issued an exec­ in the “least restrictive alternative setting, utive order requiring the heads of all including in facilities outside the institu­ agencies not serviced by the Civil Service tion ”; for failure “to give proper warnings Commission to “administer, under the | . before an exam; ” for failure of a staff psy­ present Commission contract arrange ­ f-' chiatrist at Philadelphia “to inform a ments” the forty-one technical and profes ­ patient of Thorazine ’s possible side sional positions in the executive branch effects”; for the “use of electro-convulsive his order cited. therapy over a patient ’s objections ”; for Amo ng those jobs named in the “summary revocation ” of a patients ’ leave Leader executive order were a number of of absence “without notice or right of state hospital positions, including mental appeal ”; and many other cases all leading hospital medical directors, nurses, occupa ­ to the 1972 Alabama decision in Wyatt v. tional therapists, pathologists, physical Stickney for the “right to treatment.” therapists, psychiatric physicians, and The courts were not alone, however, psychologists. in their activities in support of mental Finally eight years later on August patients. Between 1963 and 1966 the 27, 1963, Governor Scranton approved Scranton Administration took several amendments to the Civil Service Act that major steps that changed the mental extended coverage in a single, uniform, health picture in Pennsylvania. modern legislative civil service system to a William W. Scranton was a large portion of the state’s workforce, Republican, but a moderate. According to including those previously covered in a biographer, George D. Wolf, Governor Governor Leader’s executive order. Scranton was an ardent advocate of civil In addition to such provisions as stan­ rights legislation as well as other liberal dardized recruitment and selection meth-

k ods, the act prohib ­ 87 ited discrimination against any person because of political, religious, or frater­ nal affiliations, race, national ori ­ gin, or other non ­ I merit factors. In addition to those in a dozen other agen ­ cies the act covered all positions now r existing or here­ after created in the Office of Mental f Health. Governor Raymond Shafer at Byberry, October 1967. After assuming control at Philadelphia, Dr. Daniel Blain embarked Then following on a program of inviting legislators and finally the governor to see firsthand the conditions at the hospital. Shafer is a third “special ses­ being greeted by Dr. Blain and members of the hospital staff on the governor's arrival from Harrisburg. ■f* sion ” of the legisla ­ r ture that Governor Scranton called in appropriate services as close to a patient ’s April 1966 to consider establishing in law home as possible. the recommendations from a planning ini­ Act 6 of the 1966 Special Session pro ­ tiative begun in 1963, Pennsylvania’s vided comprehensive coverage of all I mental health program was revised in a aspects of mental health care: voluntary direct, more visible way. (Special Sessions and involuntary commitments, the rights ► were required because the Pennsylvania of those committed, the control of their Constitution placed limits on the regular funds, habeas session.) While professionalizing the work ­ corpus proceed ­ force would, over time, improve the level ings, transfer of f of care patients received, the enactment by patients between the legislature of a bill authorizing a facilities, even return to a tiered system of county, city, the use of and state responsibility for mental health mechanical care dramatically changed its basic char­ restraints. r These, of acter. Following the lead of the federal government, the legislature established a course, were comprehensive system by which counties largely a codifica ­ or groups of counties could provide or pur ­ tion of existing chase preventive, diagnostic, therapeutic, laws or practice. or rehabilitative services for the mentally It was the estab­ in. lishment of coun ­ The act provided for the administra­ ty mental health Inspecting a ward with Dr. Blain and Charolotte S. Kelly, presi ­ tion of community services according to and mental retar­ dation programs dent of the hospital board of trustees. L to R: Dr. Joseph annual plans as approved by the Adlestein, deputy secretary, Office of Mental Health, unidenti ­ Department of Public Welfare. The county that was new. fied, Dr. Thomas George, Secretary of Public Welfare, Governor systems were to be run by county mental Under Act 6, Shafer, Dr. Blain and Mrs. Kelly. health and mental retardation boards. The those counties intent, of course, was to make available that wanted to develop —singly or jointly 88 there were four areas: Dauphin, Cumberland/Perry, York/Adams, and Lancaster.) C In many cases these units were designed to coincide with newly estab­ lished or planned Community Mental Health centers. The breakup into units was intended to be a “therapeutic tool, ” however, not simply an administrative 1 arrangement. Unitization was founded on the concept of decentralization in which authority and responsibility for patient care was placed in the hands of the clini­ cal director of each unit. At Philadelphia, the reorganization into units came to be know at the “Great * Governor Shafer talking to a worker in the hospital cafeteria. Migration. ” In less than a month during October 1967, 4,500 patients were trans­ r ferred (and sometimes retransferred) to with a neighbor —mental health plans tak­ their new locations. More important, vir­ * ing advantage of grants available from the tually all the hospital staff was affected by 4 federal government, could now begin to the moves. (Organizational Obstacles to construct mental health clinics or hospi ­ Change in a Large Mental Hospital, tals. Howard M. Kaplan and Daniel Blain, talk Following the signing of Act 6, the I presented at the 125th Annual Meeting of counties adopting such plans began to pro ­ the American Psychiatric Association, vide both outpatient and in-hospital serv­ Miami Beach, Florida, May 5-9, 1969) ices. They became the first agency of While there were difficulties in mak­ recourse for the mentally ill, with the ing the mass patient moves, even greater state mental hospitals handling referrals problems arose in staff acceptance and of the more severely disturbed and long ­ adjustment to the change. Departments term cases. 1 and even units within departments began to battle over changing responsibilities, The Unit System lines of accountability, and especially over patients. A typical attitude of the nurses In line with similar developments and attendants, even in some cases of the I across the nation, Pennsylvania’s state psychiatrists was: “I’m not sending my hospitals began conversion to a “Unit ‘good ’ patients to other units. If I do, I’m System” in the mid-1960s. At Philadelphia going to get stuck with all the problem State Hospital this new approach divided patients from the other units, as well as the facility into six smaller hospitals, each the ones who already are here.” In some of designed to he more manageable, easier to the larger hospitals, it took nearly a year administer, and more responsive to patient for the disputes and especially personal needs. Where patients previously had been attitudes to resolve themselves. segregated by “sex, symptoms, and prob ­ The unit system was also designed to lems,” the new units were organized break up the staff “caste” system that around “catchment” areas (the community existed at most state hospitals. or county from which a patient had come). Multidisciplinary teams, consisting of a At Harrisburg State Hospital, for example, psychiatrist, a psychologist, rehabilitation 89

Group therapy session at Philadelphia State Hospital, ca. 1970s. \

counselors, nurses, social workers, and more as a management measure than a aides were organized for each catchment therapeutic device. area. And the medical teams became more closely allied with the community mental Psychiatric Nursing health unit in the county which they served, than with their fellow profession ­ While the duties of an attendant als in the other “units” in the hospital. changed little over the years—remaining Patients and community volunteers, more ­ largely tasks in maintaining order —those over, participated in treatment decisions. of a nurse evolved by the middle of the The objective as expressed in one report twentieth century into duties that was that mental hospitals should be required a skilled professional. “schools for living, ” not “dormitories for The requirements of helping the indi­ dying. ” vidual reestablish mental health are quite By most accounts the conversion was different from those employed with a considered a success, the turmoil associat ­ patient suffering from a physical disease. ed with making the change worth the Arthur Noyes summarized this difference strife. According to Franklyn R. Clarke, well when he wrote in his A Textbook of superintendent of the Philadelphia State Psychiatry: Hospital, for example, the transformation For the most part the agencies to a unit system at that facility was the employed by the psychiatric nurse in an effort to cure her patient are “most successful” therapeutic tool avail­ not drugs or surgical techniques able to the hospital since the advent of but measures which as far as pos ­ tranquilizers in the previous decade. sible reestablish interests, activi­ Throughout many of the other state hospi ­ ties and contacts of normal life and tals, however, the unit system was viewed promote a happy, effective and social functioning of the personali- w

90 ty. These agencies should be ly without wrinkles—patients had to be regarded as medical measures and checked regularly for any difficulties in received the same zealous and breathing or weakening of the pulse. thoughtful application, as do the Feeding of mental patients was measures of physical treatment. In the case of physical disease another important nursing responsibility. the treatment of the patient ’s Large numbers of patients required spe­ symptoms may often be quite cial attention. Many arrived at the hospi ­ \ impersonal, but in mental disorder tal undernourished, others would not take we must remember that it is the sufficient food, and some would refuse to patient and not his hallucinations, eat at all. Persuasion or spoon-feeding delusions or tics that we wish to treat. worked for some of these; for others tube feeding was necessary. One of a nurse’s first tasks with a The real test of a nurse’s suitability new patient was gaining his or her confi ­ for handling psychiatric patients was her dence. The nurse’s bedside manner, the \ methods of caring for disturbed and excit ­ atmosphere she created, acted as subtle ed ones. The behavior of the restive, therapeutic measures, exerting a real destructive and ill-tempered patient could influence on the patient. As Noyes noted,

■ be exasperating, but the nurse, in the “the patient attaches little value to mere words of famed psychiatrist, Adolph * verbal professions of benevolence. He is Meyer, “must be capable of rising with quick to note the intonations of the voice, impartiality and benign serenity above the the aspects of the face and all those distortions and aggravations of a fighting expressive movements of the body which \ patient. ” speak more truthfully than do words. ” Suicide watch of any patient suspected Moreover, as the physician was usual­ of such inclinations was an important part ly able to see each patient no more than a of the nurse’s duties. Patients would employ few times a week, the nurse became his or what one would imagine to be the least like­ her main contact. It was necessary, there­ ly methods in successful attempts; one fore, for a psychiatric nurse to develop and thrust a needle into her heart. maintain accurate and complete records In closing his thoughts on psychiatric covering the patient. The record to be nursing, Noyes wrote, “The nurse should maintained included a description of the remember that the chief end of treatment patient and his or her behavior, what kind ... is to make the patient again a social ­ of an individual the patient was at the ized member of his community, ... by onset of illness as well as how his malad­ reestablishing emotional bonds, the sever­ justments had developed. ance of which has isolated him from his Among the many unique techniques fellows. ” that the mid-twentieth-century psychiatric Perhaps the most difficult obstacle the nurse had to master were those of admin­ nurse had to overcome in achieving this istering the various hydrotherapies: wet was to allay the psychological traumas sus­ pack and continuous-flow bath. Patients tained by enforced hospitalization. The dig ­ undergoing either treatment required nity, pride, and self-respect of a patient almost constant monitoring. Any patient who had been removed from his home, in a bath had to be watched to prevent an often unceremoniously and against his attempt to drown him or herself. And wishes, thrust behind locked doors and when employing the wet pack, which barred windows, deprived not only of his required a careful wrapping of the patient freedom but his clothing and personal in layers of wet sheets and blankets effects, and forced to live with strangers in mummy fashion —but snugly and smooth-

a what was perceived as a hostile environ ­ In its April decree, the court agreed 91 ment would certainly suffer extreme blows. with the plaintiffs that the hospital ’s At mid-century there were twelve treatment program was “deficient in that hundred nurses in the state’s mental hos ­ it failed to provide a humane psychological pitals. This was about one nurse for each and physical environment, ” that there fifteen patients. Although the ratio in were insufficient doctors to “administer Pennsylvania was slightly better than the adequate treatment,” and that “non-thera- national average, the number of nurses peutic, uncompensated work assignments ► was only 46 percent of the quota estab­ and the absence of any semblance of priva­ lished by the American Psychiatric cy, constituted dehumanizing factors. ” Association. There were wide variations, The court ’s decision was no less than moreover, across the system. At Danville a patient ’s “bill of rights. ” It provided the number of nurses was 85 percent of among other things that \ the APA quota while at Farview it was a • Patients have a right to priva­ meager 13.6 percent. cy and dignity. All student nurses in Pennsylvania • Patients have a right to the were required at that point to take three least restrictive conditions nec­ months ’ work in psychiatry at an accredit­ essary. ed affiliate institution. Nearly all of the • Patients have an unrestricted state hospitals offered in-patient training right to send sealed mail. r programs for graduate nurses, while the • Patients have a right to be free University of Pittsburgh and the from unnecessary or excessive University of Pennsylvania offered both F medication. advanced courses and a masters degree ► • Patients have a right to be free with a major in psychiatric nursing. from physical restraint and isolation. Wyatt v. Stickney • Patients have a right not to be subjected to treatment proce ­ On April 13, 1972, the U.S. Middle dures such as lobotomy, elec­ Court in Alabama issued its final decree in tro-convulsive treatments or f the case of Wyatt v. Stickney. The case other unusual or hazardous began when Ricky Wyatt, through his treatment procedures without aunt, sued the state of Alabama—Dr. their consent. Stonewall B. Stickney, as Commissioner of • Patients are not deemed Mental Health and the State Mental incompetent to manage their Health Officer—over the quality of care he affairs, to contract, to marry, to was receiving at Bryce Hospital, register and vote, or to hold Tuscaloosa. His case, however, soon professional or occupational or became a class action suit on behalf of all vehicle operators ’ licenses by “patients involuntarily confined for mental reason of their commitment to treatment purposes in Alabama mental a mental hospital. institutions. ” In an earlier decision the court with­ The District Court further stipulated held its final disposition of the case for that its order would be implemented “forth ­ appointment of a master and professional with and in good faith,” and that “unavail­ advisory committee to “oversee the mini­ ability of funds, staff or facilities would not mum constitutional standards” that a fed­ justify a default by the defendants.” eral court, might reasonably assume over Following the court ’s decision in Wyatt a state-operated organization. v. Stickney—which was applicable nation- w

92 wide —almost all aspects of daily exis ­ Patients were permitted to work on a 1 tence at Pennsylvania State Hospitals voluntary basis after Wyatt, but all such i were completely reordered. The thrust of labor had to be compensated in accordance the court ’s decision was that each patient ’s with the prevailing minimum wage. Since treatment (including all therapeutic tasks these operations could only be run effi­ and any labor) must be tailored to his or ciently by the state using uncompensated her individual condition and needs. patient labor, and contracting out the farm \ : ■ After Wyatt a separate “treatment and dairy herds made them too expensive plan ” was required for each patient. The for the return in meat and produce, farm­ < U.S. District Court, moreover, established ing stopped at all state hospitals. precise staffing ratios, the minimum acceptable number for each position in a The State Hospital as “City” state hospital. It specified, for example, that two psychiatrists, four physicians, In spite of Wyatt v. Stickney, peon ­ three psychologists, twelve nurses and age —as it came to be called—died a hard seventy aides were required for each 250 death at Pennsylvania State Hospitals. In patients. It even set standards for the her budget presentations to the Penn­ 1 number of toilets and showers, the fre­ sylvania General Assembly two years after quency of linen service, the size of the the Alabama District Court ’s decision in physical plant, and the patient ’s nutrition ­ the Wyatt case, Secretary of Welfare al requirements. Helene Wohlgemuth, informed the mem­ The case was a major blow to the idea bers of the House that many of the state < of the hospital as self-sufficient. The provi ­ hospitals were still keeping patients with sion of the decree that stated, “no patient special skills or even those who were “needed” as laborers long after they had shall be required to perform labor which ■i qualified for release. - involves the operation and maintenance of I the hospital, ” spelled the end of farm, While this was reported by orchard, dairy, and garden operations Wohlgemuth —and picked up by the using patient labor. press—as if it were an egregious evil, the whole fabric of asylum life was built around peonage, and the adjustment to 1 fully state-supported institutions would be a dramatic “change-of-life ” as well as an expensive transformation. By the beginning of the twentieth cen­ tury, the state’s lunatic asylums were largely self-sufficient communities. Like medieval principalities —with the superin ­ tendent as prince and the patients and staff as serfs—they functioned as sepa ­ rate, self-contained cooperatives. The system had been established dur­ ing the previous three-quarters of a centu­ ry, not just to satisfy the medical profes ­ sion ’s theory of labor as therapeutic for the mentally ill, but also to fulfill the legisla ­

Special Philadelphia State Hospital work detail, 1946. ture’s desire to keep the cost of running the asylums as low as possible.

1 As late as 1915, for example, in the pounds of butter, 12,162 dozen eggs, 93 act to establish Torrance State Hospital, 17,159 pounds of ham, 51 barrels of salt the legislature had specified that the prop ­ fish, 9,025 pounds of coffee, 1,699 barrels erty be of arable land so that “as far as of flour, and 205 gallons of oysters along 1 practicable, the food for the inmates of with smaller amounts of clams, crabs and r. i. said hospital may be produced on said lobster. The latter items probably ended \ land.” up, however, in the staff rather than the The two needs—the physician’s and the legislature ’s—had blended into a har­ monious whole, a mutually satisfying arrangement for economically fulfilling the state’s sense of obligation to its mentally disturbed. The legislature did continue to supply funds for new buildings as well as major renovations to old ones, and a modest three dollars (at the turn of the century) v1 per patient for subsistence, but the ■ remainder of the hospital ’s needs came from the farm, garden, orchards, piggery, and the wide variety of manufacturing operations carried on at each institution. Except for staples such as coffee, sugar CompLeted in 1900 the "Farm Colony" building at Warren was removed from the hospital and coal, virtually all of the products that proper. It was intended not only as a temporary structure for the patients and atten ­ were consumed were produced on the hos ­ dants who worked on the farm, but also to relieve the crowding in the main building. pital grounds with patient labor. J Wernersville took special pride in its patient dining rooms. dairy herd of Ayrshire and Holstein cows. Even Farview, which was built as a For many years this herd ranked third in prison-hospital for the criminally insane, Berks County for the production of milk maintained extensive farm property. It I poundage and butter fat. The hospital also was hewn out of one hundred acres of maintained several greenhouses. what was described by a 1926 Wayne v Thousands of two- to six-inch flowerpots County local history as “wild land.” were used each year during the cold- In 1896 an Industrial Building was weather months to start plants for the erected at Wernersville. The structure was garden and farm. used to manufacture brushes, brooms, rugs, And in 1903, the legislature appropri ­ and baskets, as well as provide facilities for ated $10,000 for the state hospital at shoe repair and weaving. A print shop was Harrisburg to purchase yet another adja­ established in the east end of the building cent farm bringing the hospital ’s acreage in 1917. It was in almost continuous opera ­ up to 412. By that year the farm at tion during the next sixty years. According Harrisburg was producing more than a to a 1976 history of the institution by hundred tons of hay each season —enough George H. Merkel two hundred different to supply all of the facilities’ needs. And administrative and medical forms were we learn from hospital steward J. B. printed there in large quantities. A photo ­ Livingston ’s meticulously kept records graphic darkroom was installed in 1958 and that the kitchen used prodigious amounts the shop became a combination letterpress- of food. In 1904 the patients and staff con ­ offset printing facility, complete with a sumed 173,793 pounds of beef, 29,109 process camera and platemaker. 94 Although Thomas Kirkbride had cau­ While potatoes, wheat, and corn were tioned against the therapeutic value of the main crops, they were only the big hard labor, all of the facilities took advan­ money items. In addition to vegetables tage of their available free work forces. At such as beans, cabbage, carrots, cucum­ Harrisburg they dug sewer and water bers, lettuce, onions, squashes, and toma ­ lines as well as building foundations. At toes, the gardens at Harrisburg, for exam ­ Danville they graded roads. At Werners- ple, also produced asparagus, eggplant, ville they were used to renovate old and kale, parsnips, parsley, rhubarb, rutabaga, erect new buildings. At Warren they con ­ radishes, spinach, salsify, turnips, and structed bridges to the islands in the river mushrooms. And each hospital maintained on which the patients then fabricated pic­ an herb garden in which most of the spices nic facilities that were widely used by the used in the kitchens were grown. patients and staff. The “piggery ” was an integral part of At all of the hospitals the men were nineteenth-century asylum life as well as employed shoveling snow in the winter and at the county almshouses. Kirkbride had cutting grass in the summer. The latter specifically included provisions for them in they did with hand mowers but in teams of his original plans for a hospital, and in a dozen or more men. And each spring they conducting his survey in 1914, C. Floyd were busy plowing, planting, trimming Haviland had mentioned piggeries —ques ­ fruit trees, fertilizing the fields, and tend­ tioning their proximity to the water sup ­ •< ing stock. The women were also actively ply—at a number of the facilities he visit- employed year round. They sewed and ed. repaired clothing and items such as pillow ­ Gradually as the 1970s progressed, cases, worked in the laundry and the iron ­ each of the state hospitals wound down ing room, served in the kitchen, and manu­ their farm, garden, and manufacturing factured or repaired many of the small operations. At first, some of them made objects used throughout the hospital. attempts to use patients on a voluntary basis—as part of their written therapy plan—but the justifica­ tions for such use were hardly worth the result. In some instances contract labor was used. Eventually, all of the hos ­ pitals accepted the Wyatt deci­ sion and eliminated patient labor from their programs. Much of the farmland at those state hospitals still in existence has been sold off for commercial development or is used by the state for other func­ tions. At Harrisburg, for exam ­ ple, the State Police, the Pennsylvania Game Commission, and the Patients at Harrisburg shoveling snow off the Department of Environmental hospital's walkways in the 1950s. Protection are now occupants of some of the former State Hospital ’s farm property.

A i Vecchione v. Wohlgemuth that she had been denied due process, but 95 that her Social Security benefits were Two years after Wyatt v. Stickney, the Pennsylvania Secretary of Welfare Helene shielded from the claims of creditors including the state, and that throughout Wohlgemuth was sued by a seventy-year- old widow who had been held in Byberry her hospitalization at Byberry she had as “a person in need of observation, care, been “afforded less than the constitution ­ ally required treatment under Wyatt v. and treatment for a mental disability.” Stickney.” This latter, according to them, Elvira Vecchione, who was entirely r without means of support other than her thereby prolonged her stay and the costs Social Security benefits, had been confined she had been assessed, or possibly even at Byberry for a year and a half commenc ­ warranted that she should not have been ing in October 1971. Her sole assets committed at all. beyond her monthly Social Security check On July 11, 1974, the U.S. District were $500 she received during her stay at Court found for Vecchione. Having estab­ the hospital as her share of an estate. lished without sufficient justification two Under Commonwealth law Elwood N. classes of individuals—those who were Shoemaker, the revenue agent at Byberry, competent and those who were not —the had assessed Vecchione for the costs of state law did not grant her (the state’s i care and maintenance and appropriated attorneys had agreed that she was compe ­ $2,610.48 of her Social Security benefits, tent) any procedure to seek restoration of I and also took custody of her personal her property. The court found, however, an belongings and bank account. A portion of even “more fundamental problem ” with this amount was returned at the time of the state’s attempt to justify its statute in her discharge pursuant to the Penn­ its statements concerning the law’s “factu­ r al underpinning. ” sylvania statute, but at no point was she given an opportunity to challenge the The District Court ’s decision rejected action or the amount of the charges the the hypothesis “that mental patients may be presumed less competent to handle \ state had assessed her. Under the law, the defendants were their own assets than the public at large. ” not required to grant her a hearing, make Moreover, it cited Elvira’s situation as a final determination of liability, or even similar to that of an accident victim who as the U.S. District Court found, initiate a was temporarily unable to leave a hospital court proceeding or make any kind of to “manage ” his or her funds. The state accounting of its action. had no authority to seize the property or The case was processed as a civil assets of an individual in such circum­ rights matter that dealt with the right of stances. patients confined in state mental hospitals Following Vecchione v. Wohlgemuth, who were not incompetent and had less Pennsylvania State Hospitals returned all than $2,500 in assets to control and man­ funds they had taken from patients includ­ age their own property as opposed to the ing petty cash sums for them to use in the right of the Commonwealth to summarily cafeterias and canteens. The case was of seize—without prior notice or hearing — minor impact on the state’s funding of and make disposition of the funds during patient care, but it was a significant blow to the patient ’s hospitalization. (The state their “authority ” over other patient actions. law did require the hospital to initiate court action for those patients who were Patient Abuse incompetent or had more than $2,500.) From the first, the annual reports of Not only did Elvira’s attorneys argue r nineteenth-century Pennsylvania asylum 96 superintendents included occasional com ­ six patients had died following mistreat­ ments about the firing of attendants not ment. It was the conclusion of the Shapp just for incompetence but also for the Task Force on Maximum Security abuse of patients. Much of the abuse, of Psychiatric Care that Farview be closed course, never was reported. Moreover, as and three regional facilities near the the patient population rose in late nine­ state’s major population centers be built. teenth-century asylums, the ratio of nurs­ It was hoped that—among other enhance­ es and attendants to patients dropped at ments—this would permit the hiring of a many institutions leading to greater more competent, professional staff. 1 inducements for mistreatment of patients. When Governor Dick Thornburgh fol ­ The result: overworked attendants lowed Milton Shapp into office in 1979, he who in confronting situations of destruc­ appointed a second task force to review the tive or unruly conduct frequently attempt­ situation. The new group advocated keeping ed to secure acceptable behavior through Farview open as the state’s maximum-secu ­ coercion or the increased use of restraints. rity facility for the criminally insane. They And the excessive, especially long-term recommended a $4.25 million plant renova ­ use of restraints often became a barely tion, the hiring of additional medical per­ disguised form of abuse. Locked up or sonnel, and the implementation of a series straightjacketed patients easily could be of management reforms. The Inquirer called ignored or forgotten —for days, sometimes it a “capitulation to politics. ” even for weeks. While the instances of abuse appar ­ I Although the problem of patient abuse ently declined, the problems at Farview was far more prevalent in county and city continued. In December 1980, the superin ­ 1 institutions than in state hospitals, it also tendent resigned following several armed existed there; it also continued well into the escapes with guns that a visitor had smug ­ twentieth century. As late as the 1970s gled into the facility. Secretary Helene Wohlgemuth had to fire one of her state hospital superintendents Mental Health Plans who refused to stop incarcerating disruptive In the years following the passage of patients in animal-like cages. His defense the Mental Health Act of 1966, the at the hearing at which his dismissal was I Commonwealth began emphasizing the upheld was that use of the cages was “ther­ preparation of planning reports, first peri­ apeutic” rather than punitive. odically, and then by the 1980s on a three- Perhaps the most pervasive instances year cycle with annual updates. The Office of abuse that surfaced at the state hospi ­ of Mental Health considered these reports tals in the late twentieth century—other to be the most “effective mechanism for than at Philadelphia State Hospital — establishing program direction ” as well as occurred at Farview in 1975. the “basis for rational decision making. ” Following a series of articles in the The reports were lengthy documents cov ­ Philadelphia Inquirer during 1976, ering both the state hospitals and the com ­ Governor Milton Shapp appointed a task munity mental health system. Much of the force that, at the conclusion of an eight- “planning ” was directed at, or driven by month study, reported that a “pattern of budgetary considerations. brutality, corruption and crime was ram­ According to the 1986 plan, the state pant ” within Farview and had been going hospital population was continuing to on for years. The study noted that the decline while that of the community mental abuse of patients was systematic; it health system continued to grow, although included instances not only of gross neg ­ fifteen state hospitals with a census of lect but also of frequent beatings. At least

A 1 7,869 patients were still in operation. The ty system presents some interesting con ­ 97 Joint Commission on Accreditation of trasts. The community mental health sys­ Hospitals accredited eleven of these fifteen tem was being estimated to cost $148.7 mil­ hospitals and fourteen were certified to lion a year while the state system ran at receive Medicare patients. $439.8 million —85 percent of which was for Many, however, of the Common ­ staff salaries. Slightly over 25 percent of wealth’s counties —primarily those in rural the state hospital budget was covered by areas—did not have a community mental the federal government and an additional health system in 1986. Only eighteen of 11 percent ($46.48 million) was still being r the state’s counties had active programs, received in collections from patients. although twelve more were developing The 1986 Office of Mental Health plans or discussing the possibility of insti­ report summarized the role of the state tuting a community mental health system. mental hospitals as that of providing The 1986 report estimated the future “active inpatient psychiatric treatment to rate of decline in the number of state hos ­ individuals whose mental illness requires pital patients to be around 3 percent a more extended treatment than acute inpa­ year, although at that point the office had tient care provided in the local communi ­ no plans to close additional state facilities. ty,” or treatment which consisted of “spe­ 4 -■i A reduction in staff, however, of 583 (from cialized services which cannot be provided 12,255 to 11,672) was planned during the economically by most local communities. ” I next three-year cycle. It was aimed at cov ­ The System Organization and Manage ­ ering the drop in number of patients, but ment section of the plan closed optimisti ­ was scheduled to be accomplished cally by stating: “through carefully managed attrition ” Recognizing that there will r rather than dismissals. probably be no significant budget At the same time, it was anticipated growth in the near future, the hos ­ that the state hospital patient population pital system will be managed with a strong emphasis on cost contain ­ would “increasingly consist of the serious ­ ment and cost efficiency while ly ill psychiatric patients, ” including the maintaining and improving “chronically ill” young adults who “cannot patient care. be treated in community settings. ” I Farview was the only state hospital to According to the report, the patient popu ­ be singled out in the report for a detailed lation was “younger and more seriously ill critique. Although Farview was the desig ­ and difficult to treat than at any time in nated “maximum security” facility for the the past. ” state, there were “forensic units” at other During the 1980s, patients with “schiz­ state hospitals, especially those like ophrenic reactions ” were still the predomi ­ Philadelphia that were in metropolitan nant group among the state hospital popu ­ areas. lation —around 60 percent of the total. In the years between the 1980 investi­ Schizophrenics also accounted for much of gation at Farview and the 1986 Office of the movement into and out of the state hos ­ Mental Health report, various plant reno ­ pitals during this period. They comprised vations had been completed to upgrade 57 percent of the admissions and 66 per­ security and to bring the hospital in com ­ cent of the transfers in (from community pliance with the provisions of the 1974 mental health facilities). Schizophrenia Rehabilitation Act. was also the predominant mental disorder Moreover, during that period, Farview of those who died in the hospitals. had implemented revised policies and pro ­ A comparison of the budget require ­ cedures to provide for improved patient ments between the state and the communi ­ 98 admission, discharge, and continuity of In the book, he reflected on what he had care; the making of reports to the court; seen there: the use of seclusion and restraints; in Hundreds of patients sleeping developing an Affirmative Action Plan and in damp, bug-ridden basements. increasing the number of minority employ ­ Noisy and violent patients made ees; and in training the clinical staff in the life intolerable in barn-like day- rooms because there weren’t seclu­ management of “assaultive behavior. ” sion rooms where they might be isolated until calmed down. . . .” Closing of Byberry in Philadelphia As I passed through some of 1 Byberry’s wards, I was reminded A lake where all the world ’s tears have of the pictures of Nazi concentra ­ flowed tion camps at Belsen and Buchenwald. I entered buildings In 1988, the Department of Public swarming with naked humans Welfare announced the closing of the herded like cattle and treated with Philadelphia State Hospital at Byberry. less concern, pervaded by a fetid ' During the previous half century the very odor so heavy, so nauseating, that word, Byberry had become infamous, one the stench seemed almost to have that signified the neglect of Pennsylvania’s a physical existence of its own. mentally ill—just as the name of the The Shame of the States included pho ­ London hospital, Beth-lem, had entered tos of the male “incontinent ward,” which the language two hundred years earlier as Deutsch described as “a scene out of I Bedlam, portraying a place of noise and Dante’s Inferno, [where] three hundred confusion. nude men stood, squatted and sprawled in Byberry was among the hospitals that this bare room, amid shrieks, groans, and Albert Deutsch had visited in preparation unearthly laughter. ” for his 1948 book The Shame of the States. As part of its “State Care” act elimi­ nating local and county mental hospitals, the state had taken over Byberry in 1938 and renamed it Philadelphia State Hospital. When he signed the legislation in September 1938, Governor George Earle proclaimed: “Today Byberry and all its horrors end—tomorrow brings a new institution, a new hope for those unfortu ­ i nate patients. ” The new year, however, saw a new Governor, Arthur James. According to the Philadelphia Inquirer (July 10, 1938), James met, within weeks of being elected, with Philadelphia Republican party lead­ ers to decide how to fill the hospital ’s eight hundred patronage positions. As a city facility, Byberry had a long history of patronage problems. When earli­ er superintendents had fired attendants In an effort to improve patient qualify of care, Governor George M. Leader con­ for incompetence as well as for neglect or ducted on-site inspections of numerous state hospitals. Here Governor Leader abuse of patients, the dismissed individual points to inadequate sanitation facilities at Byberry in Philadelphia in 1956. would frequently go to City Hall and get the director of Public Health and Charities to order the attendant rehired, often with because of the “abominable conditions ” its 99 a raise. inspectors found there. In December 1938, the newly appoint ­ By the early 1960s, Byberry had a ed state board of trustees met at Byberry rated capacity of 4,200 patients but the for its first meeting. One of the members numbers housed there ran to more than became so sickened by the stench, howev ­ 6,800. Two thousand of these simply er, that the meeting was moved back to roamed the hospital property that strad­ center city. During the meeting several of dled Roosevelt Boulevard in northeast r the trustees told D. H. Woolley, the new Philadelphia. Some of them actually lived superintendent that Governor Earle had on the grounds, a few even died there appointed, that they would handle all hir­ unmissed until their rotting bodies were ing and firing so he “wouldn ’t he burdened accidentally discovered. with the responsibility. ” In 1966 the National Institute of Woolley reportedly told them, “If you Mental Health conducted an in-depth think you ’re going to turn Byberry back study of Byberry at the request of the into a political roost while I’m superin ­ Scranton Administration. The institute’s r tendent, you ’re crazy. You can get in your report included a recommendation to cars and start out for Byberry right now, appoint a first-rate psychiatrist as super ­ because you ’re the new superintendents. ” intendent. Governor Scranton selected The trustees did not hold another Daniel Blain, who was serving as the med­ 1 meeting for two years. Woolley, however, ical director for the American Psychiatric remained for twenty-seven months. Association, but had previously served as During that period he fired more than two president of the organization and at one hundred attendants for abusing patients. time had been the commissioner of mental r When he resigned in January 1941 he told health for California. reporters gathered at the hospital: The seventy-year-old Blain arrived in I wake up at night in horror October 1966 and started the practice of over this place. I can see myself taking state legislators on tours of the and members of my staff before a facility. When they were appalled at what coroner ’s jury and a grand jury they saw, he told them, “You get what you charged with the responsibility for F pay for! ” And continued to push the legis ­ roasting to death aged and blind people. Yet in every report I ever lature for more money. made to the state, I outlined this Blain told a reporter that when he condition very thoroughly because arrived there, Byberry received $5.15 per i it is so horrible. And it still exists. patient for daily maintenance, as com ­ Byberry finally burst onto the public ’s pared to the $32 Haverford State Hospital awareness as a snake pit following World received for each patient. Philadelphia not War II. Not only did Deutsch’s book —with only received the lowest level of support of its chapter on Byberry—appear, but sever­ all of Pennsylvania’s mental hospitals, it al national magazines, including Life and ranked near the bottom nationally. PM published lengthy exposes, and a num­ During his tenure as superintendent, ber of conscientious objectors, who had Dr. Blain worked to increase funding and served at Byberry during the war went to reduce the patient population and public with their stories of patient neglect, change the hospital from a custodial to a abuse, and in one case even murder. Then treatment facihty. In three years the num­ in 1946 the Veterans Administration ber of patients was down to 3,600. And abruptly terminated an agreement it had with continued reductions in the number made with the hospital just months earlier 100 of patients, Dr. Blain expressed the hope about the same degree of frequency, to turn Byberry into a “treatment” rather although men usually first become ill in than a “custodial ” facility. their early twenties, while the onset in But the days of the large state mental women is usually five years later. hospital handling thousands of patients in Typically those who become ill with the one facility were over. The advent of psy­ disorder have several episodes during chotropic drugs and the return to a com ­ their lifetime. munity mental health system saw the Recent research confirms Bleuler’s start of a dramatic reduction in the num­ belief that schizophrenic patients are not 1 ber of patients being hospitalized in state missing a normal store of words, but that facilities. By the time Byberry finally they are missing a “goal-directed access” closed in 1990 the number had dropped to them. Their disordered thinking below five hundred. processes have difficulty producing normal Fifty years of state management had word associations. One of Bleuler exam ­ little more than marginal impact on ples was “wood-dead cousin, ” a meaning ­ Byberry. Over the years, innumerable less jumble spoken by one of his patients. grand juries and “blue ribbon ” committees When he learned, however, that the 1 from the legislature had investigated the patient ’s cousin had died recently and had hospital. But in 1987 a state report still been buried in a wooden coffin, it became called for “immediate and drastic action obvious the expression had been construct ­ ... to reverse Byberry’s history of neglect, ed out of an indirect association. 1 poor management, absence of treatment Another frequent symptom of schizo ­ and rampant abuse.” phrenia is delusions. Although delusions Thousands of people knew about the by definition are ideas with an unlikely, 1 « conditions; no one seemed able to do any­ impossible, or false content, to the individ­ thing about them. Writing for the ual experiencing a delusion, its reality is Philadelphia Inquirer in 1988, William beyond question, or refutation. Ecenbarger called Byberry “a lake where Acute delusions are frequently accom ­ all the world ’s tears have flowed. ” panied by strong emotions and increased anxiety. In her semi-autobiographical 1 novel I Never Promised You a Rose The Schizophrenic Mind Garden, Joanne Greenberg writes of the About 1 percent of the population “darkmindedness” of schizophrenia, of see­ develops schizophrenia during its lifetime. ing and hearing the external world as if (In the nineteenth century those who “through a key hole, ” and of her manic exhibited the symptoms were classified as episodes as an “erupting volcano, ” a vol ­ i suffering from dementia praecox.) cano so fierce it “would not let her rest” Although the cause of schizophrenia is but “kept hurling her from one side of the still unknown, the disorder was named by room to the other. ” Eugen Bleuler following his observations Individuals in an acute delusional in the early 1900s, of his patients at a state are often suspicious and apprehen ­ Swiss hospital whose word associations sive. When acute delusions become part of had lost their continuity —he referred as a person ’s basic values and attitudes, they schizophrenic. are considered to have become chronic. When people think or talk of “mad­ Acute delusions can be effectively treated ness,” they are usually referring to the with drugs, while chronic delusions sel­ symptoms of schizophrenia —delusions, dom respond to them. disordered thoughts, and confused speech. The use of drugs in treating the men­ The disease strikes men and women with tally ill dates back to the Middle Ages when it was believed laxatives would elim­ Harrisburg State Hospital in 1958, the 101 inate toxins bottled up in the colon. For results showed that they “produced some several centuries opium, and by the begin ­ degree of change in our total hospitalized ning of the nineteenth century morphine population, and in some produced changes were employed to sedate agitated patients. to a marked degree, assisting in reclaim­ (Kirkbride prescribed morphine in water ing heretofore inaccessible ‘back hall’ for his patients.) By mid-century sedatives patients, at least to a working status.” such as potassium bromide became popu ­ As much as the 1960s public policy r lar in asylums. change that led to the community mental During the early asylum years those who did not respond to the available “treatments” that were intended to keep them quiet, especially at night, were iso ­ lated in wards away from the less manic patients—the depressed, the epileptic, the senile—to avoid disturbing them. For this t reason the most agitated residents were typically housed in the “dreaded” seventh and eighth wards which, as one of Thomas Kirkbride’s patients wrote, were filled \ with “yelling and howling. ” In the early decades of the twentieth century physicians began experimenting t with various convulsive-shock treatments * (insulin and Metrazol) after they discov ­ ered that inducing convulsions in patients reduced their excitement level. Later, when it was found that the shock (leading \ to a convulsion) could be administered more effectively by electro-convulsive devices, these machines quickly replaced the earlier treatment methods. Then in 1951 a Paris physician, Henri Laborit, who was interested in improving anesthetics used in surgery, began admin­ istering antihistamines to a large number of mental patients as a test group and observed that the patients became sleepy and less apprehensive. He got the drug Female patient at Philadelphia State Hospital ca. 1960. I into the hands of several Paris psychia­ trists who confirmed his observations. Although the results of their tests were not equally impressive in all patients, health system, the new drugs were also those who responded dramatically had one responsible for helping to empty the state thing in common —they were schizophren ­ hospital system and “return” large num­ ics. By the 1960s the “psychotropic ” drugs bers of the mentally ill to society. The diffi­ were in wide use throughout the United culty in a progressive release policy lies, of States. course, in making certain that patients con ­ r When the drugs were first used at the tinue to take their medication after being 102 discharged. Unless they are in the care of decades, few states, including Penn­ someone responsible to see that they do, sylvania, had any law providing for an they often stop. Thus, like roving bands of insanity defense during the period. In his Medieval madmen, large numbers of these final message to the Commonwealth in patients have been expelled to wander January 1845, Governor Porter highlight ­ unattended the city streets—to sleep in ed the problem facing mid-nineteenth-cen­ doorways, on grates, and under bridges. tury Pennsylvania courts: Now , however, with our greater Although the system of understanding of the mind and mental ill­ imprisonment adopted by 1 ness, we seem to be on the verge, at the Pennsylvania some years ago . . . has been justly regarded as the start of a new century, of developing even most admirable . . . yet there is better therapeutic strategies for schizo ­ one department which remains to phrenics. be provided for, that of establish­ ing, ... a department for the Not Guilty by Reason of Insanity charge of the insane inmates. There have been, almost every Today the words insane and insanity year, since I have been governor are only used in legal parlance. In the . . . some unfortunate persons con ­ eyes of the law individuals can be judged fined in the penitentiary . . . who to be “Not Guilty by Reason of Insanity.” either were partially insane when In this sense insanity is not a specific dis­ committed, or became so after­ wards. As the law now stands, ease but a question of whether the individ­ 1 there is no remedy for these cases, ual knew right from wrong at the moment but to pardon them, or confine of committing a crime. them in the same manner as other The concept of an insanity defense in criminals are confined. Both these p a criminal case has a long history in modes are oftentimes wrong, and I English common law dating to early in the respectfully urge it upon your con ­ sideration to make some provision fourteenth century. Although the insane for redressing the evil in the were not acquitted they were usually future. spared by a royal pardon, but forfeited all Almost as soon as the asylum at their property to the King. By the seven­ Harrisburg opened in 1851, John Curwen 1 teenth century jurists began devising was called on by the courts to examine “tests” for determining the degree of criminals judges suspected might be insanity that rendered a person not guilty insane and to provide them with “expert ” by reason of insanity. This culminated in opinions concerning the man or woman. It the eighteenth century when an English was not until April 20, 1869, however, that judge laid down his “wild beast” test. the General Assembly codified any rules According to Judge Tracy, “a man must governing an insanity defense. Act 54 of [have been] totally deprived of his under­ that year stated: “Whenever any person is standing and memory, and not know what acquitted in a criminal suit, on the ground he did, no more than an infant, than a of insanity, the jury shall declare this fact brute, or a wild beast; such a one is never in their verdict, and the court shall order the object of punishment. ” The notion of the prisoner to be committed ... for safe not guilty by reason of insanity was finally keeping or treatment.” Thus the codified in English law in 1843 and was Pennsylvania state hospitals themselves first cited in a U.S. case the following became the location at which the criminal­ year. ly insane were incarcerated. Although such a plea was entered in When the jury gave a not-guilty-by- individual cases over the next several reason-of-insanity verdict in a homicide

f case the prisoner had to undergo three With the help of the medical profes ­ 103 years of treatment and could only be dis­ sion and the increasingly liberal inclina­ charged from the asylum following the tion of the public toward the mentally ill “unanimous opinion of the superintendent, during the middle years of the twentieth the managers of the hospital, and of the century, the interpretation of what consti ­ court before which he or she had been tuted criminal insanity was redefined and tried that the man or woman “has recov ­ expanded by many state legislatures and ered and is safe to be at large. ” courts. By the end of the century state hospi ­ During the last several decades of the tal superintendents were called on more twentieth century, however, public outcries » and more to testify in such cases. (For over a few prominent cases, such as that i example, at the trial of Charles Guiteau, of John Hinckley, who shot President who shot President James Garfield in Reagan, led to a definite shift in public 1881, no less than eight medical witness policy, to a more restrained approach in testified in favor of Guiteau’s insanity determining the criteria for such a while fifteen asserted that he was sane defense. The records show, however, that and responsible under the law.) the defense of criminal insanity or “dimin­ Early in the twentieth century the ished capacity” (which was one of the mid­ psychiatric profession began entering the twentieth century refinements of the law) discussion more actively than previously, is seldom used and moreover is often when it mainly had been involved in giv ­ unsuccessful. ing testimony concerning the sanity of A far greater change in policy has individuals. Following celebrated cases— occurred in recent decades, however, in the ► the assassination of President Garfield, area of involuntary commitment to state ► the attempt on Theodore Roosevelt ’s life, facilities. Whereas in the 1960s, public \ and the murder of the architect Stanford policy turned away from forced commit ­ White by the wealthy Harry Thaw—mem­ ment and to moving patients out into the bers of the American Psychiatric community, by century’s end, the number Association began efforts to frame the of involuntary placements in state facili­ issue around psychiatric concerns rather ties began to grow once again —by 1995 it than legal ones. was estimated nationwide at 1.2 million a One writer, Gregory Zilboorg (One year. Family members initiate most of Hundred Years of American Psychiatry) these commitments, however, not the legal calls the 1920s the “golden years of awak­ system, and most of them come from lower ening in the field of psychiatric criminal socio-economic levels. jurisprudence. ” In 1923, for example, William White, superintendent at St. A New Century Elizabeths in Washington, D.C. pleaded for less aggressive and revengeful motives As the Commonwealth enters the in criminal law and for the individualiza­ third century of ministering to its mental­ tion of each case. White argued to over ­ ly ill poor, we might well ask, ‘What have turn the legal system’s “separation of the we accomplished? ” “How far have we act from the actor. ” According to White, come? ” “What remains to be done? ” “The remedies upon which the law seems These are not easy questions to answer. to repose are hangovers of a theological Each question is burdened with complica ­ age. ” He also suggested that to gain a tions, each answer subject to dispute. more balanced perspective criminal Although the greatest number of men­ lawyers serve an internship in a prison tally ill patients is now being treated in just as doctors serve one in a hospital. community mental health centers around 104 the Commonwealth, the state hospital sys­ express pride in the results, the effort was tem is still intact—but with a greatly commendable. reduced number of facilities and a much Perhaps the most serious mistake of smaller patient load. the policymakers was to assume that the Allentown, Clarks Summit, Danville, mere placing of county facilities, such as Harrisburg, Mayview, Norristown, Philadelphia ’s Byberry, under state man­ Torrance, Warren, and Wernersville are agement —because experience had shown still accepting patients—mainly on refer­ that service by the counties and cities was ral from a community center. Hollidays- so much poorer —would change the lot of burg was closed in 1977, Eastern those who were hospitalized in them. It < Pennsylvania Psychiatric Institute in did not. Without the means and will to 1981, Dixmont in 1984, Philadelphia in manage huge numbers of patients in any 1990, Woodville in 1991, Embreeville in meaningful way, the source of control 1997, and Haverford in 1998. Retreat, made little difference. Placing them into a Somerset, and Farview State Hospitals series of smaller facilities might have pro ­ were transferred to the Department of vided some relief, but the cost to build and Corrections in 1980. staff them in the numbers required was The goal at the state hospitals is to probably beyond anything the legislature i move residents into appropriate communi ­ would have been willing to suffer. ty programs whenever possible and pro ­ While it may seem, moreover, that little < vide long-term care for the others. The if any progress was made in the treatment of typical caseload at each of the nine open mental illness until the middle of the twenti­ state hospitals is now between three hun­ eth century and the advent of psychotropic I dred and four hundred. A few of these drugs, like an aspirin to a headache, they < patients are considered to be chronic, and only treat the symptoms of diseases such as in one or two instances the individual has schizophrenia, not the cause. \ been hospitalized for as long as twenty Even the newer drugs being devel­ years. oped today —for want of a better term they In retrospect, the state’s effort are being call “atypical”—still treat the between 1851 and 1951 at handling the symptoms. They do show promise, howev ­ flood of new mentally ill patients appears er, of helping greater numbers of schizo ­ to have been largely ineffectual. It was for phrenics with fewer of the side effects of the General Assembly as much as for the the psychotropic drugs developed in the patients a “subway with no stops! ” as the 1950s. Philadelphia Inquirer once called Byberry. Research, of course, seems to show It must be acknowledged, however, that the way to the future. According to the venture was a valiant, if not a heroic Michael A. Swartz [New Insights into one. The construction of hospital after hos ­ Understanding and Treating pital; the search for new means with Schizophrenia] the results of recent which to handle the enormous influx; the research into the brain and how it func­ continuing debate over whether local or tions are helping us to develop an under­ state control was preferable (although the standing of the various etiologies of schizo ­ various shifts never seemed to change the phrenia—what needs to be done (the lot of the patients, many of whom lived in changes that have to occur in the brain of cruel circumstances), all give evidence of a schizophrenic), but not, at this point, the concern that was felt by a broad con ­ how to do it. Swartz concludes, “Perhaps stituency in the General Assembly, the in another decade.” executive departments, and among the When drug therapy is successful in general public. While not many would relieving a patient ’s psychotic event, mov-

I ing him or her back into the community is not easy to do. To expect family mem­ 105 often destroys necessary support mecha­ bers to be able to do so is unrealistic, espe­ nisms. Although a patient ’s failure to take cially since neither science nor govern ­ his or her medication is often cited as the ment has a good answer. most pressing problem, that is only a Along with “promoting and improv ­ symptom of a larger problem. Recent stud­ ing ” the quality of family life, the key com ­ ies into psychosocial treatment issues have ponent of the Department of Public made it abundantly clear that adequate Welfare’s mission is still “to protect and support is essential to prevent relapses for serve Pennsylvania’s most vulnerable citi­ those released to the community. zens.” Among the department ’s deputy sec­ There is strong evidence that given retaries is one for “Mental Health and the right circumstances the mind can heal Substance Abuse.” The services provided itself, at least, partially. Just as the body include inpatient treatment and rehabili­ has restorative powers, so too the mind tation, outpatient, partial hospital care, has shown that it is not only capable of emergency and crisis intervention, psy­ restoring (replacing) damaged cells but chosocial rehabilitation, family support also of infinitely extending itself—far services, specialized behavioral health ■ -* beyond what was believed only a few years rehabilitation for children and adoles ­ f ago. But it requires a substantial support cents, and community residential and system for the individual for this to occur. treatment services. f Understanding families (or their sur­ There is a role in the current scheme rogates) are needed—as much as to insure of things for a state hospital system. that a patient “takes his or her medica­ Those who are chronic or acutely ill need r ■ tion ”—to provide constant, understanding more than a few days or even weeks in a support to help the individual rebuild community mental health center. And con ­ basic coping mechanisms in order to learn tinued research into mental illness is how to handle a wide variety of even the mandatory. It is not clear, however, most simple life situations, especially ones whether the requirement for a state hospi ­ that produce stress. tal role is continuing to shrink, has leveled t Curiously the one constant through ­ off, or can be replaced eventually by some out one-and-a-half centuries of concern other form of support. over mental illness has been that of the Although state and federal concern importance of “early treatment.” From the has expanded well beyond that of caring first, the superintendent-alienists regular ­ for the indigent —into providing facilities ly sounded the note and modern psychia­ and support for those who have the means trists still consider it an important ele­ as well as into basic research—it is the ment in treatment. Determining the dif­ poor who still bear the brunt of inade­ ference, however, between a first psychotic quate service episode and an idiosyncrasy or eccentricity £

I o cr>

MENTAL HEALTH CARE ACTS 1 of the PENNSYLVANIA GENERAL ASSEMBLY f

I Hospital Date of Act2 Act Number Establishment PURPOSE

May 11, 17513 Pennsylvania Hospital to contribute two thousand pounds and provide for the incorporation of an asylum to be built for the relief of the sick poor and for the reception and care of lunatics. April 29, 1835 152 to exempt from taxation privately owned real estate in Philadelphia County held to construct an asylum for persons deprived of their reason. March 4, 1841 34 to construct an asylum for treatment of the insane. 4 April 14, 1845 440 Harrisburg to establish the first State Hospital

March 18, 1848 218 Dixmont to incorporate private hospital as a voluntary organization with state funding making it a quasi-state facility. April 8, 1861 supplement 5 to return chronic insane criminals to the penitentiary or county prison from which they had come. April 13, 1868 49 Danville appointed site-selection commissioners. April 20, 1869 54 to establish and insanity defense law. April 24, 1869 66 to establish a Board of Public Charities. March 27, 1873 54 Danville approved appointment of hospital board by governor. August 14, 1873 (1874) 223 Warren appointed site-selection commissioners.

1 Excludes minor acts, especially those appropriating bi-annual operating funds or for building maintenance or new construction. 2 Date of the governor ’s signature approving the act. 3 Act of the Provincial Assembly; confirmed by the King in Council, May 10, 1753. 4 Land was purchased across the Schuykill River from Philadelphia but the building was never erected. 5 Supplement to Act 440 of April 14, 1845. A second supplement the same date added trustees to the hospital board.

APPENDIX A I

Hospital Date of Act Act Number Establishment PURPOSE

May 5, 1876 89 Norristown

June 4, 1879 83 to encourage/authorize the appointment of female physicians to treat female patients. June 8, 1881 83 Warren approved appointment of hospital board by governor. May 8, 1883 21 gave the Board of Public Charities authority over all places housing insane persons. Also established a Lunacy Committee within the Board. June 22, 1891 379 Wemersville to serve only the chronic ill from other state hospitals. May 25, 1897 64 “Dual Care Act” permitting the treatment and care of insane patients in county and local institutions. July 18, 1901 737 Allentown to serve those desiring homeopathic care

May 11, 1905 400 Farview to provide a separate facility for the criminally insane. April 16, 1903 to provide for the commitment of individuals who are habitually “addicted to alcoholic drink or intoxicating drugs ” to a state hospital. May 28, 1907 221 to provide for employment of patients and for the distribution and sale of such manufactured goods to other state institutions. May 28, 1907 290 & 292 established the Joint Legislative Commission to Investigate Various Charitable Institutions. May 1, 1913 101 to authorize the Board of Public Charities to obtain indictments against officers of institutions for failure to provide proper care or maintenance of patients. June 18, 1915 1055 Torrance

APPENDIX A

o h-i o 00

Hospital Date of Act Act Number Establishment PURPOSE

May 6, 1921 272 to commit all persons afflicted with syphilis to Werners ville. July 11, 1923 414 first Mental Health Act. Established uniform admission, commitment and discharge procedures; and codified all acts since 1845. Also revised mental health terminology to be used. April 11, 1929 487 authorized Department of Public Welfare to determine legal residence of patients and require proper district to pay costs.

June 23, 1931 324 Western State Psychiatric Designated to specialize in diagnosis and research. May 28, 1937 267 to imposed liability on individuals, counties, and poor districts for care of mental patients. September 29, 1938 53 Clarks Summit, Embreeville “Full State Care” act that abolished all county Hollidaysburg, Mayview, and community mental health facilities. Eight Philadelphia, Retreat, hospitals named were taken over as state Somerset, and Woodville hospitals April 18. 1949 599 Eastern Pennsylvania Psychiatric

December 14, 1955 853 to change the duties of hospital boards from management of their facilities to a strictly advisory role. Also established the position of Commissioner of Mental Health as a deputy secretary. July 13, 1957 582 to consolidate the Departments of Welfare and Public Assistance into one.

APPENDIX A

j, j 1 Hospital Date of Act Act Number Establishment PURPOSE

June 13, 1961 319 Haverford and Eastern State School and Hospital

August 26, 1965 381 to authorize state participation in the new federal Medicaid program.

October 20, 1966 96 to establish in law major recommendations from the planning initiatives begun in 1963 providing for a community services system taking advantage of federal grant funds.

July 31, 1968 unassigned to set forth the details of the state’s Medicaid program.

April 14, 1972 221 to remove responsibility for treatment of persons and with problems of alcohol or drug abuse from December 6, 1972 Department of Public Welfare and the Office of Mental Health. Split mental health and mental retardation programs into two separate offices. July 25, 1975 93 removed the stipulation that the superintendent must be a physician. July 9, 1987 207 removed the requirement that the Commissioner of Mental Health have credentials as a psychiatrist.

o I-* M O

STATE HOSPITAL SYSTEM at the peak of its maturity-1947

PLANT ANNUAL NUMBER OF AVERAGE COST STATE HOSPITAL INVESTMENT OPERATING COST PATIENTS PER PATIENT

Allentown $6,728,943 $744,438 1,966 $379 Philadelphia $13,453,357 $2,111,014 6,100 $346 Clark's Summit $1,440,000 $574,396 1,046 $533 Danville $5,168,714 $903,586 2,918 $642 Dixmont $1,776,307 $332,358 973 $596 Embreeville $500,000 $135,700 300 $832 1 Farview $3,826,025 $585,103 1,098 $281 Harrisburg $5,958,888 $1,568,173 2,441 $368 Hollidaysburg $529,957 $219,957 369 $314 Laurelton $3,408,320 $750,883 903 $421 Norristown $9,355,200 $1,390,333 4,954 $504 2 Pennhurst $6,464,431 $837,736 2,279 $420 3 Polk $5,192,162 $998,091 3,176 $329 Mayview $8,500,000 $1,265,489 3,005 $370 Retreat $2,699,012 $556,430 1,103 $803 4 Selinsgrove $3,603,797 $376,401 897 $369 Somerset $891,169 $152,212 463 $491 Torrance $5,038,907 $944,263 2,551 $549 Warren $6,868,324 $2,057,047 2,562 $310 Wernersville $4,176,072 $682,366 1,851 $342 Woodville $6,516,765 $1,193,215 2,428 $452

$102,096,350 $18,379,191 43,383 $424

NOTES: 1. Farview was the hospital for the criminally insane. It is now run by the Department of Corrections. i: 2. Pennhurst served mentally defective children from the eastern half of the state. E. 3. Polk was the equivalent of Pennhurst for the western half of Pennsylvania. 4. Selinsgrove was a "colony" for epileptics 5. Figures are taken from the 1947 Pictorial Report on Mental Institutions in Pennsylvania. Hospitals that are still open are shown in bold print.

APPENDIX B

r- *ew«- -IW.41SMI Bibliography 111

Ahmed, Paul I. and Plog, Stanley C. State Mental Hospitals. New York: Plenum Medical Book Company, 1976.

Alexander, Franz G., M.D. and Sheldon T. Selesnick, M.D. The History of Psychiatry. New York: Harper and Row, 1966.

Beers, Clifford W. A Mind That Found Itself. Garden City: Doubleday & Co., 1921.

Biddle, Elizabeth. Addison Hutton: Quaker Architect, 1834-1916. Philadelphia: Art Alliance Press, 1974.

Bond, Dr. Earl D. Kirkbride and His Mental Hospital. Philadelphia: J. B. Lippincott Company, 1947.

Caplan, Ruth B. Psychiatry and the Community in Nineteenth-Century America. New r York: Basic Books, Inc., 1969. Clark, Philip Michael. “Bedlam in Penn’s Woods. ” Pennsylvania Heritage 15, no. 3 (Summer 1989).

Cohen, Neal L., editor. Psychiatry Takes To The Streets. New York: The Guilford Press, 1990.

Cope, Thomas P. Diary, 1800-1851. South Bend: Gateway Editions, 1978.

Curwen, John, History of the Association of Medical Superintendents of American Institutions for the Insane. Warren: Cowan Printers, 1885.

__ A Manual for Attendants in Hospitals for the Insane. Philadelphia: William S. Martien, 1851.

Dain, Norman. Clifford W. Beers, Advocate for the Insane. Pittsburgh: University of Pittsburgh Press, 1980.

! Deutsch, Albert. The Mentally III in America. New York: Columbia University Press, 1937.

The Shame of the States. New York: Harcourt, Brace, New York, 1948. L Dix, Dorothea L. Memorial to the Senate and the House of Representatives of the Commonwealth of Pennsylvania, Harrisburg: February 3, 1845.

Foley, Henry A. and Steven S. Sharfstein. Madness and Government. Washington: American Psychiatric Press, Inc., 1983.

Foucault, Michel. Madness and Civilization: A History of Insanity in the Age of Reason. New York: Pantheon Books, 1965.

Gilchrist, Agnes Addison. William Strickland, Architect and Engineer: 1788-1854. New York: Da Capo Press, 1969.

!

i «

112 Graham, Thomas F. Medieval Minds: Mental Health in the Middle Ages. London: George Allen & Unwin Ltd., 1967.

Greenberg, Joanne. I Never Promised You a Rose Garden. New York: Holt, Rinehart and Winston, 1964. i Grob, Gerald N. Mental Institutions in America, Social Policy to 1875. New York: The Free Press, 1973.

__ Mental illness and American Society, 1875-1940. Princeton: Princeton University J; | Press, 1983.

Hall, J. K., editor. One Hundred Years of American Psychiatry. New York: Columbia University Press, 1944.

Hartz, Fred R. and Arthur Y. Hoshino. Warren State Hospital, 1880-1980, a Psychiatric Centennial. Bend, Oregon: Maverick Publications, 1981. ? I Horwitz, Elinor Lander. Madness, Magic, and Medicine: The Treatment and Mistreatment of the Mentally III. Philadelphia: J. B. Lippincott Company, 1977.

Kirkbride, Thomas Story. On the Construction, Organization, and General Arrangements of Hospitals for the Insane. Philadelphia: J. B. Lippincott Company, 1880. : Kittrie, Nicholas N. The Right to be Different; Deviance and Enforced Therapy.

Baltimore: Johns Hopkins Press, 1971. i

Levinson, Daniel J. and Eugene B. Gallagher. Patienthood in the Mental Hospital: An Analysis of Role, Personality, and Social Structure. Boston: Houghton Mifflin Company, 1964.

McGovern, Constance M. “The Community, The Hospital, and the Working-Class Patient: The Multiple Uses of the Asylum in Nineteenth Century America,” in Pennsylvania History 54, no. 1, (January 1987).

Marshall, Helen E. Dorothea Dix, Forgotten Samaritan, Chapel Hill: University of North Carolina Press, 1937.

Morrison, Ernest. The City on the Hill: A History of the Harrisburg State Hospital. Harrisburg: Historical Committee of the Harrisburg State Hospital, 1992. i

Morrissey, Joseph P. and Howard H. Goldman. “Cycles of Reform in the Care of the i. j Chronically Mentally Ill,” in Hospital and Community Psychiatry 35, no. 8 (August V J 1984). i l

Neaman, Judith S. Suggestion of the Devil: The Origins of Madness. Garden City: 11 Anchor Books, 1975.

Noyes, Arthur P. and Lawrence C. Kolb. Modern Clinical Psychiatry. Philadelphia: W. B. ■ H Saunders Company, 1958. i Noyes, Arthur P, William P. Camp and Mildred Van Sickel. Psychiatric Nursing. New York: Macmillan, 1964. 'i

; k ■ p-

Peterson, Dale, editor. A Mad People ’s History of Madness. Pittsburgh: University of 113 Pittsburgh Press, 1982.

Porter, Roy. A Social History of Madness: The World Through the Eyes of the Insane. New York: Weidenfeld & Nicolson, 1988.

Rosen, George. Madness in Society. Chicago: The University of Chicago Press, 1968.

Rothman, David J. The Discovery of the Asylum: Social Order and the New Republic, 2 vols. Boston: Little, Brown & Company, 1977.

Showalter, Elaine. The Female Malady: Women, Madness and English Culture, 1830- 1980. New York: Pantheon Books, 1985.

Shorter, Edward. A History of Psychiatry. New York: John Wiley and Sons, 1997.

Silverstein, Max.Vital Connections. Lexington: Lexington Books, 1990.

» Simon, Bennett, M.D. Mind and Madness in Ancient Greece. Ithaca: Cornell University Press, 1978. si Singer, Erwin. Key Concepts in Psychotherapy. New York: Random House, 1965.

■ Stroup, Atlee L. and Manderscheid. “The Development of the State Mental Hospital System in the United States: 1840-1980, ” in the Journal of the Washington Academy of Sciences 78, no.l (March 1988).

Talbott, John A. State Mental Hospitals, Problems and Potentials. New York: Human Sciences Press, 1980.

Tiffany, Francis. Life of Dorothea Lynde Dix. Boston: Houghton Mifflin Company, 1890.

Tomes, Nancy. A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum­ keeping, 1840-1883. Cambridge: Cambridge University Press, 1984. \ Tulipan, Alan B. and Dietrich W. Heyder. Outpatient Psychiatry in the 1970s. New York: Brunner/Mazel, 1970.

Ullman, Leonard P. Institution and Outcome: A comparative Study of Psychiatric i: Hospitals. New York: Pergamon Press, 1967. y Valenstein, Elliot S. Great and Desperate Cures. New York: Basic Books, Inc., 1986.

Wilson, Dorothy. Stranger and Traveler: The Story of Dorothea Dix, American Reformer. Boston: Little, Brown, 1975. Front Cover (clockwise): Dorothea Lynne Dix. early advocate for the mentally ill. Roosevelt Avenue entrance to Philadelphia State Hospital in the 1950s. Interior of Female One at Harrisburg showing one of the day sitting areas, about 1910. Superintendent Henry A. Hutchinson, M.D. standing in front of a three-story wing of Dixmont.

Back Cover: Top: Occupational therapy at Byberry in the 1930s. Bottom: Betty Williams of St. Francis Hospital administering a spray water treatment at Mayview State Hospital in 1946.

Pennsylvania Historical and Museum Commission ISBN.0-89271-101-9