Chapter 1. Introduction

The initial two articles from the 1840s were written by Amariah Brigham, the first editor of The American Journal of Insanity, the original name of the journal. These essays focus on “moral treatment,” the name for the approach to the care and treatment of mental illness introduced in Europe in the late eighteenth century. Moral treatment was imported to the United States and incorporated into practice in the early nineteenth century. Brigham described the origins of moral treatment and explained its dependence on a combination of what are now called psychosocial and biomedical interventions. He believed that the former were more important than the latter, decrying the excessive use of medicines, physical restraints, and remedies such as bleeding and purging. (In so doing, he gently criticized the revered Dr. Benjamin Rush, widely regarded as the founder of American psychiatry.) Brigham also warned of the dangers of overreliance on manual labor as a remedy, referring to the practice derived from the workhouses and poorhouses of the time. He promoted, instead, “mental activity” and instruction of all kinds in the service of recovery.

In his brief article from 1844, Brigham outlined his strong and well-reasoned opposition to the proposal to build “asylums exclusively for the incurable insane.” His arguments reflect the optimism of moral treatment, its egalitarian spirit, and its belief in the power of reason. Brigham raised concerns about the potential for abuse and neglect in such institutions and about the danger of policies motivated primarily by a desire to provide care “at less expense.” He also discussed the inaccuracy of determinations of incurability, the dangers of removing hope, the potential for rehabilitation of those “deranged but on one or two subjects,” and the problems of monitoring care in a decentralized system of care. The currency of these concerns of 150 years ago is astonishing.

A contrast to the asylum for incurable patients is provided by Pliny Earle’s description of the Belgian village of Gheel, a town devoted to the care of individuals who were mentally ill. Held up as a model of the humane treatment of mental disorder, the commune of Gheel in Flanders had for centuries provided care to individuals with mental illness, who were distributed to families throughout the town and its surrounding farms. By the mid-nineteenth century their numbers reached 1,000, among a population of some 10,000 nonpatients. Earle, superintendent of the Northampton (Massachusetts) Asylum, a skeptic and debunker (as reflected in his 1885 article, also reprinted in this issue), provided a generally favorable portrait of Gheel, but not without his trademark concerns.

The final article from the period of moral treatment is the 1845 treatise on the organization of mental hospitals “extracted principally from the reports of Thomas S. Kirkbride, M.D.,” physician to the Pennsylvania Hospital for the Insane. The article describes the evolution of that institution from the “insane department” of the Pennsylvania Hospital, the first in the United States, which had been opened in 1752. The separate asylum was opened for patients in 1841 and became a model for the design and organization of mental hospitals throughout the country. These hospitals came to be known as “Kirkbrides” because of their characteristic architectural style, with patient care wards spreading out as wings from a central structure that served as a residence for the superintendent and as a hub for the administration of the hospital.

Originally designed to support moral treatment, hospitals of this efficient design eventually became the model for the ever-enlarging hospitals of the post-moral-treatment era. The warnings of Amariah Brigham and others about the dangers of large institutions, especially for incurable patients, eventually were eclipsed by practical concerns about cost. The first institution for the chronically insane, the Willard (New York) Asylum, opened in 1865 and ushered in an era of asylum growth and pessimism about the curability of mental illness.

The quality of care in mental hospitals had deteriorated to a very low level by the occasion of the 50th anniversary of the American Medico-Psychological Association in 1894. Numerous scandals had plagued private as well as public asylums. The association invited a critique by S. Weir Mitchell, a renowned Philadelphia neurologist and novelist, who addressed the assembled profession at its annual meeting “on the dividing year” of its first century. Mitchell’s stinging criticism was never published in the journal, probably out of a sense of pique, although the proceedings of the annual meeting contain the speech. The critique is so important as a reflection of turn-of-the century psychiatry that the text of his speech, as it was published in the Journal of Nervous and Mental Disease, is included in this section.

Mitchell’s analysis of the problems of late nineteenth-century psychiatry are fascinating and have unfortunate relevance today. He provided a brilliant critique of the role of political interference in the management of the mental hospital, but he saved his sharpest comments for the profession itself. He was particularly critical of the lack of scientific progress in the care and treatment of mental illness, due to the separation of the practice of psychiatry from the mainstream of medical practice and research. “Your hospitals are not our hospitals; your ways are not our ways” is the oft-quoted phrase that sums up his critique. He admitted that some advances had been made in recent years, but that progress was the exception rather than the rule and that best practice was not widespread. Mitchell encouraged the profession to leave its isolated hospitals and move into the general hospital and out into the community. Like several other important contemporaries who were “outsiders” to psychiatry (e.g., Clifford Beers and William James), he stimulated the mental hygiene reform movement of the early twentieth century. His call for a scientific basis for psychiatric practice strikes a modern theme, but it is interesting that some of his ideas about technical advances (e.g., the use of faradic stimulation and massage), as well as his obvious class consciousness, appear to the modern reader as smug acceptance of old-fashioned ideas.

Walter Channing of Massachusetts, a reformer who had worked to broaden the definition of the profession and achieved the change in the name of the AMSAII to the Medico-Psychological Association, offered a response to S. Weir Mitchell’s address in the journal in 1894. Channing’s comments are remarkably nondefensive. He agreed particularly with Mitchell’s call for scientific advance, but he reaffirmed the central role of the profession in the management of the hospital. “The medical superintendent … deficient in practical ability,” he wrote, “though he might write a volume on the cerebral anatomy of a spider, would be of no value whatever.” Channing also criticized Mitchell for minimizing the problem faced by running asylums with very limited resources. This is a familiar theme for today’s leaders in psychiatry, especially those who are scientists running academic departments with large public service responsibilities.

Adolf Meyer’s article “A Short Sketch of the Problems of Psychiatry” was written in 1897, while Meyer was an assistant physician and neuropathologist at the Worcester (Massachusetts) Lunatic Hospital and “docent of psychiatry” at Clark University in Worcester. The essay, the first in this section to use the term “psychiatry,” focuses broadly on psychopathology and nosology. It was written comparatively early in Meyer’s illustrious career, prior to his moves to the New York State Psychiatric Institute and to the Phipps Clinic at the Johns Hopkins University Medical School and Hospital. Meyer’s involvement at Clark University with the psychologist Stanley Hall (who brought Freud to Worcester) reflects both his interest in psychology and his belief in the importance of professional work beyond the walls of the hospital. Although this article emphasizes a “biological conception of man,” it also underscores the importance of the “psychological as well as physiological and anatomical methods.” Meyer concluded, “A mental disease is a disorder of the person following the laws of general pathology like any other disease.” This argument played an important role in the reforms of the mental hygiene movement that Meyer led in the next decade, and it has been a rallying cry in the reforms of our own era.

Abraham Myerson’s two articles provide a transition from the view of psychiatry offered by Meyer to the view presented by William Menninger in his essay in this section. Myerson’s own views, as reflected in the two articles, are much closer to those of Meyer. With ideas rooted strongly in a medical and biological understanding of mental illness, Myerson was also a student of psychology who tried to bridge the dualism of body and mind. Writing from the Division of Psychiatric Research at the Boston State Hospital, Myerson, who had also been at the Boston Psychopathic Hospital in its early years, was a scientist and a clinician. He was an empiricist who favored experimental evidence. “Results count,” he said in his essay on attitudes toward psychoanalysis, “and where the results are clear-cut, the technique which brings them wins the day.” He was troubled by the lack of results from psychoanalysis, so he conducted a survey of neurologists, psychiatrists, and psychologists to learn their opinions about “one of the oldest systems of concepts and of therapeutics in modern medicine.” His own results were somewhat confusing, but they were telling and sometimes amusing as he dissected opinions about psychoanalysis.

The same tension between the biological and psychological in the profession is discussed in Myerson’s article “Some Trends of Psychiatry,” which presented his own review of psychopathology. Again, the emphasis is on science and the “great reality” of “experimental psychiatry.” Myerson predicted “that when the history of psychiatry is written for the one hundred fiftieth anniversary of the American Psychiatric Association, the end of the era of therapeutic defeatism will be found to date from the time of the introduction of the shock treatments, and that the advent of these queer and rather barbaric additions to the ‘gentle’ art of healing will mark the beginning of a real and much better therapeutics.”

William Menninger presented a different view in his distinctly post-World War II article “The Role of Psychiatry in the World Today.” This essay is as expansive as the title suggests. Menninger’s emphasis was on psychiatry as a social science as well as a medical science. His view was broadly social, involving issues of what we now call “family values” (i.e., divorce, single-parent families, working mothers, sexuality, and alcohol and other drug use), as well as the issues of racism, crime, unemployment, and illiteracy. His vision was global, concerned with world war and world peace. And he was optimistic that the profession of psychiatry would have something to offer in the way of greater understanding and help for the ills of the world. Menninger admitted “that we are not now in a position even to deliver much of the available information that we might assemble …. We must extend our frontiers of knowledge …. We need to develop more medical statesmanship.” Menninger was not a passive dreamer; he worked hard to try to improve the position of psychiatry. He described several of these efforts, including the formation of the Group for the Advancement of Psychiatry and the passage of the National Mental Health Act, which ultimately led to the creation of the National Institute of Mental Health.

The psychiatry of the past was a creature of the mental hospital; the psychiatry of the future was to be a community-based practice. The mental hygienists of a half-century before had made some tentative steps into the community; the psychiatrists of the post-World War II era were to become firmly rooted there.

This section concludes with three different but interesting articles. One is a biography of Dr. Benjamin Rush by Clifford B. Farr, written for the APA centennial to honor the first American psychiatrist, who was also a signer of the Declaration of Independence. The other is a post-World War II perspective on “Current Trends in German Psychiatry” by Kurt Schneider of the University of Heidelberg. The perspective of this short report is decidedly biological. John Romano’s reminiscences carry us from this era into the present and beyond.

The one consistent theme in these papers is change; they chronicle the evolution of attitudes and policies. Each of the reforms in psychiatry has been the product of a creative tension between a desire for positive change and the limits of our knowledge about how to effect that change. The American Journal of Psychiatry has been a regular vehicle for communicating ideas about reform and for presenting the results of our research. Each of these authors, no matter how optimistic or grand his vision, recognized the need for knowledge. Subsequent sections of this sesquicentennial issue present some of those findings. This section has presented the major themes that shaped that research.

HOWARD H. GOLDMAN, M.D., PH.D.