EMIL R. PINTA
Samuel M. Smith, "Dr. Cure-Awl's"
Assistant at the Ohio Lunatic Asylum:
His 1841 Case-Reports on Insanity
The first half of the nineteenth century
was an enlightened era for under-
standing and treating mental illness.
One prevailing theory was that insanity
was a physical disease. This replaced
beliefs that considered the mind to be an
"emanation from the Creator"
and therefore not subject to physical laws and
interventions.
In 1812 Benjamin Rush (1745-1813), the
"Father of American Psychiatry,"
published his landmark text, Medical
Inquiries and Observations upon
Diseases of the Mind.2 This was the first textbook on this subject in
America, and it affected the perception
and treatment of mental illness for sev-
eral generations. Insanity, according to
Rush, was principally an inflamma-
tory disease of the brain's blood
vessels.3 Since the mentally ill were sick-
instead of bad-this fostered a
sympathetic attitude toward the mentally ill and
encouraged a form of treatment called
"moral therapy."4
Emil R. Pinta, M.D.. is on the emeritus
faculty of the department of psychiatry, The Ohio
State University College of Medicine,
and is chair of the history committee of the Ohio
Psychiatric Association.
1. H. A. Buttolph, "The Relation
Between Phrenology and Insanity," American Journal of
Insanity (AJI), 6 (October, 1849), 133.
2. Benjamin Rush, Medical Inquiries
and Observations upon the Diseases of the Mind
(Philadelphia, 1812).
3. Ibid. To reduce this inflammation,
Rush advocated blood-letting and various mechanical
devices, such as a "gyrator"
board that utilized centrifugal force to reduce blood flow to the
heads of patients who were strapped to
this device.
4. Moral therapy began in Europe during
the latter part of the eighteenth century as a prod-
uct of the Enlightenment. The word
"moral" referred to a variety of psychological-instead of
physical-treatments, e.g., education,
diversion, labor, exercise, amusement and occupational
activities. Harmony, balance and
regularity in daily activities were important. Nature itself
was considered therapeutic: therefore
most asylums were located in rural settings away from
the stresses and noises associated with
cities. For discussions of moral therapy, see Amariah
Brigham, "The Moral Treatment of
Insanity," AJI, 4 (July, 1847), 1-15; Eric T. Carlson and
Norman Dain, "The Psychotherapy
That Was Moral Treatment," American Journal of
Psychiatry (AJP), 117 (December, 1960), 519-24; Albert Deutsch, The
Mentally Ill in
America: A History of Their Care and
Treatment from Colonial Times, 2nd ed.
(New York,
1949), 87-113; Norman Dain, Concepts
of Insanity in the United States, 1989-1965 (New
Brunswick, N.J., 1964), 12-14, 204-06;
Nancy Tomes, A Generous Confidence: Thomas Story
Kirkbride and the Art of
Asylum-Keeping, 1840-1883 (Cambridge,
Mass., 1984), 4-6; Gerald N.
Grob, The Mad Among Us: A History of
the Care of America's Mentally Ill (New York, 1994),
Assistant at the Ohio Lunatic
Asylum 59
Samuel M. Smith (1816-1874) was a
pioneer Columbus physician and
psychiatrist during the middle of the
nineteenth century when the specialty of
psychiatry achieved formal
recognition.5 In 1847 Smith was
appointed
"professor of medical jurisprudence
and insanity" at the Willoughby Medical
College of Columbus, a forerunner of The
Ohio State University College of
Medicine.6 This was the first
professorship of psychiatry (or its equivalent)
at an American medical school.7
Smith's professorship began February 19,
1847, and ended less than one
year later on January 28, 1848, when the
Willoughby Medical College was
reorganized as Starling Medical College.8
College records, however, show
that he delivered his "lectures on
insanity" for at least six years.9 In 1847
Smith's lectures were part of the
required curriculum, whereas several other
subjects were offered in a preliminary,
non-required session.10
Yet, in the writings of some scholars,
Smith's professorship has been ig-
nored.1 These individuals were
probably not aware of any writings by Smith
64-71.
5. Psychiatry as a specialty dates to
1844 with the formation of the Association of Medical
Superintendents of American Institutions
for the Insane (now the American Psychiatric
Association). See Walter E. Barton, The
History and Influence of the American Psychiatric
Association (Washington, D.C., 1987), 38-39.
6. Amariah Brigham, AJI, 4
(October, 1847), 181; The Ohio State University College of
Medicine: A Collection of Source
Material, 1834-1934 (Blanchester,
Ohio, 1934), 510. The
Willoughby Medical College of Columbus
became Starling Medical College in 1848. In 1907,
it became Starling-Ohio Medical College
and, in 1914, The Ohio State University College of
Medicine. See ibid., 324.
7. For articles regarding Smith's
professorship, see Philip C. Rond, "Samuel Mitchel Smith,
M.D., Medical College Psychiatric
Lamplighter," part 1 and 2, Ohio State Medical Journal, 53
(November, 1957), 1266-67, 53 (December,
1957), 1405-06; Philip C. Rond, "The First
Professor of Psychiatry-Samuel Mitchel
Smith," AJP, 114 (March, 1958), 843-44; Emil R.
Pinta, "Samuel M. Smith, M.D., and
the Beginning of Psychiatry at The Ohio State University,"
chap. 1 in A History of Psychiatry at
The Ohio State University, 1847-1993 (Columbus, Ohio,
1994), 3-12; Emil R. Pinta, "Samuel
Smith, M.D.: First American Professor of Psychiatry,"
Hospital and Community Psychiatry, 45 (April, 1994), 369-71.
8. The Ohio Press, Columbus,
Ohio, March 6, 1847, 3: The Ohio State University College of
Medicine, 97-99. At Starling Medical College, Smith was given the
title "professor of materia
medica and medical jurisprudence. See
ibid., 142.
9. Smith's lectures on insanity are
listed in the class announcements for Starling Medical
College until at least 1853. There is
then a gap in extant bulletins until 1868, when they were
delivered by William L. Peck, professor
of insanity and nervous disorders. See Catalogue of
the Officers and Students of Starling
Medical College, 1848-1853, 1868 (Columbus,
Ohio).
10. The Ohio State University College
of Medicine, 77-80. The course announcement stated,
"Professor Smith will give a series
of lectures on the nature and treatment of insanity, and those
diseases leading to it, for which his
connection for several years with one of the best hospitals
peculiarly qualifies him." See
ibid.
11. John Gray, in two AJI
editorial comments, overlooked Smith's appointment and lectures,
although they were recognized seventeen
years earlier by the previous editor, Amariah
Brigham (see note 6). See John Gray, AJI,
20 (January, 1864), 359, 525. Franklin Ebaugh as-
serted that no systematic course on
mental diseases was given in America from Benjamin
Rush's death in 1813 until 1867, when
William A. Hammond was granted a professorship of
nervous and mental diseases at New
York's Bellevue Hospital Medical College. See Franklin
60 OHIO
HISTORY
on the subject of insanity nor familiar
with his knowledge and training in this
field.12 Smith, however,
reported seven cases of insanity in the 1841 annual
report of the Ohio Lunatic Asylum (OLA).13
These little-known case-reports
demonstrate knowledge of prevailing
theories regarding the nature and treat-
ment of mental disorders. Moreover,
Smith studied at two highly regarded
medical colleges and was an assistant
physician at one of the premier institu-
tions for the mentally ill.
Smith's Education and Training
From 1832 to 1836, Smith attended Miami
University in Oxford, Ohio,
where he received a broad, classical
education.14 Afterwards, he had the bene-
fit of a medical education obtained at
two leading institutions of the time. He
attended the 1837-1838 lectures at the
medical department of the Cincinnati
College.15 The following year, he attended lectures at
the University of
Pennsylvania, receiving a medical degree
from this institution in 1839.16
The University of Pennsylvania was then
the nation's leading medical center
and its largest medical school.17
The medical department of the Cincinnati
College was founded by Daniel
Drake (1785-1852), a luminary of medical
education in early Ohio. This
G. Ebaugh, "The History of
Psychiatric Education in the United States from 1844 to 1944,"
AJP, 100, supplement, (April, 1944), 151-60. Henry Bunker.
while acknowledging Smith's
professorship, seemed to regard it as
unimportant, repeating Gray's contention that Harvard
University in 1863 had the first
psychiatry program in the country. See Henry A. Bunker,
"American Psychiatry as a
Specialty," in One Hundred Years of American Psychiatry, ed. J. K.
Hall (New York, 1944), 483. Albert
Deutsch repeats Ebaugh's assertion. See Deutsch,
Mentally Ill in America, 282.
12. Philip Rond believed that Smith's
professorship was overlooked because he was thought
not to have written any scientific
articles. See Rond, "The First Professor."
13. Ohio Lunatic Asylum Annual
Reports (AR),3 (1841), Ohio
Executive Documents, 1841-
1842, Part 1, Vol.
6, Doc. 14, 43-48. When Smith's case-reports were published, there were
no journals devoted exclusively to
psychiatry, with the exception of several phrenological jour-
nals. The annual reports
of the institutions for the mentally ill were important sources for
sharing psychiatric information.
See M. K. Amdur. "Psychiatry a Century Ago (in 1840),"
AJP, supplement, 100 (April, 1944), 18-28; Eric T. Carlson, "Edward Mead and the
Second
American Psychiatric Journal," AJP,
113 (December, 1956), 561-62; Gerald N. Grob, Mental
Institutions in America: Social
Police to 1875 (New York,
1973), 101.
14. Thadeus A. Reamy, "Deceased
Presidents: S. M. Smith, M.D.," Transactions of the Ohio
State Medical Society, 31 (1876), 103-4. Miami University during this time had
a superior
classics department and a reputation
as the "Yale of the West." See Henry Howe, Historical
Collections of Ohio, Volume I (Cincinnati, Ohio, 1888), 354; W. O. Thompson,
"Universities of
Ohio," in Ohio Centennial
Anniversary Celebration (Columbus, Ohio, 1903), 429-30.
15. "Catalogue of
Students of the Medical Department of the Cincinnati College," Western
Journal of the Medical and Physical
Sciences, 11 (July, 1837), 668.
16. The Ohio State University College of Medicine, 428.
17. Earl D. Bond, "Psychiatry in
Philadelphia in 1844," AJP, supplement, 100 (April, 1944),
16-17.
Assistant at the Ohio Lunatic
Asylum
61
school had a brief existence, from 1835
to 1839, but its accomplishments
prompted historian Otto Juettner to call
it "the greatest medical school the
West has ever seen."18 Drake's
contributions to insanity and medical ju-
risprudence have been noted by Stanley
Block.19 In 1821 Drake had an im-
portant role in founding the Commercial
Hospital and Lunatic Asylum of
Cincinnati, the first hospital in Ohio
for the mentally ill.20
From July 25, 1840. to July 10, 1843,
Smith was an assistant physician at
the OLA."21 Organized in 1835, the OLA was one of the
pioneer institutions
for the mentally ill west of the
Allegheny Mountains.22 William M. Awl
(1799-1876), a prominent psychiatrist,
was superintendent of the OLA during
this period.
Smith became a highly respected and
well-known physician in nineteenth-
century Ohio. Other positions he held included dean of Starling Medical
College (1849-1858, 1860-1863), surgeon
general of Ohio during the Civil
War (1862-1864) and twenty-fifth
president of the Ohio State Medical Society
(1869-1870).23
The Ohio Lunatic Asylum and William
Awl
On March 5, 1835, an act of the
Thirty-fourth Ohio General Assembly or-
ganized the OLA, the first totally
state-supported institution for the mentally
ill in Ohio.24 Thirty acres of land were purchased in Columbus, approxi-
mately one mile east of the State House
on the north side of East Broad Street
between Washington Avenue and East
Public Lane (now Parsons Avenue).
The first patient was admitted on
November 30, 1838. The original building,
18. Otto Juetter, Daniel
Drake and His Followers (Cincinnati, Ohio, 1909), 182. While it
can be argued that Juettner's
description is an overstatement, the faculty of "Drake's School,"
as it was commonly known, did include a
number of physicians (in addition to Drake) who be-
came leaders in their fields: Samuel
Gross, the country's first professor of pathological
anatomy; Joseph Nash McDowell, founder
of the Missouri Medical College, the oldest college
west of the Mississippi; and Willard
Parker, the first American physician to perform an appen-
dectomy. See ibid., 188-200.
19. Stanley L. Block, "The First
146 Years: A Chronicle of the Department of Psychiatry of
the University of Cincinnati," Comprehensive
Psychiatry, 9 (July, 1968), 453-63; Stanley L.
Block, "Daniel Drake and the
Insanity Plea." Bulletin of
the History of Medicine,
65 (Fall,
1991), 326-39.
20. Block, "The First 146
Years."
21. AR, 2 (1840), Ohio
Executive Documents, 1840-1841, Doc. 13, 7; AR, 5 (1843), Ohio
Executive Documents, 1843-1844, Vol. 8, Doc. 11, 62.
22. Deutsch, Mentally Ill in America,
140.
23. Reamy, "Deceased
Presidents."; The Ohio State University College of Medicine, 101,
106, 428.
24. George E. Bell and Gregory K.
Castetter, ed., The State Hospital and Its Doctors, 1835-
1985 (Columbus, Ohio, 1985), A-1. The Commercial Hospital and Lunatic Asylum of
Cincinnati, constructed between 1821 and
1824, was supported primarily by local revenues.
See Grob, Mental Institutions in
America, 127-28.
62 OHIO
HISTORY
measuring 95 by 295 feet, was built
chiefly by convict labor at a cost of
$80,000.25
Awl was appointed the first
superintendent of the OLA, a position he held
from November 1838 to June 1850.26 While Smith's contributions to psy-
chiatry are relatively unknown, the
contributions made by Awl are well doc-
umented.27 He was one of thirteen hospital
superintendents who met in
Philadelphia on October 16, 1844, to
organize the Association of Medical
Superintendents of American Institutions
for the Insane (AMSAII), the origi-
nal name of the American Psychiatric
Association; he served as the second
president of this organization from 1848
to 1851. Awl was a member of the
"inner circle" of the AMSAII,
sometimes referred to as the "brethren."28
The Ohio Legislature appointed Awl one
of the directors to supervise and
manage the construction of the OLA.
During the period of construction, he
visited the Worcester (Massachusetts)
State Lunatic Hospital, where he stud-
ied under its superintendent, Samuel
Woodward (1787-1850).29 Awl utilized
this hospital as a model for the OLA.30
Awl, who was twelve years younger
than Woodward, developed a strong
admiration for his mentor, giving the
name "Woodward" to a son born
in 1840.31 The OLA was designed to
25. AR, 4 (1842), Ohio
Executive Documents, 1842-1843, Vol. 7, Doc. 10, 11. On
November 18, 1868, a fire destroyed the
OLA, causing the death of six patients. In 1870
crews began construction of a second
state hospital located three miles west of Columbus on
the National Road. See Howe, Historical
Collections, 632.
26. AR, 12 (1850), Ohio
Executive Documents, 1850-1851, Vol. 15, Doc. 17, Part 1, 271;
William T. Martin, History of
Franklin County (1858; reprint, Columbus, Ohio, 1969),415.
27. Starling Loving, "Wm. Maclay
Awl," Transactions of the American Medical Association,
31 (1880), 1009- 11; Winfred Overholser,
"The Founders and the Founding of the Association,"
in Hall, ed., One Hundred Years, 53-54;
Philip C. Rond, "Ohio Psychiatric Pioneer--William
Maclay Awl (1799-1876)." Ohio
State Medical Journal, 111 (September, 1955), 882-83;
Constance M. McGovern, Masters of
Madness; Social Origins of the American Psychiatric
Profession (Hanover, N.H., 1985), 74-79; Barton, History and
Influence, 306-07.
28. Tomes, A Generous Confidence, 267,
371 n. 3. Other notable physicians in the "inner
circle" included Samuel Woodward,
Amariah Brigham, Isaac Ray, Luther Bell and Pliny
Earle.
29. Samuel Woodward was a co-founder and
first president of the AMSAII. From 1832 to
1846, he was superintendent of the
Worcester State Lunatic Hospital, a hospital at the forefront
of humane and enlightened treatment. See
George Chandler, "Life of Dr. Woodward," AJI, 8
(October, 1851), 119-35; Overholser,
"The Founders," 47-50; Grob, Mental Institutions in
America, 98-103; McGovern, Masters of Madness, 79-85.
30. "Annual Message of the Governor
[Joseph Vance]," Ohio Executive Documents, 1838-
1839, Doc. 1, 16; "Report of the
Ohio Lunatic Asylum Directors," Ohio Executive
Documents,
1838-1839, Doc. 18, 1-6; Isabel A.
Bradley, "Columbus State Hospital," Ohio State Medical
Journal, 32 (October, 1936), 988-90.
31. AR, 6 (1844), Ohio
Executive Documents, 1844-1845, Vol. 9, Doc. 15, 29-30. Awl
wrote that while Woodward was
superintendent the Worcester Hospital was the place he
would have elected to go for treatment
if "I should ever should go crazy (and some folks think
I should not have far to go)." See
Awl to Thomas S. Kirkbride, May 27, 1847, quoted in Robert
E. Jones, "Correspondence of the
A.P.A. Founders," AJP, 119 (June, 1963), 1132. Pliny Earle
noted this admiration in unflattering
terms, referring to Awl as Woodward's "disciple" who
had "studied at his feet." See
Pliny Earle, "The Curability of Insanity," AJI, 33 (April,
1877),
Assistant at the Ohio Lunatic Asylum 63 |
|
acommodate 145 patients; this was erroneously thought to be sufficient for the needs of the state for many years.32 Smith and Awl, who had living-quar- ters in a center structure of the OLA, were the only physicians for these pa- tients. In 1841 Awl complained that treatment at the Asylum was especially difficult because of "an increase in the average number [of patients], and a house overcrowded with chronic and incurable cases."33
"Dr. Cure-Awl"
During the 1840s, with great conviction in the effectiveness of their treat- ment, the superintendents of most institutions for the mentally ill reported cure-rates in the 80 to 90 percent (and above) range. Albert Deutsch used the
502. 32. AR, 10 (1848), Ohio Eecutive Documents, 1848-1849, Vol. 13, Part 2, Doc. 19, 276. Within a short time, the OLA filled to capacity. Court-ordered patients had to be confined for extended periods in alternative arrangements, such as jails, until space became available. In 1846 this situation improved with the addition of two wings, each for 10( patients, for a total capacity of 350 patients. The final cost of the buildings was $150.000. See AR, 8 (1846), Ohio Executive Documents, 1846-1847, Vol. 11, Part 1, Doc. 4, 35-36. These additions soon proved to be insufficient, and by 1849 plans were made to construct additional state hospitals in the northern and southern parts of the state. See AR, 11 (1849), Ohio Executive Documents, 1849- 1850, Vol. 14, Part 1, Doc. 19, 159. 33. AR, 3 (1841), 42. As a state-supported institution, the OLA was required to accept long- term cases, generally regarded as incurable. See McGovern. Masters of Madness, 76. |
64 OHIO
HISTORY
term "cult of curability" to
describe attitudes existing in this era.34 Pliny
Earle, superintendent of the Northampton
(Massachusetts) State Hospital for
the Insane, explained that cure-rates
were exaggerated by using statistics at the
time of hospital discharge (thereby
excluding deaths and incurable patients
that remained in the hospital) and by
counting remissions rather than perma-
nent cures. Earle also accused
superintendents of not explaining criteria for
"cured" or
"recovered."35
At the OLA, Awl reported one of the
highest cure-rates in the country. In
1843, during a ten-month period when
Smith was assistant physician, Awl
announced a phenomenal 100 percent
cure-rate, causing humorists to label
him "Dr. Cure-Awl."36 Awl
achieved this rate by examining discharged pa-
tients with acute illnesses, i.e., less
than one-year duration. His cure-rate for
patients with chronic illnesses was
significantly lower: about 22 percent.37
Awl probably wanted to show that
treatment at his facility compared favor-
ably with that of institutions in the
Atlantic states, which were held in high-
est regard; however, the accusation that
he used statistics to hide his treatment
failures, as critics such as Earle
maintained, seems unwarranted. Awl had
other reasons for reporting cure-rates
in the manner described.
By reporting cure-rates for acute cases,
Awl was emphasizing the impor-
tance of early treatment. He made the
following observations: "The prospect
of cure diminishes with increasing
rapidity, according to the duration of the
disease. Indeed, when the disease has
been of very long continuance, so that a
lesion of the brain has probably
supervened, the hope of cure is well nigh ex-
tinguished."38 Awl
believed that treatment of insanity would be successful if
begun early in the course of the
disease.
By reporting cure-rates at the time of
discharge, Awl was justifying the
cost-effectiveness of asylum care by
demonstrating that he was returning pa-
tients to productive lives. Beginning in
1841, he routinely included charts in
his annual reports that favorably
compared asylum treatment with the long-
term costs of providing for the mentally
ill in the community.39 Providing
for the mentally ill in the community
usually meant custodial care at a
county poorhouse if the person was a
pauper or, if dangerous, a jail or prison.
34. Deutsch, Mentally Ill in America,
132-57.
35. Earle, "Curability of
Insanity," 483-533.
36. Deutsch, Mentally Ill in America,
153.
37. AR, 5 (1843), 19.
38. AR, 11 (1849), 156.
39. Awl estimated that the average cost
of treating acute cases at his institution was approx-
imately $64. This was based on a weekly
all-inclusive rate of slightly less than S3 and an aver-
age duration of treatment of 21.75
weeks. He then randomly selected twenty chronic cases of
insanity. He estimated the average cost
of providing for these cases in the community had
been $1,414, based on an average
duration of 13.6 years of illness and an estimated cost of $2
per week. Awl believed that most of
these cases would have been cured if treated early. See
AR, 3 (1841), 28, 38-39.
Assistant at the Ohio Lunatic
Asylum
65
In 1 849, his last full year as
superintendent, Awl defended his methods and
statistics. He explained that statistics
regarding the mentally ill were difficult
to accumulate with accuracy and-at
best-were an "approximation of real-
ity." Awl also defined his criteria
for recovery, basing this in the majority of
cases on "restoration in the full
use of their intellectual faculties, and capable
for years of as great mental efforts as
previous to the affliction."40
Smith's Case-Reports on Insanity
Awl introduced Smith's case-reports on
insanity in the OLA's 1841 annual
report: "The following cases have
been selected from the recoveries of the past
year, and are reported for publication
by my faithful assistant, Samuel M.
Smith, M.D., whose ability in the
discharge of his various duties, it gives
me great pleasure to acknowledge."41
Case One: Smith described a member of the clergy with a family
history
of insanity. He experienced an episode
of insanity accompanied by violent
behavior after he was prevented from
attending a religious meeting by his
friends, who had observed
"unaccountable eccentricities, indicating the ap-
proach of disease." His behavior
required physical restraints, which were re-
moved upon admission. Following the
removal of restraints, he appeared su-
perficially normal. Smith remarked:
To a stranger, the full extent of
insanity existing, would not have been apparent.
Though loquacious and excitable, his
manner and opinions seemed rather the ex-
travagance of an ill-balanced mind,
under the impulse of a warm temperament. But
beneath this comparatively smooth
surface, there was a mass of delusions, and a
dismal foreboding of some fearful fate,
with an entire misapprehension of his con-
dition and relations.42
This patient responded to a combination
of moral therapy and medical
treatment (see "Treatment of
Insanity" below) and was discharged after a stay
of two months. Smith explained:
Kind and soothing treatment, and
directing his mind to other topics, by degrees,
lured him away from his gloomy
contemplations. ... A kind attention to his
wants, dissipated his delusions; proper
medical treatment, restored impaired
40. Ibid., 192-94. In his annual
reports, Awl also provided his cure-rates based upon admis-
sions. Percentage of recoveries based on
admissions (a running total) was 40.44 in 1842 (AR, 4
[1842], 14);42.91 in 1843 (AR, 5 [1843],
19); and 46.52 in 1849 (AR, 11 [18491, 192). The
1849 figure was based on a total of
1,365 admissions during Awl's eleven years as superinten-
dent (1838-1849) and included deaths at
his institution (8.3 percent of all patients) and patients
who remained in the Asylum.
41. AR. 3(1841), 43.
42. Ibid.
66 OHIO HISTORY
health; the delights of 'a mind at ease'
returned, and in two months from the time
of his admission, he left us . . .again
to take his place at the altar in the solemn
responsibilities of his ministrations.43
Case Two: Smith described this patient as a man of great
strength. He
was a chronic abuser of alcohol but had
not used alcohol for over a year when
a "false friend" persuaded him
to indulge. The result, described by Smith:
[Hel soon was a sot--and then a furious
maniac.... When brought to the asylum,
he was secured in a manner that
indicated the terror which his fury and strength had
inspired. As usual, we removed his
irons, and thus, for the time being, seemed to
secure his good will. But disease obeyed
the impulse of gratitude only for a short
time; and soon we were visited with a
torrent of unrestrained abuse, marked as is
usual in cases for intemperance, with
the lowest vulgarity.44
This patient was treated with
medication, which was partially withdrawn
when he improved. When symptoms
reappeared, medication was reinstated.
Medication was eventually discontinued
prior to discharge when the patient
recovered.
Case Three: This woman was admitted after she developed impulses to
harm her child. Smith described a
"lady of amiable disposition, and a retiring
modesty; but insanity left no traces of
her natural character. The tenderly af-
fectionate mother and devoted wife,
became suddenly the furious maniac."45
Smith believed that her condition was
precipitated by the actions of a
preacher, who read biblical passages to
her that engendered extreme guilt.
Smith believed that her impaired health
aggravated the impact of this upon
her mental state. She was admitted after
her husband found her struggling
against impulses to harm her child.46
This patient was given medication that
led to increased socialization and
participation in occupational
activities. Her feelings of affection toward her
family returned, and she returned to
"the discharge of her duties and to rejoice
the little circle that mourned her
absence [from home]."47
Case Four: Smith wrote: "This was an unmarried lady, whose
insanity was
of four years duration at the time of
her admission into the asylum. Her re-
covery was a happy illustration of the
power of moral means, independent, in
a great measure, of medical
treatment."48 She was described as "noisy and
43. Ibid., 43-44.
44. Ibid., 44.
45. Ibid., 45.
46. Ibid. It is unclear from Smith's
description whether she actually harmed her child or
successfully fought these impulses.
47. Ibid.
48. Ibid.
Assistant at the Ohio Lunatic
Asylum 67
restless; sometimes jumping and singing,
at others [other timesl patching to-
gether all the pieces of rags and calico
she could procure, and then arraying
herself in this fantastic apparel."49
She was regarded as someone "possessed
of a sensitive pride," whose
condition was brought on by a sudden loss of
property and the need for public
charity.
She responded to moral treatment,
including occupational activities, and
was discharged with "no traces of
insanity remaining." Smith believed that
her recovery was remarkable because of
the length of time insanity had been
present. "From the length of time
that had intervened since the attack [four
years], the prospect of cure was
unfavorable."50
Case Five: Smith began his description, "The leading feature
of this case,
was a strong, ungovernable propensity to
suicide."51 This patient had been
kept in the county jail for several
months prior to his admission, was de-
scribed as having "a fixed and
cheerless melancholy," and preoccupied with
ending his life. During his
hospitalization, he attempted suicide at least
twice, once by attempting to cut his
throat with a knife taken during meal-
time and, on another occasion, by
jumping into a heating shaft. Smith ex-
plained that the knife was too dull to
do any harm; and there was no heat in
the shaft so the only result was that he
became lodged for a brief period of
time.
This patient showed a poor response to
medication: "Medical treatment was
long persevered in with but little
encouragement." However, with continued
use of medication and moral treatment he
responded. Smith described his
treatment:
[With the] constant appliance of moral
means, some little improvement was se-
cured. Inducements to labor were held
out, and this best of all moral means had the
happiest effects. Suddenly he seemed to
wake, as from a dream, happy to find that
the fearful delusions of the past were
not realities. With a full realization of the
change, he rapidly improved, and soon
left us entirely well.52
Case Six: This was an elderly man with a history of chronic
alcohol use.
At the time of his admission, he had
become extremely violent so that it was
necessary to place him in seclusion. He
was treated with medication that,
over a period of time, allowed him to
socialize with other patients and to par-
ticipate in various activities. Smith
wrote: "Labor improved his health, and
confirmed the happy result; and, at the
end of five months, he returned to his
family, in the enjoyment of reason and
health."53
49. Ibid., 46.
50. Ibid.
51. Ibid.
52. Ibid., 46.
53. Ibid.
68 OHIO HISTORY |
|
Case Seven: Smith described a woman with a five-month history of insan- ity with "religious despondency," "gloomy melancholy" and "a multiplicity of horrid delusions." She was in poor health, which, according to Smith, made her more susceptible to "moral," i.e., psychological, causes of insanity. This created a vicious circle in which poor health aggravated her mental prob- lems, which in turn led to a worsening of her physical condition. After admission, she developed a delusional system regarding her hospital treatment. Smith explained:
The swing, with which others amused themselves, was to her, the gibbet upon which she was to suffer a disgraceful death. The medicine, daily administered, was but repeated portions of poison .... She avoided the company of her fellow pa- tients, and seemed to dread the approach of anyone. But medicine had its desired effect, disease silently yielded to its persevering application, and returning health was accompanied by a corresponding improve- ment of the mind.... She began to express an interest in her former pursuits; be- ing fond of music, and having given some attention to its cultivation, she now amused herself and friends at the piano, attended the Matron's weekly parties, en- gaged with delight in all the amusements of the house, also giving a cheerful and valuable assistance in the sewing room. A complete restoration soon followed this rapid improvement, and produced as great a change as could be conceived of.54
54. Ibid., 48. |
Assistant at the Ohio Lunatic
Asylum
69
Smith's case-reports will be discussed
in the context of opinions of the
time regarding the nature, causes and
treatment of insanity. Attention will be
given to Awl's beliefs and to treatment
at the OLA at the time of Smith's
appointment. As a young physician who
had recently received his medical
degree, Smith would have valued the
opinions of Awl, who was seventeen
years his senior and a respected expert
on the subject of insanity.55
Nature of Insanity
Awl accepted the prevailing opinion that
mental disorders had a physical
basis. In 1841 Awl explained,
"Mental derangement is strictly and entirely a
physical disease, and ... its immediate
cause is the direct obstruction, or im-
pairment, of one or more organs of
tissues of animal life."56 He
believed
that insanity progressed through acute,
sub-acute and chronic stages. In its
acute stage, generally lasting less than
one year, insanity was believed to be
almost entirely reversible and the
physical changes were believed to be only
"functional." Awl believed
that four to six months was the usual time re-
quired to cure insanity in this stage.57
In its final stage, the physical changes
were thought to have become
"structural," i.e., a lesion of the brain had de-
veloped and patients were unlikely to
respond to treatment.58 In accordance
with these beliefs, the OLA had wards
graded by stages of illness.59
Understanding the complex nature of
mental illness was problematic for
Awl and others of his time (and remains
so today). In 1847 Awl wrote:
"There are questions, however, in
connection with the theory and causes of
this disease, which are yet, and perhaps
always will remain, in obscurity...
Those difficulties attending an
investigation of the causes of insanity are,
doubtless, in part, attributable to the
mysterious character of the human mind,
and can never be fully removed."60
Judging by his case-reports, Smith
believed that insanity progressed in
stages and had a physical basis. In Case
Four, he anticipated a poor progno-
sis because of the advanced stage of
illness. The other cases Smith described
55. Even if Smith and Awl had different
opinions regarding patient care, those of Awl's
would have prevailed. The chief
physician, or superintendent, had authoritarian control over
almost all aspects of asylum care. This
"one-man" system was considered essential for proper
hospital management. See Tomes, A
Generous Confidence, 146-47; Grob, The Mad Among Us,
72-73.
56. AR, 3 (1841), 42. Most
medical experts believed that there was a physical basis for in-
sanity. See Amariah Brigham,
"Definition of Insanity-Nature of the Disease," AJI, 1 (July,
1844), 97-116; Dain, Concepts of
Insanity, 84-85.
57. AR, 1 (1839), 5; AR, 2
(1840), 41.
58. AR, 11 (1849), 156.
59. AR, 1 (1839), 4-5. Patients
were thought to become restless if they were placed on
wards with less rational patients. See
ibid.
60. AR, 9 (1847), 206-07.
70 OHIO
HISTORY
were recent (present for less than one
year) and, expectedly, responded well to
treatment. In Case One, Smith described
early warning symptoms "indicating
the approach of disease," which
suggests that he also acknowledged a prodro-
mal or preliminary stage for mental
disorders.61 Smith
frequently used the
word "disease" in his
descriptions (Cases One, Two, and Seven), implying his
acceptance of a physical cause for
insanity.
Smith did not describe his diagnostic
groupings for mental disorders, al-
though he used the term
"melancholy" in a descriptive sense; viz., "a fixed
and cheerless melancholy" in Case
Five and a "gloomy melancholy" in Case
Seven. Smith may have avoided diagnoses
because annual reports were not
scientific journals and were intended
for public use; however, there are indica-
tions that Awl, and presumably Smith,
did not consider diagnosis as essential
to the understanding and treatment of
mental disorders. Awl wrote that diag-
noses were often interchangeable and
that the classification of mental disorders
given in his reports was only "for
convenience."62
In his annual reports, Awl described a
"homicidal impulse" as a complica-
tion of moral insanity. In these
instances, an individual was persuaded by a
"headstrong and irresistible"
impulse to commit violent acts, while retaining
the capacity to know right from wrong.63
Awl believed there were instances
when a homicidal impulse legitimately
excused criminal responsibility; how-
ever, these were different from those in which the defendant was simply
"depraved or perverse." He
wrote, "Unquestionably, the pre-meditating, cold-
blooded murderer, deserves to forfeit
his miserable life upon the gallows."64
61. John Allen, superintendent of the Kentucky Lunatic Asylum, also identified
early warn-
ing symptoms of mental
illness, including "eccentricities, change
of manner or habits, [and]
unusual petulance." See John R. Allen, "On the Treatment of Insanity," AJl, 6 (January,
1850), 263-83.
62. AR. 9 (1847), 202-03. Allen
also believed that diagnosis was unimportant and described
a treatment regimen based on the
symptoms and stages of mental illness.
See Allen,
"Treatment of Insanity." Awl
classified insanity as mania, melancholia, moral insanity and
dementia. Sec AR, 21 (1843), 50.
His nosology was typical of the time. See J. E. D. Esquirol,
Mental Maladies: A Treatise on
Insanity. trans. E. K. Hunt (1845; reprint,
New York, 1965),
29-30; John Evans, "Evans
on Insanity," AJI, 3 (January, 1847), 253-61.
63. AR, 2 (1840), 37. The term
moral insanity was used by James C. Prichard in 1835
to de-
scribe a condition where there was a
"morbid perversion" of natural feelings and emotions
with no intellectual deficit,
hallucinations nor delusions. See Prichard quoted in Gregory
Zilboorg and George W. Henry, A History
of Medical Psychology (New York, 1941), 417.
The concept of moral insanity became
highly controversial, particularly when used to excuse
criminal responsibility. See C. B.
Coventry, "Medical Jurisprudence of Insanity," AJI, 1
(October, 1844), 134-44; Isaac Ray,
"An Examination of the Objections to the Doctrine of
Moral Insanity," AJI, 18
(October, 1861), 112-38; Dain, Concepts of Insanity, 73-81. Moral in-
sanity described by Ray (above) would
today include the diagnoses of brief reactive psychosis,
impulse control disorder and antisocial
personality disorder.
64. AR, 5 (1843), 28. Awl's
concerns regarding the diagnosis of homicidal impulse (he
refers to the interest of the
"public at large" in this diagnosis) may have been in response to a
highly publicized case heard by the Ohio
Supreme Court in December, 1843. The defendant,
William Clark, pleaded not guilty by
reason of insanity for killing a prison guard with an ax at
Assistant at the Ohio Lunatic
Asylum
71
Awl believed that previous affection for
the victim, lack of motive, absence
of delusions and hallucinations, and an
absence of emotion related to the event
were characteristic of moral insanity
complicated by homicidal impulse.65
Smith's description in Case Three is
consistent with that of insanity ac-
companied by a homicidal impulse, and it
provides some insight into his
opinions regarding this condition. Smith
demonstrated sympathy and kind-
ness toward this mother, who struggled
with impulses to kill her child (and
possibly surrendered to them). His
description was free of moral condemna-
tion; he indicated an unhealthy mind
made her unaccountable for her actions.
Causes of Insanity
Awl regarded insanity as having "remote" and "exciting" causes.66
Examples of remote causes included
heredity, ill health of almost any kind,
epilepsy, chronic intemperance and
previous head injury. Heredity was re-
garded as an especially important factor
in insanity and in the propensity for
suicide.67 Exciting causes,
which today would be called precipitating or situ-
ational causes, included domestic
trouble, rejected affection, ill treatment from
parents or guardians, jealousy, poverty
and religious causes.68 These
were
also referred to as "moral or
mental" causes.69 Like many psychiatrists of his
time, Awl believed that the "secret
vice," i.e., masturbation, was a frequent
cause of insanity and mental
retardation.70
Awl, however, believed that separating
causes into remote and exciting was
artificial; he rarely distinguished
between them in his reports. He believed
that it was difficult to differentiate
the causes and effects of insanity, stating
"effects are too frequently
mistaken for causes."71
In the cases presented by Smith, poor
physical health was a contributing
cause in Cases One, Three, Six, and
Seven; alcoholism (intemperance) in
Cases Two and Six; and heredity in Case
One. Situational, or exciting,
causes included religion in Cases One
and Three; poverty in Case Four: and
unspecified "moral causes" in
Case Seven. Of interest is Smith's explanation
the Ohio Penitentiary, Clark was
eventually found guilty and hanged. See Clark v State, 12
Ohio Reports 395-406 (1843); Martin, History of Franklin County, 421-22.
65. AR, 2 (1840), 6, 37.
66. AR, 1 (1839), 15. For similar
descriptions, see Esquirol, Mental Maladies, 45-54; Pliny
Earle. "On the Causes of
Insanity," AJI, 4 (January, 1848), 185-211; Dain, Concepts of
Insanity, 84-113.
67. AR, 9 (1847), Ohio
Executive Documents, 1847-1848, Vol. 12, Doc. 10, 207-8; AR, 11
(1849), 181.
68. AR, 10 (1848), 294.
"Religious causes" referred to states of religious fervor with ex-
citement, perplexity, exaltation, or
fear of punishment and guilt. See AR, 1 (1839), 14.
69. AR, 11 (1849), 294-95.
70. AR, 5 (1843), 47.
71. AR, 9 (1847), 206.
72 OHIO
HISTORY
in Case Seven regarding a reciprocal
condition, whereby physical illness ag-
gravated insanity, which then led to
further impairment of health.
Treatment of Insanity
Treatment of mental disorders at the OLA
consisted of a combination of
moral and medical therapies.72 In moral therapy, one can trace the
founda-
tions of modem psychosocial and
psychotherapeutic concepts. Honest com-
munication with patients and humane treatment
was a high priority. Awl
cautioned against deceit of any kind
with patients, including false promises to
induce patients to come to the Asylum
for treatment.73
As an example of humane treatment, Awl
removed iron chains and re-
straints upon admission. He declared:
We allow no one in our employ to insult,
taint, ridicule, abuse, strike, whip,
chain, or iron a patient under any
circumstances, whatever. There never was a man
or woman chained, or put in irons of any
kind, since the asylum received a patient;
and we never had a straight-jacket in
our possession.74
At a time when there was debate
regarding the advantages and disadvantages
of physical restraints, Awl was an
advocate of minimal restraints. He ex-
plained that leather restraints were
used occasionally "for a few hours at a
time"; leather mittens or muffs
were also utilized to prevent self-injury.75
Awl was proud that measures to prevent
self-injury allowed only two suicides
in eleven years of operation of the OLA
(1838-49).76
In his case-reports, Smith revealed
himself to be a strong advocate of moral
therapy. Moral therapy was utilized in
all the cases presented and included
(but most likely was not limited to)
kindness, labor, diversion, education and
occupational activities. In some
instances, Smith appeared to give moral
therapy priority over other
treatments. In Case Four, he referred
to the
"power of moral means independent
of medical treatment." He indicated that
an important benefit of medical treatment
was that it allowed patients to be-
come more receptive to moral therapy.77
72. AR, 2 (1840), 27; For an
explanation of moral therapy, see note 4.
73. AR, 7 (1845), Ohio
Executive Documents, 1845-1846,
Vol. 10, Doc. 14, 155-56. See
also Carlson and Dain, "The
Psychotherapy That Was Moral."
74. AR, 4 (1842), 67.
75. Ibid. For discussions of the
restraint controversy, see John Conolly, "Mechanical
Restraint in the Treatment of the
Insane," AJI, 13 (January, 1857), 281-90; Deutsch, "Conflict
of Theories: Restraint or
Non-restraint," chap. 11 in Mentally Ill in America, 213-28; Henry
Alden Bunker, "American Psychiatric
Literature During the Past One Hundred Years," in
Hunt, ed., One Hundred Years, 201-3;
Dain, Concepts of Insanity, 122-24; and Grob, Mental
Institutions in America, 206-11.
76. AR, 11 (1849), 181.
77. Many psychiatrists of the time had
more confidence in moral therapy than in medical
Assistant at the Ohio Lunatic
Asylum
73
Smith seemed to be especially impressed
with labor as a means of moral
treatment, mentioning the benefits of
labor and employment in Cases Three,
Four, Five, and Six. In Case Five he
referred to labor as "this best of all
moral means."78 Smith
was also an advocate of no (or minimal) restraints.
He mentioned the removal of restraints
upon admission in Cases One, Two
and Six, noting this was the usual
procedure.
Awl believed that poor physical health
created a predisposition to mental
disorders, and that the symptoms of
insanity became more pronounced when
health was impaired. Therefore,
improvement of general health was of prime
importance in treating the mentally ill.79
Smith addressed general medical problems
in the majority of his case-re-
ports. In Case One, Smith emphasized the
importance of restoring impaired
health in his overall treatment of the
patient. In Case Seven, Smith ex-
plained that impaired health caused an
increased susceptibility to insanity, and
that a return to good physical health
was accompanied by an improvement in
the patient's mental state.
Awl did not describe his medical regimen
in his annual reports, but he was
critical of various techniques, such as
heavy bleeding and the drastic use of
cathartics. He believed that bleeding
"by use of the lancet" was more often
injurious than beneficial and noted that
most superintendents of hospitals for
the mentally ill held this opinion.80
According to Awl, there was a place for
local bleeding, by leeching or cupping,
in cases of acute mania. He also re-
ferred to the usefulness of cold and
warm baths and of a "shower box," where
cold water was poured from a height to
calm extremely agitated patients.81
In his case-reports, Smith referred to
medical treatments and remedies, but,
like Awl, he did not provide details. He
mentioned pharmacologic treatments
treatment. See Brigham, "Moral
Treatment"; Grob, Mental Institutions in America, 168.
Thomas Kirkbride believed that drug
therapy was a preliminary step to moral treatment. See
Grob, Mad Among Us, 65. Although
convinced of the effectiveness of medical treatment,
Woodward acknowledged that a benefit of
medication was to help patients become amenable
to moral therapy. See Dain, Concepts
of Insanity, 229, n. 44. James Bates, superintendent of
the Maine Insane Asylum, believed that
medical therapy was more important in the early
stages of mental illness, while moral
treatment was more important in later stages. See James
Bates, "Report on the Medical
Treatment of Insanity, and the Diseases Most Frequently
Accompanying It," AJI, 7
(October. 1850), 97-110.
78. Brigham also emphasized the
importance of manual labor, but believed that its benefit
was due to "engaging the attention
and directing the mind to new subjects of thought." See
Brigham, "Moral Treatment."
79. AR, 5 (1843), 47. Woodward
also believed that in treating insanity the patient's health
should be made as perfect as possible
and that the "first object of treatment" should be to im-
prove the patient's physical condition.
See Samuel Woodward, "Medical Treatment of the
Insane [excerpted from his annual
reports]," in "Lunatic Asylums in the United States," ed.
Amariah Brigham, AJI 3 (April,
1847), 64; Samuel Woodward, "Observations on the Medical
Treatment of Insanity," AJI, 7
(July, 1850), 16.
80. AR, 7 (1845), 154-55.
81. AR, 1 (1839), 26; AR, 4(1842),
68; AR, 7(1845), 155.
74 OHIO
HISTORY
in Cases One, Two, and Seven and may
have used them in the others. In
Case Seven he noted that medicine was
administered daily.82
Awl and Smith probably followed the
pharmacologic regimen used by
Samuel Woodward at the Worcester State
Lunatic Hospital.83
Woodward was
a strong advocate of opiates in mania
and in cases of melancholy, especially
where there was strong suicidal propensity.84 Opiates were administered
orally (the hypodermic syringe was not
developed until the 1850s) as lau-
danum (tincture of opium), morphine, or
in combination with ipecac (an
emetic) as Dover's powder.85
While many experts of the time advocated
opium for treating mental ill-
ness, others were less enthusiastic, and
the American public took a dim view
of opiates.86 Great Britain and China were fighting
the Opium Wars at the
time Smith wrote his case-reports; many
Americans saw the wars as a British
attempt to force a harmful drug
upon the Chinese for the sake of profit.
Although it is not certain that Smith
used opiates, his treatment in what
appears to be a case of manic excitement
(Case Two) strongly suggests
Woodward's recommendations for opiates
in this disorder.87 In addition,
82. Medication at the OLA was routinely
administered three times per day. See AR, 1
(1839), 26-27.
83. Awl's admiration of
Woodward and of policies at the Worcester State
Lunatic Hospital
has been mentioned.
See note 31.
84. Woodward, "Medical
Treatment of the Insane,"; Woodward, "Observations on
Medical
Treatment." A description of Woodward's
pharmacologic treatment is also found in William
Malmud, "The History of
Psychiatric Therapies, " in One Hundred Years, 281-84. In
addition
to opiates, Woodward used other
sedatives, e.g., stramonium, hyoscyamus, digitalis, lupulin,
and conium. Tonics and
stimulants, in the form of quinine, aromatics and wine, were used
to
treat conditions where
lethargy existed; he also used laxatives and mild emetics.
85. Eric T. Carlson and Meribeth M.
Simpson, "Opium as a Tranquilizer," AJP, 120
(August,
1963), 112-17. Nausea was regarded to
have a calming effect on agitation. Woodward be-
lieved that combining opium with an
emetic would reduce the amount of opium required. See
Woodward, "Observations
on the Medical Treatment," 11-13.
There is evidence today that opiates are
beneficial in some psychiatric disorders, such as
schizophrenia, by
inhibiting the production of neurochemicals believed to cause these disor-
ders. See Marianne
J. Reymond, Charanjit Kaur and John C. Porter, "An Inhibitory Role for
Morphine on the Release of Dopamine
into Hypophysial Portal Blood and on the Synthesis of
Dopamine in Tubcroinfundibular
Neurons," Brain Research, 262
(March 7, 1983), 253-58;
Claudia Schmauss, Alexander Yassouridis
and Hinderk M. Emrich, "Antipsychotic
Effect of
Buprenorphine in Schizophrenia," AJP,
144 (October, 1987), 1340-42.
86. See Carlson and Simpson, "Opium
as a Tranquilizer." It is conceivable that Awl and
Smith avoided details of their medical
treatment because of concern about public reaction re-
garding the medicinal use of opium, just
as a public outcry would be expected today were a
state-supported hospital discovered to
be prescribing opiates to psychiatric patients.
87. Woodward wrote: "The operation
of these remedies [opiates] should be narrowly
watched, and the
dose increased or varied according to the effect. If the patient becomes
more quiet the doses may be gradually
lessened, but the medicine should not be suddenly with-
drawn lest the excitement returns. If
the excitement continues, the remedy may be increased
gradually or rapidly till it controls
the symptoms." See Woodward, "Observations on Medical
Treatment," 15.
Assistant at the Ohio Lunatic
Asylum
75
Woodward recommended that opiates be
discontinued once the patient achieved
a healthy state of mind, a procedure
Smith also followed in this case.88
Summary
Smith's teachers included two pioneers
of American psychiatry, Drake and
Awl; by the mentor-to-mentor
transmission of knowledge, he had contact
with a third, Woodward.89 Smith received
experience in psychiatry as an as-
sistant physician at the OLA, an institution
at the forefront of modern treat-
ment.
Smith's case-reports demonstrate a
comprehensive approach to mental ill-
ness. He believed that mental illness
went through progressive stages, and he
accepted the belief that insanity was a
physical process acted upon by situa-
tional factors. He recognized the
difficulty of obtaining cures in long-stand-
ing cases, and he appeared to believe
that insanity was reversible if treated
early.
A strong advocate of moral therapy,
Smith also believed in the judicious
use of medical remedies. His use of
moral treatment included kindness, labor,
diversion, education and occupational
activities. Humane treatment included
the removal of restraints and a
compassionate, non-judgmental attitude toward
patients.
Smith used medication to make patients
more receptive to moral treatment,
but, if possible, medication was
withdrawn when sanity was restored. Smith
most likely used opiates for severe
cases of mental illness, and he probably
utilized other medical treatments as
well. Because he believed that physical
disorders made the patient vulnerable to
mental disorders, the restoration of
general health was a primary objective
of treatment.
In conclusion, Smith, the first professor of psychiatry in America,
practiced
psychiatry in accordance with
enlightened ideas of the time regarding the na-
ture, causes and treatment of insanity.
88. Ibid., 14.
89. By the mentor-to-mentor model of
education, Smith was also exposed to the teachings of
Benjamin Rush. Nathaniel Chapman
(1780-1853), the first president of the American Medical
Association, was the dominant figure at
the University of Pennsylvania when Smith attended
this institution and received his
medical degree. Chapman had been Rush's pupil; in fact, for
over sixty years they consecutively
occupied the same position at the University of
Pennsylvania. See Howard A. Kelly and
Walter L. Burrage, Dictionary of American Medical
Biography (New York, 1928), 213: Bond, "Psychiatry in
Philadelphia."
EMIL R. PINTA
Samuel M. Smith, "Dr. Cure-Awl's"
Assistant at the Ohio Lunatic Asylum:
His 1841 Case-Reports on Insanity
The first half of the nineteenth century
was an enlightened era for under-
standing and treating mental illness.
One prevailing theory was that insanity
was a physical disease. This replaced
beliefs that considered the mind to be an
"emanation from the Creator"
and therefore not subject to physical laws and
interventions.
In 1812 Benjamin Rush (1745-1813), the
"Father of American Psychiatry,"
published his landmark text, Medical
Inquiries and Observations upon
Diseases of the Mind.2 This was the first textbook on this subject in
America, and it affected the perception
and treatment of mental illness for sev-
eral generations. Insanity, according to
Rush, was principally an inflamma-
tory disease of the brain's blood
vessels.3 Since the mentally ill were sick-
instead of bad-this fostered a
sympathetic attitude toward the mentally ill and
encouraged a form of treatment called
"moral therapy."4
Emil R. Pinta, M.D.. is on the emeritus
faculty of the department of psychiatry, The Ohio
State University College of Medicine,
and is chair of the history committee of the Ohio
Psychiatric Association.
1. H. A. Buttolph, "The Relation
Between Phrenology and Insanity," American Journal of
Insanity (AJI), 6 (October, 1849), 133.
2. Benjamin Rush, Medical Inquiries
and Observations upon the Diseases of the Mind
(Philadelphia, 1812).
3. Ibid. To reduce this inflammation,
Rush advocated blood-letting and various mechanical
devices, such as a "gyrator"
board that utilized centrifugal force to reduce blood flow to the
heads of patients who were strapped to
this device.
4. Moral therapy began in Europe during
the latter part of the eighteenth century as a prod-
uct of the Enlightenment. The word
"moral" referred to a variety of psychological-instead of
physical-treatments, e.g., education,
diversion, labor, exercise, amusement and occupational
activities. Harmony, balance and
regularity in daily activities were important. Nature itself
was considered therapeutic: therefore
most asylums were located in rural settings away from
the stresses and noises associated with
cities. For discussions of moral therapy, see Amariah
Brigham, "The Moral Treatment of
Insanity," AJI, 4 (July, 1847), 1-15; Eric T. Carlson and
Norman Dain, "The Psychotherapy
That Was Moral Treatment," American Journal of
Psychiatry (AJP), 117 (December, 1960), 519-24; Albert Deutsch, The
Mentally Ill in
America: A History of Their Care and
Treatment from Colonial Times, 2nd ed.
(New York,
1949), 87-113; Norman Dain, Concepts
of Insanity in the United States, 1989-1965 (New
Brunswick, N.J., 1964), 12-14, 204-06;
Nancy Tomes, A Generous Confidence: Thomas Story
Kirkbride and the Art of
Asylum-Keeping, 1840-1883 (Cambridge,
Mass., 1984), 4-6; Gerald N.
Grob, The Mad Among Us: A History of
the Care of America's Mentally Ill (New York, 1994),