Ohio History Journal

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),

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.

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."