Beyond the asylum and before the 'care in the community' model: exploring an overlooked early NHS mental health facility

This article discusses the Admission and Treatment Unit at Fair Mile Hospital, in Cholsey, near Wallingford, Berkshire (now Oxfordshire). This was the first new hospital to be completed in England following the launch of the National Health Service. The building was designed by Powell and Moya, one of the most important post-war English architectural practices, and was completed in 1956, but demolished in 2003. The article relates the commission of the building to landmark policy changes and argues for its historic significance in the context of the NHS and of the evolution of mental health care models and policies. It also argues for the need for further study of those early NHS facilities in view of current developments in mental health provision.

The ambivalent role of the institution in the history of child and adolescent psychiatry: a case study of the Hawthorn Centre in Michigan, USA

Historians have examined the role of psychiatric institutions in the USA and addressed whether this form of care helped or harmed patients (depending on the perspective of the time period, historical actors, and historians). But the story for children's mental institutions was different. At the time when adult institutions were in decline, children's mental hospitals were expanding. Parents and advocates clamoured for more beds and more services. The decrease in facilities for children was more due to economic factors than ideological opposition. This paper explores a case study of a hospital in Michigan as a window into the different characteristics of the discussion of psychiatric care for children.

'As syllable from sound': the sonic dimensions of confinement at the State Hospital for the Insane at Worcester, Massachusetts

As the first state hospital in the USA, the Worcester State Hospital for the Insane at Worcester, Massachusetts (est. 1833), set a precedent for asylum design and administration that would be replicated across the country. Because the senses were believed to provide a direct conduit into a person's mental state, the intended therapeutic force of the Worcester State Hospital resided in its particular command over sensory experience. In this paper, I examine how aurality was used as an instrument in the moral architecture of the asylum; how the sonic design of the asylum collided with the day-to-day logistics of institutional management; and the way that patients experienced and engaged with the resultant patterns of sound and silence.

Through a glass darkly: patients of the Illinois State Hospital for the Insane at Jacksonville, USA (1854-80)

The State Hospital for the Insane at Jacksonville, Morgan County, Illinois, was the first public hospital of its kind to be established in the state and among the earliest to be built on the 'Kirkbride Plan'. It opened for patients in 1851. We describe the background to the establishment of the hospital and, so far as is possible from publicly available sources, its catchment area, the nature of the patients held there up to 1880, its mechanisms of discharge, and supposed causes of death. We end with a plea that after over 150 years, the release of hospital casebooks and similar records in digital form would be of considerable benefit to historians of psychology, scientific biographers, genealogists and demographers.

The Final Years of Central State Hospital

There is a rich literature on the deinstitutionalization movement in the US but few, if any, parallel histories of state mental hospitals. Under attack from the 1950s on, state hospitals dwindled in size and importance. Yet, their budgets remained large. This paper offers a case study of one such facility, Indiana's Central State Hospital, between 1968 and 1994. During these years, local newspapers published multiple stories of patient abuse and neglect. Internal hospital materials also acknowledged problems but offered few solutions. In 1984, the US Department of Justice intervened, charging Central State with having violated patients' civil rights, the first such action filed under the 1980 Civil Rights of Institutionalized Persons Act. Although Indiana signed a consent decree promising major reform, long-lasting change proved elusive. Civil and criminal lawsuits proliferated. In 1992, as Central State continued to attract negative attention, Indiana Governor Evan Bayh ordered the troubled hospital closed. His decision promised to save the state millions of dollars and won plaudits from many, but not all, mental health advocates. Even as the last patients left in 1994, some families continued to challenge the wisdom of eliminating Indiana's only large urban mental hospital, but to no effect.

Psychiatric Jim Crow: Desegregation at the Crownsville State Hospital, 1948-1970

The Crownsville State Hospital, located in Maryland just outside of Annapolis, provides a thought-provoking example of the impact of desegregation in the space of the mental hospital. Using institutional reports, patient records, and oral histories, this article reconstructs the three phases of desegregation at Crownsville. First, as a result of its poor conditions, lack of qualified staff, and its egregious mistreatment of patients, African American community leaders and organizations such as the NAACP called for the desegregation of the care staff of Crownsville in the late 1940s. Second, the introduction of a skilled African American staff created unprecedented and morally complex issues about access to psychiatric therapeutics. Last, in 1963, Health Commissioner Dr. Isadore Tuerk officially desegregated patients in all Maryland state hospitals. Though desegregation brought much needed improvements to Crownsville, these gains were ultimately swamped by deinstitutionalization and the shift towards outpatient psychiatric care. By the 1970s, Crownsville had returned to the poor conditions that existed during segregation.

Malariablood in the pocket

For the first time on June 5, 1919, at the Hamburg State Hospital Friedrichsberg, two paralytics were artificially infected with malaria, subjecting them to the new malaria fever treatment according to Wagner-Jauregg (1917). This article examines the life stories and medical histories of these patients, an opera singer and a yardmaster, and provides an interpretation based on their medical files. Relevant contemporary medical publications contextualise the specific configurations of their hospital stay. In both cases, a detailed comparison between each medical file and the published case history reveals remarkable.discrepancies. A specific concept of remission, mainly determined by the level of restoration of a patient's working power, i. e. the ability to work, was implemented. Finally, the article considers the question of why the new therapy method was introduced in Hamburg specifically on June 5, 1919.

The Birth of a New Branch of Medicine: Psychiatry

Psychiatric treatment prior to 1955 seemed to be at a standstill. All kinds of treatments, including surgical ones, were used ineffectively. Then suddenly, out of nowhere, a new treatment -chlorpromazine - created a worldwide revolution. Here is what we saw in Delaware. It was not much different in the rest of the world. Patients improved and were rapidly dischargedfrom mental institutions causing workforce reductions. I was sitting on a state employee job application evaluation committee and witnessed these events. It was also exciting to see rapid changes in administration at the state hospital. Since what happened in Delaware also happened nationally, this was a national event and should be recognized as such. The following few pages are to remember the details. Major changes made psychiatry more of an accepted medical specialty. Psychiatrists are no longer "outsiders." I would be glad to answer any questions about the information presented here.

Duty and 'Euthanasia': the Nurses of Meseritz-Obrawalde

This article examines the actions and testimonies of 14 nurses who killed psychiatric patients at the state hospital of Meseritz-Obrawalde in the Nazi 'euthanasia' program. The nurses provided various reasons for their decisions to participate in the killings. An ethical analysis of the testimonies demonstrates that a belief in the relief of suffering, the notion that the patients would 'benefit' from death, their selection by physicians for the 'treatment' of 'euthanasia', and a perceived duty to obey unquestioningly the orders of physicians were the primary ethical reasons that were stated for their behavior. However, 20 years had elapsed between the killings and the trial, thus giving ample opportunity for the defendants to develop comfortable rationales for their actions and for their attorneys to have observed successful defenses of others accused of euthanasia.

[Neuropathological research on organs of patients of the "Heil- und pflegeanstalt" (state hospital) Günzburg]

BACKGROUND

The two Kaiser Wilhelm-Institutes (KWI) in Berlin (1914, new building 1931) and in Munich (1917, new building 1926-28), specialized on pathologic anatomical as well as psychiatric genetic research, were set up before times of National Socialism.

METHODS

Data evaluation is based on patient documents and annual reports of the archive of today's district hospital Günzburg and on patient documents (copies) of the historical archive of today's Max-Planck Institute of Psychiatry.

RESULTS

The KWI in Munich was indirectly provided with brain material by Bavarian "Heil- und Pflegeanstalten" (state hospitals) including the state hospital Günzburg.

CONCLUSIONS

During National Socialism patients' organs were sent from the "Heil- und Pflegeanstalt" (state hospital) Günzburg to the KWI in Munich for the purpose of conducting research. Commemorating patients' fates and clarifying what happened defines a place of remembrance.

[Sterilization surgeon and researcher: life and career of Benno Ottow (1884-1975)]

The activities of the gynaecologist and member of the Erbgesundheitsgericht Benno Ottow (1884-1975) in the "Third Reich" have been described in a couple of publications. During the Nazi dictatorship Ottow demonstrated great commitment to putting the ideological and legal demands into practice. Drawing on sources from private and state archives in Estonia, Germany and Sweden, this paper investigates the biography of Benno Ottow: from his time as a junior physician period in Estonia and Russia to his directorship of the Brandenburg gynaecological state hospital in Berlin-Neukölln and the postwar-years in Sweden.

From cure to custodianship of the insane poor in nineteenth-century Connecticut

Connecticut was the exception among the Northeastern and Middle Atlantic states in not founding a public institution for the insane until after the Civil War when it opened the Hospital for the Insane at Middletown in 1868, a facility previously neglected by scholars. The state had relied on the expedient of subsidizing the impoverished at the private Hartford Retreat for the Insane that overtaxed that institution and left hundreds untreated. Despite abundant evidence to the contrary, well meaning officials oversold the idea that the Middletown site would promote cures and be cost effective. A number of unanticipated consequences occurred that mirrored fundamental changes in nineteenth-century psychiatry. The new hospital swelled by 1900 to over 2,000 patients, the largest in New England. Custodianship at the monolithic hospital became the norm. The hegemony of monopoly capitalism legitimated the ruling idea that bigger institutions were better and was midwife to the birth of eugenic responses. Class based psychiatry--the few rich at the Retreat and the many poor at Middletown--was standard as it was in other aspects of the Gilded Age. Public policy toward the insane poor in Connecticut represents an outstanding example of the transition from antebellum romanticism to fin de siècle fatalism.

Creating order. A quantitative analysis of psychiatric practice at the Swiss mental institutions of Burghölzli and Rheinau between 1870 and 1970

This paper analyses the concepts of order and normality underlying the daily psychiatric practice of two Swiss mental health institutions between 1870 and 1970, based on a representative random sample of 1330 patient records from the two state institutions in the Canton of Zurich. The quantitative analysis covers the types of psychiatric measure taken in these cases, as well as the rationales behind them. It is concluded that the order of the institution, of society and, above all, the order of gender played an important role in the choice and implementation of various measures.

David Shakow and schizophrenia research at Worcester State Hospital: the roots of the scientist-practitioner model

As Chief Psychologist and Director of Psychological Research at Worcester State Hospital (WSH), David Shakow (1901-1981) made substantial contributions to the scientific study of schizophrenia and by extension to the study of psychopathology in general. His methodological innovations--particularly on issues of diagnosis and conditions of testing-set a new standard for experimental rigor in the field. Shakow helped to establish many of what are considered basic facts about schizophrenia. His empirical work at WSH-specifically on the crossover effect--provided the scientific foundation for his theory of schizophrenic cognition, known as segmental set. Moreover, Shakow's schizophrenia work informed his developing ideas on the synergy between clinical practice and research.

Fantome Island lock hospital and aboriginal venereal disease sufferers 1928-45

In this article the Queensland government's response to suspected and confirmed cases of venereal disease amongst the state's Aboriginal population is examined through the micro history of Fantome Island lock hospital, which operated between 1928 and 1945. This history offers an interesting case study into the complexities of medical and racial segregation in twentieth century Queensland. While other scholars have positioned Fantome Island lock hospital as a justifiable attempt to control syphilis and gonorrhoea infections amongst the Queensland Aboriginal population, I propose a different interpretation and argue that white perceptions of Aboriginal sexuality and health contributed to government depictions of an Aboriginal venereal disease 'epidemic.' I demonstrate that disease diagnosis was still highly problematic prior to World War II and was differentially applied across different sub-populations.

Researching dementia in imperial Germany: Alois Alzheimer and the economies of psychiatric practice

In the writings of Alois Alzheimer and many of his contemporaries, complaints abounded about psychiatric hospitals not only failing to appreciate the importance of senile dementia, but also inhibiting scientific research into the nature and causes of the disorder. This article exploits these discontents in order to examine what Alzheimer and others thought to be optimal conditions for psychiatric research on dementia. It first analyzes the various institutional contexts in which Alzheimer worked during his career (especially in Frankfurt and Munich). It then traces some of the administrative and diagnostic practices that were deployed to enhance the conditions for his clinical and pathoanatomic research. Finally, it reflects on the implications of these practices for psychiatric care and patient experience.

Neuropathological research at the "Deutsche Forschungsanstalt fuer Psychiatrie" (German Institute for Psychiatric Research) in Munich (Kaiser-Wilhelm-Institute). Scientific utilization of children's organs from the "Kinderfachabteilungen" (Children's Special Departments) at Bavarian State Hospitals

During National Socialism, the politically motivated interest in psychiatric genetic research lead to the founding of research departments specialized in pathological-anatomical brain research, the two Kaiser Wilhelm-Institutes (KWI) in Berlin and Munich. The latter was indirectly provided with brain material by Bavarian State Hospitals, to three of which "Kinderfachabteilungen" (Special Pediatric Units) were affiliated. As children became victims of the systematically conducted child "euthanasia" in these Special Pediatric Units, this paper will address the question whether and to which extent the organs from victims of child "euthanasia" were used for (neuro-) pathological research at the KWI in Munich. By means of case studies and medical histories (with focus on the situation in Kaufbeuren-Irsee), I will argue that pediatric departments on a regular base delivered slide preparations, that the child "euthanasia" conduced in these departments systematically contributed to neuropathological research and that slide preparations from victims of child "euthanasia" were used in scientific publications after 1945.

Idiocy in Virginia, 1616-1860

Like the English, Virginians tended to think that idiocy, a condition analogous to intellectual disability in the twenty-first century, was congenital, untreatable, and incurable, and they adopted legal remedies that corresponded closely to the laws of England. In addition, concepts of idiocy reflected some of the unique aspects of Virginia's social system, which was dominated by a coterie of powerful men. With a need to preserve social order and maintain decorum, the Virginia legislature established in 1769 the Eastern State Hospital to house unruly and objectionable people who were mentally disabled. Although idiots were among the hospital's first patients, they were eventually banished due to their presumed failure to respond to treatment. The social stigma attached to idiocy extended from Virginia's city streets and jails to the private homes of prominent families. Personal reticence regarding shameful family matters hid the identity of people thought to be intellectually disabled. Even Thomas Jefferson, a prolific author, entered only cryptic notes about the limitations of his sister, Elizabeth. In summary, Virginians' response to idiocy suggests a two-tiered approach: public disclosure and disdain of poor and dependent people with intellectual disabilities, and silent avoidance of the problem in prominent families. In both situations, idiocy represented images of shame and humiliation that threatened the social order.

Psychosurgery in Sweden 1944-1964

This study presents results on hitherto unknown data on lobotomies performed at the former State Mental Hospital of Umedalen (from here on called simply "Umedalen") in the north of Sweden. More than 700 operations were carried out from 1947 through 1960, and we calculated the average rate of postoperative mortality to 7.4 percent, and that 63 percent of those who were operated were women. By considering annual hospital reports to the National Board of Health (Medicinalstyrelsen), we also made the first mapping of early psychosurgery in Sweden; approximately 4,500 lobotomies were performed between 1944 and 1966. Statistical analysis, qualitative content analysis, and discourse analysis were used. The study supports earlier findings of female preponderance in the number of lobotomy operations.

Nursing care in a state hospital before and during the introduction of antipsychotics, 1950--1965

Oral history methods were used to describe the experiences of American nurses who practiced in a state mental hospital before and during the introduction of antipsychotic medications. The nurses described their responsibilities for supervising staff, administering patient care, and assisting with special psychiatric treatments. They expressed resignation and frustration with trying to provide care despite obstacles such as unqualified physicians, crowded wards, and inadequate personnel and supplies. The nurses adopted a Cartesian approach in which they focused on the patient's body, instead of the patient's mind, and developed camaraderie among nurses through which they found acceptance and were able to continue to do a thankless job.

Long-stay patients in state psychiatric hospitals at the end of the 20th century

OBJECTIVES

The purpose of this study was to assess the characteristics of long-stay patients in contemporary state psychiatric hospitals and to identify factors representing possible barriers to alternative placements for these patients.

METHODS

All patients in inpatient units of the Massachusetts Department of Mental Health who had been hospitalized for at least three years as of April 1, 1999, were assessed by their treatment teams with a standardized data collection instrument. Domains assessed included medical problems, need for nursing care, psychiatric diagnosis, and history of problematic behaviors.

RESULTS

The 330 individuals identified as long-stay patients had an array of medical problems and nursing care needs that likely would have been manageable in other long-term-care settings. A total of 276 patients had at least one significant medical problem. However, some patients exhibited behavioral problems that might have complicated such placements, especially when behavioral problems co-occurred with the need for medical supervision. A total of 228 patients had exhibited a significant problematic behavior in the previous 30 days.

CONCLUSIONS

Although the number of long-stay patients in state psychiatric hospitals declined dramatically during the second half of the 20th century, a small group of patients still requires care in this setting. State psychiatric hospitals continue to occupy a significant niche in the mental health system.

[National socialist "children's euthanasia" program in the province of Westphalia (1940-1945)]

As part of the organization structure of the "Reich committee for scientifically registering genetic and inherent serious illnesses" "childrens' special wards" were established in the province Westphalia in the child-psychiatry St. Johannesstift in Niedermarsberg (end of 1940), and then in the Provinzialheilanstalt Aplerbeck (end of 1941). The establishment thereof and personnel recruiting were done in close operation with provincial authorities. In Niedermarsberg external nurses were also employed. When the activities in the Marsberger ward became public despite efforts to keep them secret, the provincial association felt forced to establish a replacement ward in Dortmund-Aplerbeck. This ward was integrated stronger into the hospital-internal and regional care structures regarding personnel and institutional aspects than the previous ward. The actions of "child euthanasia" were based on a combination of hierarchical decision-making structures, limited responsibility, and scientific justification. The people performing these activities were provided action options withdrawal possibilities. For the affected parents the events were shifted into a psychological grey area which did not force decisions in principle. The internal conditions of the "childrens' special wards", the procedures and the "treatments" of the children were clearly regulated; the "euthanasia" activities themselves can be comprehended only in fragments from testimonies. By analyzing the reception books in connection with the medical files it is possible to make statements regarding the number of deaths, the death rate and cause, and also several social characteristics of the children. The fate of the children in the Westphalian "childrens' special wards" shows that the work in these regional "Reich committee wards" was limited to caring, observing, selecting and killing. The attempts of scientific justification are exposed as cover-ups.

["Euthanasia of children" during dictatorship of national socialism: "special children's department" Ansbach in Germany]

Focus of this paper is a description of "child euthanasia" during National Socialism 1939-1945 in the "specialized children's department" of the Ansbach state hospital. The historical and ideological bases for euthanasia and the development of child and adolescent psychiatry are explained. Material was found in public archives and trial records of German courts. 156 case histories of children who were killed in the Ansbach state hospital were evaluated. Child euthanasia in Ansbach was done in the same stereotyped way as in other specialized children's departments. The 156 children were aged between one week and 16 years. 39 children died within the first three months, 31 children died within three to six months in hospital. Most children were autopsied, at least 86 brains were examined neuropathologically. The trials against the involved physicians were quashed finally in 1968.

[Early days of the Ocean Road Hospital in Dar es Salaam: from mission hospital to government hospital]

On 1 October 1997 Ocean Road Hospital in Daressalam commemorated one hundred years of its existence. As early as 1888 a provisional hospital had been set up in Zanzibar by the German Lutheran Church to serve the needs of the Germans living and working on the East African coast. But when the British established their protectorate over Zanzibar in 1890, the hospital was moved to Dar es Salaam. As cooperation between Mission hospital and Government authorities proved difficult, the German colonial administration was determined to build an hospital of its own. Lack of funds delayed the construction of the building which had to be built on a more modest scale than originally planned. But when the hospital was inaugurated in October 1897, people were impressed both by its functional usefulness and aesthetic attraction. The history of the German Government Hospital reflects the political context of the time as well as the progress of medicine in combatting endemic diseases. While patients were often segregated by race--the Government Hospital in Daressalam almost exclusively reserved for Europeans--all were benefitting from the results of medical science. For Robert Koch the hospital (and its laboratory) served as basis for his research in the field of malaria, black water fever, sleeping sickness, and relapsing fever. It was from Africa that the embarked on his journey to Stockholm to receive the Nobel Prize in December 1905. During the First World War Ocean Road Hospital, as it was called from now on, was taken over by the British. Since independence, the Tanzanians are in charge. It is presently the only tumor hospital of the country, closely cooperating with the German Cancer Research Center (DKFZ) in Heidelberg. Restoration of Ocean Road Hospital, completed at the beginning of this year, was made possible by a grant of the Federal Republic of Germany.

History of clinical chemistry in a children's hospital (1914-1964)

The historical development of a charitable children's hospital and the evolution of its clinical laboratory are presented. With the appearance of practical quantitative blood chemistry tests in the period between the two World Wars, applications to pediatrics were hampered by the need for ultramicro procedures then unavailable and for improved skin-puncture blood sampling. World War II brought economic demands that forced the hospital to privatize its beds and to charge fee-for-services. In turn, this brought added income, allowing the hiring or subsidizing of a professional staff, including the clinical chemist. The development of ultramicro blood chemistry followed, along with improved skin-puncture technology.

LINDA RICHARDS AT THE KALAMAZOO STATE HOSPITAL

Linda Richards was the first nursing graduate in America and a major pioneer in nursing education. Moral therapy was the major treatment at the Kalamazoo Asylum and its use persisted into the early 20th century under the supervision of Richards, one of its adherents. Richards added district nursing experience in the City of Kalamazoo to the curriculum and the school was described by the Trustees as being in vigorous condition during her leadership.

Therapeutic effectiveness and social context: the case of lobotomy in a California state hospital, 1947-1954

Images

Voices of the mad: patients' letters from the Royal Edinburgh Asylum, 1873-1908

BACKGROUND

This paper is based on a rich archive of 1151 letters by patients, who were admitted to the Royal Edinburgh Asylum during the reign of Thomas Clouston (1873-1908).

METHODS

All letters were examined for evidence of psychopathology, and the material obtained was organized under the various psychopathological categories, such as delusions or hallucinations, as defined by Sims (1988).

RESULTS

A descriptive account of patient symptomatology is given. It is found that nineteenth century psychopathology is very similar to that of the modern day, and that most forms of morbid mental phenomena can be found in the patients' letters. More specifically, most of the cardinal symptoms of schizophrenia were described in the patients' correspondence. The letters also illustrate how mental symptoms reflect the cultural and scientific concerns of their time.

CONCLUSIONS

The evidence in the patients' letters argues for the unchanging nature of mental illness across time, at least for the last 120 years. It also demonstrates that patients admitted to the Royal Edinburgh Asylum suffered from serious mental illness, and it undermines the view that the Asylum was simply a dumping ground for society's disaffected.

The architecture of psychological management: the Irish asylums (1801-1922)

This analysis examines some of the psychological, philosophical and sociological motives behind the development of pauper lunatic asylum architecture in Ireland during the time of the Anglo-Irish union (1801-1922). Ground plans and structural features are used to define five psycho-architectonic generations. While isolation and classification were the prime objectives in the first public asylum in Ireland (1810-1814), a combination of the ideas of a psychological, 'moral', management and 'panoptic' architecture led to a radial institutional design during the next phase of construction (1817-1835). The asylums of the third generation (1845-1855) lacked 'panoptic' features but they were still intended to allow a proper 'moral' management of the inmates, and to create a therapeutic family environment. By the time the institutions of the fourth epoch were erected (1862-1869) the 'moral' treatment approach had been given up, and asylums were built to allow a psychological management by 'association'. The last institutions (1894-1922) built before Ireland's acquisition of Dominion status (1922) were intended to foster the development of a curative society.