First Place in the 2018 calendar year Medical Humanities Best Essay Competition

“A patient, long before he becomes the subject of medical scrutiny, is, at first, simply a storyteller, a narrator of suffering—a traveler who has visited the kingdom of the ill. To relieve an illness, one must begin, then, by unburdening its story.” – Dr. Siddhartha Mukherjee[1]

I. Introduction

The historical account, Three Years in a Mad-House: The Story of my Life at the Asylum, my Escape, and the Strange Adventures which Followed, published in 1893 by Augustin and E.B. Fleming, offers a perspective on psychiatric treatment in north Texas in the 1880s. This account, digitized in the archives of the Texas Medical Center, will serve as the primary source for this research project on the treatment of mental illness in the late-nineteenth and early-twentieth centuries in Texas. The narration details the experience of E.B. Fleming, who was institutionalized for melancholia, caused by “nervous depression arising from a disordered state of the system, and commercial reverses” in 1886 until escaping the hospital three years later and travelling across the United States.[2] For the purposes of this research, the analysis will focus on the first section of the narrative, entitled “Life in an Insane Asylum,” which recounts Fleming’s experiences within the hospital. The text, often narrated in the first-person by E.B. Fleming, allows the reader to understand the facility through a patient’s point-of-view. This account offers insight on various aspects of daily life within the institution, including living facilities, medical treatment, and social routines among the patients. Moreover, the medical practices described by Fleming underscore the differences between regional and national trends in psychiatry during this period, as emphasized in the conflict between traditional and progressive modes of treatment during a critical point of transition within the field. This project will examine Fleming’s account through several levels of analysis, including institutional environment, quality of patient care and patient life, and mechanisms of social control, in order to understand how this narrative depicts the conflict and contradictions among several emergent trends in Texas psychiatry at the end of the nineteenth century.

The sources used to analyze Fleming’s account through these different lenses include different geographic and historical perspectives on the treatment of mental illness. French philosopher Michel Foucault’s Madness and Civilization: A History of Insanity in the Age of Reason explores philosophies about mental illness from the end of the Middle Ages to the end of the eighteenth century and discusses how modes of social control and confinement often eclipsed the medical treatment of mental conditions. Foucault’s work is particularly relevant to the discussion of confinement, control, and exclusion as opposed to more progressive institutional philosophies in the nineteenth century. Gerald N. Grob’s Mental Illness and American Society: 1875-1940 considers contrasting perspectives on psychiatric treatment between the nineteenth and twentieth centuries. Grob examines the structural organization of inpatient psychiatric hospitals and emphasizes changing trends in treating acutely and chronically ill patients in institutions at the end of the nineteenth century. This text underscores the variety of patients that were institutionalized and evaluates the quality of care within those facilities. A more regionally-focused text, Life at the Texas State Lunatic Asylum, 1857-1997, by Sarah C. Sitton, focuses on another psychiatric facility in Austin, Texas, that shares several parallels with the North Texas facility. This source offers information on the philosophies concerning location, architecture, and social norms of psychiatric institutions in Texas at the time. Another regional focus emerges in sources from the Texas State Historical Association, which provide information about the founding of mental health facilities in Texas and the need to expand institutions throughout the nineteenth century. Moreover, these sources examine the rurality and psychological advances that were occurring in this era and the extent to which they were incorporated into psychiatric care in Texas. These texts, when put in dialogue with Fleming’s account, highlight the intersection of different philosophies and practices in psychiatry that often came into conflict with each other in the transitional period of the late-nineteenth century.

II. Institutional Environment

To analyze the institutional environment Fleming describes in the context of the 1880s, the history of the North Texas Hospital for the Insane must first be examined. The North Texas Lunatic Asylum was founded in 1885 for patients with chronic mental illness due to overcrowding at the State Lunatic Asylum in Austin, founded in 1861.[3] During this period, newly established hospitals in Texas reflected evolving approaches to the treatment of mental illness at the time. The North Texas facility exemplified this evolution, as its name was changed to the North Texas Hospital for the Insane in 1887, underscoring changes in attitudes toward psychiatry and treatment during the time.[4] In 1851, the Association of Medical Superintendents of American Institutions for the Insane, which would become the American Psychiatric Association, released new standards for the construction of asylums.[5] These guidelines stipulated that asylums should be situated in rural environments to “provide quietude and removal from the stress of urban living” that was thought to exacerbate mental illness.[6] Moreover, it was strongly recommended that asylums should have at least “fifty acres of land devoted to gardens and pleasure gardens for its patients.” Within this context of reform, mid-nineteenth century psychiatrist Dr. Thomas Kirkbride released a “linear” plan for asylums that focused on the role of architecture in the healing process. Kirkbride believed that fences and confinement should not be the focus of the institution.[7] Instead, this plan emphasized the importance of natural air and light as well as a linear design of the hospital in the process of healing.[8] Additionally, it forbade that patients’ living quarters be built underground.[9]

Within Three Years in a Mad-House, these new guidelines can be observed in Fleming’s description of the facility as well as in historical images of the North Texas Hospital. Designed using the Kirkbride plan for asylums, the North Texas facility had multiple wings and wards exposed to natural light and air as well as expansive green space for patients, as evidenced in several photographs and postcards of the institution. As seen in Figure 1, which is a photograph of the institution, the separate wings and spacious windows of the hospitals highlight the linear design as well as the importance of natural light and air.[10]

Figure 1: This image of the North Texas Hospital for the Insane exemplifies the Kirkbride plan for asylums.

In Figure 2, which features a postcard including an illustration of the hospital grounds, the verdant image focuses on the gardens and the manicured lawns of the facility.[11] In accordance with the new Kirkbride plan for asylums, modern approaches to constructing a welcoming and natural environment of healing were paramount in this new institution.

Figure 2. A 1907 postcard illustrates the verdant entrance to the North Texas Hospital for the Insane.

Fleming’s account corroborates the images of this progressive structure through the description of the hospital’s ground as “beautifully laid off and ornamented” and having “the appearance of being constantly swept and tended.”[12] Dialogue from physicians included in the narrative also highlights the importance of the outdoor environment in patients’ treatment and routines, as one doctor pointed out to Fleming that “‘Yonder . . . is the park where patients, under guard, of course, exercise themselves during the day.’”[13] These descriptions align with the mid-century standards for asylums that emphasized the importance of gardens and greenery in the healing process. With that in mind, the North Texas facility appeared quite progressive from a structural perspective. However, the institutional dynamic within the hospital revealed deeper historical conflict concerning the quality of patient care by staff and norms in the daily routines and behavior of patients.

III. Quality of Patient Care and Patient Life

While the design of the institution and the exterior conformed to a more progressive and humane approach toward treating mental illness, Fleming’s account of daily life in the asylum suggests that certain modes of coercion and discord were perpetuated through the end of the nineteenth century in Texas. Fleming devotes much of his account to describing interactions between patients. Several examples indicate conflict between the progressive and idealized external design of the facility and the traditional and more restrictive practices within the hospital. In contrast with the serene architecture of the hospital and the green space around it, the description of patient life at the facility offers a much less peaceful portrait, as Fleming describes the “regular fights [that] were now and then occurring about the grounds, either between the lunatics themselves, between them and their keepers.”[14] In addition to fights on the grounds and gardens, conflicts were also common within the interior of the facility, as “rows and disturbances were often occurring in the various dining-rooms as well as elsewhere. There was no general eating-apartment, or hall, for the use of the inmates collectively.”[15]

In addition to the constant fights among patients, to whom Fleming refers as “inmates,” and conflict with staff, he also describes coercive treatment by the staff.[16] He narrates an instance upon arriving at the hospital when all patients were required to be clean-shaven, but Fleming resisted the barber and requested that his beard be kept. The barber’s subsequent response demonstrates the threats and force used to coerce patients:

This cool treatment of his faltering but earnest request roused the poor lunatic’s resentment, and he made a few vain struggles to break loose and rise from the chair. This resistance angered the barber very much. 'Do you want me,’ he roared, flourishing his razor aloft, ‘to cut your blasted throat? Are you going to make me do it? If you are, it’s all right. If you ain't then why the h- don't you lie still.’ The patient, overawed by this terrific outburst, made no further objection, and the beard was removed.[17]

The force and coercion with which patients were treated also suggest the forms of social control at work within the institution.

As evidenced in Fleming’s writing, the distinction between the design of the hospital and the dynamic within the institution reflects a conflict between progressive and traditional treatment of the mentally ill. The more progressive modes of treatment developed in the nineteenth century focused on constructing asylums as reprieves from stressors that exacerbated mental illness.[18] The new asylum movement functioned with the intent to cure, rather to contain, patients with mental illnesses. An open location and environment were considered to be directly involved in the healing process, as “the idea that a beautiful location could have curative power derived from the new moral treatment for insanity, which emphasized kindness instead of coercion and a daily routine incorporating social contact, exercise, and productive labor.”[19] In addition to environmental design, aspects of patient care evolved during the mid-nineteenth century. For example, the use of mechanical restraints was strongly discouraged in both European and American asylums; instead, violent patients in Texas asylums were isolated in rooms “padded with cotton and lined with sailcloth” in an effort to reduce coercive measures within the facilities.[20]

In spite of these progressive goals and certain implementations, the realities of institutional organization still emphasized authority and hierarchy, as involuntary commitment of patients continued to be a very common practice in mental hospitals through the nineteenth century.[21] Additionally, institutions across the United States, and especially in rural Texas, faced overcrowding and a lack of funding that affected their ability to dedicate sufficient resources to innovative and curative treatment.[22] At the end of the nineteenth and beginning of the twentieth century, mental hospitals continued “to assume a mainly custodial role, [as] the belief that sufferers of mental illness would be cured waned.”[23] In this way, traditional theories of confinement continue to manifest in the treatment of mental illness within institutions.

Foucault examines the role of the institution in perpetuating control of patients in Madness and Civilization, which discusses the rise of confinement as an accepted approach to treating psychiatric conditions. Traditional modes of treatment in Western Europe in the seventeenth and eighteenth centuries largely centered around confinement. Foucault describes how the mentally ill became social pariahs subjected to exclusion at the end of the Middle Ages, when the incidence of leprosy, an ancient disease of social exclusion, began to decline in Europe.[24] Social exclusion of this marginalized group intensified during era of “The Great Confinement,” beginning in France in the seventeenth century, when hospitals designed to confine the mentally ill emerged.[25] Foucault identifies this moment as a critical point in the history of madness throughout Western culture, asserting that, “From the middle of the seventeenth century, madness was linked with this country of confinement, and with the act which designated confinement as its natural abode.”[26] In addition to the phenomenon of confinement, institutionalizing multiple marginalized groups within the same facility became commonplace at this time.[27]

It became common practice in the seventeenth century to “assign the same homeland to the poor, to the unemployed, to prisoners, and to the insane.”[28] This classification indicates the modes of social control at work within institutions that aimed to confine certain groups deemed problematic by society. Foucault contextualizes this category of urban concerns in “the moment when madness was perceived on the social horizon of poverty, of incapacity for work, of inability to integrate with the group; the moment when madness began to rank among the problems of the city.”[29] The act of controlling populations within a social and medical facility resonates in a distinct geographic and historical context in Fleming’s nineteenth century account, which exemplifies similar modes of containment within the North Texas hospital.

IV. Mechanisms of Social Control

Within Fleming’s description of the facility, several moments exemplify methods of social control within the hospital through the lenses of confinement, race, and gender. These methods offer insight into social norms of the era. Confinement is the most common example within the text, as Fleming describes his experience as an “infringement upon personal liberty,” suggesting his involuntary committal to the institution.[30] In addition, Fleming often compares the mental hospital to a prison. For example, upon being admitted, all patients were required to undergo the same routine of being shaven, “put in to a bath and dressed in the asylum uniform, a cheap suit of coarse grey with the words North Texas Insane Asylum indelibly branded upon every garment.”[31] This description conjures images of a prison uniform, used to exert control over large groups through conformity of appearance.

In another parallel to imprisonment, punishment was frequently used to maintain order. In his narrative, Fleming cites the forced administration of medication and punishment for resisting treatment. He explains that “they gave me medicine regularly; but it generally cost the attendant a struggle to do so, for I dreaded the medicine worse than any spoiled child and would not take it except upon compulsion.”[32] Fleming compares the facility to a prison more directly when he discusses resistance, explaining that “rebellion in a mad-house, as in a prison, is never tolerated and it is suppressed by such prompt and rigorous measures that the delinquent does not care to repeat the offense very often.”[33] As evidenced in this example, confinement was enforced using punishment and fear as governing forces in the institution. Within the modern architecture of the North Texas Hospital for the Insane, centuries-old methods of control continued to be standard practice in the treatment of the mentally ill.

While several moments in Fleming’s account exemplify traditional norms of confinement, other modes of social control offer insight into the specific race and gender dynamics of the late nineteenth century. In terms of race, psychiatric facilities in Texas mirrored the practice of segregation observed throughout several sectors of society. In describing the patients’ routine in the facility’s park, Fleming notes that African-American patients “too walked in the park· but they were allotted a certain part for their exclusive use, and were not permitted to intrude upon that portion occupied by the whites.”[34] In addition to the segregation within the facility, the systematic abuse of African-American patients appears in the Fleming’ account of daily life at the facility.

In describing the aggression of white patients toward African-American patients, Fleming includes an incident in which a white patient intentionally crossed into the section of the park restricted to African-Americans and began to beat an African-American patient, who then fought against him.[35] In response to the African-American patient’s self-defense, “the white men in the park, though lunatics to a man, with the exception of the keepers, at this occurrence seemed to feel all the rancor of racial hatred rising within them.”[36] This systematic racism within the institution, though occurring between patients, was perpetuated through the cultural authority of medical and social beliefs of the era. At the time, many American psychiatrists exhibited beliefs in intrinsic racial differences that negatively affected their treatment of African-American patients[37] and contributed to segregation within institutions under the seemingly progressive design of wards used to separate patients, which instead perpetuated divisiveness and conflict among patients.[38] Within these examples of racial stereotypes and discriminatory actions by patients and institutions entering into the practice of medicine, Fleming describes efforts to control patients through segregation by race and through abusive practices that perpetuated profoundly racist ideologies of the late-nineteenth century in Texas.

Societal attitudes toward gender in the late-nineteenth century also emerge as a mode of social control in Fleming’s account. Social norms regarding the separation of men and women resonated in the social organization of the North Texas hospital, in which “the lunatic men and women were careful1y kept apart, and were never allowed together except when they met by accident or in the hospital dance-room.”[39] Beyond the physical separation of men and women, the freedoms given to male and female patients also differed substantially. In the hospital’s park “in good weather, under the watchful eye of a sufficient guard, the male lunatics spent their time, and were allowed many liberties not permitted elsewhere.”[40] The specificity of the phrase “male lunatics” and the absence of commentary relating to women’s routines in the park suggest that male patients were afforded different privileges. Gender expectations of the era not only pervaded the practices within the hospital but also the tone of Fleming’s writing itself, as he writes that “it must be remembered that in nearly all cases the male lunatic loses all that natural gallantry and reverence for the fairer and gentler sex that is so characteristic of every true man who is in his sober senses.”[41] This attitude juxtaposed with the regulation of patients in the text underscores that methods of social control also reflected views about gender in the era. Within Three Years in a Mad-House, complex trends emerge in the modes of control utilized within the institution. While traditional, centuries-old practices of punishment and confinement were commonplace, social practices that revealed the influence of beliefs about race and gender within that specific era also aimed to control the patients in the North Texas Hospital for the Insane. This conflict between the tradition and progress resonates with the text’s insight into established practices and emergent trends in American psychiatry during the time of Fleming’s institutionalization.

V. Evolving Trends in Psychiatry between the Nineteenth and Twentieth Centuries

Major changes in psychiatry between the nineteenth and twentieth centuries addressed treatment modalities and the efficacy of treatments within and outside of institutions. The progressive treatment of psychotherapy used extensively in the twentieth century is conspicuously absent from Fleming’s experience, as Sigmund Freud, an Austrian neurologist largely considered to be the founder of psychoanalysis, was still in his early career in the 1880s and would not produce the bulk of his written works until the first two decades of the twentieth century.[42] Throughout the text, Fleming describes the norms for medical treatment in the 1880s, which consisted of the administration of medication, exercise and outdoor recreation, and social routines. Psychoanalysis would not be fully incorporated into American mental hospitals until after World War II.[43]

Fleming’s account also highlights the failure of institutions to organize patient populations based on severity of diagnosis, even amidst the implementation of the Kirkbride design for wards that separated patients. In describing the patients in the North Texas hospital, Fleming writes that “there were among us, as would naturally be expected, patients in every stage of 1unacy, from the most tragic to the most disgusting or ridiculously comic”[44] This conflict in structural organization arises from the disconnect between the founding of the North Texas hospital as a facility for the chronically ill and the reality of the diverse conditions that were observed in the hospital, as evidenced in Fleming’s acute case of melancholia. At the end of the nineteenth century, the implementation of “psychopathic” hospitals throughout the United States that aimed to treat acute disease became more common as scientific and evidence-based psychiatric medicine developed.[45] Psychopathic hospitals and psychiatric wards within general hospitals followed the common approach to hospitalization of patients with acute medical problems at the time, characterized by short-term stays to treat acute mental illnesses, thereby deemphasizing the role of confinement within mental institutions.[46]

In Texas, the end of the nineteenth century was a transitional era concerning the institutionalization of the chronically and acutely ill. Fleming’s observation that "of the large number of unfortunates who are yearly confined there, there are many who never leave it alive” alludes to the confinement of the chronically ill in the North Texas facility.[47] In Texas, advances in institutional structuring of patients emerged soon after Fleming’s experience upon the founding of a new facility in Texas that separated patients with neurological and psychological illnesses.[48] Curative treatment began to eclipse the focus on confining American psychiatric patients at the end of the nineteenth century.[49] The context of Fleming’s account precedes the major advocacy for deinstitutionalization arising from new knowledge about causation and treatment of mental illness in the mid-twentieth century, which moved toward treating the acutely ill through interventions outside of the institution.[50]

The rate of implementing psychiatric advancements during this period also depended on the rurality and access to resources within mental hospitals. The rurality of Texas at the end of the nineteenth century and throughout the early twentieth century affected the dissemination of psychological advances to facilities in the state. For example, psychoanalysis arrived in the East Coast in the 1920s but would not be used in Southern mental facilities, especially in rural Texas, until after the end of World War II.[51] Disparities in state funding and public policy for mental healthcare also influenced the rate at which treatment advanced. Regional poverty in Southern states contributed to less welfare funding for marginalized groups in the late nineteenth century.[52] In fact, the per capita cost of maintaining psychiatric facilities Texas and several other states in the southern and southwestern United States continued to be much lower than that spent in northeastern states throughout the first half of the twentieth century.[53] Moreover, public policy about mental healthcare during the early-twentieth century was often underemphasized due to the lack of representation of mentally-ill patients in external interest groups.[54]

The conflict among different trends in psychiatry at the turn of the century is evident in Fleming’s experience, situated in a historic transitional point in American psychiatry. The many contradictions within Three Years in a Mad-House allude to the transition between older vestiges of confinement and progressive psychodynamic advances. While Fleming often describes the discord among patients and abuses by staff members, he also includes reflections about the humane demeanor of the physicians in the hospital, writing that “I find myself wondering at the considerate care and kindness, as well as the calm and benignant temper that invariably characterized Dr. Wallace’s demeanor, as well as that of his great-hearted associate, Dr. F.S. White.”[55] Indeed, Dr. F.S. White, who later became superintendent of the State Lunatic Asylum in Austin, was a progressive figure in psychiatry at the time, advocating for psychiatric institutions that utilized a treatment-based approach rather than confinement for the chronically ill.[56] In addition, White criticized patients’ daily routines in traditional asylums, noting that “the monotony of such a life is something terrible.”[57] By including reflections on both the injustices and the advancements within psychiatric institutions in the 1880s, Fleming constructs a broad and complex portrait of the challenges and realities of hospitalization and treatment. This portrait offers a narrative approach to examining the ideological progress and practical stagnation within psychiatry as observed in facilities for the mentally ill.

VI. Summary and Conclusion

This project has examined the historical account of E.B. Fleming, Three Years in a Mad-House: The Story of my Life at the Asylum, my Escape, and the Strange Adventures which Followed, to gain insight into the text’s depiction of psychiatric trends in the final decades of the nineteenth century. Fleming’s reflections on the exterior appearance of the facility, the patients’ lives within the institution, and the methods of control used to maintain order within the hospital highlight a critical transition point between contrasting treatments focusing on confinement and exposure to natural environments and the emergence of psychoanalytic approaches to treating the mentally ill. While the progressive Kirkbride design of the North Texas Hospital for the Insane intended to foster an open exposure to nature and offered a modern exterior for the containment of chronically-ill patients, the environment within the hospital reflected the realities of a traditional dynamic of authority and control. The modes of social control in the hospital varied, ranging from the centuries-old tradition of social exclusion of the mentally ill through confinement as outlined by Foucault to the manifestation of late-nineteenth century views on race and gender in the facility’s restriction on patient interactions. Fleming’s account of his experience in a mental institution offers profound insight into the challenges of psychiatry in rural environments and in facilities that did not yet utilize more progressive treatments for chronically and acutely ill patients. Woven throughout Fleming’s writing are his contradictory reflections on a facility from which he eventually felt the need to escape, condemning it as a place that ended the “high hopes and burning ambitions” of patients.[58]

The contrast between Fleming’s descriptions of the abuse and humane treatment of patients in his account encapsulates the historical challenges to advancements in psychiatry, caught between traditions of confinement and coercion within institutions for marginalized populations and the movement toward restructuring psychiatric environments to better serve the needs of diverse patients. In a synthesis of these complex trends, Fleming summarizes the approach of the North Texas Hospital for the Insane toward patient care, noting that “while it is vitally necessary to control the inmates of an asylum as with a rod of iron, it is necessary that the hand of steel be concealed under the softest of gloves.”[59] In many ways, the serene exterior of the North Texas Hospital for the Insane concealed an inner dynamic rife with conflict concerning patient care, quality of life, confinement, and control that mirrored the contrast between ideological advancements of the nineteenth century and the reality of psychiatric treatment in rural Texas.

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