State Control, Moral Treatment, and Patient Care Philosophy
In 1834, due mostly to economic circumstances, the State of Maryland assumed the management of the hospital. Renamed the Maryland Hospital For The Insane, it initially employed nuns from the Order of the Sisters of Charity to act as attendants. This arrangement lasted until about 1840. The races were likely kept separate though it was not an all-white patient facility. Until the late 1850s, the hospital had a regular public visiting day where Baltimoreans and others were invited in to tour the building in order to dispel their negative perceptions about mental institutions. Patients were not exhibited intentionally to these visitors.
Treatment changes promoted by sources abroad would ultimately influence and modify how American doctors viewed their mentally ill patients. Many historians point to the actions and teachings of Dr. Phillipe Pinel as initiating a revolution in the care of the mentally ill. In 1793, he boldly removed the chains from the male patients at the Bicêtre Hospital in Paris, ushering in a new era of “non-restraint.” Pinel believed that within a carefully constructed environment, the mentally ill could be taught self-control and eventually regain their reason.
This revolution in patient care, given the name “Moral Treatment,” was embraced by most American doctors caring for the “insane” by the mid-nineteenth century. Hospital superintendents discovered that occupational or work therapy seemed to improve the condition of certain patients. Toiling in the hospital garden, walking its grounds, even engaging in domestic work, seemed to produce beneficial results. Acute cases might even be allowed to leave the premises for walks with an attendant. To supplement these activities, some hospitals offered hydrotherapy, patients soaking in tubs or being placed into showers.
Early reforms relating to patient care at the Maryland Hospital were internally driven. Moral Treatment appeared to have been fully instituted after the State took control of the facility in 1834. Observations by a visitor in 1835, a jurist from Williamsburg, Virginia describe an enlightened patient care philosophy in place:
Its plan is new to me, and rather new in the world–an entire departure from the English and Virginia (Wmsburg) methods, of treating lunatics, with du[n]king, strait-jackets, iron-grated cells, and the lash… Kindness–engaging the patient’s affections and thoughts–amusing him–affording him exercise, by light labor, walking, riding, music, dancing–with wholesome diet, and cheerful conversation–these are the chief material medica.
The narrative portion of the Maryland Hospital’s own 1844 annual report further underscores the presence of moral management and the non-restraint philosophy at the institution. “Our efforts to supply the inmates with ample means of useful employment, exercise in the open air, and amusements… have been unremitting. In carrying out the moral treatment, these means are indispensable… Among these agents, manual employment for those accustomed to it, holds first rank.” Patients were kept active either by work or by participation in various recreational activities, such as reading within the patient library or attending hospital-organized classes. Annual reports from other state hospitals during this period note similar descriptions and offerings.
Occupational or work therapy offered the first hope of a recovery for certain classes of patient. The 1844 annual report documents a case of a man suffering from obsessive thoughts and depression:
During our hay-making season, last summer, many of our male patients [were] employed in aiding the work, some as spectators. Among them was one who had been for many months in the state of monomania with depression, and had made several attempts at suicide… He was a farmer …After some persuasion, but principally by the example of others, he was induced to amuse himself by mowing a little. As the period of engagement in this activity increased, his mental state improved and in about four weeks afterwards, he returned home entirely restored. Cases similar to this are of frequent occurrence.
Many, but not all patients engaged in some type of work, with certain duties reserved to a particular gender. No one was required by the staff to engage in work nor was any remuneration paid for such efforts. For the male patients choosing to labor, jobs included gardening, working in the carpenter shop, the carting of wood and coal around building or assisting the attendants in other duties performed within the building. The female patients generally involved themselves in the more domestic or gender-based duties of sewing, knitting or assisting in the wash-house or kitchen.
Recreational pursuits were universally appealing to patients. Individuals might choose simply to read the daily newspaper, periodicals, or novels, many of which were donated to the hospital through the benevolence of local businesses. The pursuit of music making, singing, and the playing of games, such as checkers or billiards, helped to pass the hours of a day. Others might stroll about the almost seven acre grounds, through the grove in the back and, perhaps, out to the front lawn to glimpse the cityscape that stretched outside the institution’s walls.
The hospital walls, however, did not limit the diversions available to certain types of patients. These residents often ventured forth into the city and intermingled with its citizens. Carriage rides occurred on an almost daily basis, for distances that ranged from five to fifteen miles. Patients, escorted by attendants, sometimes took a coach to attend church, a public meeting or an “amusing exhibition.” For those wishing more exercise, frequent walks of several miles could be pursued. Fishing parties, sometimes lasting all day, also appeared to be popular with male patients. The close proximity of the Hospital to the nearby Fairmount Park, a private pleasure ground that hosted concerts, fireworks displays, and the occasional balloon ascension, offered additional entertainment.
By the 1850s, the limited space to accommodate patients and the encroachment of the city upon the once rural site prompted the hospital Board of Managers to relocate the facility elsewhere. While it took close to twenty years to complete a new building, the Maryland Hospital moved from its original site to Catonsville in Baltimore County in October 1872. Most of the old hospital was razed by the end of 1873.
Digital image from the Maryland State Archives: MSA SC 5980-1-34.