As the United States transitioned from the destructive effects of the Civil War, the imperative of institutionalization increasingly gained momentum all over the country. With the construction of public lunatic asylums came the problem of regulating admission. By the late 1880s, every state had formulated specific laws for the care and custody of people experiencing psychological sufferance. Most of them accepted the assumption that the treatment of dangerous and non-dangerous “lunatics” was best carried out inside public or private establishments. Provisions differed greatly from state to state, however.
This article examines the evolution of the laws for confinement into mental institutions in the United States from the 1880s to the 1910s. The regulation of hospital and asylum admissions in the US did not depend on the Federal Government as it rested on the jurisdictional authority of states. Each state thus developed its own legislation related to cases of mental impairment and disability. The most delicate questions concerned the authority to determine lunacy, the kind of expertise it involved, and how to conduct the examination.
In spite of their great diversity, the provisions adopted in the 49 states can be grouped into four major categories depending on the qualification and status of the decision-makers. Here is a scheme for understanding the actors involved in the determination of lunacy in the US.
- No Medical Judgement: This category includes all states where decisions about lunacy depended on the opinion of common citizens or public officials with no medical intervention. In most cases, this meant that individuals showing signs of mental derangement would be arrested by police officers and having their status determined in a public hearing which did not include doctors of medicine.
- Joint Medical and Lay Judgement: This category includes all states where the determination of insanity took the shape of a joint statement performed by lay people, public officials, and physicians. Generally, states falling in this group mandated the insanity of individuals to be decided before a jury which included at least one doctor of medicine. Because the examination and the decision was collective, the law admitted no asymmetry between the medical and the lay opinion.
- Priority to 1 Physician: This category includes all states that required individuals to be individually examined by one doctor who produced a certificate of insanity. Although it was mostly up to judges, justices of the peace, or commissioners to appoint a general practitioner, civil confinement in these states required the expert opinion of one physician.
- Priority to 2 Physicians: This category includes all states that required individuals to be separately examined by two medical practitioner who produced certificates of insanity. Just like in the previous case, it was judges, justices of the peace, or commissioners who appointed practitioners, but confinement in these states required the expert opinion of two separate physicians.
This scheme has obvious limitations for it is not representative of the entire mental health policies effective in the 49 states. It focuses specifically on the qualifications of actors involved in decisions about insanity and how they expressed their judgement. Despite its lacks, however, it allows us to understand the principles behind the determination of lunacy in many jurisdictions. In particular, it highlights the legislators’ views on insanity as pertaining to the medical or to the public sphere, the need for a jury trial for determining the person’s status, and the prerogatives allowed to the expert opinion of physician(s). Furthermore, this scheme provides us with an opportunity for tracking the evolution of legal provisions over a period of thirty years.
In the following maps, each state has been assigned with a color based on how it regulated civil confinement according to the scheme above mentioned. These maps represent a snapshot of the US in different periods, namely the 1880s and the 1910s. By comparing the two maps, it is possible to see a shift in the gradual adoption of the medical expertise in decisions about civil confinement. The table included at the end of this paper shows this significant change in numbers.
Legal Provisions for Civil Confinement in the 1880s
Following the works of George Harrison (1884), Stephen Smith (1892), and Charles Folsom (1884) who collected all the original statutes effective in the 49 states during the 1880s, this map shows the distribution of the four categories.
Legal Provisions for Civil Confinement in the 1910s
Following the work of John Koren (1912) who collected all American statutes related to asylum admission until 1912, this map shows the distribution of the categories for this period.
Data & Trend
Explaining historical change requires a level of analysis that is beyond the purposes of this article. By adopting a macro-perspective, this paper gives us interesting material for making sense of the development of mental health policy in the US. In particular, it highlights that over a period of thirty years:
- The vast majority of states came to accept the priority of medical judgement in the determination of lunacy
- Of all states which required no medical intervention in the 1880s, only one did not change its legislation in favour of the medical expertise
- Those states who mandated the presence of physicians already in the 1880s, did not “upgrade” their legal provisions in favour of two independent physicians
- Northeastern states came to recognize en bloc the need of two medical practitioners (similar provisions were active in the UK, in the Eastern provinces of Canada, and in many parts of the British Empire)
Clouston TS and Folsom CF (1884) Clinical Lectures on Mental Diseases to Which Is Added an Abstract of the Statutes of the United States and of the Several States and Territories, Relating to the Custody of the Insane. Philadelphia, PA: H.C. Lea Son & Co.
Harrison GL (1884) Legislation on Insanity. A Collection of All the Lunacy Laws of the States and Territories of the United States to the Year 1883, Inclusive. Philadelphia, PA: Privately Printed.
Smith S (1892) The commitment of the insane. Report of the committee on the commitment and detention of the insane. In: Barrows IC (ed.) Proceedings of the National Conference of Charities and Correction. Boston, MA: Geo. H. Ellis, pp. 94–154.
Smith S (1892) Unification of the laws of the States relating to the commitment of the insane. American Journal of Insanity 49(2): 157–183.
Koren J (1912) Summaries of Laws Relating to the Commitment and Care of the Insane in the United States. New York, NY: The National Committee for Mental Hygiene.
Hurd HM (ed.) (1916) The Institutional Care of the Insane in the United States and Canada, 4 Volumes. Baltimore, MD.