THE 
RELATIONS OF FEMALE PATIENTS TO HOSPITALS 
FOR THE INSANE; 
THE ' 
NECESSITY ON THEIR ACCOUNT OE A BOARD OF CONSULTING 
PHYSICIANS TO EYERY HOSPITAL. 
BY 
HORATIO ROBINSON STORER, M. D., 
OF BOSTON, 
S PEG EON TO THE NEW ENGLAND HOSPITAL FOR WOMEN. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1864. THE RELATIONS OF FEMALE PATIENTS TO HOSPITALS FOR THE 
INSANE: THE NECESSITY ON THEIR ACCOUNT OF A BOARD OF 
CONSULTING PHYSICIANS TO EVERY HOSPITAL. 
In late communications to the American Academy of Arts and 
Sciences, and to the Suffolk District Medical Society of Massachu- 
setts,1 I have stated certain fundamental propositions or laws, whose 
acceptance is essential to any rational explanation or treatment of the 
mental diseases of women. These propositions are as follows : 
I. That in women mental disease is often, perhaps generaliy, 
dependent upon functional or organic disturbance of the reproduc- 
tive system. 
11. That in women the access or exacerbation of mental disease 
is usually coincident with the catamenial establishment, periodical 
access, or final cessation. 
111. That the rational and successful treatment of mental dis- 
ease in women must be based upon the preceding theories, which 
I claim are established, 
1. By many analogies, physiological and pathological, in the 
cerebral manifestations of the human female and that of the lower 
mammals; 
2. By clinical observation; and 
3. By the results of autopsies of the insane, both in private 
practice and, where made with equal impartiality, in insane asy- 
lums. 
I have worded the last expression with especial reference to the 
facts that in autopsies by psychological specialists, diseases of the 
brain are naturally those first sought for: and that in autopsies of 
insane women as compared with those of insane men, disease of the 
brain as a primary lesion very rarely exists. These facts are ac- 
knowledged ; for further remarks upon them I must refer to the 
preliminary paper to which I have already alluded. 
1 Boston Med. and Surg. Jonrn., April, 1864, p. lr9. 4 
From the above propositions, corroborated, I believe, by the ex- 
perience of every unbiassed observer, we advance to three plain 
and practical questions, which are to open up a new, broad, and 
very fruitful field of obstetric work. These are:— 
First. To what extent can the insanity of women be medically 
or surgically treated ? 
Second. Is such treatment at present generally effected or even 
attempted in Insane Hospitals ? and 
Third. How can it there be accomplished ? 
lam aware that I have broached a delicate topic. The compa- 
rison, however, of doubtfully insane, of almost insane, and of de- 
cidedly insane women, in all their range from aggravated hysteria 
to actual madness, has so long been my daily occupation that I am 
enabled to express myself plainly upon this subject. It is one that 
has been hitherto neglected, for the sole reason that its proper side 
of approach, that from an obstetric point, happens from circum- 
stances beyond their control, almost always to have been closed to 
superintendents and others charged with the management of the 
insane. 
The first question that I have now proposed, To what extent can 
the insanity of women be medically and surgically treated ?—has as 
yet hardly been propounded in insane asylums at all, although its 
solution in active everyday practice is, within certain limits, of 
common enough occurrence. I have purposely limited my state- 
ment of the extent to which this treatment has as yet been carried 
in private practice. Instances in point, however, the ordinary forms 
of the so-called puerperal mania, and of that other type of obstetric 
insanity to which in its different manifestations I would attach the 
equally legitimate title of catamenial mania, are familiar to every 
observer. In these and in others of the host of deviations from 
mental sanity in women, there is some reflex transference of irrita- 
tive action, the source of which, if searched for, is almost always to 
be discovered. It is just as unscientific here, and generally as futile, 
to treat merely or primarily the mental disturbance, which is usu- 
ally a symptom only or a consequence, as it has been to amputate 
an hysterical knee, to attempt the Caesarean section, or to cut for 
ovariotomy in cases of the so-called spurious pregnancy, or, as is 
still constantly done, even at the present day, to stimulate or blister, 
or apply the moxa or actual cautery to spines irritated sympatheti- 
cally and through reflex action by an abraded, displaced or other- 5 
wise disturbed womb. The necessity of removing a cause to pre- 
vent or to cure its effect is as decided in mental pathology as in 
physical. We recognize it everywhere else; we must recognize 
it in the treatment of insane women—no matter whether from quiet 
and inoffensive creatures, or chaste and pure, they have become 
habitually thievish, profane, or obscene, despondent or self-indul- 
gent, shrewish or fatuous, or, as the parturient cat or sow, they have 
destroyed their offspring, or in other cases have attempted to destroy 
themselves. ' 
In many of these instances the relation of cause to effect, if other- 
wise doubtful, is at once shown by the result of the treatment. I 
might relate many cases in illustration of this fact from my own 
experience, but shall confine myself to a single one. 
Case.—During the past year I have had charge of a young lady 
afflicted with that not uncommon disease, mechanical dysmenor- 
rhoea. This patient, unmarried and formerly a schoolteacher, was 
sent to me by a physician and had previously consulted several 
others. She confessed to me that while she never had had sexual 
intercourse, she had experienced, from a period long preceding 
her first seeking medical aid, excessive sexual desire, amounting 
indeed to what is technically termed nymphomania—a symptom 
merely, as are most of the mental disturbances of women. The 
attacks of this were very clearly coincident with the menstrual 
period, and so extreme that the patient could with difficulty restrain 
herself from soliciting the approach of the other sex. She could 
not restrain herself from frequent and excessive masturbation. 
There was little irritability about the clitoris or other external or- 
gans, the patient herself being inclined to recognize a deeper and 
inner origin for her suffering. The morbid desires and the dis- 
gusting propensity thence arising ceased together with the dysmen- 
orrhoeal pain, upon freely incising the cervix uteri and dilating its 
canal. They have not since returned, save in one single instance, 
when an acute attack of the erotic desire, plainly resulting from in- 
dulgence in so-called pepper tea, was at once allayed by the appli- 
cation of potassa fusa to the cervix. Now were not this treatment 
based, as it is, upon a broad and general physiological principle, its 
effect as a defence in similar cases to female chastity, threatened 
and undermined by sources of irritation within the patient herself, 
would be sufficient to entitle it to our respectful consideration. 
The above case must not be thought more pertinent than others of 
a similar reflex character, where, however, there is no erotic desire 6 
or other direct symptom of genital irritation. However masked, 
they all instance a single law. 
It would be difficult to state precisely to what extent appropriate 
medical and surgical treatment can be effectual in the cure of 
female insanity, the subject as presented in this light being compara- 
tively new to the profession. There can be little doubt, however, 
that in so far as the mental disturbance retains its original reflex 
character and has not merged into organic cerebral change, which, 
as I have said, is comparatively rare in women, to this extent and 
so long should we have a reasonable hope of success, nearly as great, 
perhaps, as in relieving the other reflex disturbances to which the 
female is confessedly so prone. 
As regards the second question I have broached—ls such treat- 
ment effected or even attempted in Insane Hospitals?—the answer 
is patent. As hospitals are at present organized, the proper treat- 
ment cannot be afforded insane women, for sufficient reason. 
To the general organization of our public asylums, or to its 
details, so far as they go, I would take no exception. My complaint 
is, that their most excellent organizations do not go quite far enough 
to cover the important class of cases we are now considering. They 
stop just one step short of the mark. I am here speaking from 
personal observation, of the working, theoretical and practical, of 
many asylums, among the best in this country—and there are in 
the world none in advance of the American hospitals for the insane—• 
so that in my remarks upon this subject I speak with perfect confi- 
dence. 
The reason that mental disease in the female, dependent upon 
reflex uterine or ovarian irritation, is not generally treated at hospi- 
tals for the insane in the same manner or as successfully, barring- 
only the lessened risk of homicide or of suicide before cure, as in 
private practice, is in the main the following. 
The whole and sole charge of the patients, medical, moral, and 
economical, is thrown entirely upon the superintendent of the 
hospital. This is certainly an advantage in everything concerning 
the government of the establishment, for it prevents all clash of 
opinion, all evasions of duty. It is excellent in every respect, save 
alone as concerns the weight and the extent of medical responsibility. 
I would by no means lessen the superintendent’s authority, but, 
as will be seen, would free him from his present involuntary 
embarrassment. 
The superintendent, as at present situated, cannot make such examination of a female patient, or pursue such methods of treat- 
ment as are absolutely required for the relief of many forms of 
obstetric disease, upon the existence of which, as I have said, her 
mental malady not unfrequently depends. He is absolutely pre- 
vented from this alike by regard for the patient’s welfare, for his 
own personal reputation, and for that of his hospital. So constantly 
compelled to see the patient, he appreciates the importance as 
regards other details of treatment, moral, &c., that he should retain 
her confidence and escape her fears; he recognizes the dariger lest 
an endeavor to arrive at a proper diagnosis of her disease should 
seem to the disordered mind only an attempt at improper and un- 
pardonable liberties with her person, and should she ever entirely 
recover her reason, be so represented to friends and to the commu- 
nity by her perverted and imperfect memory. These risks, so great 
in sane patients under temporary aberration from anaesthesia, have 
been realized to the full by Hr. Beale, of Philadelphia, and others; 
with the insane they are increased. 
In this strait, upon whom is the superintendent to rety ? Hot 
upon his assistants, surely, younger men and often merely pupils— 
at any rate, placed in the same relations as himself to the patient, 
the hospital, and the outside world. Here is the strange and para- 
doxical example of a physician pledged by even higher than ordi- 
nary motives to the relief of his suffering patients, concerning a 
large proportion of whom, however, his hands and his judgment are 
practically and entirely fettered. He cannot search for the mani- 
festations of disease, nor were they known to be present can he 
relieve them; and yet we all contend and strive to persuade the 
community that our hospitals for the insane are no longer prisons, 
that they are not houses for detention, but for cure. The existence 
of these facts, and the justness of the above reasoning, superintendents 
have repeatedly acknowledged to me with regret and a hope that 
the evil may be remedied. 
A change is necessary; how can it be accomplished ? By 
appointing to every asylum in the land a board of consulting phy- 
sicians, useful in ordinary cases of insanity, but absolutely indis- 
pensable in the instance of insane women. These gentlemen should 
be selected from practitioners in the immediate neighborhood of 
each asylum, due regard of course being had to their character and 
to their professional fitness. The position should be an honorary 
one, and like that at general hospitals, unattended by pecuniary 
emolument; and the superintendent should be left entirely to use 8 
his own discretion, as to calling or not upon the members of his 
board for advice, just as is allowed to attending physicians or 
surgeons at general hospitals; the intention being to render consulta- 
tions and a division of medical responsibility possible, not compul- 
sory. Strange as it may seem, there appears to exist but a single 
asylum in this country, to which there is appended a board of 
medical consultation. I refer to that most admirable establishment, 
the Butler Hospital at Providence. So far as I have been able to 
ascertain, and I have been aided by those most excellent authorities 
in all matters pertaining to the insane, Drs. Pay, of Rhode Island, 
and Edward Jarvis, of Massachusetts, in no instance save the one 
referred to, have boards of medical advice been included among their 
officers and means of management, at our insane hospitals. 
The Connecticut Retreat has a Board of Medical Visitors, whose 
position is an anomalous one; as much supervisors of general 
administration apparently as advisory in the treatment of patients, 
they are perhaps in reality more strictly honorary than either. 
There was formerly an Advisory Board attached to the City 7" 
Lunatic Hospital of Hew York at Blackwell’s Island, discontinued 
for no known reason. 
The Hew York Hospital has Consulting Surgeons and Consult- 
ing Physicians, but they appear to have nothing to do with the 
Bloorningdale Asylum, although it is under the same general 
authority as the hospital. The case is similar to that of the 
McLean Asylum, which, though under the same trustees, is yet 
separate from the Massachusetts General Hospital. The last has 
Consulting Physicians and Surgeons, but they have nothing to do 
with the insane department. They may, it is true, have been occa- 
sionally consulted by Dr. Bell, and possibly by his successors, in 
cases of doubtful sickness of a general character, just as other 
gentlemen from time to time have been called upon to give 
opinion; as matters now remain, such consultations are wholly 
unofficial, and Dr. Ray’s establishment, therefore, would seem at 
present to stand alone and to furnish, with its skilful advisory staff 
of Drs, Mauran and Miller, an example to be followed. 
So far these remarks have been based upon my own personal 
observation of the needs and advantages of the measure I have 
proposed. lam able to go farther than this, however, and to give 
corroborative evidence from superintendents themselves. 
In a report recently rendered to the Legislature of Massachusetts, 
the views of the writer as one of the State Commissioners in 9 
Insanity were embodied, he fully recognizing, however, and admit- 
ting the fact that the appointment of boards of medical consulta- 
tion, as a part of the internal management of hospitals, should 
devolve upon their boards of trustees, and in no way be controlled 
by the State. The various opinions and recommendations pre- 
sented in the report alluded to were very properly submitted to 
the Superintendents of the several State asylums by the Legisla- 
tive Committee to which it had been referred, and almost without 
exception they were cordially endorsed. With respect to the pro- 
priety of appointing consulting physicians to the hospitals there 
was not a dissenting voice; Drs. Tyler, of the McLean Asylum, 
Walker, of that at South Boston, and Choate, of the Taunton 
Hospital, acknowledging that they had each felt the need of such 
assistance, and would gladly avail themselves of it were it afforded 
them, while Dr. Ray, of Providence, who alone could speak from 
personal experience of its advantages, gave the Committee to 
understand that he considered his Board as at once comfort, relief, 
and safeguard. Such would probably be found to be the unani- 
mous opinion of gentlemen engaged in this most responsible 
specialty. 
I have now presented the subject onljr in its relations to patient 
and superintendent, and have endeavored to show the advantages 
and necessity, alike to both, of the measure proposed. I might well 
cease here, confident that my remarks have been sufficiently conclu- 
sive. The subject is no less important, however, to the commu- 
nity at large, in its relations to obstetric practice and obstetric 
jurisprudence. 
Obstetric practice, as I have already hinted, covers legitimately 
the greater number of cases of female insanity, but it is to hospitals 
for the insane that the profession must necessarily send many of 
these patients, and it is to hospitals for the insane that we must 
therefore look for the most effectual trial of rational methods of 
treatment, and from them trust for examples of successful cure. 
For this success they have already, with the single exception 
alluded to, every possible adjunct: seclusion of their patients from 
exciting causes; their absolute control as to diet, habits, and whole 
detail of life; the possibility, so far as skilled attendance is con- 
cerned, of carrying out any desired plan of treatment. Were such 
endorsed by men experienced in similar methods as applied in 
everyday practice, the superintendent’s responsibilities, doubts and 
risks would all be lightened, and the measures indicated be readily 10 
enough pursued. Before long there would he a mass of digested 
observations and medical reports issuing from these very hospitals, 
which would be of immense value to the profession in civil life. 
I have referred, and I trust it will not be thought with dis- 
respect, to the tendencies at asylums, in the search for cerebral 
lesion, to ignore all others. I could relate many instances corrob- 
orative of this fact, but it is unnecessary. The very nature of 
mental disturbance would of itself be sufficient to explain it, did 
we not have additional reason in the position in which I have 
shown hospital officers to stand in relation to their cases of insane 
women. It is evident in the very details of asylum autopsies as 
compared with those at general hospitals, in the statements of ap- 
pearances found, and in the silence upon points not supposed 
essential, I would not imply that there are not most faithful and 
thorough pathologists among psychologists—a combination, of 
which Dr. Workman, of Toronto, is by far the most excellent 
example with whom lam personally acquainted; nor do I believe 
there are many superintendents in this country who sympathize 
with their other Canadian representative, Dr. Douglass, of the 
Lower Province, whose assertion to me of contemptuous disbelief 
in the need or advantage of autopsies of the insane was only addi- 
tional proof, had such been needed, that his Government Asylum 
at Beauport, near Quebec, however fair in outside seeming, is 
based on an erroneous view of management; that it is conducted 
for private rather than for public good, and, by comparison with 
that of Canada West, that it should be abated as an error and a 
nuisance by Parliament. This is no digression. The topic, both 
personal and theoretical, is one intimately related to that we have 
been considering, and I shall discuss it more fully upon another 
occasion. When autopsies of insane females shall have become 
more frequent and more carefully studied, the importance of the 
doctrines now urged will become the more apparent. 
I have intimated that the appointment of medical advisers to 
insane hospitals would be of advantage to obstetric jurisprudence. 
We are all familiar with those difficult cases of supposed or 
alleged insanity in females that from time to time make their 
appearance in our courts of justice, on writs of habeas corpus or 
otherwise, from asylums, puzzling counsel, medical experts, and 
judge. Such cases are common enough in private practice, and 
are found generally amenable to treatment. There is no reason that 
they should still be allowed to serve as excitants of public scandal, 11 
or to bring discredit upon hospital management, or to subject their 
officers to suspicion as venal. 
There is a vast field above and beyond all this, which many 
writers have approached, none more boldly than has just lately Dr. 
Eay'—important beyond all estimate in its jurisprudential rela- 
tions, but which has hardly as yet been entered, certainly not to 
any extent, from the quarter in which we are now standing, I 
refer to the legal and moral responsibilities of women, whether 
maniacal or but partially affected; a matter of infinite interest, of 
infinite practical importance, I can now but allude to pt. It is 
another proof to us of what may be the results, scientific and effec- 
tive, from insane asylums when they shall have been made what 
they may more fully become, hospitals for research, for rational ex- 
periment, and for cure. 
In accordance with the arguments now submitted, I would offer 
the following resolutions, which I trust the Association may unani- 
mously see reason, in its wisdom, to adopt and to render effective:— 
Resolved, That in the opinion of the American Medical Associa- 
tion it is expedient that there should be attached to every public 
hospital for the insane, one or more consulting physicians, who may 
be consulted at the discretion of the superintendent; such measure 
being alike for the interest of the hospital, its medical officers and 
its patients. 
Resolved, That a copy of the above resolution be transmitted to 
the Board of Trustees of each of our public hospitals for the insane; 
and also to the Secretary of the Association of American Superin- 
tendents, with the request that it may be endorsed by that body 
and the action proposed be urged upon the respective boards with 
which its members are officially connected. 
The above paper having been read before the Section on Obstetrics, and warmly 
approved by many of its members, the resolutions appended were referred to the 
Association at large, and were endorsed by a unanimous vote. 
1 Treatise on Mental Hygiene ; Report of Butler Hospital for 1864.