OCCUPATION IN 
TREATMENT OF INSANITY. 
By HORACE WARDNER, M. D., 
Superintendent Illinois Southern Hospital 
for Insane. 
Anna, Illinois, 
Reprint from 
The Alienist and Neurologist, 
St. Louis, April, 1888. [Reprint from The Alienist and Neurologist, April, 1S8S, St. Louis.] 
Occupation in Treatment of Insanity/* 
By Horace Wardner, A. M., M. D., Anna, Ills., 
Superintendent Illinois Southern Hospital for Insane, at Anna. 
A LIFE spent in aimless idleness is a life of morbid 
A- discontent, even in the midst of luxurious surround- 
ings. This is true, as we all know, of people in the sane 
world, and it is likewise true concerning the insane. 
It is a well-recognized physiological fact that the 
systematic exercise of the muscles is essential to a proper 
growth and development of the physical powers; and the 
same is true in regard to the development and strength 
of the mental faculties. The best results are obtainable 
only when both the physical powers and the mental 
faculties are properly and systematically exercised within 
the limits of the powers of endurance, but without exces- 
sive fatigue or exhaustion. All will agree that this is true 
of persons who are in their normal state of health. 
It is also a well-known fact that the proper exercise 
of a part that is recovering from an injury, caused by 
violence or disease, is an essential element of the treat- 
ment, after a suitable period of quiescence, during which 
there is a readjustment of tissues. 
The individual parts under the readjustment may not 
bear the same relation to each,other that they did before 
the injury or disease affected them. The movements of 
such injured part may not be the same as they were 
before. It may be crippled in the performance of its 
functions, and its usefulness may be greatly impaired. 
Judicious exercise of such an affected part is, however, 
essential to the restoration of its functions. Without such 
exercise, a limb, for example, that has been fractured 
would in time suffer atrophy, and its usefulness would be 
entirely destroyed. 
• Read in the Psychological Section of the Ninth International Medical 
Congress. 
1 2 
Horace Wardner. 
In recovering the functions there will, in a large pro- 
portion of cases, be a deviation from the normal action, 
depending upon the alteration of the tissues from loss of 
substance, the presence of adventitious matter or change 
of relation and adjustment. 
These facts are as true concerning the brain and 
nervous system as of any other part of the body. 
Insanity is the result of injury from violence or from 
disease, either functional or structural,, by which the 
operations of the mental faculties are disarranged, per- 
verted or paralyzed. 
The treatment of acute mania is analogous to that of 
an injured limb, both requiring restraint, rest, and suitable 
medication during the period of exaltation as indicated by 
the inflammatory action in one case, and by the abnormal 
and excited mental action in the other. 
The analogy may be traced through subsequent stages; 
but it is the stage of convalescence with which we are at 
present most concerned. It is during this period that we 
attach the greatest importance to such occupation as will 
interest the patient and divert his thoughts from himself 
and his imaginary troubles. 
With the commencement of the stage of convalescence, 
when the patient begins to recognize his surroundings and 
realizes the fact that he is under the care of other per- 
sons, and is deprived of his liberty, he becomes discon- 
tented, and grows weary of the restraint of hospital life 
and longs for his freedom and his home. He cannot 
understand why he is kept under surveillance, and 
is likely to attribute sinister motives to his friends and 
the attendants. Somebody is doing him injustice for 
selfish ends. 
Being relieved of all personal responsibility, and his 
life being regulated for him, he is left to the contempla- 
tion of himself and his imaginary troubles. If left in idle- 
ness he dwells upon the wrongs that he thinks have been 
inflicted upon him, and continues a prey to his delusions 
until they may become fixed ; or he may dwell upon the Occupation in Treatment of insanity 
3 
subject of his home and his family, who are, as he 
believes, unjustly deprived of his society and help. 
If his returning energies during convalescence are 
repressed, and not permitted to gain strength by proper 
exercise, the ennui becomes depressive, and he may sink 
into a condition of listless inactivity, or dementia. 
It is at this stage of his case that diversion and occu- 
pation should be made available for his benefit. He 
should be encouraged in every way to think upon subjects 
outside of himself, and muscular exercise in the form of 
some light work, in which he can become interested, and 
to which his thoughts will be diverted, is the most suit- 
able as a hygienic and therapeutic measure. 
With no effort of this kind, at this stage of his disease, 
the patient will, in no great period of time, show the effects 
of such neglect. The scope of his mental life will shrink, 
and the brain and muscular system will become weaker 
until he reaches a condition of permanent debility from 
which he may not be reclaimed. 
Here the analogy holds good as between the treat- 
ment of insanity and the treatment of other forms of 
somatic injury. 
But all patients do not recover. In fact the majority 
become chronic and incurable. 
With all the efforts that can be made in their behalf, 
some must pass into the state of dementia, in which they 
are incapable of any intelligent action, while others will 
retain a certain degree of mental capacity that suffices for 
some kind of useful occupation. 
They will, however, be found to have suffered loss of 
certain faculties, and a weakening of others, and mental 
action will remain crippled during the rest of their lives. 
They undergo as it were, a reorganization upon a lower 
plane of mental life. 
Occupation or labor, not of a severe character, is essen- 
tial to the welfare and happiness of this class of patients. 
I select a few cases from among the many to illustrate 
more fully this idea: • , 4 
Horace Wardner. 
Case I.-P., aged thirty-nine, was a man born with an 
insane temperament, who had received a fair degree of mental 
training. He was educated to a profession, and had been 
successful in its practice. Under the influence of a grow- 
ing hallucination that it was his duty to preach, he saw 
the Holy Ghost one night, who commended him to give 
up his profession and assume the duties of an evangelist. 
He obeyed the mandate of the Spirit, and demanded 
ordination and consecration, which he obtained. But the 
devil laid snares for him, and his mental troubles increased. 
His eccentricities led him into various errors and excesses. 
He formed a strong and controlling delusion concerning 
his wife, against whom he manifested the bitterest of 
feelings. 
He broke up his family, and after a short but checkered 
and stormy career, lost all self-control and was placed in 
a hospital for the insane, where he remained for many 
years, suffering under the weight and torture of his delu- 
sions, which assumed different forms and degrees. 
However, after five or six years the mental excitement 
had sufficiently subsided so that he took kindly to the 
suggestion of light occupation in one of the departments 
of the hospital; an occupation with which he l|ad had 
some familiarity in his boyhood. 
He worked in this way more or less of the time for 
several years and became quite proficient and skillful, and 
was trusted with the management of the department. 
Although his delusions had become fixed, they were 
gradually more or less buried and ceased to control his 
daily thought and action, and he began to think more of 
the world at large and his relations thereto. The idea of 
freedom and independence gradually grew upon him. 
He began to realize that his services were of value, and 
he became clamorous for compensation. This was an 
expression of natural feeling and was considered as indic- 
ative of returning reason. 
He became confident that he was capable of taking 
care of himself, and without waiting for official sanction. Occupation in Treatment of Insanity. 
5 
acted upon the idea that his time had come to leave the 
institution, and taking advantage of a favorable occasion, 
left the place and rested not until he had put himself out- 
side of the jurisdiction of those who had power to arrest 
and detain him. 
After various struggles for about one year to gain a 
livelihood, he finally settled down to the work he had 
followed at the hospital, opened a small shop, and event- 
ually established himself in a fair business, which he has 
conducted regularly and with fair success for several 
years. He has lost all interest in his former profession, 
has sunk it in the ocean of forgetfulness, as he has also 
the idea that it is ^is duty to preach. 
His life has, in fact, been rearranged on the plane and 
basis of his early experience, and he is as happy and con- 
tented as the average of humanity, except, perhaps, an 
occasional disturbance, when something occurs to bring to 
the surface a memory of his buried delusions and 
troubles. 
I have no doubt that had this man been kept in idle- 
ness in the wards he would now be a hopeless dement, 
or have fallen a victim to fatal disease. 
Case II.-W., a school teacher, aged fifty-three, became 
insane through pressure of domestic afflictions, and was 
committed to an asylum. For more than three years he 
was in dense mental darkness, and governed entirely by 
his delusions. He was greatly excited and was considered 
a bad case. 
In time the abnormal excitement gradually subsided, 
and he was capable of some small degree of self-control. 
There came sufficient rays of returning mental light to 
enable him to realize that something was wrong with himself, 
but everything appeared to him as dark and hopeless, 
and he constantly lamented the great misfortune that had 
overtaken him. At this point he was encouraged to think 
of other things and to do something that would be use- 
ful to himself and others. By a few hours' light work each 6 
Horace Wardner. 
day, he became, in a few months' time, so much improved 
that it was deemed safe to trust him with the liberty of 
the grounds on parole. His inclinations taking a turn 
for thrift, he was encouraged, by the promise of a reward 
for his labors, to prosecute the destruction of rats and 
other pests of the institution. He became much interested 
in the pursuit of this work, and was a great benefit to 
the institution, and the diversion was a much greater 
benefit to himself. He gradually regained the control of 
his thoughts and emotions, and came finally to regard 
himself as having been insane. By his efforts he showed 
clearly that he had the ability to take care of himself. 
He reasoned well, and was correct and clear in his busi- 
ness transactions. About this time he was sent away 
from the hospital on furlough and placed upon his own 
responsibility. He continued to improve, overcame his 
delusions and prejudices, and was regarded as recovered, 
and was so discharged. Without the encouragement to 
the exercise of his mental faculties in connection with 
physical exercise there is no doubt in my mind that he 
would still be an inmate of the hospital, and still under the 
influence of his delusions and enveloped in mental darkness. 
Differing in result from the foregoing, the following 
cases are typical of a class that may become useful under 
proper care and guidance: 
Case HI.-K., aged thirty-seven, was a night watchman, 
who had become insane as was supposed from want of sleep 
and religious excitement. His insanity was of the mani- 
acal form. He made several attempts at homicide before 
he was committed to the hospital. After some years, 
when the maniacal excitement had somewhat subsided, he 
was encouraged to assist about the farm, but it was a long 
time before there was sufficient self-control to enable him 
to do anything in a proper manner. As his homicidal 
impulses ceased, he was permitted to go about the 
premises, and was induced to help take care of the young 
stock. This proved to be the occupation that fitted his Occupation in Treatment of Insanity. 
7 
case. He began to take an interest in it, and eventually 
became a very useful man. The young cattle are his daily 
companions, and no one could be more faithful in the 
care of them. He has forgotten wife and children, and 
apparently all of the past. Conjugal love, paternal affec- 
tion, and all the ambitions of his former life are dead. He 
is only a remnant of his former self, but his remaining 
faculties have been readjusted to fit the environment of 
a new life. A life reorganized on a lower basis and very 
limited in its range of thought. 
Case IV.-Mary D., spinster, aged thirty-three. Prodromic 
symptoms were noticed for a period of three months 
before acute mania developed, which lasted more than 
three years. From the exhaustion resulting from long- 
continued excitement she was to all appearances passing 
into a stage of drooling dementia, when the attending 
physician made an effort to kindle into activity what little 
spark of intellect there might be left. He attempted to 
engage her in the common game of checkers. She had 
no conception of the game. It was necessary to take 
hold of her hand and aid her to move the pieces. Little 
by little she began to understand and eventually became 
a very fair player. She was also, as she improved, given 
some light, easy work to do, under the care and direction 
of an attendant. At the end of three years of this kind 
of care and exercise she was capable, under supervision, 
of doing ordinary work in a very fair manner; could talk 
with some degree of intelligence, regained her self-control 
to such an extent that she could act in harmony with the 
environment of hospital life; but on being taken to her 
home on a trial visit, it soon became evident that when 
this restraint was removed, the mental machinery had lost 
its governor, and that the regime of an asylum is neces- 
sary to keep her impulses and actions under proper control. 
These cases represent classes of cases found in every 
asylum. The first presents an example of those cases in 
which the delusions are buried, at least for the time, but 8 
Horace Wardner. 
may retain a slumbering vitality that may be awakened into 
activity by certain exciting causes. This man does not 
acknowledge that he has been insane. His delusions are 
fixed, and while he has learned to conceal them in defer- 
ence to the opinion of others, his belief in them as reali- 
ties is as firm as ever. They may be easily awakened by 
a well-directed question or by conversation directed to 
awaken his suspicions. The safety of this man's future 
will depend upon the absence of such exciting causes, 
and an environment calculated to keep the mind in chan- 
nels of thought that will lead away from the contempla- 
tion of his delusions. Occupation in which the patient 
will be interested is the only resource in his case. 
In the second case we observe a recovery after a long 
period of convalescence. This man recognizes the fact 
that he has been insane. He has corrected or conquered 
his delusions by rational processes. In his case employ- 
ment was the best of therapeutic agents, and was the 
means of accomplishing what drugs could not do. 
In case number three we observe the loss of mental 
powers that in many cases follows an attack of insanity. 
But this loss does not extend to the condition of dementia. 
It is to a great extent a loss of adjustment. The 
rearrangement of the mental forces on a lower plane, and 
with narrower scope, is such as to render him a very use- 
ful man under proper oversight. 
The fourth case represents a large class of the chronic 
insane, who become amenable to the regime of hospital 
life under which they may render some useful service, 
but are without rational and self-guiding powers when 
removed from this controlling environment. 
In all these cases employment is an important factor 
in effecting a cure or modifying the course of disease. 
Comments on the subject of occupation for the insane 
have appeared of late in many of the reports of the 
superintendents of the American asylums. 
The following extracts, taken from these reports, show 
the tendency of American thought at the present time. Occupation in Treatment of Insanity. 
9 
Dr. C. W. King, of the Dayton Asylum, says (in 31st 
Report): 
insanity ^being largely a functional disturbance frequently indepen- 
dent of organic lesions, the rational remedy in such cases would be to fur- 
nish healthful exercise to the organ whose functions are disturbed, and to 
prescribe such employment as will best meet the requirements of each case 
and most thoroughly divert the patient's mind from thoughts of himself 
and his condition. 
Functions of the brain, as well as those of the muscles, are impaired 
by inactivity, and no patient who has not degenerated into chronic 
dementia, should be permitted to remain in a ward from day to day and 
week to week unemployed. No doubt many cases have been lost, where if 
proper employment had been supplied in the beginning, they might have 
been saved. 
Dr. C. M. Finch, of the Columbus Asylum, says (in 
the 47th Report): 
The prime object should be to throw around the insane an environ- 
ment of agencies which have for its objects the attainment of mind diver- 
sion, mental employment and bodily exercise of a proper kind and quality, 
sufficient to secure and maintain physical health. 
Dr. W. W. Godding, of the Government Hospital for 
the Insane, says (in the 31st Report): 
Whatever may be exceptionally true of the need of rest and the 
avoidance of all mental application in some acute, and rarely some recur- 
rent, cases, the fact remains, that with our inmates the best road to quiet 
content, if not to cure, lies in the regular occupation of body and mind 
with some work not too hard of comprehension, nor too taxing to the 
strength in its performance. 
Dr. W. T. O'Reilly, Inspector of Asylums and Public 
Charities, Province of Ontario, says: 
When acute symptoms are succeeded by convalescence, and when the 
disease has passed into the chronic and incurable state, the foremost ques- 
tion is, what can be done to divert their attention from hallucinations, to 
stop them from nursing their delusions, and to aid them to retain at least 
a remnant of intelligent activity. Occupation here becomes an element of 
treatment which receives increased attention from year to year as the old 
shackles of mechanical restraint drop off. 
Dr. A. H. Knapp, of the Osawatomie Asylum (5th 
Biennial Report), observes that: 
The good effects of regular work are forcibly illustrated by the con- 
trast presented, not only in the physical, but mental condition, when 
accustomed exercises are suspended during the winter months. When our 
outside working force go into winter quarters, and have nothing to do for 
three or four months, it becomes interesting, and in a few cases painfully 
so, to note the individual changes which take place. All grades of mental1 10 
Horace Wardner. 
worry and discontent, a gradual return of vicious propensities, depression 
and excitement, a capricious appetite, loss of sleep, loss of flesh and 
strength, are noticeable changes which occur in a greater or less degree 
with many of this class of patients. On the contrary, those who are fur- 
nished regular employment the year round are exempt from the reac- 
tionary mental and physical changes mentioned as affecting those who are 
by force of circumstances deprived of work for several months in the 
year. As a rule, those who go out to work regard it as a privilege which 
carries with it at least an implied obligation to place themselves upon 
their good behavior. This aids and strengthens their power of self- 
control, and helps to life their deranged minds from the ruts and grooves 
into which real or imaginary troubles invite them, enlarges their sphere 
of thought and observation, and with all who are suceptible of recovery 
operates as a powerful factor in restoration. 
Dr. G. B. Chapin, of the Pennsylvania Hospital, 
(Report 1886) says: 
Even work of a continuous monotonous character leads to the forma- 
tion anew of habits of industry which become fixed and re-established. 
These utterances are all of recent date. They are 
taken, more or less, at random, from a number of reports, 
in which the subject of occupation is discussed. 
One or two experienced superintendents maintain con- 
servative views on this subject, but the current of thought 
is against them. The conclusions to which we arrive 
are: 
First, that occupation is one of the best of therapeutic 
agents in the treatment of insanity, especially during con- 
valescence. 
Second, that it is of the greatest value in diverting 
the chronic insane from their fixed delusions, and turning 
their thoughts into healthier channels. 
Third, that it is the treatment most favorable to a 
re-adjustment and equilibrium of mental forces, from the 
wreck of acute mania, in which the mind is only partially 
destroyed. 
Fourth, that it is applicable to the treatment of nearly 
all cases of insanity, but its use requires good judgment, 
more especially in the acute forms of mania. 
Fifth, that it should be considered an essential ele- 
ment in the, organization and administration of hospitals, 
for the insane.