Hektoen International

A Journal of Medical Humanities

Caring for the mentally ill: The cycle repeats itself

Robert Biggar
Bethesda, Maryland, United States

The halls of the abandoned Trans-Allegheny Lunatic Asylum. Photo by Sean Robertson on Unsplash.

A traveler driving through Weston, a small community in the hills of West Virginia, will find it typical of the hundreds of similar bypassed towns: pleasant but a bit run-down and sliding into poverty and abandonment. However, it has one spectacular and historic monument that lies just off the highway: the Trans-Allegheny Lunatic Asylum. Its story and massive building complex (open for tours as a private enterprise) shock the senses, but the asylum also encapsulates a very long moment of Western attitudes toward mental illness.

In European history, custodial care for the mentally ill was generally at home, with severely ill patients hidden from view out of concern that the family would be tainted by scandal. Religious orders sometimes provided care for unmanageable patients. Documents about the Bethlem Royal Hospital in London (founded in 1247 by the Order of Bethlehemites) indicate that by 1401 the patients included the insane. Like many church institutions, it was gradually secularized, operated by the City of London from the mid-sixteenth century. By the seventeenth century, it was dedicated to confinement of the insane. So notorious were its wards, as witnessed by paying spectators, that Bethlem’s name gave rise to the word “bedlam.” 

The need to deal with the mentally ill overwhelmed cities everywhere. Two hundred years ago, town elders typically contracted private houses to provide for the mentally ill abandoned by their families. The conditions of confinement were often appalling and even lethal. Recognizing the need for more humanitarian standards and hoping for improved care, European social reformers in the 1820s took on this challenge among others (e.g., prison reform, alcoholism, unwed mothers).

In the US, this movement was led by the noted reformer Dorothea Dix, who inspired the Massachusetts assembly to reform their mental health care with a report that included: “I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience.”1 Over the next decades, these principled efforts toward better care led many state and local governments to form “hospitals” for the care of the mentally ill. These well-intentioned plans often had disastrous results.

One such outcome was the Trans-Allegheny Lunatic Asylum, soon renamed the West Virginia Hospital for the Insane. This facility was generously funded by the state government of Virginia in 1858 and situated in the Allegheny Mountains, a bucolic setting (and perhaps sited conveniently out of the way). The model was developed by Dr. Thomas Kirkbride (1809–1883), a physician in Philadelphia. He had seen the crowded, dark rooms full of restrained patients and the “bedlam” that ensued, and he developed a theory that these conditions were causative, or at least contributive to mental illness. His answer was to develop institutions that were the complete opposite: light-filled, roomy, and pleasant surroundings in which patients were free to roam at will. Aside from substantial capital costs, the institutes would be self-sustaining, having farms to produce food and light industries to provide goods for sale.

The state of Virginia paid for a Kirkbride-model facility just before the onset of the Civil War, gold that was soon confiscated by Union forces to fund “the Alternative Government of Virginia” (based in Wheeling). Despite the war, construction continued, and the first patients were admitted in 1864. In conception, the facility would enroll 250 persons, each having a single room and sharing a common dining hall and recreation room. Patients were expected to work the land or produce according to their abilities, and were able to wander as they pleased on the spacious grounds or even into the community. 

This idyllic concept did not last long. Among other problems, there were no medical standards for admission. By law, the Asylum had to accept any person attested to be “insane” by the head-of-family (a male), with the criteria for discharge being that the same head of family deemed that patient worthy to come home. Yet sometimes he would never return. Within a decade, the place was overcrowded. Patients had all manner of mental issues from mental deficiency to homicidal psychoses. In one instance, two men murdered a fellow patient, and the court returned them to the facility because they were insane. They also included persons unwanted for any reason, from abandoned children, disenchanted wives, or irascible elders. Things got steadily worse. At its peak in the 1950s, the Asylum had 2,500 patients, with five or six “patients” per room and people sleeping in the halls. Staff, by then a majority immigrant nurses from Asia supervised by a few doctors, were overwhelmed and in considerable danger of assault from their patients.

This was typical of many institutions for the mentally ill. By 1940, more than a million Americans were institutionalized for mental problems.2 It became bedlam revisited. Such numbers were possible only with new drugs, such as chlorpromazine (Thorazine) introduced in 1950 and similar drugs. While hailed as the first antipsychotic, doctors at the institution used Thorazine in such heavy doses that patients were dull and befuddled, but controllable. Added to the drugs were isolation, straightjackets, ice baths, electroshock therapy, and insulin-induced coma—barbarous procedures done under the banner of science.

Moreover, in the post-WWII years, frontal lobectomy, sometimes described as “soul surgery”, became commonplace in Europe and then the United States. In 1949, the Portuguese surgeon Egan Moniz received the Nobel Prize for his pioneering explorations of this technique. In that year, over 5,000 lobotomies were performed (60% women), and in the two decades of its wide application, from 1945 to 1965, there were estimated to be 50,000 lobotomies in the United States and at least as many in Europe.2

In the United States, Walter Freeman,3 a Washington, DC neurologist with no surgical training, was intrigued by lobotomy. Among his early patients, he operated on President John F. Kennedy’s younger sister, Rosemary, who suffered from a mild mental disability and seizures probably resulting from anoxia at birth. Following a lobotomy at age 23, she survived to 86 but was partially paralyzed, unable to talk clearly, and had the mind of a two-year-old.

Freeman went on to develop a simple technique for lobotomy, “transorbital lobotomy,” touting this procedure as something any doctor could do. After inducing a seizure by electroconvulsive shock therapy, he would hammer an icepick two inches into the edge of the eye socket on each side and sweep the shaft back and forth to sever the neural connections between the mid-brain and the frontal cortex. In his hands, this was a 10-minute office procedure, and in an exhibition, he once did 25 lobotomies in a single day, lining up patients on the floor to repeat the procedure without sterilization. In one report, he claimed about 60% did “well” (meaning they were less agitated even if left in a vegetative state or with childlike behavior), 25% were unchanged, and 15% died.4 In his data, deaths were counted as successes because the patients were no longer agitated. By his own estimate, he did about 4,000 lobectomies during his time in practice in some 25 states before finally being disbarred from doing further surgeries in 1967.

European doctors generally abandoned lobotomy in the early 1950s, the former Soviet Union being the first country to outlaw it as inhumane. However, mental institutions across America used lobotomy even into the 1960s, seeking ways to deal with the vast numbers of unmanageable patients in their care. Although very rarely done now, it is still legal in the United States.

The horrific conditions at the Trans-Allegheny Asylum in this era drew the interest of news reporters from the Charleston Gazette, published in West Virginia’s State Capitol, and in the 1960s, their stories induced the legislature to demand reforms. These came slowly, in part because no one could figure out what to do with the patients, but by the 1970s, enrollment was dropping. West Virginia ultimately built a new 150-bed psychiatric hospital in Weston in the 1980s. Even so, it was not until 1994 that the Asylum was finally closed for good.

It is all too easy to understand how this happened, but perhaps what is most shocking is that these asylums continued to operate under appalling conditions for more than a century, even into our own times. Without any understanding of the pathogenesis of mental illness, the caretakers floundered under the patient loads and lifetime care. Institutions quickly deteriorated from idealist visions to terrible prisons for incarcerating the mentally ill, patients for whom they could do nothing, as well as other abandoned persons.

One wonders how far we have come since then. The genesis of mental illness remains a mystery and we are returning to home care, using modern psychotropic drugs for outpatient management of many mentally ill persons, although a few institutions still exist to house those who represent a threat to others or themselves. Those responsible for their care confront difficult ethical and legal dilemmas as they balance prison custody and humanitarian concerns for their patients.


  1. Dix, Dorothea. “Memorial to the Legislature of Massachusetts 1843.” Page 2. Retrieved November 12, 2010.
  2. Dully, Howard. My Lobotomy. Crown Publishers. 2007.
  3. “Walter Freeman II.” Wikipedia, accessed December 9, 2023.
  4. Rowland, Lewis. “Walter Freeman’s Psychosurgery and Biological Psychiatry: A Cautionary Tale.” Neurology Today 5, no. 4 (2005):70-2.

DR. ROBERT J. BIGGAR is a physician-epidemiologist accredited in pediatrics and infectious diseases. His research focused on HIV/AIDS, cancer, infectious disease, and immunity. He has published more than 350 peer-reviewed articles and several professional books. His most recent book, Eyewitness to AIDS (2001) describes the science history of the AIDS epidemic and is now available on Amazon Books.

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