CARE AND THERAPY: FOOD AND THE INSTITUTIONALIZED MENTALLY ILL IN THE LONG PROGRESSIVE ERA By Amanda Lynn Brewer A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of History – Doctor of Philosophy 2022 ABSTRACT This dissertation explores how psychiatrists, food scientists, public health officials, professionals, government officials, and patients understood the relationship between food and mental illness in the United States during the Long Progressive Era. This exploration is centered on St. Elizabeths, the federal mental hospital in Washington D.C., and William Alanson White, its superintendent from 1903 to 1937. While historians have written at length about the Progressive Era, food reform, and the history of psychiatry, there has been a gap in the literature at the intersection of the histories of food and psychiatry. This study thus seeks to help fill this gap by examining the role that food and diet played in mental institutions and in ideas about the etiology and symptomology of mental illness. It utilizes a range of sources including hospital administrative files, patient case files, medical articles, newspapers, and government documents to show that longstanding ideas about diet and health from Hippocratic to nineteenth-century medicine, including moral treatment, held an important place among the changes that U.S. society and psychiatry underwent at the turn of the twentieth century. I also argue that psychiatrists and medical staff primarily viewed food and diet for patients in the mental hospital as care, an administrative provision of the humane necessities that public institutions were expected to provide, and as therapy, a medical treatment for disease. At the turn of the twentieth century, scientists, professionals, legislators, and psychiatrists—including famous home economist Ellen Richards and nutrition scientist Wilbur Olin Atwater—debated over and studied how to properly feed institutionalized patients in mental hospitals. These conflicts over diet highlight a significant strand of therapeutic optimism in psychiatry that was bolstered by concerns about humane care, even as increasing numbers of chronically ill patients contributed to psychiatrists’ therapeutic pessimism. A comparison of legislative investigations at St. Elizabeths and the South Carolina Hospital for the Insane illustrates how regional differences, the pellagra epidemic, and investigation findings led to different hospital diets. This dissertation also examines how the eating habits of the mentally ill, such as food refusal and overeating, required surveillance and intervention from hospital staff. This benefitted many patients but for others, served to pathologize their eating habits. Briefly, the dissertation moves outside of St. Elizabeths to examine how D.C. District Jail authorities and reporters cast radical women’s suffragist Alice Paul’s refusal of food during her hunger strike as a symptom of insanity. This ultimately led to an examination and confirmation of Paul’s sanity by White. I also seek to build on the work of other scholars in arguing for the usefulness of the concept of the Long Progressive Era by viewing World War I as a catalyst of Progressive energy. The continuities of how dynamic psychiatrists like White thought about the interconnected health of mind and body combined with the changes that World War I spurred at the hospital. Patients and their own dietary preferences and ideas, however, provided one significant disruption to an overly simplistic categorization of food in the hospital as care and therapy. I explore the unique writings of two patients to demonstrate how patients used their own dietary preferences, such as vegetarianism, or their knowledge of public health and hygiene to change their diet and challenge medical authority at St. Elizabeths. Ultimately, this dissertation’s examination of food and diet at St. Elizabeths reveals how significant threads of continuity accompanied the changes that U.S. society and psychiatry underwent during the Long Progressive Era. Copyright by AMANDA LYNN BREWER 2022 iv This dissertation is dedicated to Pops, also known as Frank Jandrowitz (1938-2021). I would not love history without having known his love of it first. v ACKNOWLEDGEMENTS Thank you to my advisor, Naoko Wake, for all her support and guidance throughout my graduate journey and major illness. This dissertation would be very different without her detailed and thorough feedback on my chapter and full drafts. Thank you to my committee members, Helen Veit, John Waller, and Sean Forner, who all provided valuable feedback to me at important points along the way. I also owe thanks to Michael Stamm, whose comments on the first iteration of this project pushed me to continue to both refine and broaden my arguments. Thank you to Elyse Hansen and Jennifer Desloover for all their efforts and help navigating the university bureaucracy. Thank you as well to MSU Library staff and Bobby Smiley, who sent me a link to the St. Elizabeths material at the National Archives. I would also like to thank the Michigan State University Graduate School and the Michigan State History Department for their financial support. Thank you to those outside of MSU who supported my dissertation research and gave me useful feedback on my work. Thank you to Bill Creech at the National Archives for his help finding and requesting St. Elizabeths material during my research trips. Thank you to Matthew Gambino for his generous and invaluable phone call that set me up for success during my research trip to the National Archives. Thank you to those who provided feedback at the Organization of American Historians and the American Association for the History of Medicine Conferences in 2019. Thank you as well to the SHGAPE committee for the OAH Conference Travel Award that helped me to attend OAH. I would also like to thank those teachers and professors who inspired my love of history. Thank you to Mr. L (Larry Letellier) at the Commonwealth Governor’s School for making history fun, exciting, and challenging. I would also like to thank my undergraduate mentors at vi the University of Richmond History Department for providing me with the methodological foundations and research experiences necessary to succeed in a doctoral program. Thank you especially to Joanna Drell for always believing in me and giving me tough love when it’s been necessary. I would also like to thank the donors to and selection committees of the Maude Howlett Woodfin-Susan Lough Grant for Graduate Study from the University of Richmond for their generosity and financial support. Thank you also to Debbie Govoruhk for her help with the application process. I also need to thank my family and friends for their support through the years. Thanks to my friends at MSU for making graduate school not only intellectually fun, but also just plain fun. I would like to give special thanks to my friends Alyssa Lopez and Kerry Boland for their writing help, taking all my impromptu phone calls, and giving the best pep talks. Thank you to my parents, Mark and Denise, and my brother, Shane for their support. My mom deserves a special big thank you for always being there on the other end of the phone. Thank you to my wonderful in-laws, Kari and Ted, for your encouragement and in helping to make Michigan feel like home. To Vienna, thank you for being my “lucky lap cat” and writing buddy, even if Artichoke is trying to fill/steal your shoes now. Finally, thank you to Dylan, my husband. Thank you for being my rock, my best friend, and the reason I was able to weather the storms. Without your love, support, and encouragement, this dissertation would not have been possible. vii TABLE OF CONTENTS LIST OF ABBREVIATIONS ...................................................................................................... x INTRODUCTION ........................................................................................................................ 1 Historiographical Review ................................................................................................... 6 Chapter Outline ................................................................................................................. 13 CHAPTER 1: Professionals’ Discourses on Diet for the Mentally Ill at the Turn of the Twentieth Century ...................................................................................................................... 20 Introduction ....................................................................................................................... 20 Food as Therapy: Humoral Theory, Moral Treatment, Mental Hygiene, and Neurology ......................................................................................................................... 24 Diet for the Institutionalized “Insane” in the American Journal of Insanity .................... 38 Ellen Richards and Home Economics in the American Journal of Insanity..................... 58 Nutrition Science, Wilbur Olin Atwater, and Pratt and Milner’s Study ........................... 61 The Aftermath of Nutrition Studies: Scientific Promises and Therapeutic Pessimism .... 71 Conclusion ........................................................................................................................ 74 CHAPTER 2: Early-Twentieth-Century Mental Hospital Investigations and Diet: Progressive Reform, 1906-1914 ................................................................................................. 77 Introduction ....................................................................................................................... 77 Progressive Reform, Food, and Psychiatry ....................................................................... 81 William Alanson White and James Woods Babcock: An Overview ................................ 85 The St. Elizabeths Investigation of 1906 .......................................................................... 89 The South Carolina 1909 Investigation .......................................................................... 104 Conclusion ...................................................................................................................... 117 CHAPTER 3: Radical Women, Hunger Strikes, Forced-Feeding, and Insanity in the Popular Press, 1909-1917 ......................................................................................................... 120 Introduction ..................................................................................................................... 120 “Militant Suffragist Madness” ........................................................................................ 125 The “Matteawan Cure for Hunger Strikers” ................................................................... 139 “Fear of Miss Paul Being Held Insane” .......................................................................... 149 Conclusion ...................................................................................................................... 163 CHAPTER 4: The “Problems” of Feeding the Mentally Ill and the Nation, 1914-1918 .... 167 Introduction ..................................................................................................................... 167 “The Insane Have Their Own Problem”: Patients’ Eating Habits .................................. 171 “The Problem at Asylums”: Pellagra, Psychosis, and Patients’ Dietary Habits ............. 178 “Each Hospital Can Do Its Bit": Mental Hospitals’ Solutions for WWI Food Problems ......................................................................................................................... 193 Conclusion ...................................................................................................................... 207 CHAPTER 5: Diet as Care and Therapy: Veterans, Women Professionals, and “Organism as a Whole” in St. Elizabeths, 1919-1937 ............................................................ 209 viii Introduction ..................................................................................................................... 209 “Crazed Yanks Starved”: Veterans, the 1919 Investigation, and Dietitians ................... 217 Investigations in the late 1920s: Dietary Critiques and Updates .................................... 228 Moral Treatment or Modern Therapy? Food and Occupational Therapy....................... 238 Food, Psychosocial Health, and Red Cross Women ....................................................... 252 Nurses’ Training, Dietotherapy, and “Organism as a Whole” in the 1930s ................... 258 Conclusion ...................................................................................................................... 264 CHAPTER 6: “I feel that I really need something to eat”: Patient Perspectives on and Challenges to Institutional Food and Medical Authority in the Long Progressive Era ..... 268 Introduction ..................................................................................................................... 268 Jacqueline Page ............................................................................................................... 272 James Kalter .................................................................................................................... 280 Conclusion ...................................................................................................................... 291 CONCLUSION ......................................................................................................................... 293 BIBLIOGRAPHY ..................................................................................................................... 296 ix LIST OF ABBREVIATIONS AJI – American Journal of Insanity AMPA – American Medico-Psychological Association AMSAII – Association of Medical Superintendents of American Institutions for the Insane IWW – International Workers of the World NWP – National Woman’s Party USDA – United States Department of Agriculture USPHS – United States Public Health Service WSPU – Women’s Social and Political Union x INTRODUCTION In 2015, the president of the International Society for Nutritional Psychiatry Research Felice Jacka said that a “very large body of evidence now exists that suggests diet is as important to mental health as it is to physical health.”1 Nutritional psychiatry, a new subspecialty of the field, has been growing steadily over the past decade based on these very principles and research at the nexus of nutrition science and psychiatry. Part of this growing interest included research showing the gut microbiome may have important implications for brain health. By 2019, Richard Schiffman, writing for the New York Times, asked readers: “Can what we eat affect how we feel?”2 Even though the science is still developing, many psychiatrists and everyday people alike believe that bodily health and mental health are connected through the food that people eat. To begin to understand how these ideas have manifested in the early twenty-first century, a study of the historical intersection of food and psychiatry is necessary. Although the history of psychiatry and the history of food in the United States are not new fields of study, historians have not investigated them together. This dissertation serves as a beginning to filling this gap in research by investigating the role of food and diet in the care and treatment of mentally ill people institutionalized in mental hospitals in the United States during the late nineteenth and early twentieth centuries. St. Elizabeths, the federal mental hospital located in Washington, D.C. and originally named the Government Hospital for the Insane, is the institution central to this study.3 It serves as the focal point from which to analyze larger trends in psychiatry and in American 1 Kelli Miller, “Can What You Eat Affect Your Mental Health?” WebMD. August 20, 2015, https://www.webmd.com/mental-health/news/20150820/food-mental-health#1. Accessed February 18, 2021. This quotation appears in many blogs, medical sites, and nonprofit sites online, fueling popular interest in the topic. 2 See Richard Schiffman, “Can What We Eat Affect How We Feel?” New York Times, March 28, 2019, https://www.nytimes.com/2019/03/28/well/eat/food-mood-depression-anxiety-nutrition-psychiatry.html. Accessed February 18, 2021. 3 Congress changed the name of the hospital in 1916, and the official spelling of St. Elizabeths does not include an apostrophe. It will thus appear without an apostrophe throughout this dissertation. See Thomas Otto, St. Elizabeths Hospital: A History (Washington, DC: U.S. General Services Administration, 2013), 30. 1 society as they related to food and mental illness more broadly. Psychiatrist William Alanson White, who served as St. Elizabeths’s superintendent from 1903 to 1937, is also at the heart of this study. By studying the development of food and diet in St. Elizabeths throughout his thirty- four-year tenure, the traditional chronology of the Progressive Era gives way to a “Long Progressive Era.”4 A central argument of this dissertation is that psychiatrists’ understanding of the body’s relation to the mind through nutrition changed remarkably little during this period despite the radical changes nutrition science brought to food reform. The language used by psychiatrists to discuss the proper diet or therapeutic work for mental patients adapted to these new scientific understandings of human nutrition and food production rather than undergoing a revolutionary transformation. My argument is one about the important threads of continuity that accompany the changes psychiatry and United States society underwent at the turn of the century. While the ever-increasing numbers of chronically ill patients drove therapeutic pessimism during this period, battles over the appropriate diet to feed patients at St. Elizabeths highlight a significant strand of therapeutic optimism that was in fact underpinned by humane care. Although the harsh realities of overcrowding in mental hospitals across the country remained, the continued liberal diet given to patients at St. Elizabeths, and likely many hospitals in the Northeast, reveals a bright spot in psychiatry during a time otherwise largely characterized by darkness. This dissertation uses food as a lens with which to reexamine the history of psychiatry. Food is unique because it is something that every person needs in order to live, yet people think about food in all sorts of ways. Some people focus on food as fuel, even as their culture shapes their food choices. To others, food is an important part of their identity or their religion. Eating 4 I adopt this term from Rebecca Edwards, “Politics, Social Movements, and the Periodization of U.S. History,” The Journal of the Gilded Age and Progressive Era 8, no. 4 (October 2009): 466. 2 with others provides a social experience that many people enjoy. Some people grow their own food, while others purchase food solely from others. Scholars debate the best diet from a public health standpoint or from the standpoint of feeding people in institutions. Scientists discover what types of diets are therapeutic for specific diseases. During wartime or global crises, nations and their governments must decide how to feed both troops and citizens. Food is a useful thing to examine in history precisely because it is so hard to categorize. For all these reasons, I use food as an analytical lens because it helps reveal both continuities and changes over time. One goal of this dissertation is to show how turn-of-the-century psychiatrists did not view food for patients primarily from the standpoint of food as sustenance. Humane care of institutionalized people included at least a subsistence-level provision of food. While caring for the mentally ill, however, physicians realized a need to provide better, more nutritious food to patients, which at times they understood as therapeutic rather than as strictly providing necessary sustenance. This means that in an institutional setting, food was, on the one hand, seen as care— an administrative provision of the basic necessities that public institutions were expected to provide. On the other hand, food was understood to be therapeutic, as it was used to treat and cure disease, whether mental or physical. These two different ways of viewing food within the mental hospital existed simultaneously and can be pictured as existing on a pendulum where both always exist and sometimes focus swings more one way than the other. Chapters 1 through 5 of this dissertation explore the ways that food’s varying roles as administrative and therapeutic manifested. The belief that diet can prevent or even treat mental illness has waxed and waned over the centuries, but during the nineteenth century, pre-modern humoral understandings of food as therapeutic merged with moral treatment, biological theories of mental illness, and early 3 functional and psychoanalytic explanations of mental disease. Many physicians recognized that their theorization of mental and physical health was part of their effort to incorporate science into a modern, more secular world, but that much of what they saw as ancient wisdom stemming largely from Hippocrates continued to inform their therapeutics, whether in the mid-1800s or the early 1900s. During the Progressive Era, alienists became psychiatrists and drug therapies and laboratory science eclipsed moral treatment. But moral treatment never left. As I will show, it was foundational to the treatment of mental illness in mental hospitals and offered a “common- sense” treatment program of sunlight, fresh air, clean water, exercise, rest, and nutritious food combined with attention to the individual patient that could not be disposed of.5 Similarly, the desire to prevent mental illness through a program of mental hygiene that was first articulated in the mid-1880s, was picked up and reborn by reformer Clifford Beers with the help of Adolph Meyer and prominent psychiatrists, psychologists, and neurologists including White to form the mental hygiene movement. At the turn of the twentieth century, food in the mental hospital was at the nexus of the formation of home economics and dietetics as a profession, the success of laboratory science, physiological chemistry, agriculture as practiced in the USDA agricultural experiment stations, the rise of the “modern” hospital, and the legitimation of psychiatry as a medical specialty. Moral treatment evolved as it continued to adapt to the changing demands of science, institutions, and society. It can be easy to see the mental hospital as its own world, disconnected from larger societal trends, but this is not the case. 5 I am not the first to recognize the continuation of moral treatment in St. Elizabeths during White’s tenure, but I am the first to view it in the context of food as an aspect of both care and therapy. See Frank Rives Millikan, “Wards of the Nation: The Making of St. Elizabeths Hospital, 1852-1920” (PhD diss., George Washington University, 1990), 183, 201, ProQuest Dissertations. The “common sense” approach is taken from Charles P. Bancroft, “Presidential Address: Hopeful and Discouraging Aspects of the Psychiatric Outlook,” American Journal of Insanity 65, no.1 (July 1908): 6. 4 At the same time, individuality and the subjective nature of the engagement between humans and food disrupts the dichotomy between care and therapy. Individual patients and their dietary preferences and quirks interacted with and complicated the administrative and therapeutic understandings of food in the institution. Everyone has certain cultural, religious, or other ideas about food which play a role in what food they not only find appealing, but also in what they ultimately choose to eat. The last chapter of this dissertation, chapter 6, thus focuses on patients’ perspectives of the foods that they ate within the confines of the hospital. Chapter 3 also explores another disruption to this dichotomy; it moves outside but adjacent to the mental hospital to government-run jails, where the forced-feeding of hunger strikers took place, to show how an individual’s choice to refuse food in jail—to engage with food in a political way—complicated the view of food as simply sustenance or therapeutic. Here, it is important to note that the individuals who engaged in the first political hunger strikes in the United States were women. Government authorities used the threat of institutionalization in a mental hospital for women who transgressed gender norms for proper behavior. Their political action, then, was closely bound up with the relationship of gender to psychiatry. This dissertation draws upon a wide variety of sources in order to examine the various ways that food and mental illness were intertwined in the minds of psychiatrists, scientists, and members of the public. Professional publications, monographs, administrative records, and testimony from congressional investigations illuminate the role of food as both medical and administrative in the mental hospital. Newspapers and magazines reveal how the media criticized and celebrated food in the hospital as well as perpetuated a dangerous stereotype of gender- transgressing women as insane and in need of institutionalization. Lastly, patients’ own writings that are contained in their hospital case files bring to light how one important, yet heretofore 5 understudied, way in which patients asserted their agency during their institutionalization was through their relationship with food. Historiographical Review This dissertation engages with three primary strands of historical scholarship: the histories of the United States Progressive Era, psychiatry, and food. While historians have explored the impacts of the Progressive Era on psychiatry and on food, the intertwined history of food and medicine has not yet been fully explored. This is because some of the first studies at the intersection of the history of food and the history of medicine has only occurred within the last several years. Elizabeth A. Williams’ work, primarily in nineteenth-century French medicine and early psychiatry, forms one important foundation of this new branch of scholarship in the history of psychiatry in particular.6 Juliana Adelman and Lisa Haushofer discussed the state of this newly emerging field in their 2018 article “Introduction: Food as Medicine, Medicine as Food,” for a special issue of the Journal of the History of Medicine and Allied Sciences. They argued that the special issue’s articles “show that the relationship between food and medicine emerges, at times, as a process of demarcation, maintenance, and co-construction or re-negotiation of existing power dynamics.”7 In this dissertation, these processes will be clarified through a case study of St. Elizabeths and its surrounding medical and scientific communities. I also seek to answer the call to “denaturaliz[e] seemingly self-evident categories such as food and medicine” by understanding the myriad of ways that food was seen as administrative care (sustenance) and 6 See Elizabeth A. Williams, “Neuroses of the Stomach: Eating, Gender, and Psychopathology in French Medicine, 1800–1870,” Isis 98 (2007); Elizabeth A. Williams, “Stomach and Psyche: Eating, Digestion, and Mental Illness in the Medicine of Philippe Pinel,” Bulletin of the History of Medicine 84, no. 3 (January 2010); Elizabeth A. Williams, “Gags, Funnels and Tubes: Forced Feeding of the Insane and of Suffragettes.” Endeavour 32, no. 4 (2008). Her most recent monograph examines the development of medical and scientific approaches to appetite specifically. See Elizabeth A. Williams, Appetite and Its Discontents: Science, Medicine, and the Urge to Eat, 1750-1950 (Chicago: The University of Chicago Press, 2020). 7 Juliana Adelman and Lisa Haushofer, “Introduction: Food as Medicine, Medicine as Food,” Journal of the History of Medicine and Allied Sciences 73, no. 2 (April 2018): 134. 6 therapy (medicine) simultaneously in the mental hospital setting.8 In the context of medicine, physicians understood food not only on physically therapeutic grounds—the psychological aspects of food presentation and the eating environment were themselves seen as therapeutic for mentally ill patients. This focus on the multifaceted forms of food makes this dissertation a useful contribution to the history of psychiatry and the scholarly debate over the complexity of psychiatric thought and practice during the Progressive-Era United States. Historians once saw a clearer delineation between nineteenth-century moral treatment, a biological turn by the end of the nineteenth century, and another turn to Freudian psychoanalysis completed after World War I.9 Recent work, building off of Gerald N. Grob’s identification of the “disunity of early twentieth-century psychiatric thought,” has begun to reexamine psychiatry at the turn of the twentieth century, finding that the period was one in more transition than scholarship had previously illustrated.10 For example, Naoko Wake examined how understandings of psychiatry between 1910 and 1935 were gradually shifting and difficult to categorize as either biologically- or psychologically- oriented as an expression of “the fluidity of the era’s modernity-in-the-making.”11 S. D. Lamb’s study of Adolf Meyer has also been particularly influential to my thinking, as she explored the multifaceted theories and applied therapies that made up Meyer’s theory of “psychobiology” between 1892 and 1917 as part of a period that was a “transformative interlude in the 8 Adelman and Haushofer, “Introduction,” 134. 9 See, for example, Francis J. Braceland, “Foreword,” in Psychiatry and Its History; Methodological Problems in Research, edited by George Mora and Jeanne L. Brand (Springfield, IL: C.C. Thomas, 1970), vii-x. 10 Gerald N. Grob, Mental Illness and American Society, 1875-1940 (Princeton, NJ: Princeton University Press, 1983), 111. See also Tom Lutz, “Varieties of Medical Experience: Doctors and Patients, Psyche and Soma in America,” in Cultures of Neurasthenia from Beard to the First World War, eds. Marijke Gijswijt-Hofstra and Roy Porter (New York: Rodopi, 2001) and Jonathan Sadowsky, “Beyond the Metaphor of the Pendulum: Electroconvulsive Therapy, Psychoanalysis, and the Styles of American Psychiatry,” Journal of the History of Medicine and Allied Sciences 61, no. 1 (2005). 11 Naoko Wake, “Homosexuality and Psychoanalysis Meet at a Mental Hospital: An Early Institutional History,” Journal of the History of Medicine and Allied Sciences 74, no.1 (January 2019): 34-35. 7 development of American psychiatry.”12 As I show, following food’s place in psychiatric thought and practice reveals different facets of the evolution of psychiatry and modern American society during the early twentieth century. The “new psychiatry” led by Meyer alongside other prominent psychiatrists including William Alanson White was important to this evolution. It abounded with therapeutic optimism as they reconceptualized mental illness “from insanity to maladjustment” in the first decade of the twentieth century.13 Although Meyer is widely regarded as the “most recognizable, authoritative, and influential psychiatrist in the United States” during the first half of the twentieth century, White’s contributions to psychiatry, especially as the superintendent of the prestigious federal mental hospital during this period of modernity-in-the-making, are equally substantial.14 Even as psychiatrists like White pushed for the understanding of mental illness as a spectrum of abnormal to normal rather than a dichotomy of sane or insane, psychiatrists who were mental hospital superintendents continued to guide psychiatry from the hospital.15 Indeed, in April of 1935, Fortune Magazine named White the “No. 1 U.S. practicing psychiatrist,” giving Meyer the title of “No. 1 U.S. research psychiatrist,” showing how psychiatric research and hospital practice overlapped at the time.16 Outside of studies of St. Elizabeths specifically, however, White has gotten little attention from historians beyond his roles as an early promoter 12 S. D. Lamb, Pathologist of the Mind: Adolf Meyer and the Origins of American Psychiatry (Baltimore: Johns Hopkins University Press, 2014), 3. 13 Lamb, Pathologist of the Mind, 110. 14 Ibid., 1. This is the consensus among historians, however, Gerald Grob once mentioned, in what amounted to an aside, that White was “a figure whose influence equaled that of Meyer.” Gerald N. Grob, The Mad Among Us: A History of the Care of America’s Mentally Ill (New York: Free Press, 1994), 161. 15 For this shift, see Elizabeth Lunbeck, The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America (Princeton, NJ: Princeton University Press, 1994). 16 Quoted in Arcangelo R. T. D’Amore, ed. William Alanson White: The Washington Years, 1903-1937 (Washington, DC: U.S. Department of Health, Education, and Welfare, 1976), 8. 8 of psychoanalysis and supporter of the mental hygiene movement.17 My dissertation aims to remedy this historiographical shortcoming by exploring how he balanced his roles as an administrator, psychiatrist, and mental hygiene reformer. St. Elizabeths, as the federal mental hospital in the United States, has long occupied a unique place in the history of psychiatry.18 However, it only came under close examination by historians of medicine beginning in 1990 with Frank Rives Millikan’s dissertation “Wards of the Nation: The Making of St. Elizabeths Hospital, 1852-1920,” which argued that moral treatment continued during White’s tenure at St. Elizabeths, thus providing an important foundation for later work.19 Matthew Joseph Gambino’s dissertation was the next in-depth study of the hospital, arguing that St. Elizabeths psychiatrists sought to rehabilitate patients into good citizens while employing different visions of citizenship for patients based on their gender and race.20 Gambino has also explored the experimental use of malarial fever therapy for neurosyphilis at St. Elizabeths from 1922 to 1953, drawing attention to how the “medical staff at St. Elizabeths promulgated a virulently racist theory of black mental illness” and treated black patients 17 The only study of White was funded by the U.S. government. See D’Amore, William Alanson White, cited above. Nathan G. Hale Jr. asserted that White’s Thoughts of a Psychiatrist on the War and After was a “perfect embodiment of the moralistic outlook of progressive America and of the new eclectic American psychiatry. […] This essay, with its easy acceptance of Wilsonian idealism, typified the spirit of progressive reform that survived among zealous psychiatrists in the 1920s.” He does not go further into White’s work, however, which I aim to remedy in looking at both his intellectual work as well as his administrative role at the hospital. Nathan G. Hale, Jr., The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans, 1917-1985 (New York: Oxford University Press, 1995), 23. For other discussions of White in general histories of psychiatry, see Nathan G. Hale, Jr., Freud and the Americans: The Beginnings of Psychoanalysis in the United States, 1876-1917 (New York: Oxford University Press, 1971), 379-383, 432, 436-41; Hale., The Rise and Crisis of Psychoanalysis, 93; Helen Swick Perry, Psychiatrist of America: The Life of Harry Stack Sullivan (Cambridge, MA: The Belknap Press of Harvard University Press, 1982), 179-188. 18 St. Elizabeths has generally been recognized as “the” federal mental hospital (as its original name—the “Government Hospital for the Insane”—indicated), but the U.S. Government created the Canton Asylum for Insane Indians in South Dakota in 1899. However, it closed in 1933, sending its remaining patients who could not be discharged to St. Elizabeths. See Matthew Joseph Gambino, “Mental Health and Ideals of Citizenship: Patient Care at St. Elizabeths Hospital in Washington, D.C., 1903-1962” (PhD diss. University of Illinois at Urbana-Champaign, 2010), 114, ProQuest Dissertations. 19 Millikan, “Wards of the Nation.” 20 Gambino, “Mental Health and Ideals of Citizenship,” ii, 15-16. 9 differently from white ones.21 Most recently, Martin Summers wrote the first historical monograph of St. Elizabeths using race as the primary lens of analysis. He showed how St. Elizabeths’ psychiatrists incorporated their own ideas about racial difference into their care and treatment of patients. This, he argued, led to the prioritization of white patients’ experiences of and suffering from mental illness and a generalized, though “unarticulated project that conceptualized the white psyche as the norm.”22 My dissertation builds off this scholarship on St. Elizabeths by using food as a new lens of analysis through which to understand the different aspects of Progressive reform, including that related to gender and race, that shaped psychiatrists’ care and treatment of patients at the hospital. My focus on food also adds new dimensions to our understanding of White as a Progressive reformer by carefully looking at how the reform played out within the hospital. Historians have examined how food during the Progressive Era was used as a vehicle not only for dietary and physical health reform but for social and moral reform. As Laura Shapiro argued, “The recuperative powers of a scientific diet were often imagined to be moral as well as physical, a hope that more than justified the hiring of domestic scientists to scrutinize the food served in prisons, reformatories, workhouses, and asylums.”23 Additionally, Charlotte Biltekoff argued that health is both a cultural concept and a moral discourse, and therefore “dietary health is clearly about more than a physiological relationship between food and the body.”24 Helen Zoe Veit has also revealed how moral discourse, especially focused on self-control, was an essential 21 Matthew Joseph Gambino, “Fevered Decisions: Race, Ethics, and Clinical Vulnerability in the Malarial Treatment of Neurosyphilis, 1922- 1953,” Hastings Center Report 45, no. 4 (2015): 46. 22 Martin Summers, Madness in the City of Magnificent Intentions: A History of Race and Mental Illness in the Nation’s Capital (New York: Oxford University Press, 2019), 3-4. 23 Laura Shapiro, Perfection Salad: Women and Cooking at the Turn of the Century (New York: Farrar, Straus, and Giroux, 1986), 162. 24 Charlotte Biltekoff, Eating Right in America: The Cultural Politics of Food & Health (Durham: Duke University Press, 2013), 6. 10 component of Progressive Era food and diet that has had lasting effects on the modern American diet.25 The ideology of self-control also had an important place in early-twentieth-century psychiatric ideas as well, because as mechanical and chemical restraint fell out of favor in psychiatry, “psychiatrists were left with little else but persuasion […] to instill in patients a desire for self-control, a desire to discipline themselves.”26 The power of psychiatrists and the institutionalization of the mentally ill have been explained as a “cultural project” which represented psychiatry’s social role in early-twentieth-century America.27 Food, therefore, is a useful analytical focus in not only understanding the changing definition of mental health and illness, but also in revealing the cultural and moral assumptions reformers and psychiatrists made about the mentally ill and what kind of treatment they deserved. Much of the historical narrative of Progressive-Era food reform has focused on the efforts and theories of reformers themselves, rather than the people that their reforms were meant to impact. As Biltekoff admitted, she did “not attend to whether or not dietary reform actually affected people’s eating habits” and did “not address what the targets of dietary reform thought about it, how they reacted to the dietary advice directed at them, or what ‘eating right’ meant to them.”28 Furthermore, she called for further historical study to analyze “how the assumptions embedded in the discourses I study have been adopted, resisted, and contested by the people who have been the targets of reform, and we need to explore how people who are not reformers have generated and acted on their own ‘truths’ about good food.”29 This dissertation seeks to add a new perspective to the growing literature on ordinary people’s thoughts and practices about food 25 Helen Zoe Veit, Modern Food, Moral Food: Self-Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century (Chapel Hill: University of North Carolina Press, 2013), 1-3. 26 Lunbeck, The Psychiatric Persuasion, 181. 27 Gambino, "Mental Health and Ideals of Citizenship,” ii-iii. 28 Biltekoff, Eating Right in America, 11. 29 Ibid., 11. 11 during the Progressive Era by examining two mentally-ill patients’ perspectives through their own writings in chapter 6. Patients’ writings illuminate the ways that they advocated for food they believed to be “good” as well as why they chose to adopt or resist the diets provided by the institution. The last historiographical intervention this dissertation seeks to make is to add to scholarship arguing for caution when applying strict periodization to currents of social, cultural, and political movements. The traditional periodization of the Progressive Era has long been roughly 1880 to 1920. Richard Hofstadter, in The Age of Reform: From Bryan to F.D.R, posited a clear break between Progressivism, from 1900 to the beginning of World War I in 1914, and the New Deal.30 Robert Wiebe’s periodization spanned from the end of Reconstruction until 1920.31 Similarly, Michael McGerr argued that the height of the Progressive movement was during World War I, but that the war also sparked its death.32 Within the last 20 years, however, historians have begun to challenge this periodization. In 2009, Rebecca Edwards questioned the enduring usefulness of the terms “Gilded Age” and “Progressive Era” to describe the late- nineteenth and early-twentieth centuries. She suggested the possibility of a “Long Progressive Era” which would be based on the analysis of certain historical threads between 1877 and 1920—even up to 1932.33 Daniel Rodgers, in his transnational and transatlantic study Atlantic Crossings, opened up a new chronology with which to view social reform and the legacy of Progressivism past the 1920s. Rodgers provided the possibility for a longer period of the Progressive spirit even beyond 1932, as he theorized the New Deal as “a great, explosive release 30 Richard Hofstadter, The Age of Reform: From Bryan to F.D.R. (New York: Vintage Books, 1955), 325. 31 Robert H. Wiebe, The Search for Order, 1877-1920 (New York: Hill and Wang, 1967). 32 Michael McGerr, A Fierce Discontent: The Rise and Fall of the Progressive Movement in America, 1870-1920 (New York: Free Press, 2003), xvi. 33 Edwards, “Politics, Social Movements, and the Periodization of U.S. History,” 472. 12 of the pent-up agenda of the progressive past,” thus marking the beginning of World War II as the end of Atlantic, Progressive social politics.34 Following Rodgers and Edwards, I broaden the periodization of Progressive reform to the late 1930s by viewing World War I as a catalyst of Progressive energy. The example of St. Elizabeths during the tenure of William Alanson White between 1903 and 1937 provides the foundation of this chronology and also shows the usefulness of individual lives to shed light on how stark periodization can miss important continuities in order to advance a narrative of change. Dietitians played a particularly important role in changing the hospital’s diet and food service, which played out through the 1930s. A swelling of public concern for veterans after the war also shaped the hospital in important ways by reviving a humanitarian spirit similar to the one that inspired nineteenth-century moral treatment and mental hospital reform. My use of the “Long Progressive Era” thus positions World War I not as the death of Progressivism but a catalyst for Progressive reform in St. Elizabeths, especially in the threads of professionalization and scientific authority exemplified by the growing role of female dietitians, social workers, and occupational therapists in mental hospitals like St Elizabeths. Chapter Outline This dissertation is comprised of six chapters which are thematic, but also anchored to chronology. St. Elizabeths hospital and William Alanson White serve as important anchors for each of the chapters, helping to tie the larger arguments about food’s place as an aspect of Progressive reform and in the transitional nature of psychiatry from the 1890s through 1937. Chapters 1 through 5 move through this “Long Progressive Era” linked to White’s tenure at St. Elizabeths and concentrate most strongly on the voices and perspectives of medical and scientific 34 Daniel T. Rodgers, Atlantic Crossings: Social Politics in a Progressive Age (Cambridge, MA: The Belknap Press of Harvard University Press, 1998), 416. 13 professionals including psychiatrists, physicians, home economists and dietitians, and nutrition scientists. Chapter 3 differs from the other chapters, however, by moving beyond the walls of the mental hospital to investigate how strongly the public and doctors alike associated food refusal with insanity by examining newspaper coverage of radical women’s hunger strikes. Chapter 6 breaks with the rest of chapters, highlighting the voices of patients who were institutionalized during the entire period of White’s tenure. Chapter 1 examines how various professionals interested in the care and treatment of the institutionalized mentally ill—psychiatrists, nutrition scientists, and home economists— theorized what role diet played in mental illness and how best to feed mentally ill patients at the turn of the twentieth century. They believed that food in patient diets was necessary sustenance, culturally meaningful, and often therapeutic, creating a rich discourse that displays a previously overlooked way in which medicine and science were intertwined and co-constructive. The renewed focus on feeding the mentally ill in the 1890s built on ancient humoral theory and nineteenth-century homeopathy and moral treatment. The adaptation of these ideas into the new science of human nutrition which was then incorporated into psychiatry through the mental hospital represents a significant thread of historical continuity. Psychiatrists’ belief that mentally ill patients required and deserved more liberal diets than people who were mentally healthy and confined in other types of public institutions was largely adopted by nutrition scientists, which helped to establish liberal diets for the “insane” as the norm. A USDA Office of Experiment Stations diet study completed at St. Elizabeths during the first year of White’s administration is thus the lynchpin of the chapter. Overall, the analysis focuses primarily on professional journals, especially the American Journal of Insanity, and government-funded dietary studies to show how interdisciplinary interest in and theorization about the diet of the mentally ill was. This chapter 14 illuminates the heretofore overlooked importance of arguments about the proper food and diet for the mentally ill as a crucial part of Progressivism in the turn-of-the-twentieth-century United States. Chapter 2 picks up the story of White’s administration at St. Elizabeths and the changing role of food in mental hospitals by examining the importance of food and diet in the first Progressive-Era congressional investigation into White’s management of the hospital in 1906. Legislative investigations into mental hospitals occurred frequently during the Progressive Era, driven by the Progressive reform ethos. One aspect of these investigations that has been overlooked is the role that food and diet played in these investigations.35 Hospital superintendents such as White could use the argument that food was both an aspect of therapy (as medical treatment) and care (as necessary sustenance bought by administrators) to secure funding for a liberal diet as well as to justify the necessity for one institutional head rather than two. This investigation is compared with the investigation into James Woods Babcock’s management of the South Carolina State Hospital for the Insane in 1909, shedding light on the regional differences in feeding mentally ill patients—driven by a lack in funding that was compounded by racism—that contributed to the epidemic of the dietary deficiency disease pellagra that Southern institutions faced during the 1910s. At St. Elizabeths, patients had a varied, nutritious diet overall, and a humanitarian conscience could still balance economic concerns of convenience due to receptive legislators and convincing scientific experts. 35 Otto briefly discussed the emphasis on food in the 1906 investigation in the complaints brought by attendants and nurses, including complaints about the hospital’s switch to oleomargarine from butter. However, only a paragraph is dedicated to the topic; while he stated that “poor quality or insufficient quantity of food could be deleterious to patients’ well-being,” he also opined that “some of the testimony given by the disgruntled employees bordered on the trivial.” Otto, St. Elizabeth’s Hospital, 199-200. The studies by Gambino, Millikan, and Summers all mentioned the 1906 investigation but did not discuss aspects of the investigation related to food. Millikan explored food’s place in the 1876 investigation into St. Elizabeths under the management of Charles H. Nichols but focused on debates about the use of hydrotherapy and mechanical restraint during the 1906 investigation. See Millikan, “Wards of the Nation,” 90-94. 15 Chapter 3 uses White’s assessment of suffragist Alice Paul’s sanity during her 1917 hunger strike in the D.C. District Jail as a jumping-off point to examine how journalists, psychiatrists, and corrections officials used medical ideas and expert authority to pathologize political hunger striking as insane in order to threaten radical women who transgressed gender norms in their activism. Newspaper reporters used the gender of women experts who supported forced feeding to delegitimize the activism of radical women hunger strikers. The association of forced feeding with the treatment of mentally ill patients who refused food in institutions led to assertions that hunger striking was a symptom of insanity. In addition, a comparative approach to history is applied not to a regional context as it was in the previous chapter but to a transnational one in this chapter; British militant women suffragists’ hunger strikes from 1909 to 1913 inspired and formed the context for International Workers of the World member Rebecca Edelsohn’s 1914 hunger strike as well as Alice Paul’s in 1917. American newspapers also seized on this transnational comparison to promote a nationalistic notion of U.S. superiority over the British Parliament’s and physicians’ handling of suffragist hunger strikes. Ultimately, in the United States, the historical institutionalization of women who transgressed gender norms combined with longstanding stereotypes of socially different or politically radical women as “hysterical” to create a powerful threat of institutionalization against women who engaged in hunger strikes. Chapter 4 examines competing theories and rhetoric about mental illness prior to and during World War I through the lens of the diet and eating habits of the institutionalized mentally ill. This novel approach to the history of psychiatry reveals how Progressive modernity in mental hospitals was negotiated and complex, balancing administrative, financial realities of providing food for mentally ill patients with ongoing debates on the etiology of mental illness. While psychiatrists, dietitians, and researchers continued to seek a scientifically optimal diet for 16 mentally ill people—a continuation from chapter 1—they also became more interested in patients’ eating habits and the role that psychology played in that diet. Overall, debates from 1914 to 1918 show that psychiatrists, dietitians, and nutrition scientists saw patients and their eating habits as “problems” that separated them from society and that needed expert solutions. Psychiatrists’ debates about the etiology of pellagra cannot be understood without a careful understanding of how pellagra manifested differently in mental hospitals by region in addition to the context of larger debates about the dietary habits of the mentally ill and their role in the etiology of mental illness. The debates reveal the complex causality of pellagra and the importance of psychiatrists recognizing the different ways pellagra could develop in patients within institutions. But when the food problems created by World War I became apparent, institutionalized patients who were patriotic and able to labor on hospital farms became one solution to solving the nation’s food problems. St. Elizabeths, as the federal mental hospital, was an important leader of mental institutions’ food conservation efforts. Chapter 5 uses the postwar development of St. Elizabeths under White as a case study to investigate how the challenges created by World War I and developments in psychiatric thought led to the reform of various aspects of food in the hospital. Three outcomes were the growth of dietotherapy through the hiring of female dietitians, charity efforts, and occupational therapy, which included various kinds of work related to food. Although food in the hospital directly after World War I was more a matter of care (as administrative) than therapy (medical), by 1937 food in the hospital was much more balanced between the two thanks to dietitians’ changes to the hospital diet and the implementation of the cafeteria system of feeding patients. Female professionals brought not only scientific knowledge about food into the hospital that helped to maintain patient care, but they also provided interactions with patients centered around food that 17 were therapeutic. I also highlight the significance of the veteran population to policy and therapy at St. Elizabeths, which contributes to St. Elizabeths’s unique place in the history of psychiatry. Lastly, I examine how after the war, White continued developing his belief that body and mind were interconnected parts of a whole, leading to his articulation of the concept of the “organism as a whole.” Ultimately, this chapter uses policy and activities centered on food at the hospital during White’s tenure to show how Progressive reforms and ideals carried past 1920, creating a “Long Progressive Era” that highlights important aspects of both historical continuity and change. The final chapter takes a step back from the rest of this dissertation’s focus on psychiatrists and other experts, instead highlighting the perspectives of two people who were directly affected by the Progressive-Era food reforms and policies at St. Elizabeths over almost the entire period of White’s tenure as superintendent. I decided against weaving patient experiences into all the chapters because, first, I found it useful to set a strong foundation of all other aspects of food in the hospital before turning to patients’ perspectives. As hospital inpatients, their experiences never stood apart from their institutional surroundings. Second, focusing on two patients allows for their stories to be told more fully, illuminating their experiences more compellingly than analyzing their records across multiple chapters. This chapter thus serves as a starting point in filling the gap in the literature that exists regarding patients’ perspectives about food in institutions. The two patients’ writings that were saved in their medical case files by their physicians provide a glimpse into the lives and agency of patients through their own words rather than through doctors’ notes or interpretations. For patients, food held meaning connected to their identity and personal beliefs beyond a concern for sustenance. One patient believed she should have the freedom to choose a vegetarian diet and the 18 other thought that he should be able to eat an alternative diet and work as a “hygiene physician.” These patients’ stories reveal that when the everyday interactions of patients with their nurses and doctors—especially concerning food—are considered, Progressive ideals such as scientific expertise, centralized administration, and economic rationality did not quite play out in practice at St. Elizabeths. Food was an important site for negotiations over authority and control between patients and the hospital’s medical staff. 19 CHAPTER 1: Professionals’ Discourses on Diet for the Mentally Ill at the Turn of the Twentieth Century Introduction Food and diet have always had a place in the asylum and its twentieth-century counterpart the mental hospital. It is easy to dismiss feeding the institutionalized mentally ill as a mundane activity of hospital staff, but to do so misses the important therapeutic role of food. Since at least the writings of the ancient Greek physician Hippocrates during the fifth century BCE that outlined the humoral theory of disease and those of the physician Galen in the second century CE, who expanded on Hippocrates’ work, food has had a therapeutic role to play in human health. Practitioners of humoral theory presented health as the equilibrium of the four bodily humors. Over the following centuries, this led to a long tradition of physicians who viewed health as a connected, organic system which needed to be regulated through manipulation of “intake and outgo”—what people ingested and excreted.1 Throughout the nineteenth century, some doctors specializing in mental illness—called alienists before term psychiatrist became dominant in the early twentieth century—articulated the idea that mental and physical health were intertwined as part of a whole-body system, ascribing importance not only to physiological but also to environmental, physiological and psychological factors.2 Orthodox or “regular” physicians as well as homeopaths, one branch of 1 Charles E. Rosenberg, "The Therapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth- Century America,” Perspectives in Biology and Medicine 20, no. 4 (1977): 488-9. 2 See Gerald N. Grob, Mental Illness and American Society, 1875-1940 (Princeton, NJ: Princeton University Press, 1983), 12-13. The term “alienist” was adopted into the English language from the French aliénisme (originally proposed by Philippe Pinel). The French were at the forefront of studying mental illness during the eighteenth century and nineteenth centuries. Doctors in the German-speaking world were also well-respected during the nineteenth century, which is where the term “psychiatry/psychiatrist” originated, only slowly to be adopted in the United States during the early twentieth century. See Andrew Scull, Madness in Civilization: A Cultural History of Insanity from the Bible to Freud, from the Madhouse to Modern Medicine (Princeton, NJ: Princeton University Press, 2015), 12, 419n77. 20 “irregular” physicians, developed this holistic view of health.3 Homeopathy was created by a German physician, Samuel Hahnemann, and brought to the United States in 1825 by a Dutch immigrant.4 Unlike orthodox physicians, homeopaths believed that diseases could be cured by drugs that produced the same symptoms as a person’s illness, although the dose was very small.5 Through examining how diet factored into early psychiatrists’ understandings of mental health and illness, I argue that humoral theory, moral treatment, nineteenth-century theories of mental hygiene, and neurologist Silas Weir Mitchell’s rest cure created the foundation for a period of psychiatric research on and experimentation in how best to feed the institutionalized mentally ill in the 1890s. This foundation established food in the mental hospital as not only physical sustenance but also as potentially therapeutic and curative. Building on this foundation, I assert that professionals from home economics and nutrition science played an important role alongside psychiatrists in investigating and advocating for a sufficient, and arguably therapeutic, diet in mental hospitals at the turn of the twentieth century. They created a rich discourse that displays a previously overlooked way in which medicine and science were intertwined and co- constructive during the Progressive Era. Furthermore, these professionals also helped to ensure that patients in many mental hospitals from Washington, D.C. to New England received a diet that was more generous than sustenance-level at the turn of the twentieth century. In the 1890s, alienists working in mental hospitals displayed an increased interest in how best to feed mentally ill patients. As I will show, many factors went into planning a mental 3 Alternative medical sects, such as the Thomsonians and later homeopaths, became known as “irregulars.” They organized during the 1830s and 1840s to retain the ability to practice medicine, seeing themselves as stopping a monopoly of the “regular,” orthodox physicians who were trained in traditional medical schools based on the scientific, European model. See Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 57-8. 4 Starr, The Social Transformation of American Medicine, 96-7. 5 The doctrine is usually referred to as the “law of similars” or the more colloquial “like cures like.” Homeopaths also believed that a “suppressed itch” caused most diseases, according to Starr. Ibid., 96-7. 21 hospital diet from the view of mental hospital superintendents who were simultaneously administrators and physicians. While some alienists viewed diet as both sustenance and therapy, several went so far as to believe that diet was one key to curing mental illness. For example, one mental hospital superintendent gave a talk titled “Dietetics in the Treatment and Cure of Insanity” at the 1891 annual meeting of mental hospital superintendents and subsequently published it in the American Journal of Insanity.6 The earlier theories of and therapies for illness discussed in the first section, particularly in moral treatment and neurology, played an important role in how alienists advocated for what they found to be the best diet for the mentally ill. Feeding institutionalized patients included not only the proper quantity and quality of food but also the psychological and environmental aspects of food service. My focus on diet as a part of the therapeutic environment in mental hospitals parallels the historiography about asylum superintendents’ belief in asylum architecture as therapeutic.7 Psychiatrists also theorized about the reasons some patients refused food, why some ate too much, and how best to treat those behaviors. Ultimately, they also adapted these theories to new, scientific findings in nutrition science, seeking not only better conditions and therapies for their patients, but also for more scientific legitimacy as a medical specialty. The second half of the chapter thus focuses on the interdisciplinary efforts of Ellen Richards, the founder of home economics and instructor at the Massachusetts Institute of Technology, and Wilbur Olin Atwater, a United States Department of Agriculture (USDA) 6 Selden H. Talcott, “Dietetics in the Treatment and Cure of Insanity,” American Journal of Insanity 48, no. 3 (January 1892): 349. As noted in the article, it was originally read at the Association of Medical Superintendents of American Institutions for the Insane (AMSAII) in May 1891. 7 Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum Keeping, 1840-1883 (New York: Cambridge University Press, 1984), 14. She stated that “Kirkbride’s preoccupation with asylum design was intimately related to his therapeutic goals,” which was based on his understanding of moral treatment and “moral architecture.” See also, Carla Yanni, The Architecture of Madness: Insane Asylums in the United States (Minneapolis: University of Minnesota Press, 2007). 22 chemist and nutrition scientist, to establish a standard diet plan for feeding the institutionalized mentally ill. Historians have pointed out that a branch of institutional home economists developed in the 1890s, but little attention has been paid to their contributions to the larger debate among psychiatrists about the optimal diet physically, psychologically, and economically for mentally ill people in mental hospitals.8 Additionally, Atwater and others, under the USDA Office of Experiment Stations, completed the first major scientific studies of mental hospital dietaries in the United States from roughly 1897 to 1904. While the history of psychiatry has focused on the rise of the pathologist and the laboratory in the mental hospital, contributions from physiological chemists specialized in human nutrition have been largely left behind.9 The following five sections of this chapter thus illuminate this transitional period in the history of medicine and Progressive Era reform. In the first section, I investigate the published work of orthodox and homeopathic alienists as well as neurologists during the nineteenth century to highlight the importance of humoral theory, moral treatment, mental hygiene, and neurological theories of illness in creating a foundational understanding of food as therapeutic due to a view of the mind and body as interconnected aspects of health. The second section examines the work of Austin Flint, a physiologist and alienist who made some of the first 8 Laura Shapiro, Perfection Salad: Women and Cooking at the Turn of the Century (New York: Farrar, Straus, and Giroux, 1986), 162. 9 As Gerald L. Geison argued, at the turn of the twentieth century US medicine and physiology were in a “symbiotic relationship.” See Gerald L. Geison, “Divided We Stand: Physiologists and Clinicians in the American Context” in The Therapeutic Revolution: Essays in the Social History of American Medicine, eds. Morris J. Vogel and Charles E. Rosenberg (Philadelphia: University of Pennsylvania Press, 1979), 68. The first pathologist was hired at a mental hospital by John Gray at Utica Asylum in 1869, and many hospitals followed suit by the 1890s. However, little to no therapeutic progress came from the work of these research pathologists. See Grob, Mental Illness and American Society, 43-4. In addition, Grob noted that papers about the treatment of the mentally ill given at the AMSAII from about 1874 to 1894 “reflected a new interest in pathology, physiology, and pharmacology, and a willingness to experiment with surgical and endocrinological treatments of insanity. All these approaches had relatively little in common with mid-nineteenth-century moral therapeutics.” Ibid., 70. For a discussion about the history science and medicine in appetite, including in psychiatry, see Elizabeth A. Williams, Appetite and Its Discontents: Science, Medicine, and the Urge to Eat, 1750-1950 (Chicago: The University of Chicago Press, 2020). Williams’ examination of appetite in psychiatric theory, however, focused primarily on eating disorders such as anorexia nervosa. 23 scientific investigations into mental hospital dietaries in the US in New York, alongside other hospital superintendents’ articles about mental hospital diets during the 1890s published in the American Journal of Insanity. Sections three and four discuss the interdisciplinary work on the optimal diet for the institutionalized mentally ill done by Richards and Atwater, respectively. The final section explores how some prominent psychiatrists looked to diet as one therapeutic avenue amidst their profession’s growing therapeutic pessimism in the first decade of the twentieth century. Thus, even as some psychiatrists resigned themselves to the notion that nineteenth-century moral treatment was the best psychiatrists could do for their patients, others were optimistic about the scientific possibilities of physiological and dietary studies. Food as Therapy: Humoral Theory, Moral Treatment, Mental Hygiene, and Neurology The roots of the idea that food is therapy need to be considered alongside nineteenth- century medical advances to explain many alienists’ increased interest in diet in the early Progressive Era. Physicians’ conception of food as therapeutic can be traced back to humoral theory, a part of ancient medicine stemming from the teachings of the ancient Greek physician Hippocrates and his followers in the fifth century BCE. In humoralism, the body achieved health through the balance of four different humors. If there was too little or too much of one humor, the imbalance brought illness or disease. Physicians thus chose to treat a disease caused by one humor with therapies correlated with the opposite humor in order to achieve balance. Hippocratic doctors’ most-used therapy was the modification of the patient’s diet by taking away or adding particular foods, but they also utilized bloodletting and drugs.10 During the eighteenth century, physicians continued to believe that disequilibrium in the body caused disease, including mental illness. Although some doctors did recognize that 10 Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (New York: W. W. Norton & Company, 1999), 57-59. 24 psychological factors could predispose people to insanity, most believed that only somatic illness caused disease.11 Many orthodox doctors continued to think that a buildup of one humor or fluid in a particular part of the body caused disease. However, at the turn of the nineteenth century, some doctors versed in developing physiology challenged humoralism with a new theory of disease—solidism—that explained illness as emanating from irritation or damage to “solid parts of the body.”12 For solidists, a pathologic lesion or too much irritation to nerve fibers or blood- carrying arteries caused illness.13 A French physician who became popular in the United States, F. J. V. Broussais, asserted that insanity was, at its most basic, “an irritation” of the brain.14 In addition, in all these systems, eating an unhealthy diet was a significant predisposing factor for disease while particular foods served as exciting causes of disease. Broussais, for example, thought that many people became sick with chronic stomach pain from ingesting poisons, stimulating drugs, or the “influence of food too exciting;” these eventually caused patients to have nervous trouble for several years that irritated the system until the brain also became irritated, thus producing insanity.15 Although humoralism and solidism were at odds, both relied on a foundation of bodily equilibrium as necessary for health and utilized the same traditional, Hippocratic therapeutics.16 Physicians justified these treatments because they used them to regulate the “intake and outgo” 11 Norman Dain, Concepts of Insanity in the in the United States, 1789-1865 (New Brunswick, NJ: Rutgers University Press, 1964), 9-10. 12 John Waller, Health and Wellness in 19th-Century America (Santa Barbara, California: Greenwood, 2014), 13-14. 13 John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820- 1885 (Cambridge, MA: Harvard University Press, 1986), 50. See also, Dain, Concepts of Insanity, 9-10. 14 F. J. V. Broussais, On Irritation and Insanity: A Work, Wherein the Relations of the Physical with the Moral Conditions of Man, are Established on the Basis of Physiological Medicine, trans. Thomas Cooper (Columbia, SC: S. J. M’Morris, 1831), 270, HathiTrust. For his influence on American medical therapeutics, see John C. Burnham, Healthcare in America: A History (Baltimore: Johns Hopkins University Press, 2015), 72. 15 Broussais, On Irritation and Insanity, 183. 16 Dain, Concepts of Insanity, 9. Although some physicians continued to believe in the four traditional humors, by 1800 others had modified their theories of illness to focus on other bodily fluids and substances such as blood or fat. See Waller, Health and Wellness in 19th-Century, 13. 25 of bodily secretions such as sweat, urine, and feces in order to promote equilibrium.17 Whether through a humoral or solidist lens, doctors as well as their patients shared a belief that these therapies were successful based on their ability to visibly change these secretions.18 Before mid- century, many therapies were depletive, and this led to a period of “heroic medicine” or “therapeutic extremism” wherein orthodox doctors intensively utilized bloodletting, purgatives, emetics, and diet to treat patients.19 Many people with mental illness in the late 1700s and early 1800s in the United States— especially those diagnosed with mania—were chained up, isolated in cages or cells, and starved due to this focus on depletion.20 Benjamin Rush, the famous Philadelphia doctor known contentiously as the “father of American psychiatry,” promoted intense bloodletting for patients with mental illness and even advocated starving them in an attempt to redirect blood away from the brain to lessen their symptoms.21 A “low” diet, which could include starvation, was depletive, while a “high” diet was considered to be restorative, or “tonic.”22 For patients with melancholia, a depressive state, doctors prescribed tonics or stimulants.23 Meanwhile, a new approach to mental illness called “moral treatment” emerged in the 1790s and early 1800s in Europe and the United States simultaneously due to some physicians’ and reformers’ optimism about their ability to cure mental illness.24 Most famously, William 17 Rosenberg, "The Therapeutic Revolution,” 488-9. 18 Ibid., 489, 492. 19 Warner, The Therapeutic Perspective, 50, 92, 161. 20 See Tomes, A Generous Confidence, 4. 21 Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York: John Wiley & Sons, Inc., 1997), 15 and Waller, Health and Wellness in 19th-Century America, 177. For one of the earliest historiographical views of Benjamin Rush as the “Father of American Psychiatry,” see Albert Deutsch, The Mentally Ill in America: A History of Their Care and Treatment from Colonial Times (New York: Doubleday, Doran & Company, Inc., 1937), chapter 5. 22 In ancient times, a “low” diet often consisted of barley water, honey water, or a combination of honey and vinegar. See Porter, The Greatest Benefit to Mankind, 60-61. For the use of “low” diets as depletive in the nineteenth century, see Dain, Concepts of Insanity, 26-7. 23 Nancy Tomes, A Generous Confidence, 77. 24 Dain, Concepts of Insanity, 11-12, and Tomes, A Generous Confidence, 4-5. 26 Tuke, a merchant, brought moral treatment to England in 1792 when he founded the York Retreat; in France, Philippe Pinel brought it to the large French mental hospitals when he “liberated the insane” from their chains and instituted the new moral treatment.25 Pinel, breaking from earlier, fully-somatic etiological explanations for mental illness, theorized that mental strain or intense emotion could be the immediate cause of mental illness, while somatic disorder was largely a predisposing cause.26 In the United States, early psychiatrists such as Rufus Wyman, the first superintendent of McLean Asylum beginning in 1818 and Eli Todd, chief of the Hartford Retreat starting in 1824, helped to make moral treatment the dominant system in asylum medicine during much of the nineteenth century.27 Taking up this new focus on psychological causes of insanity alongside somatic ones, asylum doctors sought to treat patients as people who had merely lost their ability to be rational, rather than as hopeless, dangerous people to be chained and locked away.28 Practitioners of moral treatment explained that they strove to approach people with mental illness with kindness and respect while giving them the best environmental conditions—physically and socially—to regain their health through a routine for living that hospital staff created.29 A central part of this 25 Scull, Madness in Civilization, 161. 26 Tomes, A Generous Confidence, 78. 27 Dain, Concepts of Insanity, 24. Although Benjamin Rush was aware of moral treatment and saw the value of psychological treatments, he was not instrumental in bringing moral therapy into the early psychiatric mainstream. Ibid., 21-22. 28 See, for example, Tomes, A Generous Confidence, 4-5 and Scull, Madness in Civilization, 65-66, 196-7, 202-208. However, as Tomes notes, American physicians continued to use physical restraint as well as bleeding and purging during the time of moral treatment. Tomes, A Generous Confidence, 36. 29 Nancy Tomes’ A Generous Confidence is an in-depth study of the Pennsylvania Hospital for the Insane and its superintendent, Thomas Story Kirkbride, whose architectural plans for mental hospitals built according to moral treatment ideals became famous and widely utilized in the mid-twentieth-century United States. For some general overviews of moral treatment’s role in late-eighteenth and nineteenth-century psychiatry, see Dain, Concepts of Insanity, 12-13, 114-117 and Grob, Mental Illness and American Society, 42. Although not specifically about moral treatment, John Duffy sums up the shared view of bodily balance and health during the nineteenth century well. He wrote, “Physicians and their patients shared a general assumption that body and mind were intimately related, and that the normal body balance could be disrupted by individual physiological factors and by the physical and cultural environment.” John Duffy, From Humors to Medical Science: A History of American Medicine (Urbana, IL: University of Illinois Press, 1993), 70. 27 routine was manual labor. Working, superintendents believed, decreased pathologic thoughts and exercised the body to help promote a healthy nervous system.30 Male patients were often assigned to farm and garden, while women were expected to garden, do housework, or sew.31 Food, as part of the therapeutic hospital routine and diet, constituted an important part of moral treatment. As in earlier periods, many superintendents thought that having an “improper” diet harmed the body physically, resulting in mental illness or deterioration.32 Ingesting food, a physiological process, coexisted with the psychological and social aspects of eating, such as dining with others at mealtimes. As one physician explained in 1811, moral treatment included making patients “rise, take exercise and food at stated times” and a diet that “ought to be light, and easy of digestion, but never too low.”33 Providing patients with proper dining opportunities, such as allowing those who were not at risk of harming themselves or others to eat with a fork and knife, was also part of treating them as rational and respected individuals under moral treatment.34 Food stood at the intersection between care and therapy at moral treatment’s inception. As psychiatry began to develop into its own medical specialty that was tied to the asylum during the early nineteenth century in the United States, moral treatment inspired doctors who specialized in treating the mentally ill. This early marriage between the mental hospital and psychiatrists was reflected in the name of the first professional organization for psychiatrists in the United States, the Association of Medical Superintendents of American Institutions for the 30 Dain, Concepts of Insanity, 117. 31 Ibid., 116-117. 32 Tomes, A Generous Confidence, 85. 33 Theodrick Romeyn Beck, An Inaugural Dissertation on Insanity (New York: J. Seymour, 1811), 28, HathiTrust. He refers to “moral management,” which was another name for moral treatment before the term became popular. 34 Dain, Concepts of Insanity, 116. 28 Insane (AMSAII). It was founded in 1844 by thirteen hospital superintendents.35 The reported curative success of moral treatment in asylums in the United States and abroad combined with the efforts of reformer Dorothea Dix to catalyze a period of state-funded hospital reform and construction in the United States from about 1840 to 1860.36 By 1880, there were 139 mental hospitals in the United States, whereas there had only been 18 in 1840.37 In order to provide what they considered to be the most therapeutic environment for patients, state legislatures approved the construction of many hospitals following the “Kirkbride plan,” which were meant to have “a cheerful and comfortable appearance” consisting of a center building with one wing on each side, as well as expansive, scenic grounds for walking and farming.38 According to Kirkbride, a singular superintendent should manage the hospital, and every aspect of the hospital—including “its table service and the food”—was important in ensuring “harmony, economy, and successful results” for patients.39 Because of psychiatrists’ link to the asylum and an increasing number of people who required treatment for mental illness and lacked the means to pay for private clinics, treating the institutionalized mentally ill remained the focus of nineteenth-century psychiatrists. Under the system of moral treatment, these physicians approached health not only physically but also psychologically.40 35 Even after the AMSAII changed its name to the American Medico-Psychological Association (AMPA) in 1893 to better represent the breadth of professionals doing psychiatric research and treating mentally ill patients, medical superintendents continued to remain central figures in the association. It is notable that the British equivalent of the AMSAII, the Asylum Officers’ Association, changed its name to the “Medico-Psychological Association” in 1865, almost thirty years earlier than in the United States. See L. S. Jacyna, “Somatic Theories of Mind and the Interests of Medicine in Britain, 1850-1879,” Medical History 26 (1982): 255. The name change is not merely symbolic; psychiatry in the United States and Great Britain developed parallel to one another, so comparisons should be done carefully. 36 See Scull, Madness in Civilization, 196. 37 Tomes, A Generous Confidence, 265. 38 Thomas Story Kirkbride, On the Construction, Organization, and General Arrangements of Hospitals for the Insane (Philadelphia: Lindsay & Blakiston, 1854), 6-7, 12, HathiTrust. See also, Dain, Concepts of Insanity, 3. 39 Kirkbride, On the Construction, Organization, and General Arrangements of Hospitals for the Insane, 42. 40 Dain called moral treatment the “new psychological medicine of the 1780’s and 1790’s,” although he notes that the movement "might be considered a culmination and extension of certain aspects of accepted medical theories” of the eighteenth century. Dain, Concepts of Insanity, 5-6. 29 This period of asylum construction in the United States and the widespread adoption of moral treatment by mental hospital superintendents also coincided with a larger shift in what types of therapies were popular. Beginning around 1830 and solidifying by 1850, many physicians did away with heroic therapeutics and intensive depletive therapies, shifting instead to a preference for stimulative, tonic therapies.41 This shift included diet. A “high diet” that supported the body’s healing became more common than the use of a “low diet.”42 Although doctors continued to view the body as a system, many focused more on treating physiological processes located in specific areas of the body, such as the gastrointestinal tract, rather than treating systemic balance generally.43 Therefore, in psychiatry by the mid-nineteenth century, the view that somatic factors—lesions that could be viewed upon autopsy or even cellular deformities of brain tissue—led to mental disease was prevalent especially among alienists who wished to medicalize their field.44 The professional journal where mental hospital superintendents most discussed these issues was the American Journal of Insanity (AJI). It was the most prominent medical journal for psychiatry as well as the oldest in the United States.45 The journal was founded in 1844, the same year as the AMSAII. Although it was originally published under the New York State hospital at Utica, in practice it was the publication of AMSAII (until the AMSAII officially bought the journal from Utica in 1892). As the official professional journal of mental hospital 41 Warner, The Therapeutic Perspective, 95, 98. 42 Ibid., 145-6. 43 Ibid., 101-2. 44 Charles E. Rosenberg, The Trial of the Assassin Guiteau: Psychiatry and the Law in the Gilded Age (Chicago: University of Chicago Press, 1995), 63-64, 69, 174 and Jacyna, “Somatic Theories of Mind,” 249. 45 After the American Medico-Psychological Association changed its name to the American Psychiatric Association in 1919, the name of the American Journal of Insanity changed two years later to the American Journal of Psychiatry. This relationship remains to the present day. 30 superintendents, and then more broadly, all medical and scientific professionals interested in psychiatric medicine, the AJI served as an important forum for professional communication. Psychiatrists discussed the best diet for people institutionalized with mental illness beginning in the earliest years of the AJI using a language of energy flow, particularly for patients who had chronic mental illness. In one 1847 article, “The Medical Treatment of Insanity,” the author included the use of special diets as therapy for bowel troubles, but also pointed to the importance of diet in chronic cases of insanity based on the idea of depletion, connected to humoralism and the other medical systems. “Many cases, especially those of some months of continuance, require invigorating diet and tonic remedies,” he wrote. This change to a tonic diet, as one aspect of moral treatment then popular, reflected the shift away from the depletive treatments of Rush and earlier alienists. Further, the author posited that if grief, anxiety, or intemperance had “debilitated the system” thus causing a patient’s insanity, then those patients should not receive depletives because there was “usually danger in depleting.”46 In a time when purgatives, emetics, and bloodletting could cause patients to be uncomfortable at the least, or die at the worst, diet was a safe and well-tolerated therapeutic tool. Following the Civil War, U.S. psychiatrists continued to use a language based on the body as a system, but also talked more explicitly about how people institutionalized with insanity required a different quantity and quality of food than a healthy person. Massachusetts psychiatrist and statistician Edward Jarvis argued in 1865 that in institutions it cost more to feed the mentally ill than otherwise healthy people because they needed “a more digestible and nutritious diet.”47 Patients who were “insane” needed “nourishment, not only of better quality, 46 "The Medical Treatment of Insanity," American Journal of Insanity 3, (1847): 356. 47 “Comparative Cost of Support of the Insane and the Sane,” American Journal of Insanity 22, no. 2 (October 1865): 256. Jarvis received his medical degree in 1830 and then went into private practice. After moving to Kentucky and then back to Massachusetts, his private practice—which utilized moral treatment—became very 31 but oftentimes more abundant in quantity, to meet the excessive and morbid expenditure of force by the maniac in his excitements, and to save the melancholiac and those who are tending to dementia from sinking under their depressions into torpidity, and if possible to raise the demented out of their sluggishness.”48 This idea—that patients who were excitable/manic and those who were depressive/melancholic needed a larger quantity of food because of the energy sapped due to their mental illness—came to define the ideal hospital diet as very generous for the mentally ill up until Atwater’s early-twentieth century studies of mental hospital diets. Jarvis’ arguments, combined with the humanitarian impulse of moral treatment, justified to legislators how mentally ill patients had to be fed a better diet than inmates of other types of state-funded institutions who were mentally healthy. Even as psychiatrists were working in asylums and treating mentally ill patients, some spent time advocating for attention to be paid to maintaining mental health as part of “mental hygiene.” The avoidance, or prophylaxis, of mental illness was commonly referred to as “mental hygiene” beginning in the mid-nineteenth century, although the phrase is more commonly connected with the mental hygiene movement that gained national prominence during the early twentieth century.49 “Irregular” physicians also shaped discussions of mental hygiene beginning around 1830, as some irregular physicians and members of the public turned to personal hygiene as a way to maintain health and avoid the bloodletting and purgatives that orthodox medical successful in the 1850s, only focusing on treating mentally ill patients whose families hoped to avoid institutionalization in a hospital. His work in his practice in addition to his scholarly articles in medical journals earned him a strong reputation as a psychiatrist. See Gerald N. Grob, Edward Jarvis and the Medical World of Nineteenth-Century America (Knoxville: University of Tennessee Press, 1978), 27-8, 59-60. 48 “Comparative Cost of Support of the Insane and the Sane,” 256. 49 This will be discussed further in chapter 2. Medical historians have generally overlooked the earlier articulation of mental hygiene in the nineteenth century in favor of the mental hygiene movement in the twentieth. A strong overview of mental hygiene in the nineteenth century can be found in Jacques M. Quen, “Isaac Ray and Mental Hygiene in America,” Annals of the New York Academy of Sciences 291, no. 1 (April 1977): 83-93. 32 practitioners were known for.50 The theory that mental and physical health were co-constructive helped to create the interest in mental hygiene in both orthodox and irregular physicians and their patients. Homeopaths interested in treating mental illness as well as allopathic alienists advocated for programs of mental hygiene that integrated body and mind into a holistic system. They included diet in these programs because it was fundamental to physical health. Homeopath David Gorton argued in 1873 that “the mind, no less than the body, is subject to physical laws; and that corporeal and mental maladies may mutually supplement and counteract each other.”51 The nationally prominent asylum superintendent of Utica Asylum in New York and an editor of the AJI, John Gray, seemed to agree with Gorton’s conception of mental hygiene as program to understand and influence the relationship between the mind and body to improve health. He began his 1878 began his address “Mental Hygiene” with the argument that the “classical phrase, ‘Mens Sana in Corpore Sano,’ is a general and true expression of the related condition of the mind and body for the best functions of human life.”52 Because of this, he thought mental hygiene was “practically inseparable from Physical Hygiene” and was an expansive field that included food as one of its facets.53 In comparison, Gorton believed more strongly in the idea that food was moral, as he asserted that a person’s “mental character is modified, exalted, or depraved, according to the quality and quantity of the food one eats,” and was also wary of the 50 Duffy, From Humors to Medical Science, 87. Duffy places the end date of this movement as 1870, but these ideas remained powerful for the rest of the century. 51 David A. Gorton, An Essay on the Principles of Mental Hygiene (Philadelphia: J. B. Lippincott & Co., 1873), 12, HathiTrust. He also attempted to invoke “mens sana in corpore sano” on his title page but quoted it as “Sana mens in corpore sano.” 52 John P. Gray, “Mental Hygiene,” American Journal of Insanity 34, no. 3 (January 1878): 307. For more on Gray, including his competition with neurologists and participation in the Guiteau trial as an expert witness in 1881, see Rosenberg, The Trial of the Assassin Guiteau. 53 Gray, “Mental Hygiene,” 310, 319. Gray’s definition of mental hygiene was expansive, nationalist, and based on early eugenic ideas. 33 effects of eating too much meat.54 In humoral theory, meat was “stimulating” and “heating,” which could lead to increased vitality for some, but also selfishness and violence for others. Although alienists had shifted away from depletion, Gorton’s and other alienists’ continued belief in humoral theory made meat a somewhat contested food in diets for the mentally ill, even into the turn of the century. Food as one aspect of mental hygiene as advocated by orthodox physicians who treated mental illness was most prominent in Isaac Ray’s 1863 book Mental Hygiene. Although it was not meant to be a “complete scientific treatise on the subject” and was designed to be of interest “to the general reader,” the work outlines many fundamentals of his theory of mental hygiene and its therapeutics. Ray’s definition of mental hygiene was: […] the art of preserving the health of the mind against all the incidents and influences calculated to deteriorate its qualities, impair its energies, or derange its movements. The management of the bodily powers in regard to exercise, rest, food, clothing, and climate; the laws of breeding, the government of the passions, the sympathy with current emotions and opinions, the discipline of the intellect, —all come within the province of mental hygiene.55 Within this list, food stood out as particularly significant to Ray’s program of mental hygiene. In a section of the book explaining the impacts of “physical influences” on mental hygiene, he claimed: “Among other agencies that affect the heath of the mind, none exerts a wider influence, probably, than diet.”56 Like Gorton, Ray’s discussion of diet most engaged with the amount of meat that people in the United States ate and its relationship to health. He used humoral theory when he explained that the colder the weather was, the more “stimulating” food (meat) was required. But overall, he thought Americans consumed too much meat out of habit when many 54 Gorton, An Essay on the Principles of Mental Hygiene, 50-53. Within his discussion of “quantity in diet” as an “influential agency in mental hygiene,” Gorton noted Benjamin Rush’s recommendation for “a low diet in some forms of madness,” as discussed previously. See ibid., 58-9. 55 Isaac Ray, Mental Hygiene (Boston: Ticknor and Fields, 1863), 15, HathiTrust. 56 Ray, Mental Hygiene, 77. 34 people, particularly those who worked in sedentary jobs, could achieve good health with a diet heavy in vegetables.57 These ideas, blending humoral theory with an early understanding of how one’s job could affect metabolism, served as a precursor to psychiatrists’ later discussions about which foods were most important in feeding the mentally ill, including many who participated in some kind of labor in the hospital. While alienists had begun investigating psychological causes for mental illness alongside physiological ones by the mid-nineteenth century, neurologists also developed their own medical specialty which included brain disease and thus, mental illness. Neurologists thought that they were better qualified to treat mental illness because they had a scientific understanding of the brain and nervous system that alienists working in asylums did not.58 They argued that mental disease was due to purely somatic causes, especially nerve exhaustion.59 George Miller Beard most famously introduced the condition neurasthenia—“exhaustion of the nervous system”— into American medicine in 1869.60 Neurasthenia, he argued, was a somatic condition similar to anemia. Just as there was “want of blood” in the vascular system with anemia, there was “want of nervous force” in the nervous system with neurasthenia.61 He hypothesized that the somatic mechanism that caused neurasthenia was a “molecular disturbance” of the central nervous 57 Ibid., 83. It is important to note that Ray’s conception of “people in the United States” is likely that of white, Anglo Saxons. Throughout his discussion of diet, he compares the food of different types of people, including Chinese immigrant miners who lived mostly on vegetables, Scotch farm laborers who lived almost entirely on oatmeal, and the “diet of an Esquimaux, or African negro” which was “most easily accessible, if not the only kind within his reach, [and] is best adapted to his constitution.” Ibid., 79-81. 58 Nathan G. Hale, Jr., Freud and the Americans: The Beginning of Psychoanalysis in the United States, 1876-1917 (New York: Oxford University Press, 1971), 49. 59 By the end of the nineteenth century, neurologists and psychiatrists vied for medical authority, but psychiatrists remained firmly in control of state and federal mental hospitals, while neurologists primarily ran private clinics. See Waller, Health and Wellness in 19th-Century America, 185. 60 George Beard, “Neurasthenia, or Nervous Exhaustion,” Boston Medical and Surgical Journal 3, no. 13, New Series (April 29, 1869): 217, HathiTrust. 61 Beard, “Neurasthenia, or Nervous Exhaustion,” 217. Italics are in the original. See also Tom Lutz, “Varieties of Medical Experience: Doctors and Patients, Psyche and Soma in America,” in Cultures of Neurasthenia from Beard to the First World War, eds. Marijke Gijswijt-Hofstra and Roy Porter (New York: Rodopi, 2001), 52-53. 35 system due to chemical changes, particularly due to a loss of phosphorous.62 Its symptoms were broad and included fatigue, poor appetite, pain without an organic cause, and a loss of interest in mental labor; Beard and other neurologists came to believe that the exciting causes of neurasthenia were the pressures and struggles of new urban and industrial lifestyles, particularly on middle- and upper-class people.63 Based on Beard’s foundations, neurologists at the end of the nineteenth century thought the “principle of nutrition”—which included the therapies of “diet, rest, massage, exercise, drugs, [and] electricity”—was the best therapeutic system to help the nervous system to create and maintain the necessary energy to be healthy.64 Diet, as a foundation of physical health, became an important aspect of treating mental illness for both neurologists and alienists. The centrality of diet to good mental health and as a therapy for mental illness from the perspective of neurologists came most famously from Silas Weir Mitchell. After earning his medical degree from Jefferson Medical College and studying further in Paris with the noteworthy physiologist Claude Bernard, he began practicing medicine in 1851 in Philadelphia, Pennsylvania with his father.65 His chief contribution to the treatment of mental illness was his creation of the “rest cure” for neurasthenia and hysteria. Mitchell’s influential 1877 Fat and Blood: and How to Make Them laid out his rest cure program of “entire rest and of excessive feeding, made possible by passive exercise obtained through the steady use of massage and 62 Ibid., 218. 63 Ibid., and George M. Beard, American Nervousness, Its Causes and Consequences: A Supplement to Nervous Exhaustion (Neurasthenia) (New York: Putnam, 1881), vi, HathiTrust. He cited the primary cause for the development of nervousness in Americans during this period to be “modern civilization,” which had “steam power, the periodical press, the telegram, the sciences, and the mental activity of women” as its most distinguishing features. 64 Hale, Freud and the Americans, 53. As Hale discusses, “nutrition” was never clearly defined, which is not surprising given the advances in science and medicine during this period that frequently complicated existing physiological and theories. 65 Dennis Wepman, "Mitchell, S. Weir (1828-1914), Physician and Writer," February 1, 2000, accessed April 9, 2021, American National Biography Online. 36 electricity.”66 Alongside bedrest, a diet that was heavy in milk and fat was central to his therapy, and was not much different from what psychiatrists promoted as a nutritious diet for people with or attempting to prevent mental illness. The rest cure’s fattening diet continued a focus on tonic remedies rather than depletive ones. Because both psychiatrists and neurologists thought that mental disease and bodily disease were related, both saw diet as a potential therapy for mental illness. Asylum alienists treated cases of neurasthenia in their institutions, even as neurologists treated many cases of mild or moderate neurasthenia in their private clinics. For example, Superintendent John B. Chapin of the Pennsylvania Hospital for the Insane treated neurasthenia with a regimen derived from the rest cure. He utilized a liberal diet that “added pounds,” which corrected the exhaustion of the nervous system driven by poor nutrition.67 By the 1890s, many psychiatrists adopted the theory that nervous exhaustion could cause neurasthenia, which could ultimately lead to insanity. Even so, as I will discuss in the next section, studies into diets for mental illness that mental hospital superintendents published during the 1890s usually did not focus on neurasthenia specifically, instead highlighting longer-standing categories of mental illness such as dementia, mania, and melancholia. In the context of seeing the health of mind and body as intertwined, many alienists interested in mental illness during the mid-nineteenth century, whether allopathic or homeopathic, saw diet as one avenue for the inculcation of mental health in a program of mental hygiene and a potential therapy for mental illness. Ways of looking at diet as therapeutic from humoral theory continued to carry weight in discussions about what to feed people to maintain 66 Silas Weir Mitchell, Fat and Blood: and How to Make Them (Philadelphia: J. B. Lippincott & Co., 1877), 7, HathiTrust. 67 Dain, Concepts of Insanity, 136. 37 mental health or cure mental illness as they blended with theories of the mind and body as interdependent parts of a whole. Alienists’ and neurologists’ ideas about diet and health prominent from moral treatment, mental hygiene, early attempts to tailor food to the institutionalized mentally ill, and neurological theories about diet’s ability to restore nervous energy formed the foundation for the first major discussions of the best diet for the institutionalized mentally ill that came in the 1890s. Diet for the Institutionalized “Insane” in the American Journal of Insanity In the 1890s, advances in laboratory science as well as government interest in how to economically feed inmates of overcrowded public institutions catalyzed medical and scientific interest in the relationship between diet and insanity. While mental hygiene faded until its twentieth century reemergence as a major public health reform effort, alienists’ focus on both the physical and psychological aspects of mental illness derived from moral treatment remained, even as patient populations rose because more people admitted to hospitals had chronic, rather than acute, illness.68 As the forces of urbanization and industrialization led people to large cities, people with chronic mental illness who had been cared for by family members or their communities were increasingly committed to mental hospitals, thus leading to larger numbers of chronic patients and to overcrowding. Because of this change in patient profile, recovery rates dropped, and mental hospitals began to develop reputations for warehousing patients. In 1885, recovery rates were between 20 and 40 percent, while by 1910, they had dropped to between 15 to 35 percent.69 Facing these pressures, some psychiatrists turned to diet as one avenue to assert 68 Grob, Mental Illness and American Society, xi-xii. Much of this rise was caused by somatic diseases that had behavioral or psychological symptoms such as neurosyphilis (the bacterium was discovered in 1905) and pellagra, as discussed in chapters 2 and 4. Ibid., xi and Hale, Freud and the Americans, 52. Theories that insanity was also hereditary played a role in labeling many cases as chronic too, because heredity was fixed. Hale, Freud and the Americans, 96. 69 Ibid., 75. Hale also stated that between 1870 and 1910 recovery rates dropped fifty percent. 38 medical and administrative authority in the hospital, searching for ways to make psychiatry more scientific so as to not only create better therapies for mental illness but also to fend off harsh criticisms about the lack of science in psychiatry and the efficacy of psychiatric therapeutics from neurologists like Silas Weir Mitchell.70 In this section, these challenges will be explored through an examination of the mental hospital doctors who wrote about diet’s role in the care and treatment of the mentally ill during the 1890s. First, I introduce the psychiatrists who advocated for more attention to be paid to the diet of the institutionalized mentally ill. My analysis begins with the administrative aspects of patient feeding, including the need to balance economy and health. Then, I discuss how psychiatrists viewed diet not only as sustenance but as therapy and even cure. Next, I explain how physiology and nutrition science shaped the formation of the first standard dietaries in mental hospitals and how psychiatrists used different medical theories to explain the importance of particular articles of diet in feeding the mentally ill. The difficulties in feeding patients who refused food for various reasons are then examined alongside the ways that psychiatrists viewed psychological and cultural aspects of food as important in persuading patients to eat and in creating a healthy dining environment. Finally, I discuss some of the problems that psychiatrists had with the use of standard dietaries, and one proposed solution. Although their ideas differed at times, they illuminate a strong consensus about the therapeutic role of diet in the institution. 70 Mitchell was especially critical of the lack of scientific knowledge and effective therapeutics of psychiatrists in his 1894 keynote at the annual American Medico-Psychological Association meeting. Silas Weir Mitchell, “Address before the Fiftieth Annual Meeting of the American Medico-Psychological Association, Held in Philadelphia, May 16th, 1894,” Journal of Nervous and Mental Disease 21, no.7 (July 1894): 413-437, Ovid. A professional battle between neurologists and psychiatrists over who should care for and treat people with mental illness had been ongoing in what Bonnie Ellen Blustein called the “asylum reform movement of 1878-83.” Although her study ends in 1883, Mitchell’s keynote shows that neurologists like Mitchell still sought to use “science” as a lever of criticism against hospital superintendents. See Bonnie Ellen Blustein, “’A Hollow Square of Psychological Science’: American Neurologists and Psychiatrists in Conflict,” in Mad Houses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian Era, ed. Andrew Scull (Philadelphia: University of Pennsylvania Press, 1981), 241. 39 Psychiatrists discussed mental hospital diets in the AJI in the 1890s more frequently than in previous decades. Four psychiatrists published articles addressing this topic from 1892 to 1898. They were Selden H. Talcott, superintendent of Middletown Homeopathic Hospital in New York, J. D. Munson, superintendent of the Michigan State Asylum located in Traverse City, Michigan, Charles W. Pilgrim, superintendent of Hudson River State Hospital in Poughkeepsie, New York, and Edgar J. Spratling, the first assistant physician at the Massachusetts Hospital for Epileptics.71 Despite intense professional conflict between 1850 to 1880 from “regular” doctors seeking to gain a monopoly on medical authority, homeopathic doctors at the time of Talcott’s article in the 1890 held significant credibility with the public and amongst many orthodox physicians.72 The combination of one homeopathic alienist (Talcott), two orthodox alienists (Munson and Pilgrim), and an alienist located in a hospital for epileptics (Spratling) shows how eclectic psychiatric medicine in the 1890s was but also how overlapping ideas created a psychiatric consensus about the best diet for the mentally ill in institutions. Published outside of the AJI but referenced in many of these articles, Austin Flint Jr.’s report on mental hospital dietaries in New York state institutions was also foundational in setting a standard mental hospital diet. After he graduated medical school, he became a professor of 71 Many physicians considered epilepsy to be a form of insanity in the late nineteenth and early twentieth centuries. I categorize Spratling as a psychiatrist because of this and the fact that he primarily cared for people considered to be insane when he wrote his article. At the time Spratling worked at the newly opened Massachusetts Hospital for Epileptics and wrote his article, close to 85 percent of patients were categorized as insane. For this statistic, and a larger discussion of epilepsy as it related to concepts of insanity during this period, see Walter J. Friedlander, The History of Modern Epilepsy: The Beginning, 1865-1914 (Westport, CT: Greenwood Publishing Group, 2001), 186. 72 See Starr, The Social Transformation of American Medicine, 96-102. Homeopathy’s influence faded quickly in the first two decades of the twentieth century as biomedical breakthroughs in therapeutics proved effective and gained respect. Ibid., 107-8. Talcott, alongside other superintendents including Samuel Worcester from the Massachusetts Homeopathic Asylum, had even served as an expert witness in the trail of presidential assassin Charles Guiteau. See Rosenberg, The Trial of the Assassin Guiteau, 173. For further biographical information about Talcott, see Jonathan Davidson, A Century of Homeopaths: Their Influence on Medicine and Health (New York: Springer, 2014), 66-69. Springer Link. 40 physiology at Bellevue Medical College.73 In 1867 he used his training in physiology to complete an inspection of the dietary conditions in public institutions of all types in New York; this gave him valuable experience for assessing mental hospitals’ dietaries in the 1890s. He became interested in mental illness in the 1870s and then developed expertise in mental diseases.74 Although he was not a mental hospital superintendent and did not treat patients with mental illness, many people in the 1890s considered him to be a psychiatrist. Both Munson and Pilgrim cited Flint’s report in their articles, showing the impact of Flint’s physiological knowledge and his own expertise in mental illness on psychiatric discussion of the most healthful ways to feed the institutionalized mentally ill. As mental hospital administrators, psychiatrists had to balance economy and dietary quantity and quality when deciding what food to purchase. Superintendents agreed that it was the state’s job to provide patients with at least a sustenance diet, but many argued for a diet better than this. Talcott thought that “the quality of the food given to the insane should be of the best” and went so far as to argue that the AMSAII “should declare itself in favor of a generous and effective dietary for the insane, even though it costs much money.”75 Talcott lobbied the national professional organization to support this policy, ostensibly to put superintendents in a better position to ask their state legislatures for more money for food. In comparison, Munson noted that running a public hospital required “business management” where the superintendent kept “the cost of maintenance at the lowest price compatible with the health and welfare of the hospital population.” Significantly, however, he did not think that the food could be sacrificed to 73 Bill Scott, “Flint, Austin (1836-1915), Physiologist, Forensic Psychiatrist, and Specialist in Mental Disorders," February 1, 2000, accessed December 8, 2020, American National Biography Online. 74 He became a member of the New York Lunatic Asylum in 1878 and took two courses about mental disease with the famous psychiatrist Carlos F. MacDonald in 1887. Because of this experience and expertise, Bill Scott categorizes him as a “forensic psychiatrist” and “specialist in mental diseases” alongside his original field of physiology. Ibid. 75 Talcott, “Dietetics in the Treatment and Cure of Insanity,” 349. 41 economy, precisely because food was therapeutic. He stated that it was “of supreme importance for the cure and comfort of patients that foods, in quality and in mode of cooking, be of high order.”76 The curative properties of diet were most clearly expressed by Pilgrim, the superintendent of Hudson River State Hospital in New York. “In many cases of recent insanity the question of diet is one of life or death, or of speedy recovery or confirmed dementia,” he wrote.77 In a period when chronic cases of insanity were rising, mental hospitals were overcrowded, and no new scientific therapies were available, Pilgrim believed that diet could change a clinical outcome in the case of acute mental illness. For some psychiatrists, the right diet meant the difference between a patient making a recovery or joining the ranks of the mentally ill who were permanently institutionalized with a chronic condition. Flint, a physiologist and alienist, used a powerful combination of therapeutic and economic grounds to argue for a high quantity and quality of food in mental hospitals. In addition, he proposed a diet for use in mental hospitals that was based on “a quantity and variety of food peculiarly adapted to the insane,” and argued that “a most important part of the treatment of the insane relates to general nutrition; and many patients suffering from mental diseases require a great abundance of nutritious food, which contributes very largely to their cure.”78 Even though the cost of food may be high in the short term, he argued, it would save the state money in the long term because patients would be released sooner due to the benefits of a nutritious diet rather than continue to have to be cared for by public funds.79 Such an argument displays 76 J. D. Munson, “Asylum Dietaries,” American Journal of Insanity 52, no.1 (July 1895): 58. 77 Charles W. Pilgrim, “The Dietary of the New York State Hospitals,” American Journal of Insanity 52, no. 2 (October 1895): 232. 78 Austin Flint, “Report on Dietaries and Food Supplies for State Hospitals” in State Commission in Lunacy Fifth Annual Report (Albany, NY: James B. Lyon, State Printer, 1894): 14, HathiTrust. 79 Flint, “Report on Dietaries,” 14. 42 therapeutic optimism for food as therapy during a time when psychiatrists saw few therapeutic or scientific advances being made in their field compared to the steadily rising tide of the germ theory of disease. The idea that diet was therapeutic, even curative, also became a strategic argument for a diet in institutions for the mentally ill that was better in quantity and quality than other public institutions such as prisons and almshouses.80 Flint believed that patients with mental illness not only required a better diet because of their illness but also deserved a diet better than the sustenance-level one inmates in prisons or poor houses often received because mental illness was not “any fault of their own.”81 During this period, this represented a humanitarian view of caring for and treating patients with mental illness versus a punitive approach to other inmates. Although moral treatment was no longer dominant in mental hospital therapeutics, the desire to help this group of vulnerable people with a healthy environment and nourishing diet remained. Furthermore, studies like Flint’s set nutritional standards that likely helped ensure patients in state mental hospitals in New York and many others elsewhere were being fed at least adequately. Flint’s report became popular outside of New York institutions primarily because of his “Daily Ration” table, a suggestion for a standard diet at a mental hospital. Flint’s diet was one of the first available to hospital superintendents in the United States. He created his table by examining the dietaries of institutions for the mentally ill in Great Britain and the United States 80 Further research is required to discern how much the dietaries in different institutions varied. As one doctor wrote in 1905: “There is no [prison] dietary that can specifically be called American. In the best ordered prisons the dietaries are based on Atwater’s standards. In many States the diet is left to the steward of the prison, and no particular method is followed. Details will be found in the reports of the various institutions and in the reports of conventions of charities and corrections.” Julius Friedenwald and John Ruhräh, Diet in Health and Disease, Reprint (Philadelphia: W. B. Saunders and Company, 1905), 562, HathiTrust. 81 Flint, “Report on Dietaries” 14. He wrote: “While it may be proper to provide for ordinary paupers and criminals little more than enough to keep them in fair physical condition, the insane poor, though a charge on the State, should receive better consideration.” Ibid. 43 in addition to the accepted and “liberal” United States Army ration, which was based on the food required for physically-active workers.82 He also utilized his knowledge of physiology to calculate the quantities—weights in ounces in this case—of the food in the ration.83 Flint’s daily ration included: 12 oz. meat in any form (fresh and/or salted, including fish and poultry); 16 oz. of flour for bread and in cooking (which could be partially substituted by corn meal or macaroni if need be); 8 oz. of potatoes; 8 oz. of milk; two eggs, which equated to 4 oz.; 2 oz. of sugar, 2 oz. of butter; 2 oz. of cheese, 1.5 oz. of rice, hominy, or oatmeal; 1.5 oz. of dried beans or peas; 1 oz. of unroasted coffee; and an eighth of an ounce of black tea.84 Fruits, vegetables, and condiments were not included in the diet but could be used when available and as needed. Ideally, according to Flint’s calculations, men should receive 5 percent more than this and women 5 percent less to account for physiological differences. Besides providing the individual’s ideal “daily ration,” Flint’s report was popular because it also provided a table that listed the quantities of supplies to purchase for one hundred people to last for thirty days.85 In Pilgrim’s estimation, the table was useful and did an “admirable” job feeding “patients not under extra diet and attendants.”86 Superintendents found this particular table extremely helpful because they could pass it on to the steward, who was usually in charge of purchasing food supplies for the hospital. As helpful as Flint’s tables were, he did not include his physiological calculations or calorific values, which shows the transitional nature of science and of scientific communication at this moment. Physiologists had studied the chemical composition of most foods to the level of 82 Ibid., 15. Note that the term “liberal” here is not used in a political sense. 83 Ibid. 84 Ibid., 15-16. 85 Ibid., 17. 86 Pilgrim, “Dietary of New York State Hospitals,” 230-231. 44 the macronutrients and minerals, but vitamins had not yet been discovered. Experiments in human digestion and metabolism, particularly those using the “calorimeter” in Europe, had only just begun to make their way into American science through the famous physiological chemist Wilbur Olin Atwater.87 He first began writing about the calorie as food energy in 1896, and is discussed in a later section of this chapter.88 Flint, as a physiologist, may have heard of the calorie if he was keeping abreast of new research in the field, but may have chosen to suggest a standard diet in food weight since calories did not become a widespread way to calculate a proper diet until the 1920s.89 Some hospital superintendents welcomed this new, scientific way to discuss the proper diet of the mentally ill as neurologists continued to criticize them. Silas Weir Mitchell had told hospital superintendents gathered at the 1894 annual meeting of the AMPA that neurologists did not “believe that you are so working these hospitals as to keep treatment or scientific product on the front line of medical advance.”90 In relation to food, Mitchell stated that when he visited the wards at a city mental hospital, patients were “silent, grewsome [sic] machines which eat and sleep, and sleep and eat.”91 With prominent critiques such as this, mental hospital superintendents during the 1890s had good reason to highlight not only therapeutic benefits of diet in the hospital, but also their knowledge of new, scientific research in human nutrition being done by dietitians and physiologists. 87 Helen Zoe Veit, Modern Food, Moral Food: Self-Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century (Chapel Hill: University of North Carolina Press, 2013), 46, 48. 88 Veit, Modern Food, Moral Food, 46. 89 Ibid., 46, 48. 90 Mitchell, “Address before the Fiftieth Annual Meeting of the American Medico-Psychological Association,” 422. He also asked more than once where the alienists’ “careful scientific reports” were. Ibid., 432. Mitchell was also critical of the food mental hospitals served to their patients, writing that the diet was monotonous, and the food was “plain.” He alleged that he received a letter once from a friend who had spent time in “one of the great asylums” who wrote of his experience: “I have heard of the horrors of asylums. Let me assure you that although there is much there that is sad, nothing is half so tragic as the diet.” Ibid., 429. 91 Ibid., 431. 45 Munson, in his article published in 1895, displayed a knowledge of nutritional science rare for an alienist of the period. Furthermore, he expressed his hope that the article would signal to readers that he was a scientific psychiatrist. He asserted that he wrote the article out of a “desire to make known our experience in establishing a more scientific basis on which to furnish foods to our people.”92 After studying home economist Mrs. S. E. Wentworth’s studies at Kankakee Asylum, Munson first tried to adapt the hospital’s diet to the United States Army and Navy rations before instituting a similar diet to Flint’s suggested one. Munson understood the importance of different proportions of protein, fat, and carbohydrates in the diet as well as using calories to measure food energy. He asserted, for instance, that “the dietary for the insane must be generous, not less than 110 protein, 110 fat, and 450 grammes of carbohydrates per patient per day.”93 These proportions made sense when Munson identified the most important foods in the patients’ diets as butter, and milk, which needed to be carefully selected for quality.94 Furthermore, after noting that the Northern Michigan Asylum’s ration was 3,406 calories per day compared to the 3,175 calories at Kankakee Asylum in Illinois, Munson explained what a calorie was by quoting the applicable passage from the National Medical Dictionary.95 Munson’s marshalling of the cutting-edge nutritional science to justify his liberal diet for the mentally ill shows how food, through nutrition science, provided one avenue for psychiatrists to try to prove that their therapies and research were not stagnant. In both Flint’s and Munson’s discussion of the proper diet, some foods were seen as more healthful than others; the question of which foods were best for people with mental illness shows most clearly how this was a transitional moment in medicine, as theories of health based on the 92 Munson, “Asylum Dietaries,” 58. 93 Ibid., 59. 94 Ibid., 63. 95 Ibid., 59. 46 humors, nervous energy, and chemical nutrients overlapped. The overlap between these categories means that this discourse defies the easy categorization that has been generally useful to the historian. Indeed, psychiatrists’ discourse about the best food for people institutionalized with mental illness in the 1890s reveals how the variety of competing theories about food and illness, which originated in different eras, blended together though their common belief that mind and body were interdependent. The consensus among hospital superintendents in the 1890s was that the most important foods for feeding the mentally ill were milk, butter, and meat. Pilgrim, for example, highlighted milk as “the one article of diet in the use of which there should be little or no restriction” when it came to feeding mentally ill patients.96 Butter, another dairy product—used frequently in cooking and baking as well as a topping on toast—was particularly useful in the diet due to its high fat content.97 Cheese, unlike butter, was not a food that Americans ate a lot of during this period; thus, although physicians, nutrition scientists, and home economists familiar with European diets considered it to be healthful, it was not featured as prominently on hospital dietaries.98 Eggs were also particularly important for patients who were sick or needed extra nourishment. Fish and some seafood also appeared on hospital dietaries, but not as much as beef. Although fish had a popular reputation of being a “brain food” at the time, Talcott and other physicians dismissed this and did not feed it in large amounts to patients.99 Vegetables and fruit were similarly seen as healthy overall, but less essential compared to dairy and meat. Indeed, 96 Pilgrim, “Dietary of New York State Hospitals,” 232. 97 See, for example, Munson, “Asylum Dietaries,” 63. 98 Flint, “Report on Dietaries,” 17. He wrote that cheese “is of good quality, is a very nutritious article and is too little used in the United States.” Richards, the home economist, similarly wrote that “we have not been able to persuade the American people to eat the quantities of peas, beans, and cheese which the report calls for, even with the most careful cooking and flavoring” in Ellen H. Richards, “Notes on Hospital Dietaries,” American Journal of Insanity 52, no. 2 (October 1895): 215. 99 Talcott, “Dietetics in the Treatment and Cure of Insanity,” 344. 47 many of the first and most famous nutrition scientists thought that vegetables and fruits were of little nutritional value since they lacked protein and fat while having a high water content.100 Psychiatrists interested in feeding mentally ill patients attempted to keep pace with the new developments in nutritional science and physiological chemistry of the period to inform their decisions. Because these psychiatrists already believed that the mind and body were connected through nutrition, the new chemical findings were easily assimilated into their existing theories of health. Talcott’s discussion of the importance of milk to the diet for the mentally ill or nervous reveal this blending most acutely. This was likely due to his training as a homeopath, although his ideas aligned with the orthodox enough that his article was published in the AJI. Talcott saw feeding the body as a practice in energy-giving, and used aspects of humoral theory, the nervous system, and chemistry to explain the healthfulness of milk and meat. He held up milk as the best food for “nervous invalids” as a “bewitching elixir of life.” 101 Talcott asserted that milk should be served warm or hot because he believed that at that temperature it was digested quickly. Cold milk, he thought, created the “evils” of “indigestion, nausea, […] and consequent localized congestions of the blood,” which kept this “vital fluid” from distributing “throughout the body.”102 Here, Talcott appears to be applying how congested humors caused disease as explained in Hippocratic medicine to the flow of the vascular and nervous system prominent in George Beard’s earlier explanation of neurasthenia. Talcott was also aware of how nutrition science could play a role in prescribing certain foods for people with a mental or nervous 100 Harvey A. Levenstein, Revolution at the Table: The Transformation of the American Diet (Oxford: Oxford University Press, 1988), 57. 101 Talcott, “Dietetics in the Treatment and Cure of Insanity,” 344-5. The phrase “paps of a willing wolf” is likely a reference to the ancient Roman story of Romulus and Remus in the founding of Rome. Talcott is thus also drawing on foundational myths of western civilization to support his idealization of milk. 102 Ibid., 346. 48 disease. Regarding milk, Talcott also explained that it was the most important food for “the insane” because it contained “fat, sugar, caseous matter, hydrochlorate of potash and phosphate of potash […] lactic acid, a trace of lactate of iron, and earthy phosphates.”103 These references to macronutrients like fat as well as minerals such as iron could only be understood with some knowledge of nutritional chemistry. In fact, Talcott claimed milk was so healthful because its chemical composition was like that of blood, so that “in the former may be found the natural means for rejuvenating the latter when it is worn by the effects of disease, or wasted by hard toil or over-use.”104 Here, Talcott marries chemistry with his understanding of energy in the body in a way that did not denigrate either. Psychiatrists’ discussion of meat as a useful but also potentially harmful article of diet also reveals the continued influence of humoral theory on diet and mental illness. When physicians of any type wrote about “meat,” they were usually referring to red meat, especially beef.105 When discussing what types of patients could eat meat, Talcott said that “as a rule, very nervous patients should avoid lean meats, as they stimulate and irritate without increasing the strength of those who, while in an exhausted and irritable condition, eat them.”106 Referring to lean meat as “stimulating” and “irritating” evoked both humoral theory—in which meat was sanguine and thus linked with anger or irritation—as well as the theory of nervous energy, since physicians and neurologists often used the phrase “irritating” to describe damage to nerves. In contrast to Talcott, Munson highlighted meat as a central article of diet, stating that “meats are never excluded from the dietaries.”107 Although Munson acknowledged that meat was not a 103 Ibid., 345. 104 Ibid. 105 Pork was often used in hospitals as well, but less than beef. Superintendents and stewards of hospitals usually reported white meat such as chicken and turkey as “poultry,” if referred to generally. 106 Ibid., 347. 107 Munson, “Asylum Dietaries,” 60. 49 necessary part of health as long as some animal foods were utilized, he agreed with another doctor’s statement that it did “undoubtedly insure bodily vigor.”108 Here again, similar to Talcott’s discussion of meat, humoral ideas of food as medicine clearly surface, although Munson was less cautious in prescribing meat to ensure vigor than Talcott. In comparison to milk and meat, superintendents in the 1890s, like nutrition scientists, viewed fruits and vegetables as nutritionally inessential, but they thought that growing them was therapeutic. Further, those fruits and vegetables fed patients, giving some return of the money it cost to run the hospital farm. Most state mental hospitals had been built on large tracts of land, in part to ensure patients would have the opportunity to farm as part of their therapy.109 This aspect of moral treatment continued at mental hospitals during the late nineteenth century; Flint’s report, for example, suggested that “fresh vegetables and fruits should be used freely when produced at the institution.”110 The use of fruits and vegetables “freely” indicates their place as a non-essential item on the hospital table; in Pilgrim’s discussion of diet, which included a reference to Flint’s report, neither fruits nor vegetables made it into the food items “necessary” for the feeding of patients.111 Physicians and psychiatrists, therefore, understood vegetables as a healthful supplement to the diet while they were often products of moral therapy that were symbols of the psychological and physical health of patients who grew them on the hospital farm. However, some alienists did find scientific reasons why some vegetables might be healthy based on their putative chemistry. Munson wrote that although a variety of vegetables 108 Ibid. Here, Munson quotes a “Doctor Vaughn,” which likely refers to Victor C. Vaughn. 109 Having large tracts of land also separated the asylum from the surrounding area and provided plenty of green space for patients to walk the grounds. 110 Austin Flint, “Report on Dietaries,” 17. 111 Pilgrim, “Dietary of New York State Hospitals,” 230. 50 were in supply at his hospital, radishes, lettuce, and rhubarb, “all of which contain salts that closely resemble those in the blood,” were therefore “especially beneficial to patients.”112 Munson, like Talcott, attempted to justify certain foods as very healthy for the mentally ill based on what he understood as chemical similarities between certain foods and human blood. While Munson attempted to use nutrition science to better feed mentally ill patients, these foods were not widely viewed as especially beneficial.113 Nevertheless, this attention to food’s chemical elements in relation to health and disease in the hospital was a precursor for psychiatrists’ debates in the 1910s about the etiology of pellagra, a dietary deficiency disease, which are covered in chapters 2 and 4. As important as it was for doctors who specialized in mental illness to decide what foods were the best for feeding their patients, those foods would not make a difference if patients refused to eat them. Many patients refused food, which psychiatrists saw as a threat to their physical and mental health.114 The diagnoses of mania, melancholia, and dementia had long been associated with food refusal, and continued to be during the late-nineteenth century and well into the twentieth, even as diagnostic terms changed.115 As has been noted, there were some patients who overate, but most of the problems feeling the mentally ill came from patients who did not eat enough. As Munson observed, “experience among the insane” taught him “that there are wide 112 Munson, “Asylum Dietaries,” 61. 113 In the twenty-first century, most physicians and scientists view a diet rich in vegetables as healthy, but that is primarily due to their vitamin and mineral content, which is not directly related to feeding patients foods that match the chemistry of blood. 114 Patients had long refused food for a variety of reasons, including as a means of expressing their anger about being committed to the hospital or their treatment. Nancy Tomes discussed how some patients even used it as a ploy to get their family to take them out of the hospital if their family had the means. See Tomes, A Generous Confidence, 236. I further discuss psychiatrists’ understanding of the place of food refusal in its effect on how they viewed feeding the mentally ill in the hospital in chapter 4. 115 For example, C. B. Burr reported in 1900 that food refusal in mania was due to “inattentiveness” while “persistent” food refusal was due to “delusions” in melancholia and “dementia monomania.” See C. B. Burr, “The Care of the Recent Case of Insanity,” American Journal of Insanity 56, no. 4 (April 1900): 677. 51 differences in the amount of foodstuffs consumed, owing to idiosyncrasy, condition or health, or other causes.”116 Although some diagnoses were associated with food refusal, individual preferences for food or other unforeseeable circumstances made feeding patients a difficult endeavor. The practical realities of feeding an increasing number of chronic patients with severely deteriorated mental states in the 1890s also led to mental hospital doctors’ promotion of forced feeding as a necessary therapeutic intervention.117 Talcott, for instance, promoted “the enforced administration of sufficient quantities of food to prevent too rapid waste” as the “first essential in the dietetic treatment of the unwilling insane for curative purposes.”118 He saw this most often with patients diagnosed with mania and melancholia, although he insinuated that those with mania often refused to eat purely through “inattention” while those with melancholia were more likely to have “anorexia.”119 Though anorexia—defined as a pathological lack of appetite that might lead to starvation—was common in mental hospital patients, the diagnosis of anorexia nervosa had not yet become popular among U.S. physicians.120 The pathological nature of food refusal was an especially popular topic in France, and French psychiatrists influenced the way that American psychiatrists thought about food refusal as 116 Munson, “Asylum Dietaries,” 61. 117 Forced feeding was not new during the 1890s, as the practice had become part of medical therapy in asylums around 1800. Particularly influential was Philippe Pinel’s treatise in 1809 in which he suggested the use of a naso- gastric feeding tube. See Elizabeth A. Williams, “Gags, Funnels and Tubes: Forced Feeding of the Insane and of Suffragettes” Endeavour 32, no. 4 (2008): 135. Also, physicians realized that the threat of forced feeding was a “psychological technique of intimidation” that could coerce anorectic patients into eating. However, many doctors did express caution when recommending the technique. See Joan Jacobs Brumberg, Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease (Cambridge, MA: Harvard University Press, 1988), 104. 118 Talcott, “Dietetics in the Treatment and Cure of Insanity,” 342. 119 Ibid., 342. 120 See Brumberg Fasting Girls, 112, 110n28. According to Brumberg, anorexia nervosa was a diagnosis that was only applied at the time to adolescent females who were not considered to be insane. She reported that that between “1873 and 1900, American writing on anorexia nervosa was very sparse.” Further, she stated physicians in the United States only began to report on anorexia nervosa in large numbers in the 1920s and 1930s. 52 a symptom of mental illness.121 American psychiatry at the turn of the twentieth century still relied on British, French, and German publications to keep them abreast of developments in the field. For example, in notes from French publications and conferences reported in the AJI, psychiatrists promoted concepts such as “fasting insanity” that was “a form of hysterical anorexia,” “primary mental anorexia” that was not associated with hysteria but could be caused by “a toxic form of melancholia due to some failure of organic formation,” and “gastric psychopathies” that were primarily caused by fear of eating.122 The fear of eating was often referred to as “sitophobia,” but judging from case files at the Government Hospital for the Insane, the term “anorexia” to denote a persistent refusal to eat appeared to be more commonplace.123 Besides the physical, forceful method of forced feeding that physicians agreed had to be used if there was no other option, psychiatrists advocated for feeding patients in ways that appealed at least as much to their psychological as their physiological needs.124 Munson, Pilgrim, and Talcott all supported serving patients food in a manner that would psychologically persuade people to choose to eat, although they had different goals. Munson thought that “skillfully prepared food” was often able to “relieve irritability and fault-finding” in patients.125 While this could increase patient comfort, Munson’s language also indicates a desire to placate patients in order to have the hospital run more smoothly, with less conflict between patients and staff. Talcott similarly focused on food as a preventative for patients’ negative 121 Ibid., 110n28. She wrote that in the United States, any “reference to the disease [anorexia nervosa] usually involved neurologists reporting on French medicine and using the neurological or French terminology.” 122 See "Delire De Maigreur—Fasting Insanity," American Journal of Insanity 51, no. 4 (April 1895): 552-553; “Primary Mental Anorexia,” American Journal of Insanity 52, no. 2 (October 1895): 252; and "Gastric Psychopathies," American Journal of Insanity 53, no. 3 (January 1897): 431. 123 I discuss the term “sitophobia” in chapter 3 in relation to suffragist hunger strikers’ food refusal. 124 As Talcott wrote, “Those who prepare food for the use of human beings should be earnest students of physiological effects, as well as adepts in the aesthetics of cookery.” See Talcott, “Dietetics in the Treatment and Cure of Insanity,” 346-7. 125 Munson, “Asylum Dietaries,” 64. 53 emotions, insisting that food should be served to patients in a way that avoided “all unnecessary shocks,” so as not to disturb patients emotionally, which could prevent good digestion.126 Pilgrim also stressed the importance of preparing dishes that patients found comfort in, but rather than stressing the need for practicality or preventing bad behavior, he focused on the therapeutic potential of giving patients choice in what they ate. He supported giving patients food that they had “expressed a wish for,” such as “an omelet, a custard, a chop, or a piece of steak” which, according to Pilgrim, often “appeal[ed] to the dulled appetite of the patient when the regular fare would go untasted.”127 Giving patients choice in the food they ate was uncommon advice and likely to be deemed impractical in large mental hospitals serving hundreds of patients, but could be a concession of last resort for patients who refused to eat or insisted on particular diets.128 Alienists’ attention to food’s appeal, even as they discussed forced feeding, shows how tightly they held on the idea of food as a therapeutic. Rooted in the traditions of humoral and homeopathic ideas and the composite understanding of the mind-body, food as a beneficial agent for human hygiene was difficult to let go of. Another common psychologically oriented way that psychiatrists tried to ensure patients would be happy to eat their food was to have it prepared and served in an aesthetically pleasing manner. They often advocated serving food to patients that was an “appetizing,” “dainty,” or “delicate,” highlighting the psychological ideas about how to properly feed patients rather than only physiological ones.129 Talcott, however, articulated the importance of an environment 126 Talcott, “Dietetics in the Treatment and Cure of Insanity,” 342. Many physicians supported the theory that emotions could impact digestion and other bodily functions, and scientific research had just begun to support this. Research regarding the impact of emotions (mental states) on physiological function during the early twentieth century is summarized in Helen Flanders Dunbar, Emotions and Bodily Changes: A Survey of Literature on Psychosomatic Interrelationships, 1910-1933 (New York: Pub. for the Josiah Macy, Jr., Foundation by Columbia University Press, 1935). 127 Pilgrim, “Dietary of New York State Hospitals,” 232. 128 For more on this push-and-pull between patients and doctors over personal dietary choices, see chapter 6. 129 Munson, “Asylum Dietaries,” 66-67. 54 similar to that of fine dining most forcefully when he asserted that nurses and psychiatrists “should always offer the food after it has been prepared as attractively as possible, and served with dainty delicacy. The refined air and the scrupulous neatness of a restaurant kept by a Delmonico should be assumed in the wards of every hospital, even when a glass of milk is only being served to an insane patient.”130 At the time, Delmonico’s was a high-end French restaurant in New York that was nationally renowned for its food and service.131 Doctors hoped that treating patients this way would lead them to gain self-respect, and eventually, mental health. Although greater attention to the aesthetics of food at the turn of the twentieth century was not particular to mental hospitals, the aesthetic value of food and food service took on therapeutic meaning there.132 Moral treatment, with its focus on treating patients as individuals who had lost their ability to reason and on the importance of people’s physical and social environment to their mental health, underpinned this view of aesthetically pleasing food as therapeutic. The ideal of good ambiance in the area where patients ate clashed, however, with the difficulties of feeding large numbers of patients in a timely and organized manner. Just as patients needed to be served food that “avoided all unnecessary shocks,” the environment of the dining room needed to be controlled so that patients were not disturbed by other patients. Pilgrim noted that many patients left their plates full not because of how the food was cooked or presented or tasted, but because of “shocks” to their nerves from other patients. Convalescing patients would “almost touch elbows with the untidy dement” while a “fastidious man must 130 Talcott, “Dietetics in the Treatment and Cure of Insanity,” 343. 131 Delmonico’s was extremely popular during the early Progressive Era but declined in popularity by the 1920s. Andrew P. Haley describes it as “aristocratic” and attributes its decline to the “’middle-classing’ of American culture” during this period. See Andrew P. Haley, Turning the Tables: Restaurants and the Rise of the American Middle Class, 1880-1920 (Chapel Hill: University of North Carolina Press, 2011), 3. 132 As Harvey A. Levenstein has discussed, the aspiration for “dainty” food came primarily from native-born, middle-class Americans. By the 1920s, home economists during this period advocated for the “importance of eye appeal in convincing men and children to eat what was good for them,” which resulted in a “vogue for ‘dainty’- looking composed salads […].” See Levenstein, Revolution at the Table, 104, 167. 55 sit where he can see the glutton gorge,” and “the nervous and timid melancholiac may be startled by the piercing cry of the epileptic.”133 Because of these types of interactions and environmental stressors on patients, Pilgrim argued against large institutional dining rooms that mixed patients with different diagnoses together. He was also disliked smaller ward dining rooms which, among other issues, filled the ward with the smell of food.134 Instead, he argued that dining rooms be created that served no more than one hundred patients of a similar classification based on their illness and behavior.135 The organization of the dining room itself was thus one important environmental factor in preventing mental and physical illness from worsening at the least, and helping patients to reclaim their mental and physical health at best. Despite all the discussions psychiatrists and home economists had over how to feed patients the proper quantity and quality of food to suit patients’ physiological, psychological, and aesthetic needs, the reality of feeding large numbers of patients in the hospital setting could not be ignored. Some metric had to be used to purchase food, which was one reason why New York State Commission in Lunacy sought out a dietary report from Flint in the first place. In fact, all public mental hospitals in the state of New York adopted Flint’s table in October 1893.136 Public institutions did not have the space or budget to provide every patient an individualized meal. Many institutions set up a standard menu because of this, meant to serve most people in the institution, although some mental hospitals such as the Government Hospital for the Insane supplemented with a “sick diet” for those physically ill, additional meat for patients who 133 Pilgrim, “Dietary of New York State Hospitals,” 232. The moral language used to describe how some patients were “glutton[s]” was common for this period, as food was highly moralized. Overeating was common not only inside but also outside the hospital; reformers sought to combat this by casting moderation in eating as moral. See Veit, Modern Food, Moral Food, 5. The continuation and increase in this type of moralized language surrounding food is discussed further in chapter 4. 134 Pilgrim, “Dietary of New York State Hospitals,” 232. 135 Ibid., 233. 136 Ibid., 228. 56 performed manual labor for the hospital, and the option for a prescription of an “extra” or “special” diet for patients who required further therapeutic attention.137 This system, particularly hospitals that only had a standard diet, faced criticism from some psychiatrists who did not think individual health should be sacrificed so completely for convenience. “Why do a hundred or a thousand unfortunates sit down to partake of the same menu?” asked Edgar Spratling in 1898.138 Spratling believed that patients would ideally be treated as individuals, with diets based on their own idiosyncrasies and circumstances; these ideals echoed the liberal principles behind how many superintendents of the nineteenth century practiced moral treatment. But how could these competing interests be solved? Some psychiatrists thought that the combination of science and patient categorization was the solution. Spratling, for instance, realized that the practicalities of feeding so many patients meant that the best solution between the administrative and individual ideals was to feed patients in groups based on their dietary needs. He identified five groups: “(1) Those refusing food. (2) Those barred from solid food. (3) Those ravenously inclined. (4) Those requiring a light, easily digested, mixed diet. (5) Those needing heavy nitrogenous foods.”139 But who would decide what the best diets were? For Spratling, this was just the opportunity for “the physiologic chemist to display his almost indispensable utility.”140 Spratling’s hope to use the scientific expertise of nutrition scientists—as many physiologic chemists came to be called—was reflective of mental hospital superintendents more generally who sought to incorporate nutritional science into psychiatry. As will be discussed, the superintendent of the Government 137 For an overview of the Government Hospital for the Insane’s diet list, see Friedenwald and Rürah, Diet in Health and Disease, 578-581. Other hospital dietaries that are featured include Johns Hopkins Hospital. Ibid., 551-588. 138 Edgar J. Spratling, “Food for the Insane,” American Journal of Insanity 55, no. 2 (October 1898): 314. 139 Spratling, “Food for the Insane,” 314. 140 Ibid., 315. 57 Hospital for the Insane in Washington, D.C. enthusiastically opened the doors for a scientific study of the hospital’s diet only a few years later. Ellen Richards and Home Economics in the American Journal of Insanity Ellen Richards’ 1895 article in the AJI also displays the eclectic nature of psychiatric medicine at the turn of the century by highlighting the interdisciplinary nature of feeding the institutionalized mentally ill. Richards is the most famous home economist of the period because she founded the field and was likely the first woman chemist at the Massachusetts Institute of Technology.141 Home economics was a female profession. Its leaders hoped to carve out professional power for women through nutrition reform, which they believed was part of the world of modern science, a necessity for moving toward a better America.142 S. E. Wentworth, for example, who Richards often worked with, completed the first study of mental hospital dietaries at the Kankakee Asylum in Illinois and influenced psychiatrists’ discussions about hospital dietaries in the AJI. Although psychiatrists had carved out their own profession, they too were looking for ways to integrate science into asylums, which were more frequently referred to as mental hospitals.143 It was uncommon though not unheard of for women physicians to publish in the journal, but Richards was likely the first home economist to publish a piece there.144 Richards’ perspective varied from the strictly medical one, as Richards brought much from her role as a food reformer into her discussion of hospital dietaries. While she was similarly focused on feeding patients efficiently and healthily, her ultimate critique of hospital dietaries came from 141 Hamilton Cravens, “Establishing the Science of Nutrition at the USDA: Ellen Swallow Richards and Her Allies,” Agricultural History 64, no. 2 (Spring 1990): 126. 142 Shapiro, Perfection Salad, 9. 143 The association of the mental hospital with the modern (scientific) hospital will be discussed further in chapter 4. 144 Laura Shapiro discussed how domestic scientists like Richards became “especially prominent” in the “field of institutional feeding” during the late nineteenth century because they were respected for their expertise and had become frustrated with their failed attempts (particularly in the New England Kitchen and Rumford Kitchen) to change the diet of poor and working-class Americans. See Shapiro, Perfection Salad, 161. 58 a sociocultural understanding of large populations and the challenges of feeding culturally diverse groups. Richards’ article focused on determining a healthy but economic institutional diet through studying the two best dietary studies available—Austin Flint’s and a German study carried out by W. Prausnitz. Both Flint and Prausntiz estimated the appropriate diet allowance in terms of protein, fat, and carbohydrates, with Flint’s being more generous in every category, but especially fat.145 She did not see these two studies as robust enough to determine the optimal diet for institutions for the mentally ill but thought that the proposed diets were ultimately too generous for public institutions. Richards claimed, for example, that “the quantities of eggs and butter proposed in Flint’s dietary are beyond the means of a State institution.”146 Richards, unlike the psychiatrists and physiologists well-acquainted with the care and treatment of the mentally ill, did not think that people institutionalized with mental illness required a more generous diet or one focused on meat, milk, butter, or eggs than other types of institutions.147 Like the alienists, Richards thought that food refusal was one of the most pressing problems in hospitals of all types. Unlike doctors in mental hospitals, however, she cast food refusal more in terms of class and cultural familiarity than for any reasons linked to mental illness. Outside mental hospitals, food reformers had a hard time convincing the public to eat new foods or recipes because the reformers were usually “worsted any day by a really good cook 145 Richards, “Notes on Hospital Dietaries,” 214. She did note that “the habits of the people and the food they eat are so different that only general help can be gained from any foreign source,” when commenting on American dietary habits. 146 Ibid., 215. 147 In one section of her later work, she was very dismissive of providing generous diets for those with chronic mental illness. In the section “for those in penal and pauper institutions,” she included in the second class “the pauper past work, the hopelessly insane, and the vicious” whose food “may be dismissed with few words.” This is very different from the first class who were deemed to be “potential citizens,” whose diet she instead decided to focus on. See Ellen H. Richards, The Cost of Food: A Study in Dietaries (New York: J Wiley & Sons., 1901), 60, HathiTrust. 59 who will give the people what they like.”148 Richards thus noted the struggle that experts faced in putting theory into practice in feeding large numbers of people in public institutions, because people in that setting were likely to refuse “to eat the good things thus carefully provided for them.”149 Because of this experience, while Munson and Pilgrim focused on food as curative, comforting, and aesthetically pleasing to patients, Richards’s assessment of how food service needed to change in hospitals was based more clearly on the notion of familiarity. As if almost refuting the psychiatrists, she argued that it was not enough “to calculate the food value; not enough to select the best recipes; not enough to have the food served in a manner that is attractive to us. The food must have a familiar look and taste, or enough so that the question will not be raised whether it is a new dish or not.”150 For Richards, taste was acquired. It was a habit. A person could “learn to like almost anything.”151 Taste was also, then, a culturally constructed and often based on people’s socioeconomic status. From her position as an upper-middle class, educated, white woman, she wrote: We sometimes forget that the habit of eating civilized food is as truly a matter of education […] We are apt to think that our food should seem a luxury to those in the so-called lower classes, or to people poorer than ourselves. This is not the case, as one finds when one begins to cater to the inmates of an institution, school, or boarding-house. People like best that to which they are accustomed.152 While here Richards advocated for a better understanding of the tastes of the poor or lower-class to provide them with better overall nutrition, she does so with clear belittling, contrasting those tastes to the “civilized food” that she herself ate.153 148 Ibid., 217. 149 Richards, “Notes on Hospital Dietaries,” 216. 150 Ibid. 151 Ibid. 152 Ibid. 153 It was likely the case that Richards and other middle-class professionals ate a much more nutritious diet than many of the people in public institutions. However, Matthew Frye Jacobson has examined the link between class and the rhetoric of civilization during the turn-of-the-century, arguing that “’civilization’ was an economic concept” although it was “most often draped in the complementary logics of Christian moralism and white supremacy.” See 60 But while Richards carried her own bias against a large segment of the population that mental hospitals were meant to serve, she did advocate for understanding their tastes in order to feed patients effectively. She suggested a study of “existing habits and customs” because it was “essential in catering to any large body of people, especially those who have not been accustomed to variety.”154 Because of this, she thought feeding the mentally ill was “particularly” important compared to feeding people in other public hospitals, because “in hospitals for the insane, […] the nutrition is of the utmost consequence.”155 Ultimately, Richards’ article added a new element to the debate about how best to create mental hospital dietaries in taking a socio-cultural approach to patient tastes, but her suggestions did not take into account medical theories about the connection between physical health and mental health or psychiatrists’ own first-hand experiences feeding the institutionalized mentally ill. Once dietitians became an important part of mental hospital personnel in the 1910s but especially 1920s and forward as will be discussed in chapter 5, this way of viewing diet in the hospital would become more commonplace in mental hospitals. Nutrition Science, Wilbur Olin Atwater, and Pratt and Milner’s Study Home economists like Richards were not the only disciplinary outsiders to develop an interest in feeding people in mental hospitals. Richards teamed up with the famous physiological chemist and nutrition scientist Wilbur Olin Atwater to advance the scientific study of nutrition during the 1890s until she focused more of her efforts on food reform through building up home Matthew Frye Jacobson, Barbarian Virtues: The United States Encounters Foreign Peoples at Home and Abroad, 1876-1917 (New York: Hill and Wang, 2000), 50. Class, alongside ethnic differences, also played an important role in Hasia R. Diner’s argument that hunger drove European migration to the United States from 1820 to 1920. According to Diner, many of the migrants “came from precisely that class which could never afford to eat such fine foods. Had they eaten so well regularly in the “old country,” they might not have needed to come to America.” Hasia R. Diner, Hungering for America: Italian, Irish, and Jewish Foodways in the Age of Migration (Cambridge, MA: Harvard University Press, 2001), xvi. 154 Richards, “Notes on Hospital Dietaries,” 217. 155 Ibid. 61 economics around 1900.156 Atwater was first known for his work in agricultural chemistry at Wesleyan University, but his interest in nutrition science—physiological chemistry—developed after discussing developments in it with the famous European physiologists Carl von Voit and Max Rubner at the University of Munich in Germany.157 He went on to serve as the first director of the Office of Experiment Stations in Washington, D.C., from 1889 to 1891. After this, his proteges took over and he continued doing scientific work for the Office as a Special Agent in charge of nutrition investigations.158 These nutrition studies took place amid a boom in U.S. government-funded research into nutrition and agriculture through the USDA. The Hatch Act of 1887 created a network of experiment stations at land-grant universities as well as the Office of Agricultural Experiment Stations.159 The experiment stations are best known for their agricultural studies, but scientists also completed important work on human nutrition, thanks in part to the efforts of Atwater and Richards in securing funding for them.160 Physiological chemists who were interested in human nutrition sought to answer more precisely what the daily food requirements were for people based on their differing demographic characteristics. Ultimately, scientific studies into human nutrition grew as one important facet of the USDA alongside scientific agriculture at the turn of the twentieth century.161 Many studies in human nutrition came out of the Office of Experiment Stations in the 156 Cravens, “Establishing the Science,” 132. 157 Ibid., 123. 158 Ibid., 125-6, 130. 159 Ibid., 122. 160 Ibid., 123. 161 For more about experiment stations and the “professionalization of experiment station science” through the two roles of the “working scientist” and “research entrepreneur” that became vastly important to the organization of laboratory science in the United States during the twentieth century, see Charles E. Rosenberg, No Other Gods: On Science and American Social Thought (Baltimore: The Johns Hopkins University Press, 1976), 159, chapters 8 and 9. 62 1890s and early 1900s, and a small but significant subset of these focused on mental hospital diets. The earliest nutrition studies in the United States beginning around 1890 had taken place under the USDA in conjunction with universities, settlement houses, and penal institutions.162 However, mental hospitals had not been a focus of federal government-funded nutrition investigations throughout the 1890s despite the fact that roughly twenty-five percent of people fed in public institutions were in mental hospitals.163 In Atwater’s estimation, it was not until the New York Commission in Lunacy (that had earlier employed Flint) hired him to complete dietary studies in state mental hospitals between 1897 and 1900 that nutritional investigations in that field began to catch up with the others.164 Atwater and other Experiment Station scientists then conducted further studies in Connecticut, and then the federal mental hospital in Washington, D.C. in 1903 and 1904.165 These studies formed the first government-funded efforts to understand how best to feed the institutionalized mentally ill, driven by lunacy commission members in New York (which included a mental hospital superintendent), Atwater’s interest, and the earlier work of Flint, Richards, and the psychiatrists who wrote about diet.166 Before the studies at the Government Hospital began, Atwater formed his stance on the importance of diet for the mentally ill in institutions from his studies in Connecticut and New York, highlighting not only economic and physiological requirements but also stressing the humanitarian goals and potentially curative outcomes of feeding the mentally ill. Atwater, 162 Wilbur Olin Atwater, “Dietaries in Public Institutions,” in Yearbook of the United States Department of Agriculture, 1901 (Washington, DC: Government Printing Office, 1902), 396. 163 Atwater, “Dietaries in Public Institutions,” 394. He based this statistic on the 1890 U.S. Census. Atwater also noted that not all “insane” people were in public asylums in his discussion. 164 Ibid., 394, 402. 165 August Frank Daniel Wussow, “Dietary Studies in the Public Institutions of Illinois: (Studies in the Hospitals for the Insane),” (MS Thesis, University of Illinois, 1911). Illinois Digital Environment for Access to Learning and Scholarship Repository and H. A. Pratt and R. D. Milner, Dietary Studies at the Government Hospital for the Insane, Washington, D.C., (Washington, DC: Government Printing Office, 1904), 3, HathiTrust. 166 “The New York State Commission in Lunacy,” American Journal of Insanity 53, no. 2 (October 1896): 331-333. 63 responding to psychiatrists’ earlier observations that some patients required more food and others required less, argued that simply not enough information existed to determine whether this was true. He suggested that due to insane patients’ general lack of physical exercise compared to even a normally sedentary person, they might need slightly fewer grams of protein and calories per day.167 Like psychiatrists, Atwater did not see cost or even physiology as the only considerations for planning hospital diets. He argued that the “humanitarian considerations should be uppermost” in dietary studies.168 A humanistic spirit had been at the heart of moral treatment and psychiatrists’ subsequent discussions of how best to feed the mentally ill. They continued even in Atwater’s more quantitative and scientific study of mental hospital diets. Using the same vocabulary as Richards and the psychiatrists, Atwater argued that palatable and attractive food were important to people in hospitals and almshouses; however, following more closely with the assertions of Flint and Munson, he argued that with such food “some of the inmates of hospitals for the insane may be cured.” Less dismissive than Richards was about people with chronic mental illness, Atwater focused on how many people considered incurable could, at the very least, still find comfort or happiness in food at the hospital.169 His beliefs that feeding the institutionalized mentally ill was a humanitarian duty and was potentially curative echoed the psychiatrists’ writings on the subject throughout the nineteenth century. After the studies at the Government Hospital in D.C., Atwater would return to this discussion and clarify how mind and metabolism might be connected. The last Office of Experiment Stations study, a group of twenty-six studies altogether, 167 Atwater, “Dietaries in Public Institutions,” 399-400. 168 Ibid., 406. 169 Ibid., 407. 64 was completed at the only federal mental hospital, the Government Hospital for the Insane, in Washington, D.C. This hospital is a focal point of this dissertation, and alongside hospitals from New York, became known for its rational hospital diet in the early twentieth century. H. A. Pratt and R. D. Milner completed the studies from 1903 to 1904, which were overseen by Atwater. These studies differed from those in the AJI and were similar to, but more complex than, Flint’s study and accompanying ration tables. They were based more on quantitative data and statistics concerning food’s nutritional value and wastage for a large, institutionalized population, rather than observations and suggestions based on personal experience like most of those found in the AJI. By bringing these studies into the hospital, these nutrition scientists brought one aspect of modern science into psychiatry. Pratt and Milner likely studied the diet at St. Elizabeths because the federal government funded the institution and had an interest in keeping costs low, and because they believed the large number of veterans in the hospital provided a unique study group. They observed the amount and type of food provided as well as how much food was wasted by either poor preparation in the kitchen, or from patients’ refusal to eat the food. Cutting down on food waste also cut down monetary waste. Pratt and Milner also explained the benefits of studying St. Elizabeths in particular because “the patients were of an exceptionally good class” since “the general class of male patients of this institution differed in several respects from the average found in State institutions.”170 Many of the men, stated Pratt and Milner, had likely been in “good physical condition” before becoming insane while in military service, they seemed to be “of rather a milder type than is generally found in State hospitals, the proportion of violent and untidy patients being comparatively small” and they also appeared to be “rather above the 170 Pratt and Milner, Dietary Studies at the Government Hospital for the Insane, 7. 65 average as regards education and general intelligence.”171 As previously discussed concerning Pilgrim’s 1895 AJI article on the New York State hospital dietaries, the term “untidy” was often used as a descriptor of mentally ill patients, and by saying the majority patients at the government hospitals were not untidy, Pratt and Milner were attempting to elevate the status of these patients. However, the woman patients who were admitted from the District of Columbia, according to the authors, “were of about the same class as is found in most public institutions of a similar character.”172 Thus, it was likely male patients’ association with military service that prompted their physicians to make a stronger moralist and patriotic claim to government support. The function of St. Elizabeths as a veteran’s hospital of sorts continued to impact how hospital care, which included food, was discussed by government agents, interested members of the public, and the psychiatrists at the hospital.173 Pratt and Milner also found enthusiastic support from the alienists who served as the St. Elizabeths superintendents while the studies were completed. Superintendent Alonzo Richardson authorized the studies, but they were ultimately completed under his successor, William Alanson White. Pratt and Milner noted that White allowed the studies to continue because he “recognized the importance of the work undertaken and gave it his active support.”174 White was an optimist in treating the mentally ill and while he did not write specifically about diet in his own research articles, he did believe that mind and body were connected through his theory of “organism as a whole,” which still maintained many aspects of moral treatment. It should not be surprising, therefore, that White actively supported nutrition studies at the hospital, which could potentially 171 Ibid., 7–8. 172 Ibid., 8. 173 The role of veterans in impacting the hospital’s service, including food, is discussed throughout this dissertation, but most strongly in chapter 5. 174 Pratt and Milner, Dietary Studies at the Government Hospital for the Insane, 7. 66 give him greater insights into feeding his patients. The results of the nutrition studies performed at St. Elizabeths provided evidence of food wastage, but no answers for how to best feed mentally ill individuals or even groups of patients. Pratt and Milner found that the hospital’s diet followed the accepted standards of the period; it was adequate in calories and comparable to that of other institutions for the mentally ill, although the food wastage was too high. This was similar to Richards’ earlier findings as well as the earlier Office of Experiment Stations studies into mental hospital dietaries in New York and Connecticut. Pratt and Milner’s results also left just as many questions as answers when it came to creating precise standards by which to feed the mentally ill in institutions. Atwater and other nutrition scientists had only just begun to calculate how many calories were burned by different people depending on sex, age, and type of work done. Thus, Pratt and Milner’s discussion of the caloric standards of human nutrition reveal that scientists saw these standards as “at best tentative” and as “general indications rather than exact measures” of a person’s caloric needs.175 This also shaped the question of how, quantitatively, feeding the mentally ill may differ from feeding the mentally healthy. For Pratt and Milner, the dietary standards became even more unclear in relation to the needs of mental patients. This was because, according to them, the “uncertainty in this respect is still greater when they are applied to persons in demented or other abnormal condition.” They further stated that “some authorities believe that the bodily demands for the insane do not materially differ from those of persons in health with a corresponding amount of muscular activity, while others think that acutely insane patients may require more nourishment, and the chronic classes probably somewhat less than is required by normal persons.”176 Thus, for this government examiner of nutrition, it was still unclear how effective it 175 Ibid., 76. 176 Ibid., 76. 67 was to use dietary standards for “normal” Americans to feed those who were mentally ill. Furthermore, this discussion reveals that Pratt had an idea that mental disease could impact, either positively or negatively, the body’s caloric needs. In this way, the nascent nutrition science was linked to the study of mental illness. Pratt and Milner’s study served as the last of the USDA Office of Experiment Stations studies into mental hospitals during the Progressive Era, and Atwater summarized the findings in 1904. He wrote a subsection of the Office of Experiment Station’s Annual Report titled “Dietetics in Relation to Hospitals for the Insane,” which included a discussion of the various studies he had overseen at mental hospitals in Connecticut and New York, with particular focus on Pratt and Milner’s studies at St. Elizabeths.177 Atwater’s discussion of the results of the dietary studies regarding how best to feed “the insane” agreed with many of Pratt and Milner’s conclusions and suggestions, and set the first major scientific foundation for later discussions of how best to feed patients with mental illness. Even though Atwater was a physiological chemist, he drew on many of the previously discussed articles in the AJI, including those by Munson, Richards, and Pilgrim, to inform his analysis, showing the ways that medicine and science were co-constructive during this period. Despite his and his colleagues’ quantitative, scientific work to assess optimal dietary standards for mentally ill patients, he maintained the therapeutic ideals of psychiatrists and the legacy of moral treatment in his suggestions. He maintained, as he had in 1901, that humanitarian goals were more important than the cost of food in planning the hospital diet for mentally ill people. He reiterated that “some of the inmates of the hospitals may be cured, and everything possible 177 Wilbur Olin Atwater, “Dietetics in Relation to Hospitals for the Insane,” in Annual Report of the Office of Experiment Stations for the year ended June 30, 1904, ed. A. C. True (Washington, DC: Government Printing Office, 1905), ProQuest Congressional. 68 should be done by diet or otherwise to facilitate their cure.”178 Although Atwater had no scientific proof of the effect of a generous diet on patient outcomes in mental hospitals, he still pushed for the value of food as comforting to patients at minimum, and therapeutic at maximum. Simultaneously, he recognized that his ideal solution of feeding patients based on their diagnosis was impractical in mental hospitals. Atwater, as a physiological chemist, sought to find a common ground in the classification of patients based on psychiatric diagnoses on the one hand and physiological demands on the other. He asserted that there were two fundamental principles in providing food for patients in a mental hospital: first, that the “kinds and amounts of foods should be adapted to the actual physiological demand,” and second, “that these demands differ with different classes of persons. A distinction between patients and employees and a classification of patients according to physiological demand are therefore desirable.”179 However, Atwater was attuned to the problems with this suggestion in mental hospitals. He wrote, “To the physiological chemist it might seem that the classification which the alienist makes by the nature of mental disease and his own classification by physiological demand for nourishment might be brought into more of less accord. But it is evident that the exigencies of hospital administration do not always permit the assignment of patients to tables by such principles of division.”180 Therefore, because of the work in classification it would take to give patients both a psychiatric diagnosis as well as an assignment of physiological demand, Atwater could sense that convenience for hospital administration would win out over optimal feeding of insane patients.181 178 Atwater, “Dietetics in Relation to Hospitals for the Insane,” 492. 179 Ibid., 479. 180 Ibid. 181 This can be considered as one aspect of the warring themes of conscience versus convenience utilized by David J. Rothman. See David J. Rothman, Conscience and Convenience: The Asylum and Its Alternatives in Progressive America (Boston: Little, Brown and Company, 1980). 69 But Atwater also admitted that the accurate calculation of physiological demand “as expressed in quantities of nutrients and energy of food” for insane patients was still not established. He agreed with Pratt and Milner that caloric energy needs for “the insane” were unclear. He wrote that the primary factor in calculating nutritional needs was based on a person’s “degree of physical activity” but then stated that it was “more than likely, however, that there are exceptions to this principle; that there may be classes of the insane who eat more and may actually need more than people in normal condition with corresponding physical activity, while it is also probable that there are other classes who need less food than the normal amount.”182 These assertions were very similar to Jarvis’ mid-nineteenth-century observations as well as Munson’s in the 1890s, showing how this medical assumption impacted scientists’ investigations. While the Office of Experiment Stations’ dietary studies did not show any scientific evidence that people with mental illness needed any more food than people of similar physical health and levels of exercise, Atwater put forth a scientific hypothesis for how it might have been the case. As a physiologist, he saw the brain as the seat of mental activity and a regulator of metabolism. To him, it made sense that abnormal mental states could cause the brain to abnormally regulate the body’s metabolism. Though this was conjecture, he thought that the best representation of his hypothesis was that “there may be conditions in which the proper regulation of metabolism by the brain is so interfered with that the total metabolism of nutritive material is out of accord with the normal physiological need.”183 Although this hypothesis was driven by Atwater’s understanding of human physiology, it was also influenced by the previous work of psychiatrists throughout the nineteenth century who saw diet as therapeutic and connected to the 182 Atwater, “Dietetics in Relation to Hospitals for the Insane,” 479. 183 Ibid., 480. 70 relationship between the mind, brain, and body. The efforts of psychiatrists who argued for a generous diet made up of the foods they thought were most healthful for the mentally sick were not in vain. Ultimately, in a time when institutions began to face increasing scrutiny for their overcrowded conditions, patients in at least some prominent, public mental hospitals were getting nutritious and generous diets that at the very least provided them with a minimum level of custodial care, and potentially some therapeutic advantage. Significantly, the government nutrition studies done in Connecticut, New York, and most extensively in Washington, D.C., show that the generous dietaries promoted by psychiatrists in the AJI were being put into practice to a measurable extent at the turn of the twentieth century. Atwater reported that at St. Elizabeths, “patients and employees apparently had fully as much food as they cared to eat” and that “there was a liberal allowance of meats” in addition to a fair amount of variety in the diet.184 In more scientific terms, Atwater thought that Pratt and Milner’s study showed “decidedly that the amounts supplied much exceeded the actual demand for nourishment.”185 This finding was practically the same as Atwater saw in New York hospitals.186 Thus, mental hospitals in D.C. and the Northeast, supplied generous diets for mentally ill patients. This was most likely because there were sufficient funds from the legislatures and enough advocacy and humanitarian sentiment for the nutritional needs of the mentally ill compared to people in prison or almshouses. As I examine in the next chapter, this was not the case across the United States, particularly in Southern states. The Aftermath of Nutrition Studies: Scientific Promises and Therapeutic Pessimism Although scientific optimism had grown stronger among psychiatrists in the early years 184 Ibid., 477. 185 Ibid., 489. 186 Ibid., 485. 71 of the twentieth century, therapeutic optimism waned as mental hospitals continued to fill up with chronically ill patients. The similarly optimistic yet critical addresses of American Medico- Psychological Association (AMPA) presidents Charles G. Hill in 1907 and Charles P. Bancroft in 1908 show how viewing diet as therapy, much as it had been throughout the nineteenth century, gave psychiatrists a glimmer of hope in the sea of therapeutic pessimism. On May 7th, 1907, Charles G. Hill, an attending physician at Mount Hope Retreat in Baltimore, Maryland gave his opening address as the newly elected president of the AMPA.187 In his speech, as was customary, he commented on both the present state of psychiatry in the United States as well as future avenues for progress. His guiding question—one “always old and always new”—was: “How can we best advance the study of Psychiatry?”188 The address first investigated the problems in inaccurate or incomplete clinical descriptions of different mental illnesses. It then engaged with the ongoing charges from neurologists that psychiatric diagnoses were inaccurate; he thus discussed the benefits of using more laboratory testing and medical/scientific experimentation to study disease. He argued that mental hospitals were the best places to study states of health and disease: “Where can patients be kept more closely and continuously under observation than in large and well-equipped hospitals for the insane? Our opportunities for scientific research are unsurpassed.”189 But what kind of scientific research did Hill have in mind? Where scientific optimism had grown stronger among psychiatrists in the early years of the twentieth century, so too had the strand of therapeutic optimism related to diet and the 187 This was new name of the AMSAII, having changed in 1893. 188 Charles G. Hill, “Presidential Address,” American Journal of Insanity 64, no. 1 (July 1907): 1. Printed from its delivery at the sixty-third annual meeting of the AMPA, Washington, DC, May 7, 1907. 189 Hill, “Presidential Address,” 6. Hill had also previously claimed that case files would not yield enough therapeutic value themselves. “But this defect,” Hill wrote, “will not be remedied by the accumulation of histories overflowing the office and packed away down in the cellar or some remote store-room and never read again. We must approach it by other and more direct methods.” 72 mentally ill. Hill was excited about the possibilities of studying new drugs to treat mental illness in institutionalized patients, for instance, because despite psychiatrists’ “boasted scientific advancement,” he said, “our therapeutics is simply a pile of rubbish.”190 But besides drugs, diet remained one avenue of scientific study in mental hospitals. He wrote: The diet, the digestion, the chemical composition of food stuffs, the metabolism of water, the cause and treatment of constipation not by purgatives but by rational and natural methods, the physiology of sleep and the pathology of insomnia, all need to be especially studied in relation to their application to the insane.191 He thus called for further study of diet and the metabolism of mentally ill people. Psychiatrists like Hill continued to view diet in the hospital as one way to bring science into the asylum and to potentially gain insight into diet’s scientific value as therapy. After Hill highlighted that psychiatrists’ therapeutics were “simply a pile of rubbish,” Charles P. Bancroft, the medical superintendent of the New Hampshire State Hospital, largely agreed; he speculated that moral treatment, rather than more science, might be the best therapy. He displayed therapeutic pessimism as it was clear that cure rates were not rising even with new therapies of “drugs of various kinds, glandular extracts, electricity, hydrotherapy, open-air treatment and, last of them all, serum therapy and psychotherapeutics.”192 Psychiatrists were almost never able to treat dementia. Bancroft felt that there was just some kind of homeostasis, as we would call it today, at play for patients who made quick recoveries. He even went so far to admit: “One almost feels forced to the conclusion that the simple, common-sense remedies such as nutritive diet, fresh air, sunlight, mental and moral suggestion, rest or exercise as may be 190 Ibid. He also discussed the potential use of “mental therapy” for patients, likely pointing to the very beginnings of psychoanalysis in mental hospitals in the United States. 191 Ibid., 6-7. 192 Charles P. Bancroft, “Presidential Address: Hopeful and Discouraging Aspects of the Psychiatric Outlook,” American Journal of Insanity 65, no.1 (July 1908): 5. 73 indicated, are as efficacious as anything that has been advocated, and that the vis medicatrix naturae after all seems to be the efficient factor in the restoration to mental health.”193 Largely resorting to therapeutic pessimism due to the continuing rise of incurable, chronic cases of mental illness in mental hospitals, Bancroft instead turned to the prophylaxis of mental illness—mental hygiene. He outlined the four primary etiological factors of insanity as he saw it: “heredity, alcohol, syphilis, and environment.”194 A true Progressive-Era reformer, Bancroft thought that more laws could change poor and unsanitary environmental conditions and that education, using a wide variety of professionals was the best solution for the latter three causes. He stated: “No longer will the alienist work alone; he will join hands with workers in [the] allied sciences” of psychology, neurology, bacteriology, and penology.195 Although he did not include nutrition science or home economics on his list, both shaped his ideas of “common- sense remedies.” These scientific disciplines continued to influence psychiatric medicine and the mental hygiene movement throughout the Progressive Era. By the time of Bancroft’s speech, mental hygiene had just begun to gain traction in psychiatry once again due to the efforts of the reformer Clifford Beers and an array of psychiatrists, psychologists, and neurologists, as I explore in the next chapter. Conclusion Consideration of professional journal articles, monographs, and scientific studies from the 1890s and early 1900s shows that psychiatric discourse surrounding diet for the mentally ill at the turn of the twentieth century was an overlapping array of administrative efficiency, nutrition science, moral treatment, and even humoral theory. This approach to feeding the 193 Bancroft, “Presidential Address,” 6. 194 Ibid., 10. 195 Ibid., 16. 74 mentally ill emerged because of the shared understanding that mental health and physical health were interdependent as advanced by advocates of moral treatment in the hospital and mental hygiene more broadly since the middle of the nineteenth century. Psychiatrists and even a nutrition scientist saw food not only as administrative or physiologically necessary sustenance, but also potentially curative in mental illness. Despite the respect for Richards and other home economists who studied institutional diets, dietitians (one specific branch of home economists) did not become a mainstay in mental hospitals until the 1920s, which I discuss in chapter 5. All in all, while home economists did add to psychiatrists’ professional discussions of the best diet for “the insane” in the 1890s, most psychiatrists viewed them as outside consultants rather than as medical specialists who had a clear position of influence or authority within the hospital itself. Ultimately, the early efforts of psychiatrists, home economists, physiologists, and nutrition scientists led to a generous and nutritious diet for many people institutionalized with mental illness in the Northeast United States. While a study of all mental hospital diets across the country still needs to be done to understand how far-reaching these ideas were, it is clear that psychiatric and scientific interest spurred an effort to understand how best to feed the mentally ill that reached a critical point in the 1890s and early 1900s. Although government-sponsored studies were not continued past Pratt and Milner’s at the Government Hospital, the scientific foundation for acceptable diets in institutions for the mentally ill had been laid. As will be discussed in chapter 4, the federal government would once again look to institutions for the mentally ill, and specifically the Government Hospital for the Insane (by then referred to as St. Elizabeths); they would be one avenue for help in solving the problem of feeding America during World War I. But most immediately, these studies influenced the scientific foundation of 75 the Government Hospital for the Insane and others like it during a wave of Progressive-Era legislative investigations into mental hospitals—including their dietaries. 76 CHAPTER 2: Early-Twentieth-Century Mental Hospital Investigations and Diet: Progressive Reform, 1906-1914 Introduction Historians have identified that the “union of science and social activism” was a Progressive-Era impulse.1 While Gerald N. Grob used this phrase to discuss the mental hygiene movement, the state and federal investigations into mental hospitals during the Progressive Era as well as some psychiatrists’ efforts to combat pellagra in institutions for the mentally ill also fall under this umbrella. The intersection of nutrition science, psychiatry, and Progressivism is important to the story of many people’s search for solutions to Progressive-Era problems. It helps us to understand how human health, science, and society were intertwined during the early twentieth century, at a height of people’s concerns about adulterated food and industrial food processing. Historian David J. Rothman has shown that psychiatrists and Progressive reformers shared a particular mentality. Rothman argued that mental hospital reforms were based on a Progressive agenda of “conscience”—focused on individual treatment and returning patients to society—but ultimately failed to provide programs or results that were humanitarian or even less harmful than the institutions they were replacing largely because of matters of “convenience” for those supposed to implement these programs.2 Indeed, at the turn of the twentieth century, the state of modern psychiatry was in flux as many psychiatrists sought to distance themselves from the asylum as the psychiatrist’s only realm of authority.3 Those who continued as hospital 1 Gerald N. Grob, Mental Illness and American Society, 1875-1940 (Princeton, NJ: Princeton University Press, 1983) 178. 2 David J. Rothman, Conscience and Convenience: The Asylum and its Alternatives in Progressive America (Boston: Little, Brown and Company, 1980). I use Rothman’s terminology of “conscience” and “convenience” throughout this dissertation. 3 Gerald N. Grob, The Mad Among Us: A History of the Care of America’s Mentally Ill (New York: Free Press, 1994), 139-172. 77 superintendents faced the oversight of government officials and the ire of taxpayers. Because of this, superintendents faced pressure to implement economy, efficiency, and rational bureaucracy.4 In hospitals funded by tax dollars, whether state or federal, the drive for these Progressive ideals—all matters of convenience—was not easily dealt with. Thus, the mental hospital was one site of Progressive reform which brought together people who wanted to create social change through scientific and expert solutions. This chapter compares the earliest investigation under White’s tenure at St. Elizabeths in 1906 with the 1909 investigation into South Carolina’s State Hospital under the direction of James Woods Babcock. When it came to food and nutrition in the care and treatment of the mentally ill, the cases of St. Elizabeths hospital in Washington, D.C. and the Columbia State Hospital in Columbia, South Carolina show that convenience did outweigh conscience when it came to feeding patients in South Carolina, but that was not the case in D.C. In chapter 1, I discussed the concentration of psychiatric concern about and scientific studies of mental hospital dietaries as being in the Northeast, extending down to Washington, D.C. This focus on the Northeast has long been a feature of the history of psychiatry because of the strength of the professionals in cities like New York and Boston, but historians have continued to work toward a better understanding of the care and treatment of the mentally ill outside this region.5 Grob noted the amount of money that hospitals spent on food per capita annually varied with “significant regional differences.” He found that in the early 1890s “five Southern hospitals spent $129, as compared with $200 at Eastern and $167 at Western 4 Ibid., 172, and Grob, Mental Illness and American Society, 215. 5 One prominent example of this remains Peter McCandless, Moonlight, Magnolias, & Madness: Insanity in South Carolina from the Colonial Period to the Progressive Era (Chapel Hill: University of North Carolina Press, 1996). Newer work from Shelby Pumphrey based on the Central Lunatic Asylum for the Colored Insane—a hospital for only African Americans—continued to expand studies based in the South. Shelby Pumphrey, “Finding Asylum: Race, Gender, and Confinement in Virginia: 1885-1930” (PhD diss. Michigan State University, 2020). 78 institutions.”6 Although my comparison uses two well-known hospitals, they are in two different regions of the country. Both hospitals, however, accepted black and white patients, although they were racially segregated.7 Through the regional comparison of these two hospitals, I aim to shed new light on the ways in which not only psychiatrists but also legislators and citizens understood food and health differently in the Progressive Era. In this chapter, I track how hospital superintendents and staff members defended against legislators’ charges that the superintendent mismanaged the hospital—including the food it bought served to patients. In their defenses, some continued using the ideas about food as therapy that turn-of-the-century psychiatrists and nutrition scientists articulated. While chapter 1 focused on the discourse surrounding feeding the mentally ill that developed in professional journals and government-published writings, this chapter explores how people including hospital staff, former and current patients, family members, and scientific experts participated in decisions about what foods were appropriate to feed mentally ill people through their hearing testimony. This chapter begins with a discussion of how some of the major threads of Progressivism manifested within psychiatry at the beginning of the twentieth century. The mental hygiene movement was the most overt representation of reform ideals in psychiatry. Psychiatrists, psychologists, and other reformers sought to prevent mental illness by educating the public, especially children, on how to lead a mentally healthy life. In mental hospitals, however, pure food reform and investigative reporting had an important, if often overlooked, potential to 6 Grob, Mental Illness and American Society, 25. 7 At St. Elizabeths, there were usually separate buildings to house black and white patients as well as by gender. There were some buildings where black and white patients were housed together, but in that case, they lived on separate wards. See Matthew Joseph Gambino, “Mental Health and Ideals of Citizenship: Patient Care at St. Elizabeths Hospital in Washington, D.C., 1903–1962” (PhD diss., University of Illinois at Urbana-Champaign, 2010), 99-100. 79 challenge hospital administrators. I then examine the different careers of psychiatrists William Alanson White and James Woods Babcock, superintendents of St. Elizabeths, the federal mental hospital in D.C. and South Carolina Hospital for the Insane. Next, investigations into both hospitals are discussed and food, as something that was both administrative and medical, as discussed in chapter 1, reveals how matters of conscience and convenience were either upheld or dismissed in the findings of the investigations. In the case of St. Elizabeths’s investigations, psychiatrists’ and outside experts’ debates over the use of oleomargarine in the hospital reveal how the authority of food science—and science in general—had to be negotiated with cultural and personal ideas about what healthy food was. Further, psychiatrists’ arguments about food as both administrative and medical were able to ensure that White remained as the singular administrator of St. Elizabeths. Lastly, patients, nurses, staff members, and journalists criticized hospital food and feeding practices when given the opportunity to through their testimony in or coverage of legislative hearings. These different groups of people contributed in their own way to a local, bottom-up reform effort that can also be considered part of the larger movement of Progressivism. Overall, at St. Elizabeths, conscience still had power in the face of convenience. The comparison of St. Elizabeths with the investigation into South Carolina Hospital for the Insane shows a different outcome in the struggle between conscience and convenience. In comparison to St. Elizabeths, staff members’ appeals to scientific authority and their medical defenses of the importance of food for health in South Carolina made few dents in legislators’ minds about how much money to appropriate to the hospital, a significant portion of which was used to purchase food. This led pellagra—what we now know to be a deficiency disease due to a lack of niacin in a person’s diet—to develop in many patients in the hospital. Babcock, the 80 superintendent, devoted time and energy to figuring out the etiology of pellagra rather than to attend to structural problems that also afflicted the hospital. Although his scientific efforts and expertise were heralded by the muckraking McClure’s magazine, such coverage did little to help patients. Further, legislators’ racist beliefs that black people needed less food than white people led to an even worse diet for black patients. Without sufficient appropriations to support a varied, nutritious diet and other necessities for all patients, convenience reigned over appeals to conscience. Progressive Reform, Food, and Psychiatry Progressive reformers saw many societal ills and sought rational solutions for them. For them, industrialization, urbanization, increased immigration, and the abuses of big business were major contributors to these ills. Progressives generally thought that science and new laws were the best paths forward. As part of this, historians have long pointed to the rise of the middle class as a driving force of Progressive reform, as the middle class had become more educated and created a variety of new professionals.8 The degree to which reformers had policies that were based on social control has also been studied at length by historians of the Progressive-Era United States as well as historians of psychiatry, but social control does not explain all aspects of Progressivism or psychiatry in mental hospitals.9 Furthermore, although historians once placed a 8 See Robert H. Wiebe, The Search for Order, 1877-1920 (New York: Hill and Wang, 1967) and Michael McGerr, A Fierce Discontent: The Rise and Fall of the Progressive Movement in America, 1870-1920 (New York: Free Press, 2003) for the power of the middle class as a central aspect of the Progressive movement. For a more specific study of the growth of American universities along with middle class professionalism, see Burton J. Bledstein, The Culture of Professionalism: The Middle Class and the Development of Higher Education (New York: W. W. Norton & Company, 1978). 9 In U.S. history more generally, see Paul Boyer, Urban Masses and Moral Order in America, 1820-1920 (Cambridge, MA: Harvard University Press, 1978). The antipsychiatry movement that began in the 1960s popularized the idea that mental illness was a social construct and that the confining of people in mental hospitals was primarily the practice of social control. Two foundational books to this movement were Michel Foucault’s Madness and Civilization and Thomas Szsaz’s The Myth of Mental Illness. See Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New York: Vintage Books, 1988) and Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York: Hoeber-Harper, 1961). 81 lot of focus the efforts of white, middle-class reformers, recent scholarship has begun to broaden the definition of who can be considered a “Progressive” during this time period.10 The Progressives I will discuss in this chapter are generally middle-class, white men and women who had professional aspirations and an interest in public health. However, as I will show, patients, their families, and working- and middle-class employees of the hospital also participated in Progressive-Era reform when they testified in hearings during legislative investigations into mental hospitals. Many prominent psychiatrists were Progressives even as they continued to serve as mental hospital superintendents. Altruism and the desire for social change were frequently proclaimed values of psychiatrists during the period, as many tried to maintain a balancing act between their superintendent duties and public-facing educational and reform activities.11 The mental hygiene movement, which quickly became focused on the prevention of mental illness rather than the reform of psychiatric institutions, was one expression of Progressivism in psychiatry. In chapter 1, I discussed mid-nineteenth century definitions of mental hygiene that promoted the prevention of mental illness through a holistic view that combined mental and physical hygiene. Although some reformers founded the National Association for the Protection of the Insane and the Prevention of Insanity in 1880, it only lasted a short period of time and was unsuccessful.12 In contrast, as early-twentieth-century Progressive reforms grew alongside public health efforts that taught personal hygiene and spread the “gospel of germs” based on the germ 10 See, for example, Glenda Elizabeth Gilmore’s examination of how male and female African American reformers in North Carolina used Progressivism to resist white supremacy. She also discusses white working-class women’s Progressivism. Glenda Elizabeth Gilmore, Gender and Jim Crow: Women and the Politics of White Supremacy in North Carolina, 1896-1920 (Chapel Hill: The University of the North Carolina Press, 1996). 11 See John C. Burnham, “Psychiatry, Psychology and the Progressive Movement,” American Quarterly 12, no. 4 (Winter 1960): 458. This also includes being expert witnesses in court cases, which many psychiatrists did, including William Alanson White. 12 Grob, Mental Illness and American Society, 147. 82 theory of disease, a renewed and more expansive interest in mental hygiene developed.13 Clifford Beers founded what became known as the mental hygiene movement after publishing his popular 1908 autobiographical account, A Mind that Found Itself, of his institutionalization. With the support of famous psychiatrists and psychologists, including Adolf Meyer and William James, Beers formed the National Committee for Mental Hygiene in 1909, which became the National Mental Health Association and exists today as Mental Health America.14 When Beers first wrote his book and began the movement, he intended for it to improve the care and treatment of the institutionalized insane. It was first largely an expression of optimistic humanitarian sentiment about the future of mental hospitals in the United States.15 Gerald N. Grob described the book as “a call for action to inaugurate a new beginning in the institutional care and treatment of the mentally ill.”16 The success of Beers’ reform effort was due in no small part to the power that Progressive ideals held in American politics, but also as an expression of the cultural power of the exposé. One of the most famous exposés of the Progressive Era was Upton Sinclair’s 1906 book The Jungle, which revealed the unsafe and disgusting conditions of the meat packing industry. Although food reforms have not generally been associated with mental hospitals in historical literature, they shaped how Progressivism played out in mental hospital policy, as seen through the investigative hearings into hospital administrations during this period. In a famous interview with Cosmopolitan Magazine, Sinclair mused about what the public found important about the 13 Nancy Tomes, The Gospel of Germs: Men, Women, and the Microbe in American Life (Cambridge, MA: Harvard University Press, 1998). 14 William James is often known as the father of American Psychology. For a thorough biography of James see Robert D. Richardson, William James: In the Maelstrom of American Modernism (Boston: Mariner Books, 2006). “Our History,” Mental Health America, accessed February 12, 2021, https://www.mhanational.org/our-history. 15 Norman Dain, Clifford W. Beers: Advocate for the Insane (Pittsburgh, PA: University of Pittsburgh Press, 1980), 90. 16 Grob, Mental Illness and American Society, 149. 83 book: “I wished to frighten the country by a picture of what its industrial masters were doing to their victims; entirely by chance that I stumbled on another discovery—what they were doing to the meat-supply of the civilized world. In other words, I aimed at the public’s heart and by accident I hit it in the stomach.”17 The public’s interest, then, was captured by the quality of food they were eating, and this interest and manifested itself in concern that helped to spur government reform. After public outcry, reformers’ interest, and support from U.S. Department of Agriculture scientists like Harvey Wiley, the U.S. government and President Theodore Roosevelt passed the Federal Meat Inspection Act and Pure Food and Drug Act in 1906. That literary appeals to the stomach could be effective enough to spur national legislative action shows the prevalence of worries about food quality in the United States. Historian Michael McGerr has argued that “Progressives and their political allies triumphed in the struggle for pure food and drugs by invoking disparate Americans’ shared identity as consumers,” but this does not clearly map onto the complaints of patients, their families, and hospital employees who were not purchasing food on the open marketplace but were instead assessing food provided to them by the government.18 Still, these people’s own experiences eating or seeing poorly cooked or rotten food in a government-run institution could spur them into advocating for specific reform. In this way, patients and those who cared for them took part in Progressivism when they testified about the food in government-run mental institutions during legislative hearings. Exposés and sensational reporting more generally also influenced hospital superintendents throughout the Progressive Era. While superintendents did have enormous power over how their hospitals ran, negative newspaper reports sometimes caused the interested 17 Upton Sinclair, "What Life Means to Me,” Cosmopolitan 41, no. 6 (Oct. 1906): 591, ProQuest American Periodicals. 18 McGerr, A Fierce Discontent, 160. 84 public to agitate for reform through their legislative representatives, causing psychiatrists to go on the defensive. By the time Beers published his book in 1908, for example, psychiatrists were already “sensitive” to sensationalist exposés in the popular press.19 The most famous and most stinging was Nellie Bly’s newspaper exposé of a New York asylum—she had faked mental illness to be admitted to the institution and then convinced psychiatrists of her “insanity” although she was sane. Her series of articles turned into a book titled Ten Days in a Mad-House, published in 1887. Bly’s reporting had not only revealed abuses within mental hospitals but had also dealt a blow to the scientific authority of psychiatrists as experts who had determined Bly to be insane.20 Reports like this led Beers to make efforts to ensure book reviewers in popular newspapers did not merely present his book as an attack on the management of hospital superintendents, since the reform movement he was building relied on the support of prominent psychiatrists for legitimacy.21 Newspapers, however, did not have a monopoly on the exposé. Magazines such as McClure’s were famous for their reform-focused articles that earned their journalists the title of “muckrakers.” Overall, whether in books, newspapers, or magazines, reformers’ visions for a better hospital challenged mental hospital superintendents’ administrations. William Alanson White and James Woods Babcock: An Overview One of these prominent psychiatrists who found himself in a leading position in psychiatric reform was William Alanson White. In the last chapter, I introduced White briefly as the new superintendent of the Government Hospital for the Insane while scientists from the USDA Office of Experiment Stations were completing their studies of the hospital diet. White 19 Dain, Clifford W. Beers, 90. 20 See Jean Marie Lutes, Front Page Girls: Women Journalists in American Culture and Fiction, 1880-1930 (Ithaca, NY: Cornell University Press, 2006): 16. 21 Dain, Clifford W. Beers, 90-93. 85 served as the superintendent of St. Elizabeths hospital in Washington, D.C., from 1903 to 1937, when his death ended his tenure at St. Elizabeths. By the end of his life, White became known as one of the most important American psychiatrists who influenced the rise of Freudian psychoanalysis in American psychiatry.22 He also famously served as an expert witness in the nationally publicized trial of Harry K. Thaw for the murder of the young New York City architect Stanford White, in which Thaw’s attorneys claimed that he was insane and should be acquitted.23 Throughout his career, White published many books on psychiatry, including Outlines of Psychiatry (1907), Mechanisms of Character Formation: An Introduction to Psychoanalysis (1916), The Principles of Mental Hygiene (1917), and Foundations of Psychiatry (1921). His textbook Outlines of Psychiatry formed the first of a Nervous and Mental Disease Monograph Series and was very successful, having fourteen editions appear with only one major revision by 1935.24 White’s understanding of mental health and illness played an important role in how he administered the hospital as its superintendent. While somatic etiologies of mental illness were still essential to psychiatric thought, prominent psychiatrists, including White, stressed a holistic approach to mental health, accounting for both the mind and the body. This kind of “social psychiatry,” which took into account the individual’s environment, as well as somatic and psychological understanding of disease, was advocated by White as well Adolf Meyer, who became famous for his concept of “psychobiology.”25 When White’s ideas were still developing 22 Grob, Mental Illness and American Society,120. 23 See Helen Swick Perry, Psychiatrist of America: The Life of Harry Stack Sullivan (Cambridge, MA: The Belknap Press of Harvard University Press, 1982), 128-129. 24 “William Alanson White,” The Psychoanalytic Review 24 (1937): 210. This journal began in 1913 with the co- editorships of William Alanson White and his good friend and fellow psychiatrist Smith Ely Jelliffe. 25 For more on “social psychiatry” and others connected to the movement, see Roy Lubove, The Professional Altruist: The Emergence of Social Work as a Career, 1880-1930 (Cambridge, MA: Harvard University Press, 1965), 56. This was also called “dynamic psychiatry.” See chapter 5 for further discussion. 86 in the early twentieth century, he placed a lot of emphasis on both the somatic and psychic causes of mental illness. His composite view of mental illness informed the way that White saw his role as a mental hospital administrator as well as his public reform efforts.26 Outside of his role as St. Elizabeths’s superintendent, White was a frequent lecturer. He was most often known for his lectures in psychoanalysis, but he was also credited with being “a most active lecturer in medical societies, before social worker groups, [and] in mental hygiene conferences” more generally.27 His lectures were thus medical but also reform-oriented since he was involved in advocating for a greater public and popular focus on mental hygiene policies, which he hoped would prevent people from becoming mentally ill and being admitted to inpatient psychiatric hospitals. This at times got him into trouble with the Department of Interior, which oversaw his work at St. Elizabeths. But as a hospital administrator, White had to balance his theoretical and medical work with his administrative position, part of which included ensuring food was purchased for the hospital and approving the diet for which the food was used. His administration over the food in the hospital was one category of critique he faced from the concerned public as well as politicians. During his tenure as superintendent, White faced four official congressional investigations into his administration in 1906, 1919, 1926, and 1929. In South Carolina, James Woods Babcock served as the superintendent of the South Carolina State Hospital for the Insane from 1891 to 1915. Although he never rose to the level of fame as White, he had sound psychiatric training. Babcock, a South Carolina native, completed his M.D. at Harvard and then took a position as the second assistant physician at one of the best 26 White’s concept of “organism as a whole,” which became better articulated in the 1920s and 1930s, and its impact on the care and treatment of institutionalized mentally ill people through diet will be further explored in chapter 5. 27 “William Alanson White,” The Psychoanalytic Review, 215. 87 mental hospitals in the country, the private McLean Asylum in Massachusetts.28 He became superintendent of the South Carolina State Hospital for the Insane after one legislative investigation into Peter E. Griffin’s management in 1891 led to Griffin’s resignation. As historian Charles S. Bryan has described, the South Carolina hospital could not have been more different than McLean, as it was “public, underfunded, and a political football.”29 Babcock was eventually forced out in much the same way as his predecessor and could never overcome the underfunding of the hospital. The hospital’s underfunding combined with Babcock’s lack of administrative expertise created worse conditions and a less nutritious diet in the South Carolina State Hospital than at St. Elizabeths under White.30 While both superintendents faced limitations to their goals, White was much more able to achieve reform in the hospital than Babcock. During Babcock’s tenure as superintendent, he faced two state congressional investigations into his administration in 1909 and 1914. The fallout resulting from the latter ultimately lead to his resignation. Peter McCandless, in his foundational work on insanity in South Carolina, argued about the important role of Progressives in the reform of the state hospital through these investigations. However, while McCandless noted that the diet “may have contributed to deaths from nutritional disorders such as pellagra” which physicians thought accounted for more than eleven hundred deaths between 1908 and 1914, his discussion of the influence of diet and pellagra in the hospital ends there.31 What follows, then, seeks to better highlight the role that diet played in critiques of Babcock’s administration and to further understand how poor diet and the crisis of pellagra in the institution developed. 28 Charles S. Bryan, Asylum Doctor: James Woods Babcock and the Red Plague of Pellagra (Columbia, SC: The University of South Carolina Press, 2014), 16-18. 29 Bryan, Asylum Doctor, 21. 30 Bryan pointed to Babcock’s lack of administrative experience. Bryan, Asylum Doctor, 25. 31 McCandless, Moonlight, Magnolias, & Madness, 284. See chapter 14 for discussion of the investigations and Progressivism. 88 The St. Elizabeths Investigation of 1906 The 1906 congressional investigation into St. Elizabeths provides rich source material with which to interrogate the intersection of diet, psychiatry, and the federal government. Overall, this investigation into St. Elizabeths has been noted by historians but has not been explored with depth.32 In Otto’s view of the 1906 Investigation, the degree to which concerns about food in the hospital were raised “detracted from the more serious charges of patient abuse and neglect.”33 While certainly the issues of patient abuse and neglect were important, concerns about food—which could also include instances of abuse and neglect—should not be dismissed as trivial. As I argued in chapter 1, food was not only an administrative necessity but was also an aspect of patient care and even therapy. The 1906 investigation confirms this but also shows the ways in which food was an important avenue for patients, their families, and hospital employees to voice their dissatisfaction with the hospital administration. The investigation also reveals how what we have come to understand as a “scientific practice” was in fact a fundamentally sociopolitical endeavor in which conflicting uses of unproven theories unfolded. The 1906 investigation took place only two years after Pratt and Milner’s dietary study was completed and three years after White became the St. Elizabeths superintendent. The investigation into the hospital began when there was a writ of habeas corpus filed for a former soldier in St. Elizabeths in 1905 charging that he was held there illegally against his will. A legal battle ensued regarding D.C. commitment laws and how they should be applied to veteran 32 Matthew Joseph Gambino studied St. Elizabeths and William Alanson White during this period in his dissertation. He discussed the existence of these investigations, but they do not factor as a large part of his analysis of White’s superintendency. In exploring some of the strains that the hospital underwent in the early twentieth century, he wrote: “The institution faced congressional scrutiny in 1906, 1919, and 1926 on charges of abuse, neglect, and mismanagement, but each time White emerged unscathed, managing even to secure increased funds for the hospital.” Gambino, “Mental Health and Ideals of Citizenship,” 49-50. While true, my analysis will show that White responded to criticisms stemming from the investigation, particularly regarding administration over food. 33 Thomas Otto, St. Elizabeths Hospital: A History (Washington, DC: U.S. General Services Administration, 2013), 220. 89 patients.34 Through this battle, White’s administration came under fire from members of the D.C. Medico-Legal Society who were concerned about medical ethics.35 After significant popular press coverage of the controversies and continued pressure from the D.C. Medico-Legal Society, a Democratic Representative from Florida, Frank Clark, put forth a resolution on the House floor for an investigation into the management of St. Elizabeths.36 The inquiry had some roots in national politics and was certainly not without partisan politicking. White, due to his personal connections from New York and membership in the Republican Party, had been appointed to the position of superintendent by Republican President Theodore Roosevelt. This process was not new but opened an avenue for partisan complaints. It was thus not surprising that a Democratic representative introduced the resolution to investigate White’s administration. On the other hand, the Speaker of the House of Representatives, Republican Joseph Cannon, appointed the investigative committee on May 4th, 1906. Luckily for White, Cannon and he were friends, even to the point where White fondly referred to Cannon as “Uncle Joe.”37 Because the House was Republican at the time, three Republican congressmen and two Democrat congressmen were appointed to serve on the committee to investigate the charges against White. Over the course of several months, between May and December 1906, thirty-three public hearings took place, during which the committee examined a total of 287 witnesses.38 34 This situation continued to cause problems for White at the hospital. See chapter 5 for a further discussion of veteran patients. 35 Otto, St. Elizabeths Hospital, 219. 36 William Alanson White, William Alanson White: The Autobiography of a Purpose (Garden City, NY: Doubleday, Doran & Company, Inc., 1938), 91. 37 White, Autobiography, 89. 38 Ibid., 91. See also the Investigative Committee’s report in House Special Committee on Investigation of the Government Hospital for the Insane, Report of the Special Committee on Investigation of the Government Hospital for the Insane with Hearings May 4-December 13, 1906 and Digest of the Testimony, 59th Cong., 2nd sess., vol. 1, February 18, 1907, H. Rep. 7644, iv, ProQuest Congressional. 90 The accusations made against White’s administration of St. Elizabeths Hospital included mishandling of government funds, the physical abuse of patients (including the use of restraints and feeding tubes as punishment), and complaints about the food served to patients being of a poor and dangerous quality. The investigation, then, focused on the care and treatment of patients within the hospital. While some people who testified were happy with the food at St. Elizabeths, others criticized it. Through food, one aspect of care and therapy, both the administrative and medical branches of the hospital faced harsh allegations of mismanagement and abuse. Indeed, the first ex-patient to take the stand at the 1906 hearings alleged that doctors used tube feeding as a punishment on her. Mrs. Margaret Lochte was Catholic, married, had five children, and was committed to the hospital after a “nervous spell” that happened while she took her children to a summer health resort.39 She testified that no one gave her food for the first two days that she was in the hospital. From her perspective, a horrible miscommunication occurred when a nurse told the doctor that Lochte refused to eat. When that happened, she testified, “they gave me some kind of tube feeding, something that they would run way up in your nostrils, and it certainly was punishment. They tied me down in bed and gave it to me.”40 Lochte maintained that she would have eaten if she had just been given food, but doctors, nurses, and her case files provided evidence to the contrary. Lochte’s allegations about the use of feeding tubes in abusive or disciplinary ways in St. Elizabeth were covered by the New York Times, but the investigation committee members and psychiatrists quickly dismissed them during the hearings.41 Although at first two nurses reported 39 House Special Committee, Report, vol. 1, 61-66. She was an inmate of the institution for about 3 months between June through mid-September of 1905. Overall, she thought that she had been “treated pretty badly at St. Elizabeths. 40 Ibid., 64. 41 “Insane Veterans Ill-Used?: Grave Statements About St. Elizabeth’s [sic] Asylum Management,” New York Times, Feb 19, 1906, ProQuest Historical Newspapers. 91 that they had never seen Lochte fed with a tube, one hospital doctor testified that he did tube feed her because he deemed it to be medically necessary.42 He claimed that she was never denied food and he would “never feed a patient that would eat willingly.”43 Similarly, one of the committee members dismissed Lochte’s tube feeding, saying that what they fed her could not have been dangerous: “Certainly it was liquid food, and they were trying to keep you alive, that is what they were trying to do.”44 The use of feeding tubes was an established practice in psychiatric institutions.45 Ultimately, the majority report of the investigation committee asserted that not only was the charge that St. Elizabeths doctors used a feeding tube as a punishment “disproved,” but “the testimony which sought to show this was the case was absurd.”46 With Lochte’s case notes and doctors’ testimony that tube feeding was medically necessary, her accusations were dismissed. A different kind of complaint that patients had about food in the hospital was that it was rotten, inedible, or simply bad. While complaints over the chewiness of the beefsteak or dirty and uncooked potatoes featured in hearing discussions about food, oleomargarine was the food that took the spotlight. St. Elizabeths began serving patients oleomargarine rather than butter in 1904, and the switch did not escape the notice of patients as well as attendants at the hospital.47 As one former patient, Dawes Shuster recalled, there was no butter at St. Elizabeths, only “butterine” 42 House Special Committee, Report, vol. 1, 457, 477-8. 43 Ibid., 526. 44 Ibid., 64. 45 See, for example, Elizabeth A. Williams, “Gags, Funnels and Tubes: Forced Feeding of the Insane and of Suffragettes.” Endeavour 32, no. 4 (2008): 134-140. For more on this history, see chapter 3. 46 House Special Committee, Report, vol. 1, x. Even the more critical minority report did not mention tube-feeding explicitly, only stating that at the hospital “the medical treatment is abreast with the times” and that ‘the most approved and advanced methods are resorted to,” even if they believed there were certainly cases of cruelty. Ibid., xxxvi. 47 Annual Report, 1907, 220. The example diet provided as evidence in the hearings still cited butter rather than oleomargarine throughout the menu. It is unclear why, as the two patients whose testimony follows knew that it was oleomargarine. It is possible that White tried to pass butter off as margarine to patients. See House Special Committee, Report, vol. 1, 522-525. 92 from a factory nearby. But patients, he claimed, simply referred to it as “axle grease.”48 Likening butter to axel grease—a mechanical oil—as well as the mention of a factory, can be read to imply that some patients saw oleomargarine as a less “natural” and more industrialized product. Other patients simply viewed oleomargarine as fake butter. When asked if the butter was good in the hospital, another patient, Cornelia L. Corbett, stated matter-of-factly, “Well, of course they have not the real butter. It is oleomargarine.”49 Ultimately, however, the debates over oleomargarine and butter featured most prominently in the hearings because the committee members discovered they were unsure about the “nutritious” versus “wholesome” qualities of it.50 These debates regarding serving oleomargarine in the institution reflect doctors’ and administrators’ different views concerning which foods were safe and healthy and whether economy or palatability mattered more when buying food for a large institution. Oleomargarine was an oil-based butter substitute created out of a mix of animal lards and, often, cottonseed oil.51 It was close to nutritionally equivalent to butter but cost much less, but it did not taste very much like butter. To make it more palatable, it was churned in milk and salt was added to it. Many scientists, dietitians, and public health officials argued that oleomargarine’s lower cost mattered more than its taste, however. Other doctors expressed more concern about oleomargarine, questioning not only how “nutritious” it was, but also whether it was “wholesome” enough to feed to the mentally ill, which coincided with Progressive-Era concerns 48 House Special Committee, Report, vol. 1, 121. He claimed that people said, “Pass me the axle grease.” 49 Ibid., 133. Emphasis added. 50 For a book-length study of the social and economic competition between the two food products, albeit in Canada, see W. H. Heick, A Propensity to Protect: Butter, Margarine and the Rise of Urban Culture in Canada (Waterloo, Ontario: Wilfrid Laurier University Press, 1991). 51 House Special Committee, Report, vol. 2, 1352. For how cottonseed oil became an accept food item to many Americans during this time, see Helen Zoe Veit, “Eating Cotton: Cottonseed, Crisco, and Consumer Ignorance,” The Journal of the Gilded Age and Progressive Era 18, no. 4 (October 2019): 397-421. 93 over food adulteration. St. Elizabeths psychiatrists generally supported feeding patients oleomargarine because they viewed it as safe, reasonably palatable, and economical. One St. Elizabeths psychiatrist, Maurice J. Stack, supported the use of oleomargarine there and claimed to eat it himself. When asked about the issue, Stack said that “the butter is a problem that has caused some annoyance. We use oleomargarine. Of course, that is largely a matter of taste. I have become habituated to the use of it.”52 This idea of habituation can be linked to self-discipline and control since one must work (or be forced) to habituate to the taste of it. When assistant physician B. R. Logie was asked about the use of oleomargarine in St. Elizabeths, he justified its use by asserting how butter presented many difficulties in a large mental hospital largely due to spoilage, while oleomargarine did not have this issue. He also stated somewhat bluntly that “the patients eat it” in order to make his point that oleomargarine is sufficient, although he admitted “butter is a little more palatable.” Ultimately, for Logie, oleomargarine should be used because it is “more healthy than most butter that you get” and had an economic advantage by saving the hospital an estimated $9,000 a year. Economic concerns were especially important for Superintendent White, since his spending of government funds was subjected to much oversight, as this investigation showed. Medical doctors who testified but were not affiliated with St. Elizabeths were split in their assessment, although those in favor of oleomargarine appear to have convinced the investigation committee of its wholesomeness and economic benefits. The person most critical about serving patients oleomargarine was Charles M. Emmons, a doctor and the Secretary of the D.C. Medico-Legal Society, which had begun the investigation into St. Elizabeths. Emmons did 52 House Special Committee, Report, vol. 1, 660. 94 not think that the economic benefits of oleomargarine outweighed its bad taste. Succinctly, he stated, “I do not see why, if we are going to serve butter, we serve adulterated butter. […] I would cut butterine out entirely and give them no butter rather than give them something to which they must become habituated in order to enjoy it.”53 In contrast, George M. Kober, Professor of Hygiene at the Georgetown University School of Medicine and the President of the Association of American Medical Colleges, supported the use of oleomargarine due to the economic benefits. Kober was an expert on the question of the benefits of oleomargarine versus butter. His article “Milk, Butter, and Butter Substitutes, in Relation to Public Health” which appeared in the Journal of Social Science on December 1, 1902, was entered into evidence as expert support for the use of oleomargarine. Kober argued in his article that oleomargarine “should be more generally used, and not looked upon as an inferior article and makeshift for butter, when it is really superior.”54 Kober’s hearing testimony was based on his article and was of a similar vein to Logie’s. When asked by investigator Smyser whether the criticism of the hospital’s use of oleomargarine was merited or not, Kober replied, “I should say it is most unjust, and such criticism would not be made if the public at large was better educated as to the real merits of this food stuff.”55 Despite the arguments between medical professionals about the tradeoffs between oleomargarine and butter, the hearing testimony also shows how nutritional knowledge during this period was not widespread and was relatively new, especially to the working-class. This difference in nutritional understanding included cooks, even those employed at St. Elizabeths. 53 U.S. House, House Special Committee on Investigation of the Government Hospital for the Insane, Report of the Special Committee on Investigation of the Government Hospital for the Insane with Hearings May 4-December 13, 1906 and Digest of the Testimony, vol. 2, 59th Cong., 2nd sess., vol. 2, February 18, 1907, H. Rep. 7644, 1440-1, ProQuest Congressional. 54 George M. Kober, “Milk, Butter, and Butter Substitutes, in Relation to Public Health,” Journal of Social Science 40 (December 1, 1902): 144, 146, ProQuest. 55 House Special Committee, Report, vol. 2, 1352-1354. 95 Getting hired as a cook at the hospital did not require that one had nutritional training. When Albert Ball was hired as a cook at St. Elizabeths in 1898, he had had no previous training and learned to cook on the job.56 During the 1906 investigation, he testified that the kitchen often ran short of different food items, such as tomatoes, and that cooks had to adapt. When asked by one of the examiners what he used as a substitute for tomatoes, he said: “Well, perhaps we would substitute rice, rice cakes, or anything we could get, you know. It is hard to tell, when a man is cooking, what he will substitute.”57 Under the knowledge of the “New Nutrition” of the period, rice or rice cakes would not have substituted well in either calories or macronutrients (tomatoes have considerably less carbohydrates and less protein than rice).58 But for Ball—one of three cooks that prepared food for 1,200 people with only 20 kitchen helpers—food substitution did not come down to chemical equivalencies. Rather, the necessities of feeding such a large group of people won out over the nutritional best-practices of the period. Put another way, conscience did win out over convenience at St. Elizabeths at times. Examining food in the 1906 investigation hearings also reveals how Progressive Psychiatrists’ beliefs in professionals and scientific knowledge often clashed with everyday people and their practical decisions.59 The testimony also reveals how the segregation of patients based on race may have 56 House Special Committee, Report, vol. 1, 286. 57 Ibid., 289. 58 Harvey A. Levenstein, Revolution at the Table: The Transformation of the American Diet (Oxford: Oxford University Press, 1988), 57. Advocates of what Levestein called “New Nutrition” relied on chemistry to analyze foods, which also led them to see usefulness in substituting chemically similar foods and newly engineered food products (in terms of amounts of protein, carbohydrates, and fats) for one another. By the 1906 investigation, food substitution had become much more commonplace in discussions about institutional dietaries than in the 1890s. Importantly, however, these advocates were unaware of the existence and nutritional importance of vitamins, because they had not been discovered yet. 59 Gerald N. Grob made this point clearly: “Generally speaking, administrative rationalization had a far smaller impact than its advocates anticipated. […] Claims to the contrary, administrative techniques never approached the ability of thousands of individuals to ignore or alter regulations that appeared to be unreasonable or inappropriate.” Grob, Mental Illness and American Society, 215. Rothman made a similar argument regarding how Progressive ideals played out in the period: “In the end, when conscience and convenience met, convenience won. When treatment and coercion met, coercion won.” Rothman, Conscience and Convenience, 10. 96 affected how African American patients at St. Elizabeths were fed. African American patient and Army veteran J. Owsley testified that he called a racial slur and was beaten by an attendant in the dining room for refusing to sweep the floor. In terms of the food he received, Owsley wasn’t sure if African American patients received the same food as white ones, as African American patients dined “to themselves” in a separate dining room on their ward. He also said that he didn’t get “extra” food, perhaps signaling that he was unhappy with the quantity of food he received.60 Albert Blackistone, who was a former attendant who worked in the West Lodge Dining Room— likely the same dining room for male African American patients that Owsley ate in—also said that patients in his dining room sometimes didn’t get enough food to eat. The food was “not very good” and that even when he and other attendants tried to get more food for the patients, it would be cold by the time they brought it back from the kitchens.61 The hearing testimony otherwise did not indicate that African American patients received a different hospital diet than white ones. Both Owsley’s and Blackistone’s testimony opens up the possibility that in practice, the diet on African American wards was not equal to that on white ones. Nurses also testified at the hearings regarding the hospital diet, but their testimony differed from attendants’ overall. In general, attendants’ complaints about the diet were not that it was failing to meet nutritional standards. Instead, their complaints showed a general concern about the quality of the food and cooking, and they used language no different than that of a patient or member of the public. However, the nurses who testified and critiqued the hospital’s diet did so with more precision, likely due to their dietary education in a Nurse’s Training 60 House Special Committee, Report, vol. 1, 226-230. See also Martin Summers’s discussion of Owsley’s resistance to working at the hospital, which angered an attendant, who Owsley claimed attacked him. Summers discussed how “both black and white patients avoided ‘voluntary labor’ because of its particular racial valence.” Martin Summers, Madness in the City of Magnificent Intentions: A History of Race and Mental Illness in the Nation’s Capital (New York: Oxford University Press, 2019), 182. 61 House Special Committee, Report, vol. 1, 192-4. 97 School. For example, one former attendant, Edgar Ball, stated that the hospital food “wasn’t the best [he] had ever had” and that the food for attendants and patients was often “cold and half cooked.”62 A nurse, Mrs. McLaughlin, critiqued the amount of food under White versus Superintendent Richardson. She said that Richardson “was more freer to supply the wants of the patients. I think we had more under Dr. Richardson.”63 She, however, did explain the sick diet in the hospital’s ward for male patients, and testified that the food for the patients in her care was “all right” but thought that “occasionally they should have fresh fruit brought to them and given to them, such as oranges or bananas or lemons.”64 Unlike the attendants, who criticized the temperature and cooking of food, McLaughlin was able to suggest certain kinds of food that she thought would supplement the diet of sick patients. Although many nurses and attendants did not testify regarding the food, the testimony of those who did shows how food was scrutinized by the employees, adding another layer of responsibility for the superintendent. Nurses, better trained than attendants, knew more about the food and food service, and could critique the diet from a standpoint of the basic nutritional quality—especially in terms of variety—offered to patients, rather than commenting purely on the state of the cooking or the impurity of the food. By implementing the interdisciplinary approach to food and mental illness, then, the hospital inadvertently brought a sharper critique to its day-to-day dietary practices. Another important part of the investigation and hearings that dealt with food concerned the actual structure of St. Elizabeths administration. One of the most direct attacks on White’s authority in the hospital came regarding the hospital’s administrative structure. Some critics had 62 Ibid., 150. 63 Ibid., 274. 64 Ibid., 272. 98 pushed for a “dual management” structure to be instituted at St. Elizabeths, where one head would take care of the medical branch and the other would take care of the “purchase of supplies and the management of the buildings, etc.”65 During the height of moral treatment in the mid- 1800s, it had been common and viewed as necessary for superintendents to have “one-man rule in the asylum.”66 By the early twentieth century, however, it was not unheard of that a mental hospital had a medical superintendent and an administrative superintendent. Showing more continuity than change, then, the majority opinion found that a plan for dual management at St. Elizabeths was “not feasible.”67 The testimony of Superintendent William Mabon of Manhattan State Hospital in New York City’s became central to convincing the majority that the administration of food for the hospital needed both administrative and medical oversight. Mabon’s testimony formed one important part of the inclusion of scientific and medical experts in the hearings aligned with the Progressive-Era union of science and social reform. In their report, the majority summarized that Mabon had “testified that the mere question of food supplies should be under the immediate control of the medical superintendent, and stated that nothing was more important in the care of persons either mentally or physically ill than the question of their diet.”68 Mabon’s testimony was even more specific’ he viewed “the food of the patients [as] a medical question” in order to support keeping the current administrative structure of one institutional head—linking food as something beyond a simple purchasing choice with concerns about economy and the budget of the institution because it also was seen as central the medical care of the patients. The majority 65 Ibid., xviii. 66 Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum Keeping, 1840-1883 (New York: Cambridge University Press, 1984), 147. 67 House Special Committee, Report, vol. 1, xviii. 68 Ibid., xviii. 99 believed this argument and recommended that White continue to be the sole administrator of the institution. Of course, this did not stop him from hiring new employees in the growing bureaucratic structure of the hospital staff. Mabon had also noted that St. Elizabeths had “no steward.”69 The office of Steward was a position that asserted direct control of food and supply purchasing and reported directly to the superintendent. Ultimately, the St. Elizabeths Administration and White were absolved of any misdeeds by the majority of the members of the Special Committee on the Investigation of the Government Hospital for the Insane. Progressive concerns about mentally ill patients’ quality of life, including St. Elizabeths’s food quality and service, featured in the suggestions made to better the hospital.70 To be sure, in the majority opinion, one of the fifteen conclusions dealt with the hospital’s diet, and stated “that the dietary used at the hospital is of good quality, of proper variety, and the food is generally well prepared and cooked.”71 And yet, even with the majority opinion’s positive assessment, two out of six suggestions to improve St. Elizabeths pertained to the Hospital’s food service. The majority opinion suggested the installation of new steam heaters to keep food hot, and to build one to two new kitchens to help the convenience of food being prepared and served to both attendants and the patients. At that time, many patients’ food came from the central kitchen, and had to be transported using rail carts through passageways, or even outside of the building, so many times patient food became cold or became jostled around before 69 House Special Committee, Report, vol. 2, 1697. 70 The vote was a close one, at 3 to 2, and was split by political party affiliation. The majority report written by the Republican members characterized White as “fully qualified for the position of superintendent, is an able and distinguished alienist, and an efficient, honest, and progressive manager of all of the several branches of the hospital […].” White, Autobiography, 91, and House Special Committee, Report, vol. 1, vi-vii. White was very aware of the political nature of his position and his writing in his autobiography shows this: “The split in the committee occurred along political lines, the three Republican members making the majority report, and the two Democratic members the minority report.” 71 Ibid., xxxi. 100 serving.72 In comparison, the minority opinion found much more fault with the food served at St. Elizabeths. The two members wrote: “As to the food which is supplied to the inmates of the hospital there is a conflict of evidence; but it seems to the undersigned that the great preponderance of the testimony is that the food is generally badly prepared, badly served, and oftentimes is not of such a kind as to be fit for consumption, especially when the character of these people is taken into consideration.”73 Here, the quality of the food itself was not challenged as much as the poor preparation and serving of food, which were central to why the minority critiqued the hospital’s food as unfit for consumption. William Alanson White responded to the committee’s report as well as recommendations from the other superintendents that testified. The Annual Report White wrote in April 1907 following the investigation, showed that he created the “steward” position by promoting the storekeeper to that role. This responded to Mabon’s concerns and showed White’s willingness to delegate such duties to staff members. Furthermore, White also created the new position of “Chef” for the issuing of food supplies throughout the hospital kitchens to further centralize hospital management. White wrote that “in the same way that the issuing of ward supplies has been centralized in the office of the matron, the issuing of food supplies has been centralized in the office of the chef.”74 White’s choice to create new positions on the hospital staff, including those centered on food, shows that he took the investigation’s findings seriously. In this 1907 Annual Report, White also discussed how the accounting practices of St. Elizabeths had been overhauled while asserting his knowledge of economic purchasing practices 72 Otto, St. Elizabeths Hospital, 127. 73 House Special Committee, Report, vol. 1, xxxvii. The minority’s report considered the “food supplied to the inmates” to be the second of eight central points examined in the investigation. 74 Annual Report, 1907, 435. 101 and nutritional vocabulary. For instance, he reported that it “may be possible to purchase to advantage and at the same time maintain the necessary number of food units, calories, and the nutritional standard as regards the correct proportions of proteins, carbohydrates, and fats.”75 This use of nutritional science terminology shows a direct engagement with the growing science of nutrition and the newly important place diet had in this medical institution. At the time of the “New Nutrition,” this general description of using calories in addition to proteins, carbohydrates, and fats to create the diet was likely seen as an appropriate response to the investigation. And as White had testified, he had already believed that “Mental disease is bodily disease, and is treated along general medical principles.”76 Thus, it would make sense he would seek to be up to date on dietary standards and be familiar with the basics of nutritional science, so as to make food more firmly part of modern medical therapy. In the testimony of other hospital superintendents, the majority opinion of the investigation committee, and White’s own response to the investigation, the authority of superintendents of mental hospitals was successfully defended by creating the idea that food was both a hospital supply as well as a medically therapeutic entity that could not be divorced from either the budget and administration of the hospital or the medical care of patients. Indeed, in his Autobiography of a Purpose, White pointed directly to learning how to be an administrator during the period thought this investigation. He wrote, “I learned how to conduct myself under fire, a necessary acquisition if one is going to function as an administrative officer under the shadow of a legislature.”77 This defense was central to retaining the authority of psychiatrists as having domain over the care and treatment of the mentally ill in a period where their authority 75 Ibid., 437. 76 House Special Committee, Report, vol. 1, 904. 77 White, Autobiography, 93. 102 was being challenged by the emergence or growth of other professional specializations related to mental illness, such as social work, psychiatric nursing, neurology, and experimental psychology. Even as psychiatrists, including William Alanson White, began to extend their influence on everyday aspects of life outside of mental hospitals, hospital superintendents in the early twentieth century still sought to maintain their control over their patients and the mental hospital—the traditional site of their medical authority. White’s control over patients’ diets and his authority to hire new experts or specialists to help him with that aspect of patient care were important parts of asserting and maintaining that authority. Outside the hospital, psychiatrists like White also engaged in Public Health and Hygiene efforts. White was an advocate for the mental hygiene movement and in 1911, and not long after the 1906 investigation, White wrote an article that argued for the importance of preventative medicine for mental health as part of a strong public health program. Echoing psychiatrist John Gray’s use of the ancient concept of mens sana in corpore sano as covered in chapter 1, he wrote, “We will have learned that a healthy body is of no use to the individual or to society unless there dwells within a healthy mind. The maxim: “Mens sana in corpore sano” will still be true but in a sense amplified and vitalized.”78 With his focus on nutrition in the hospital, patients could be thus made more holistically healthy. Although the 1906 investigation showed that the diet and food service in the hospital was not always up to par, through their testimony and responses after the investigation, White and his staff showed that at St. Elizabeths, conscience had the ability to reshape convenience when it came to the hospital diet. Indeed, White’s attention to nutrition at the hospital grew further when the United States became entangled in World War I, as will be explored in the next chapter. 78 William A. White, “Preventative Principles in the Field of Mental Medicine,” Journal of the American Public Health Association 1, no. 2 (February 1911): 89, HathiTrust. 103 The South Carolina 1909 Investigation As the federal mental hospital that cared for veterans and received appropriations from the U.S. Congress, St. Elizabeths was well-funded. But not all state legislatures had budgets that allowed for generous or even sufficient appropriations for state hospitals. In South Carolina, the State Mental Hospital for the Insane at Columbia and its superintendent, James Woods Babcock, who served in that position from 1891 to 1915, faced many challenges due to poor conditions at the hospital. Like White, Babcock and his administration faced an inquiry in 1909, which will be discussed shortly. The juxtaposition of these two administrations and the investigations that each superintendent underwent in the first decades of the twentieth century allows us to see some of the important similarities and differences between how food factored into psychiatric hospital administration and patient care. Unlike White, Babcock dealt with a crisis in the hospital due to the disease pellagra, which had reached alarming levels in the U.S. South by 1906.79 Pellagra is a disease which develops in people who do not consume or absorb enough niacin (also known as vitamin B3) or tryptophan in their diet. Besides somatic symptoms of the disease such as skin sores and inflammation as well as diarrhea, the disease also manifested with mental symptoms which were generally categorized as “dementia” or simply, “delusions.” Often, psychiatric symptoms of pellagra do not present until it is relatively advanced, which made the disease harder to understand for early-twentieth-century physicians, psychiatrists, and scientists alike. If the disease is not treated, it can lead to death. When pellagra was first recognized as a disease in patients at the South Carolina State Hospital for the Insane in 1907 (having first been identified 79 See Daphne A. Roe, A Plague of Corn; The Social History of Pellagra (Ithaca, NY: Cornell University Press, 1973) and Elizabeth W. Etheridge, The Butterfly Caste: A Social History of Pellagra in the South (Westport, CT: Greenwood Pub. Co, 1972). 104 in Georgia in the year before), vitamins had not yet been discovered and the etiology of pellagra was a mystery that became hotly debated in the medical community. Many patients in South Carolina thus died from pellagra. Babcock spent much of his time as superintendent researching and attempting to understand why the Hospital faced so many patients that were admitted with pellagra or diagnosed with “pellagrous insanity” and quickly died. Just as William Alanson White spent time outside the hospital promoting psychoanalysis and the mental hygiene movement, Babcock chose to spend time outside of his administrative duties at the hospital researching pellagra.80 In D.C. and in the Northeast, it was much easier for psychiatrists to devote some attention to reform activities outside the hospital, while in the South, where there was much more poverty and pellagra, mental hygiene did not become as much of a focus. In 1907, doctors at the South Carolina State Hospital for the Insane diagnosed pellagrous insanity in one African American male, two African American females, and one white female, a total of four out of 572 patients.81 Of 256 patient deaths that year, three were attributed to pellagrous insanity (about 1.2 percent of deaths).82 The hospital faced a crisis shortly afterwards, and when Babcock resigned following an investigation in 1914, forty-five white males, fifty-one African American males, ninety-five white females, and 111 African American females—in total, 302 patients out of 955 admitted that year—were diagnosed with pellagra (this time considered under the label “psychoses due to”).83 Out of 560 deaths during the year, pellagra accounted for 80 Babcock was involved to the extent that on October 3rd and 4th, 1912 the South Carolina State Hospital for the Insane held the “second triennial meeting of the National Association for the Study of Pellagra” where there were 67 papers presented. See Annual Report, South Carolina State Hospital for the Insane,1912, 8. For secondary literature regarding the extent of Babcock’s research on pellagra outside of the hospital, see Bryan, Asylum Doctor. 81 Annual Report, South Carolina State Hospital for the Insane, 1907, 42-43. 82 Ibid., 45. 83 Annual Report, South Carolina State Hospital for the Insane, 1914, 72. 105 356, or about 64 percent of deaths.84 189 out of those 356 occurred within ninety days or less after admission, just over half of the deaths in the hospital due to pellagra that year.85 Pellagra quickly became known as the “dread disease” to hospital administrators during this time, but the dietary theories of the disease did not take hold in the hospital during Babcock’s tenure. The medical staff, like many American physicians, leaned toward a theory of the disease as one of intoxication rather than one of diet. One medical doctor, an associate professor from the Atlanta College of Physicians and Surgeons, released a state-of-the-field book about pellagra in 1912 and asserted that “the cause of pellagra is unknown” but that two broad theories competed among researchers: pellagra as an “intoxication” and pellagra as an “infectious disease.”86 Theories that explained pellagra as a toxic disease began with the premise that corn was the cause of the disease, and with a single exception were based on the idea that the spoilage of corn made corn toxic to the human body, which would then cause pellagra.87 Theories that instead saw pellagra as an infectious disease posited that it was caused by bacteria, fungi, or a parasite likely spread by an insect carrier.88 Indeed, the difficulty in classifying pellagra for reporting and records purposes shows clearly in the Annual Reports at the end of Babcock’s tenure. The first Annual Report in 1907 84 Annual Report, South Carolina State Hospital for the Insane, 1914, 74. Percent calculations are my own. 85 Annual Report, South Carolina State Hospital for the Insane, 1914, 16. 86 Stewart R. Roberts, Pellagra: History, Distribution, Diagnosis, Prognosis, Treatment, Etiology (St. Louis: C.V. Mosby Company, 1914), 231-2, HathiTrust. 87 Roberts, Pellagra, 238. 88 Ibid., 260. Pellagra made it into the popular press as well, which is not surprising given the significance and growth of muckraking journalism during the Progressive Era. As noted previously, White and St. Elizabeths faced press coverage of the investigation into the hospital and the allegations about the hospital’s conditions. Pellagra—as it quickly rose to be an endemic health issue in the American South—spurred journalistic coverage both within and beyond the region. Journalist Marion Hamilton Carter spend time as a public health muckraking journalist and published a piece in McClure’s Magazine about the discovery of hookworm in the American South in October of 1909. Only a month after, Carter published “Pellagra, the Medical Mystery of To-Day” in McClure’s, giving a graphic and emotional depiction of the disease based on her visit to the South Carolina State Hospital for the Insane, which was allowed by Superintendent Babcock. Marion Hamilton Carter, “Pellagra, The Medical Mystery of To- Day,” McClure’s Magazine 34, no. 1, (November 1909), ProQuest American Periodicals. See Carter’s footnote 1. 106 that identified pellagra in the hospital termed it “pellagrous insanity” and did not classify it under any disease group. In the next Report in 1908, pellagra was listed under the label “physical” (the other two labels used in the table were “moral” and “toxic”) for the alleged cause of insanity of patients admitted that year but “pellagrous insanity” remained its own diagnostic category for the “form of insanity” of those admitted during the year as well as for the cause of death.89 However, in 1909, the categorization of the disease changed again, this time under the label “toxic” rather than “physical”: in the alleged cause of insanity, and was further classified under “toxic” in all other tables (form of insanity of those admitted during the year and cause of death).90 Toxic forms of insanity usually included alcohol, morphine, opium, and cigarettes, but also could include conditions like goiter and thyroid disease. Pellagra was primarily classified as a “toxic” form of insanity until 1913, when the category “toxic” was removed and replaced with “Psychoses due to.”91 Pellagra rates at the hospital during Babcock’s tenure remained high, and the diet was not varied enough under his management. Although pellagra had a strong association with mental hospitals, St. Elizabeths did not experience many cases of pellagra. The first case of pellagra within the hospital reported to the Legislature in an Annual Report was in 1912, and no more than 2 cases per year were reported up to World War I.92 However, Mary O’Malley, the senior assistant physician at St. Elizabeths, later reported that when the hospital records were reviewed, there had been one case of pellagra 89 Annual Report, South Carolina State Hospital for the Insane, 1908, 48. 90 Annual Report, South Carolina State Hospital for the Insane, 1909, 63-4. 91 Annual Report, South Carolina State Hospital for the Insane, 1913, 20. Although the language had changed, the diseases in the category stayed the same. Pellagra continued to be seen as a disease that likely had an impact on the nervous system similar to thyroid disease, alcohol, opium, and arsenical neuritis. 92 See Annual Report, 1912-1917, St. Elizabeths Hospital. Cases in 1912 reported on p. 505. Note that the years in all the reports were not based on calendar years; each report covered the fiscal year which ran from July 1st to June 30th, e.g., the case occurred between July 1st, 1911, and June 30th, 1912. 107 in 1906 and one other case prior to 1911.93 In fact in 1908, Babcock, who had already begun studying pellagra based on his experience the superintendent of the Columbia State Hospital in South Carolina, visited the “colored women’s wards” of St. Elizabeths with O’Malley to find any evidence of pellagra in the hospital; no evidence was found at that time by either doctor.94 The lack of pellagra found there can be attributed to the ample diet provided to the patients at St. Elizabeths as well as the knowledge about nutrition that the hospital staff had. Indeed, O’Malley highlighted the usefulness of Pratt’s “interesting investigations” completed under the USDA at the hospital and that the diet for the hospital by 1916 was “even better than it was” when the study was done because of the suggested improvements the hospital made.95 She likely made this comment about the problem of diet in public institutions because she was familiar with the scrutiny that the hospital’s diet faced in the 1906 congressional investigation. Focus on and knowledge about nutrition science regarding the hospital diet was not a central concern for Babcock like it was for William Alanson White, however both superintendents’ administrations faced critiques of their management of their hospital’s diet when investigated by state and federal congressmen. The reasons for the two investigations were not substantially different. Both institutions faced overcrowding which led to worse patient care. Overcrowding led to lack of sufficient food for patients’ diets or a lack of sanitary conditions in the dining rooms where food was being served. In both investigations, problems with the hospital diet were explicitly recorded as topics of interest. 93 Mary O’Malley, “The Report of Twelve Cases of Pellagra and Its Relation to Mental Disease,” Interstate Medical Journal 23, no. 7 (July 1916): 514, HathiTrust. 94 O’Malley, “The Report of Twelve Cases of Pellagra and Its Relation to Mental Disease,” 514. 95 Ibid., 526 and Mary O’Malley, “Relation of Pellagra to Nutrition,” The Southern Medical Journal 9, no. 6 (June 1916): 499, HathiTrust. 108 In South Carolina, one of the reasons for the investigation was that “the dietary of the institution has not been satisfactory for some time, due to the fact that the population has far outgrown our kitchen and dining room accommodations, and the overcrowding is the fault in the dining rooms and kitchens as it is in the wards and dormitories.”96 The hospital certainly economized the purchasing of food and served oleomargarine rather than butter, although the topic was not debated like it was during the St. Elizabeths investigation. While two ex-patients did testify about oleomargarine in similar terms to patients at St. Elizabeths—one “would not call it butter” and disliked it while the other testified that he received oleomargarine and that he “could not eat it”—the examiners did not take any issue with the use of oleomargarine in the hospital.97 Regardless, the hospital’s fare was lacking; a typical breakfast included “hominy, bacon, white bread, [and] coffee” while dinner usually consisted of “vegetables (cow peas, greens, cabbage, or turnips), corn bread, hominy and rice, bacon” and fresh beef was only on the menu on Tuesdays and Saturdays in a stew, as reported by the hospital’s steward.98 The diet relied heavily on bacon, cornbread, hominy, and rice. In contrast, the St. Elizabeths menu (although critiqued as well) had a wider variety of foods and a stronger emphasis on protein and fruits. For example, the Thursday general diet, patients were served “Breakfast. —Rolled oats, baked beans, beef stew (working patients), rolls and butter, coffee. Dinner. —Pea soup, crackers, boiled corned beef, kale, and bread cakes.”99 96 South Carolina General Assembly, Testimony Taken Before the Legislative Committee to Investigate the State Hospital for the Insane at Columbia. April 28, May 4, 6, 7, 18, 19, 20, 1909, (Columbia, SC: Gonzales and Bryan, 1910), 18. https://archive.org/details/testimonytakenbe00sout/page/n12. The investigation and its testimony has been covered at length by Charles S. Bryan, so here I choose to focus on where food and diet occurred, specifically, similar to my discussion of St. Elizabeths. See Bryan, Asylum Doctor, 119-142. 97 South Carolina General Assembly, Testimony, 50, 108. 98 South Carolina General Assembly, Legislative Committee to Investigate the State Hospital for the Insane, Report of the Legislative Committee to Investigate the State Hospital for the Insane (Columbia, SC: Gonzales and Bryan, 1910), 27. Microfiche. 99 House Special Committee, Report, vol. 1, 525. The bill of fare in general and for all types of patients and employees of the hospital can be found on pages 522-525. 109 Even more damning, Babcock testified that “the per capita cost in this institution last year was $109.30, and more than that is allowed in most counties of the State for the dieting of prisoners.”100 Because mental hospitals were state-funded and carceral institutions (a majority of patients were committed to these hospitals involuntarily), it was often that the two types of institutions were compared. During later testimony, Babcock sought to remedy the situation by requesting that the per capita for the hospital budget be raised to $150 or $160.101 However, Babcock failed to make a strong enough case for why more appropriations were needed, or why mentally ill patients should be fed better than “prisoners,” a humanitarian argument of the early twentieth century made by doctors like Austin Flint in chapter 1. Indeed, the extent to which even Babcock himself saw the hospital as a place for the socially undesirable and perhaps as a primarily custodial institution due to the state’s commitment procedures is exemplified in his statement that “the State Hospital for the Insane of South Carolina is a dumping ground of every form of humanity that is undesirable in any community.”102 In the case of St. Elizabeths, investigators found there was not inadequate per capita funding compared with other mental hospitals. Instead, White was criticized for spending too much money on the patient per capita and not being economical enough overall in his spending for the institution. In 1906 during the investigations, St. Elizabeths’s per capita patient expenditure was $220 as it had been most years since 1886.103 In his 1908 Annual Report, White defended the per capita cost for appropriations by arguing that the price of fresh beef —“the largest single item we purchase”— had continued to rise in price on the market, successfully 100 South Carolina General Assembly, Testimony, 18. 101 Ibid., 399. 102 South Carolina General Assembly, Testimony, 15. He continued: “We receive feeble, broken-down old men and old women, who have worn out their welcome in their homes for no other reason under the sun than that they are untidy, and in South Carolina that has been a good and sufficient reason why they should be sent to the Asylum.” 103 House Special Committee, Report, vol. 1, xxi. 110 justifying the quite liberal appropriation for the time.104 Spending on particular items of food could thus be used effectively to argue for hospital money. In all, St. Elizabeths operated on a per capita patient budget just over twice the amount that that South Carolina State Hospital had, and this led to a wider variety of food and better quality of food available for patients at St. Elizabeths.105 The importance of diet in the foundation of the treatment of insanity was expressed strongly by one of the chief medical officers of the institution, J. L. Thompson, the first assistant physician who had been working at the hospital for about 28 years at the time of the investigation. Thompson himself had made a trip to St. Elizabeths in the fall of 1908 when he went to a tuberculosis conference in Washington, D.C.106 Thompson, one of the main medical staff that testified, said that diet was the most important treatment for insanity. He first testified that he did not think that there was any drug that served as effective treatment in “a case of insanity of the usual sort.”107 When asked then, “You are able to give an expert opinion? What is the proper treatment for insanity?” he replied, “Well, as I see it, exercise as much as you can possibly give them, fresh air and nutritious diet. It takes little treatment.”108 In this way, Thompson was echoing the realization by some psychiatrists, like Bancroft in his 1908 104 Annual Report, 1908, 326. 105 Although the cost of living in Washington, DC was likely higher than in Columbia, SC, St. Elizabeths’s per capita budget was one of the highest in the country during this period and was generally understood to be generous. During the 1906 investigation at St. Elizabeths, some hospitals in the North and Midwest had per capita rates close to $200, while others, often those in the South, had rates closer to $125 to as low as $100. See House Special Committee, Report, vol. 1, 916-919. White also did assert that the per capita cost of coal was about $20, which he did not expect to be nearly as high in the South. Ibid., 887. In 1909, St. Elizabeths spent $39,086.05 on fresh meat (this did not include poultry, fish, meats that were salted or smoked, but it is unclear from the purchasing report where lard/butterine is) for a per capita cost of $11.42 of fresh red meat per patient while (3424 patients under treatment during the year) while the South Carolina State hospital purchased $15,567.40 of “meats and lard” (this did not include poultry) for 1,507 patients for a per capita cost of $10.33. See St. Elizabeths Annual Report, 1909, 336 and South Carolina Annual Report 1909, 27-8. 106 South Carolina General Assembly, Testimony, 191. 107 Ibid., 156. 108 Ibid. 111 Presidential Address before the American Medico-Psychological Association discussed in chapter 1, that the core therapies of moral treatment might be the best therapy available for patients. Here, he explicitly listed therapeutic factors—including nutritious diet—as part of the proper treatment for insanity. He also testified that hydrotherapy could be beneficial for some cases and was generally dismissive of the importance of any kind of “electric treatment.” However, Thompson stressed the importance of diet once again when the examiner sought to summarize his expert option on the best treatment for insanity: Q. To summarize that thing, the treatment for insanity would be exercise, fresh air, exercises in the way of amusements and employment and recreation? A. Yes, sir. You have not mentioned diet. Q. And a wholesome diet? A. Yes, sir. Q. Which of them do you place first? A. A nutritious diet.109 In this line of questioning, Thompson himself had to remind the examiner that diet was left out of the summarization of his beliefs about the treatment of insanity, and then went so far as to place a nutritious diet as the first, and therefore most central, treatment for insanity. Thompson’s view of food as the primary necessity for the mentally ill can be seen as in sharp contrast to the grim picture of the hospital as a “dumping ground” that Babcock drew earlier. The critiques of this nature, then, were not absent in South Carolina. And yet, while Thompson viewed food as the most important part of treatment for insanity, the other main physicians and psychiatrists in the hospital did not. While H. H. Griffin, the assistant physician in charge of the “Colored Male Department” acknowledged the importance of “nourishing” and “good food” for the treatment of tuberculosis, he did not explicitly connect food with the treatment of insanity.110 E. B. Saunders, second assistant physician, was also not in line with 109 Ibid., 158. The original format has been slightly modified by the author for more fluid reading. 110 Ibid., 433. 112 Thompson’s understanding of the treatment of the mentally ill. When the line of questioning from the committee turned to food, she had no objections to the status quo and thought that the food prepared was “thoroughly” wholesome as well as sanitary and that while the food “could be better with more money,” the hospital did “reasonably well under the circumstances.”111 Her lack of nutritional knowledge shows when she is asked whether the food is nutritious and her reply is “I can only say so by telling the result of the food. There are few patients who come here who do not gain in flesh.”112 Here, Saunders relied on patients’ weight gain to argue that the food is nutritious, rather than using any reference to the food itself or using any vocabulary from nutrition science. From her position as second assistant physician, she did not find the diet important. Another facet of critique during the investigation at South Carolina, like at St. Elizabeths, was the misuse of feeding tubes at the institution. Unlike at St. Elizabeths, there were allegations that patients had been injured or died due to tube feeding.113 Both doctors testified that the feeding tube was necessary for the institution and that even with “reasonable caution […] sometimes accidents happen,” such as the head of the tube going the wrong way. They attributed this mistake, however, to patients’ lack of cooperation because “very often they are violent and resist.” Babcock painted this struggle so violently that he used a metaphor of war to describe it, asking Thompson if such a situation was “a part of the fortunes of war in all asylums.” Thompson said that it was.114 Hearing all this, the committee members once again established 111 Ibid., 286-7. 112 Ibid., 287. 113 For example, J. M. Mitchell, the supervisor of the white male department, would sometimes help with tube- feeding. He testified that he had never assisted with a tube feeding that harmed a patient but that he had heard Thompson tube-fed a patient and that the patient died soon after though “he did not say that was the direct cause.” Ibid., 222. 114 Ibid., 186. 113 that tube feeding was a common medical practice that was only caried out when necessary.115 It is clear from both investigations that legislators and doctors were comfortable with the use of the feeding tube as a medical procedure in mental hospitals. While the allegations in South Carolina were more severe than at St. Elizabeths, forced feeding in mental hospitals remained broadly accepted. This procedure became emblematic of the difference between being institutionalized with a mental illness and being mentally healthy. This difference played a key role in the controversy over political hunger strikes during the 1910s that I discuss in the next chapter. When the majority committee wrote their report regarding diet at South Carolina State Hospital, they chose to introduce it using a quotation from a 1907-08 report given by the superintendent of the Missouri State Hospital in St. Joseph, Missouri. Echoing late nineteenth century psychiatrists and early twentieth-century nutrition scientists like Pratt and Milner discussed in chapter 1, the superintendent stated that the “condition of the alimentary tract in the insane is always below normal […] An improvement in the mental condition frequently keeps pace with the improvement of the digestive tract. Food should, therefore, of necessity, be of a palatable, appetite-coaxing kind, and neatly served.”116 Here again, the “neat” serving of patients was key alongside the need to pay special attention to the quality of served for the mentally sick.117 While the majority committee did not view diet explicitly as treatment for insanity, it did consider it “fundamental” to health.118 One example of how the state of care given to the diet in South Carolina was lacking was that the position of “housekeeper” that was meant to use diet tables to prepare meals did not exist 115 Ibid., 222. As one committee member stated, “the custom to feed patients with a tube both in this class of institutions and in hospitals where the condition demands it.” 116 South Carolina General Assembly, Report of the Legislative Committee, 27. 117 Ibid., 25, 27. 118 Ibid., 26. 114 in any department except for the “colored women’s” when investigated. The committee established that there were no written dietary reports or records kept in the institution during the hearing testimony.119 Therefore, the diet example that the committee report reproduced could only be done “after consultation with the steward,” which was unlike the easily reproduced tables given in the St. Elizabeths investigation120 And when assessing the diet, the majority committee noted that there was “practically no variety.”121 Overall, the committee quoted social scientist and institution reformer Frederick Howard Wines’ appendix report: “We certainly would not regard the menu at Columbia as appetizing or sufficient, especially for men and women physically below par, for whom a generous supply of nourishment is essential in order to the recovery of their normal mental tone.”122 Further, the majority committee ended this statement about the substandard quality of the hospital’s diet by comparing it to other hospitals’ diets, finding that “the menu furnished at other hospitals shows greater variety and quantity than that served at Columbia.”123 119 South Carolina General Assembly, Testimony, 243-3. 120 South Carolina General Assembly, Report of the Legislative Committee, 27. 121 Ibid. 122 Ibid., 29. Unlike the St. Elizabeths investigators, those in Columbia relied on the expert testimony of Wines, who was not a hospital superintendent himself, but a social scientist and statistician involved in institutional reform effort in prisons but also in public institutions more generally. He had served as the Secretary of the Illinois State Board of Charities beginning in the late 1860s, and his report on asylums led to the construction of Kankakee State Hospital in Illinois based on the “English cottage system” of housing patients. For these and further details on Wines, see Henry Kamerling, “Wines, Frederick Howard,” February 2000, accessed July 11, 2022, American National Biography Online. 123 Ibid. As Bryan noted, Wines had, at the time, identified why pellagra was so common in South Carolina in comparison to other institutions without recognizing it. See Bryan, Asylum Doctor, 129. The report of the Legislative Committee showcases how investigations influenced one another during this period. Unlike the St. Elizabeths hearings, no expert witnesses were called to testify before the committee. Rather, the committee members secured “special reports by experts,” although none of these experts specialized in food science or nutrition. Indeed, the 1906 investigation into White’s administration played a central role in how the committee for investigating the South Carolina State Hospital decided to undertake its investigation. Members of the Committee “studied the testimony taken at the investigation of the Government Hospital at Washington, D.C., in 1905, reports of the New York and Illinois State Boards of Charities, and many of the State reports, and the Special United States Census report of 1904.” Ibid., 7. I agree with Peter McCandless’s assertion that the 1909 investigation “was typically Progressive in its thoroughness. […] Members of the committee visited state hospitals in North Carolina, Virginia, Maryland, and New York, as well as the Government Hospital for the Insane in Washington, D.C.” See Moonlight, Magnolias, & Madness, 300. I seek to clarify just exactly what made this investigation Progressive other than its 115 The legislative report noted that Kankakee's “culinary department” included, “on the kitchen staff, in addition to the head cook and his assistants, a dietician and a Pasteurizer,” and further specified that the Pasteurizer “must be a graduate of an agricultural college, familiar with the management of a dairy and more or less skilled in elementary chemistry.”124 No such positions existed at South Carolina State Hospital at the time, but after the investigation, the Board of Regents asked for appropriations for a dietitian in the 1910 Annual Report, and a “Miss Hertell, Dietitian” appeared on the hospital staff list in 1911.125 The need for expert, scientific authority thus outweighed a generous and even sufficient diet for South Carolina legislators. While dietitians were hired in several mental hospitals before World War I, it did not become more commonplace until after the war. Like at St. Elizabeths, those in charge of the hospital chose to hire new experts onto the hospital staff to provide for the patient diet, and this was even achieved in South Carolina with the notoriously tight state budget. Babcock had testified that he did not hire a cook with strong credentials because the previous superintendent “had been assailed on the ground of extravagance” and was “severely criticized because he hired an accomplished cook to come here and take charge of the kitchen, and paid him fifty dollars a month.”126 Although the appropriations for a cook and dietitian were won after the investigation, much of the testimony did focus on economy and the patient per capita. Although to a lesser extent in South Carolina than at St. Elizabeths, conscience proved to have some power to modify convenience when it came to feeding patients and hiring experts. “thoroughness” by focusing on how food and diet played a role in the investigation and in the importance placed on scientific and expert testimony. 124 Ibid., 60-1. 125 Annual Report, South Carolina State Hospital for the Insane, 1910, 10 and 1911, 2. 126 South Carolina General Assembly, Testimony, 398. 116 As the investigation ended with Babcock remaining as superintendent and larger appropriations, racist views about African Americans continued to play a significant part in how the hospital was funded and managed. While the doctors never explicitly expressed food as a means to control patients, one of the examiners, Senator P. L. Hardin, viewed food as means through which to control the behavior and attitudes of patients—particularly African American ones. Griffin acknowledged that African American patients “chafe[d] under the confinement” and “want[ed] to go home” to which Hardin responded, “I think, as a rule, negroes, if you give them plenty to eat, they are not as ambitious as white people, and are much easier to manage.”127 It is not surprising, then, that the first of the majority committee’s recommendations was to increase the per capita cost of maintenance of $150 per white patients and $125 for “colored” patients.128 Although St. Elizabeths was also a segregated hospital and may have fed African American patients differently than white ones, there was no difference in per capita cost for St. Elizabeths patients of different races. In Columbia, the committee clearly expressed that appropriations should be higher for white patients than African American ones. A common “standard of living” did not cross racial lines in South Carolina, leading to worse diets for black patients. Conclusion The investigations into the administrations of William Alanson White at St. Elizabeths and James Woods Babcock at the South Carolina State Hospital were Progressive-Era investigations where government representatives sought to assess and reform the mental hospitals. While economy and proper use of government resources factored into both investigations, many of the critiques and charges against the hospital centered on patient care, 127 Ibid., 439. 128 South Carolina General Assembly, Report of the Legislative Committee, 54. 117 including care that involved food and diet. At a time when sanitation was understood as necessary for public health, pure food became seen as equally necessary in the fight for public health. Food quality, quantity, service, and interventions (e.g., forced feeding using feeding tubes) could be used to critique the hospitals but these critiques and their outcomes reveal how significant belief in science and professional standards was beginning to become in the early twentieth century and how some psychiatrists viewed diet as an important part not just of physical, but also of mental health. Ultimately, the rising problem of pellagra—which is now understood as a dietary deficiency disease—in the South Carolina State Hospital for the Insane reveals that the diet was not varied or nutritious enough.129 While a varied and nutritious diet was more or less accomplished at St. Elizabeths where the staff, this was not the case in South Carolina. At the South Carolina State Hospital, there was a lack of scientific and medical knowledge about nutrition like that which White and O’Malley obtained through the Pratt and Milner study at St. Elizabeths. But also, voices like Thompson’s that supported a wholistic, moral-treatment-like approach to feeding patients was pushed back by economy and efficiency. In South Carolina but not St. Elizabeths, conscience gave way to convenience when it came to feeding patients in the first decade of the 1900s. In the next chapter, I focus more extensively on popular culture surrounding insanity through newspaper coverage. Moving from hearing testimony, the next chapter will explore how gender politics and popular ideas about insanity met in newspaper coverage of women suffragist hunger strikes. As I have already shown, the feeding tube was considered to be a medically 129 Although many patients came to the hospital with pellagra on admission, their condition worsened in the institution generally and other patients developed pellagra within the institution. Pellagra and its development in institutions will be further discussed in chapter 4. 118 necessary device used by psychiatrists to feed patients who were either unwilling or unable to eat. And yet, many patients and their families thought of the feeding tube as punishment. These themes will continue in the next chapter. 119 CHAPTER 3: Radical Women, Hunger Strikes, Forced-Feeding, and Insanity in the Popular Press, 1909- 1917 Introduction “I certainly owed a lot to that Dr. White because it would have been so very easy for him to have given an adverse decision and I might still at this moment be in the St. Elizabeth [psychopathic ward].”1 The famous American suffragist Alice Paul made this statement to historian Amelia Fry during an oral history interview when Fry asked about her experiences hunger striking, undergoing mental examinations by psychiatrists, and being placed in the psychopathic ward in the D.C. District Jail in 1917. Why did a hunger strike lead to Paul meeting the federal mental hospital’s superintendent, psychiatrist William Alanson White? And what made Paul think, nearly sixty-five years later, that she could have been in St. Elizabeths hospital all those years? This chapter answers these questions by placing this episode in Paul’s and other radical women protestors’ activism at the intersection of food, gender, psychiatry, the carceral state, and nationalism. The main source of my analysis is the popular press. This is in comparison to psychiatrists’ support of forced-feeding as a medical procedure appropriate for patients in mental hospitals who refused food in the American Journal of Insanity as seen in chapter 1 and legislators’ quick acceptance of tube-feeding as a routine medical procedure rather than punishment in mental hospitals during the 1906 hearings covered in chapter 2. In the Progressive-Era United States, journalists, psychiatrists, and corrections officials used medical ideas and expert authority to pathologize political hunger striking as insane and used the power 1 Amelia R. Fry, Conversations with Alice Paul: Woman Suffrage and the Equal Rights Amendment, November 1972 and May 1973, Oral History Center, The Bancroft Library, University of California, Berkeley, https://www.lib.berkeley.edu/libraries/bancroft-library/oral-history-center, 231. 120 of this connection to threaten radical women who transgressed gender norms in their political activism. In the case of Paul, White’s favorable views of the women’s suffrage movement helped to prevent her institutionalization, but the threat of being labeled insane and institutionalized was nevertheless a powerful tool of intimidation. British women suffragists undertook the first political hunger strikes in England that began in 1909 and ended in 1913. Although they were not the first political hunger strikes in history, they served as one of the main influence and cultural points of comparison for the hunger strikes in the United States led by Rebecca Edelsohn, an anarchist and member of the International Workers of the World, and Paul in the years that followed.2 Despite the Progressive Era’s trans-Atlantic exchange of “reform ideas, policies, and legislative devices” between the United States and Great Britain, however, there were large differences in how government officials, psychiatrists, and the press reacted to radical women’s hunger strikes in each country. 3 An international comparison thus reveals the ways that feminist action, psychiatric medicine, and institutional responses during the Progressive Era in the United States intersected to maintain a particularly strong, coercive threat against radical women. Although forced feeding was not a new medical therapy in either country, its application to political hunger strikers was. Forced feeding, which doctors also referred to as “tube feeding” and “artificial feeding,” had 2 As James Vernon has noted, the hunger strike as a political tactic “had a transnational career,” beginning in tsarist Russian prisons and then spreading through the British empire beginning with the British suffragists. James Vernon, Hunger: A Modern History (Cambridge, MA: The Belknap Press of Harvard University Press, 2007), 60. The influence of the Russian hunger strikes on British suffragists is also examined in a chapter by Kevin Grant. See Kevin Grant, Last Weapons: Hunger Strikes and Fasts in the British Empire, 1890-1948 (Oakland, CA: University of California Press, 2019), chapter 2. In relation to the influence of the Russian hunger strikes on Rebecca Edelsohn’s, see Maximilian Buschmann, “Der erste politische Hungerstreik in den USA: Anarchistische Rebellen und die Geschichte des Nicht-Essens als Protestform im frühen 20. Jahrhundert” in Geschichte des Nicht-Essens: Verzicht, Vermeidung und Verweigerung in der Moderne ed. Norman Aselmeyer, Veronika Settele (Berlin: Walter de Gruyter, 2018). 3 Daniel T. Rodgers, Atlantic Crossings: Social Politics in a Progressive Age (Cambridge, MA: The Belknap Press of Harvard University Press, 1998), 3, 7. 121 deep roots in asylums in Britain and in the United States. The procedure, when carried out due to food refusal, was associated with mental illness and therefore, institutions for the mentally ill. White even featured “artificial feeding” for food refusal as one of three therapeutic categories for treating insanity in his popular textbook Outlines of Psychiatry because he considered food refusal to be condition that doctors encountered rarely in the sane.4 Consistently refusing food to the point of endangering one’s health was one common symptom of mental illness, and it came under increasing scrutiny from psychiatrists who worked in mental hospitals during the early twentieth century. In the United States, physicians and government officials largely ignored the political purpose of hunger strikes, choosing instead to classify their food refusal as symptomatic of mental illness, “self-starvation,” or an attempt at “suicide,” which were then discussed as grounds to declare a hunger-striking woman insane and in need of medical intervention. Newspapers played a significant role in perpetuating the narrative of politically radical, “insane” women, thus delegitimizing their actions, while they also frequently utilized coverage to bolster American nationalism. Journalists in the United States reported on experts’ handing of Edelsohn’s and Paul’s hunger strikes in ways that revealed a modern nationalism that positioned U.S. medicine, science, and politics as superior to Britain’s. This came at a time when American doctors began citing significantly fewer German and French publications in their research articles, thus establishing the beginning of the American- and English-dominated medical literature of the twentieth century.5 Although newspaper coverage exposed the horrors that Alice Paul faced in jail, it also highlighted women experts’ voices when they justified the forced 4 William Alanson White, Outlines of Psychiatry (New York: The Journal of Nervous and Mental Disease Publishing Company, 1907), 28-30, HathiTrust. He preferred tube feeding as the method of artificial feeding used. He also preferred the use of the esophageal tube to the nasal tube overall, though he noted that the nasal tube was better to use in patients who resisted. 5 John C. Burnham, Health Care in America: A History (Baltimore: Johns Hopkins University Press, 2015), 225- 227. “English” used here refers to the language. 122 feeding of hunger striking women, capitalizing on their gender to delegitimize the political behavior of these radical women. While some women doctors did object to force feeding hunger- striking suffragists like Paul, newspapers often focused more on their political activism than their professional credentials and arguments. Women such as sociologist and corrections official Katharine Bement Davis were cast as the “proper” kind of suffragist and received a lot of positive press coverage when they supported the forced feeding of jailed suffragists or other politically radical women. Despite their credentials, women doctors with connections to the more radical suffrage organizations—such as Alice Paul’s National Woman’s Party—who spoke out against forced feeding received much more dismissive coverage from journalists. Gender, as entwined with the women’s suffrage movement and radical feminist politics, is thus at the center of this history. Anxieties about changing gender norms were expressed in medicine and politics, whereas challenges to women’s traditional gender roles were a distinct part of twentieth-century modernity.6 As I will show, the complexity of public discourse surrounding women’s hunger striking becomes clearer when understood in the context of women’s fears of being unjustly institutionalized for breaking gender norms. These fears were grounded in American women’s experiences and their history. In the 1860s, Elizabeth Packard became famous for winning a court case proving her sanity after her Calvinist husband had committed her against her will to an Illinois asylum because of their religious disagreements and what he saw as socially unacceptable behavior, including a possible affair.7 She spent much of the rest of her life, into the 1880s, as an activist for married women’s rights and protections against unjust commitments to insane asylums. Successful female journalists and authors also 6 See, for example, Nancy Cott, The Grounding of Modern Feminism (New Haven, CT: Yale University Press, 1987) and Laura Shapiro, Perfection Salad: Women and Cooking at the Turn of the Century (New York: Farrar, Straus, and Giroux, 1986). 7 See Linda V. Carlisle, Elizabeth Packard: A Noble Fight (Urbana, IL: University of Illinois Press, 2010), 2. 123 publicized women’s negative experiences with doctors specialized in the treatment of mental illness. In 1887, investigative journalist Nellie Bly published Ten Days in a Madhouse, an account of her undercover experience in New York’s Blackwell Island asylum for women. Most famously, the writer and suffragist Charlotte Perkins Gilman published The Yellow Wallpaper in 1892. This short story, which was often read as a feminist critique of male-dominated medicine, was based on Gilman’s negative experience being treated by neurologist Silas Weir Mitchell with his “rest cure.”8 As the twentieth century began, gendered conceptions of mental illness, as well as their critiques, were increasingly common among doctors and the public. This history and Alice Paul’s own experience informed her fear of institutionalization. This story also benefits from analyzing race as an additional driver of the “proper” gendered behavior of women like Paul. Although this chapter focuses on Paul and the National Woman’s Party (NWP) specifically, the woman’s suffrage movement did not only consist of white, middle-middle class women. Women of all races and ethnicities contributed to woman’s suffrage, and black women’s contributions to suffrage have come to the forefront of scholarship in recent years.9 Paul and the NWP have been criticized for turning their backs on African American suffragists, but the racial science of the era also led some doctors and the press to depict politically radical white women like Paul as transgressing both gender and racial norms when they broke laws and undertook hunger strikes. White women suffragists’ willingness to break the law, cause public disruption with her protests, and face uncomfortable, invasive forced feeding led some doctors to suggest their behavior was pathological, as it transgressed racial 8 Gilman was critical Mitchell’s treatment, feeling that his insistence that she not work or write drove her to be more ill. See chapter 1 for discussion of Mitchell and the rest cure in the context of turn-of-the-century psychiatry. When she later gave her reasons for writing The Yellow Wallpaper, she cited her desires to let Mitchell know he had been wrong in his treatment and to save other women from the same fate. Cynthia J. Davis, Charlotte Perkins Gilman: A Biography (Stanford: Stanford University Press, 2010), 102. 9 See, for example, Martha S. Jones, Vanguard: How Black Women Broke Barriers, Won the Vote, and Insisted on Equality for All (New York: Basic Books, 2020). See chapters 6 and 7. 124 norms for white women. Despite the coercive power of psychiatry and the popular image of the insane, hunger- striking, radical woman, William Alanson White’s support of Paul’s sanity shows that these repressive factors were not irrefutable. Again, twentieth-century psychiatry was not homogenous and was in flux during this period. As a prominent member of the mental hygiene movement and an early advocate of psychoanalysis, White used his understanding of the environmental, social, and individual aspects of mental health and illness to support the suffrage movement and many other aspects of feminism. This support ultimately extended to Paul and her hunger strike, ensuring that she would not be committed to St. Elizabeths and aiding in her eventual release from the D.C. District Jail. Had Alice Paul been on hunger strike in a different place and met with a different hospital superintendent, her imprisonment could have resulted in much different consequences. Although neither Edelsohn nor Paul were ultimately institutionalized, the threat that they might be had been powerful. “Militant Suffragist Madness” Although the British woman suffrage movement began earlier, branches of the movement, particularly the Women’s Social and Political Union (WSPU), became militant or “politically violent” beginning in about 1905 when police arrested protesting suffragists and those that damaged property in large numbers.10 In 1909, Marion Wallace Dunlop was the first imprisoned, British suffragist to undertake a hunger strike demanding that arrested suffragists be classified as political prisoners.11 Newspaper editors and journalists in both the United Kingdom and the United States, often aided by the reports of suffragists themselves, publicized these 10 Elizabeth A. Williams, “Gags, Funnels and Tubes: Forced Feeding of the Insane and of Suffragettes” Endeavour 32, no. 4 (2008): 134. 11 Williams, “Gags, Funnels and Tubes,” 134. 125 hunger strikes as well as suffragists’ disruption to Parliament and any instances where they destroyed or damaged public property. In the United States during the 1910s, feminism and militance “were not the same thing, but common parlance linked them,” especially after the founding of the more radical suffrage organizations the Congressional Union and its later form, the NWP.12 In Britain, hunger striking remained in use between 1909 and 1913. Jail doctors’ response, supported by the government, was to forcibly feed the women while they were in prison. Some prominent, young American women joined the British protests, creating a strong transnational linkage of woman’s suffragists. One of these women was Alice Paul, who by 1908 had participated in numerous marches with both major British women’s suffrage organizations, the National Union of Women’s Suffrage Societies and WSPU. In 1909, Paul went on a mission with the WSPU to disrupt a British cabinet member’s speech. Police arrested her and when she refused to pay a fine, sent her to the London’s women’s prison, Holloway Gaol.13 There, she participated in a hunger strike with other woman suffragists and was released after only five days due to her rapidly declining health.14 Eventually, Paul was arrested again for disrupting the annual Lord Mayor’s Banquet with a fellow WSPU member, after which she returned to Holloway Gaol.15 She went on hunger strike again, but this time was force fed fifty-five times during her thirty-day sentence.16 Paul continued to protest with the WSPU and eventually, would bring the hunger strike to her suffrage activities in the United States in 1917. The forced feeding of hunger-striking suffragists in Britain came to a halt in 1913 after 12 Cott, The Grounding of Modern Feminism, 53. 13 Jill Diane Zahniser and Amelia R. Fry, Alice Paul: Claiming Power (New York: Oxford University Press, 2014), 80. 14 Zahniser and Fry, Alice Paul, 84. 15 Ibid., 95-7. 16 Ibid., 100. 126 prison doctors and government officials had faced continued criticism. To solve the ethical, medical, and legal problems that the women’s hunger-striking posed, members of Parliament decided to pass a new law. On April 25th, 1913, the government passed the Prisoners (Temporary Discharge for Ill-Health) Act, widely known as the 1913 Cat and Mouse Act, as a different solution to the problem of imprisoned women suffragist hunger-strikers than the highly criticized use of forced-feeding.17 The Act allowed for the temporary release of women on hunger strike when their health had declined too much so that the controversial use of forced-feeding in the prisons ended. Once a hunger-striker regained her health, she was supposed to return to prison and the process would continue until her full sentence was served—thus the reference to the cruel game of “cat and mouse.” Although many politicians and suffragists criticized this policy too, the law did stop the forced feeding of hunger-striking suffragists in British prisons. Doctors’ views about the use of forced feeding on suffragist hunger strikers in Britain between 1909 and 1913 have been explored by scholars, but similar studies do not exist for the United States. Some historians have argued for the culpability of the doctors for the damage done to women suffragists through forced feeding because most doctors and the major professional organizations that represented them were silent about, and therefore complicit in, the practice.18 As historian as Elizabeth Williams explained, prominent physicians and psychiatrists argued that forced feeding had been used successfully for a long time in insane asylums, thus allowing British government authorities to justify the practice for many years.19 Ian Miller took a closer look at the development of the complex medical ethics related to forced feeding—e.g. whether it 17 “1913 Cat and Mouse Act,” UK Parliament, accessed Nov. 18, 2019, https://www.parliament.uk/about/living- heritage/transformingsociety/electionsvoting/womenvote/case-study-the-right-to-vote/the-right-to-vote/winson- green-forcefeeding/cat-and-mouse-act/. See also Grant, Last Weapons, 65. 18 J. F. Geddes, “Culpable Complicity: The Medical Profession and the Forcible Feeding of Suffragettes, 1909-14,” Women’s History Review 17, no. 1 (2008): 79-80. 19 Williams, “Gags, Funnels and Tubes,” 134. 127 was medically necessary therapy or state-sponsored discipline—during this period. He found that, while small in number, prominent doctors who argued that force-feeding woman suffragists was both potentially dangerous to their health and an example of the over-reach of state authority slowly changed physicians’ and government officials’ acceptance of the dangers of forced feeding hunger strikers.20 In Britain, newspaper depictions of hunger striking suffragists were more likely to portray mental illness than insanity.21 This distinction is important because while being labeled as mentally ill or “mad” carried cultural stigma, being labeled insane carried major legal repercussions such as institutionalization, which included loss of freedom and many citizenship rights. By 1911, major American psychiatrists such as William Alanson White had largely put aside medical discussions about the definition of “insanity” because it was primarily a legal matter; they instead turned to defining and classifying “mental disorder.”22 People who were declared insane and sent to asylums in Britain or the United States in the early twentieth century also faced a growing likelihood that they would remain in the asylum for life. The number of people diagnosed with chronic mental illnesses requiring lifelong institutionalization continued to rise; mental hospitals increasingly became seen as permanent homes for the mad. 20 Ian Miller, “‘A Prostitution of the Profession?:’ Forcible Feeding, Prison Doctors, Suffrage and Medical Ethics, 1909-14,” Social History of Medicine 26, no. 2 (April 2013): 233. Ian Miller has written much about the history of science, medical ethics, and forced-feeding in England and Ireland. For the links between controversies over vivisection and suffragist forced-feeding, see Ian Miller, “Necessary Torture?: Vivisection, Suffragette Force- Feeding, and Responses to Scientific Medicine in Britain c. 1870–1920,” Journal of the History of Medicine and Allied Sciences 64, no. 3 (2009): 333-372. For a longer discussion of the history of forced-feeding and prison hunger strikes in the United Kingdom, see Ian Miller, A History of Force Feeding: Hunger Strikes, Prisons and Medical Ethics, 1909-1974 (Springer, 2016). https://doi.org/10.1007/978-3-319-31113-5. 21 I use the term insanity to designate a legal term that referred to people who were found legally unable to take care of themselves or operate in society due to mental illness. To be certified as insane meant that a person could be— and likely was—committed to an institution against their will. In contrast, the term mental illness (or disorder) is a medical one; it is a term that can encompass psychiatric medical conditions of varying degrees of severity that may or may not require institutionalization. 22 William Alanson White, Outlines of Psychiatry, 3rd edition (New York: The Journal of Mental and Nervous Disease Publishing Company, 1911), vii, HathiTrust. 128 The main form of medicalized, discursive attacks against radical suffragists in the prominent British newspapers the Times and the Manchester Guardian characterized women suffragists as mentally unstable, fanatical, and hysterical, but were careful to delineate the woman suffragist from the “insane” patient.23 Hysteria was a gendered illness associated with women, but a diagnosis of hysteria did not mean a woman needed to be institutionalized.24 By the turn of the twentieth century many people—including men—were diagnosed with hysteria or neurasthenia, conditions that were situated on the “borderlands of insanity” and were often treated at home or in a private clinic by a neurologist or psychiatrist using Silas Weir Mitchell’s rest cure.25 Therefore, doctors, journalists, and newspaper editors acknowledged that militant women may be “hysterical” or “mentally unbalanced,” but they usually separated these characterizations from legal insanity.26 For example, the Times asserted that radical suffragists had created an “insurgent hysteria” and had “a tendency to some form of hysteria or morbid moods akin thereto,” but acknowledged that “in the strict sense insanity [was] not present.”27 23 Gay L. Gullickson, “Militant Women: Representations of Charlotte Corday, Louise Michel, and Emmeline Pankhurst,” Women’s History Review 23, no. 6 (2014): 847. See also, Grant, who argued that “critics of suffragette hunger strikers exploited this representation of mental instability to undermine the suffragettes’ political legitimacy.” Grant, Last Weapons, 27, chapter 2. 24 Although hysteria was historically associated with women since ancient Greece, men could also be diagnosed with it by the early twentieth century as it was increasingly understood as a nervous disease. Hysteria became a frequent diagnosis in Europe, particularly in France, while in the United States, neurasthenia gradually began to replace hysteria as most popular nervous disease. See Andrew Scull, Madness in Civilization: A Cultural History of Insanity from the Bible to Freud, from the Madhouse to Modern Medicine (Princeton: Princeton University Press, 2015), 28-9, 272-5. For a history of male hysteria and nervous illness, see Elaine Showalter, The Female Malady: Women, Madness, and English Culture, 1830-1980 (New York: Pantheon Books, 1985), chapter 7 and Mark S. Micale, Hysterical Men: The Hidden History of Male Nervous Illness (Cambridge, MA: Harvard University Press, 2008). 25 Scull, Madness in Civilization, 272-5. 26 This happened in private communications as well. The governor Holloway Prison wrote to the Home Office following the first hunger strike taken by suffragist Marion Wallace Dunlop. Historian James Vernon reports that the governor suggested that “it would not be easy to certify her as being legally insane, but I consider her to be a highly neurotic fanatic.” Vernon, Hunger, 76fn142. 27 “Insurgent Hysteria,” Times (London), March 16, 1912, 9. GALE, The Times Digital Archive (TDA). In addition, doctors who were anti-suffragist and decried militant suffragists’ tactics understood that the current definition of legal insanity did not fit suffragists’ behaviors. In one doctor’s letter to the editor of the London Times in response to his “insurgent hysteria” editorial, he asserted that if militant suffragists’ destructive and immoral actions continued, 129 Although the discourse about militant women suffragists was often dangerously medicalized and gendered, most people drew a clear line between mental illness and insanity.28 When it came to hunger striking and forced feeding, doctors’ delineation between mental illness and insanity strengthened; doctors (whether pro-suffrage or not) contrasted the sane, resistant suffragist with the “insensate” insane during debates about the safety of forced- feeding.29 One asylum superintendent asserted in the Times that “what differentiates ‘the hunger- striker’ from the insane person who refuses food is the purposeful and violent way she [the hunger-striker] resists and struggles until utterly exhausted.”30 Doctors and non-radical suffragist women, both in medical discourse as well as in their statements to the press, thus usually portrayed “the force-fed of the asylum as beings devoid of ordinary human feeling.”31 The outcome of these positions was that those people certified as insane were maintained as marginalized citizens, while radical, hunger-striking suffragists in Britain largely escaped being depicted in the mainstream media as being institutionizably insane, even if “hysterical.”32 British militant suffragists’ hunger strikes gained attention in some of the largest “revision” of the “lunacy laws” would be necessary. Leonard Williams, “Insurgent Hysteria: What Every Doctor Knows,” Times (London), March 18, 1912, 9. GALE, TDA. 28 In newspaper editorials, readers’ suggestions that the asylum was the best place for militant suffragists were infrequent and were often swiftly rebutted. See, for example, F. B. J. Sharp, “Women’s Suffrage,” The Sunday Times (London), February 18, 1912, 17 and the rebuttal from Cecil M. Emanuel, “Women’s Suffrage,” The Sunday Times (London), February 25, 1912, 16. GALE, TDA. In addition, the “Forcible Feeding Protest Committee of Medical Men” and other pro-suffragists only rarely publicized that women suffragists under hunger strike had been threatened with institutionalization. Once, the Committee alleged that a “well-known suffragette made an affidavit that she was threatened with this fate by a medical officer of Holloway Prison, and that he used the expression that she would first be reduced to a nervous and mental wreck, and then sent to an institution where they look after mental wrecks,” and that there was thus “the possibility that prisoners, if they did not give up the hunger strike, might be certified as insane, and incarcerated in an asylum.” See “Prisoner Who Tried the Hunger Strike: Put into an Asylum,” Manchester Guardian, July 20, 1914, 10, ProQuest HN. 29 Williams, “Gags, Funnels and Tubes,” 134. 30 “The Charge Against Mrs. Pankhurst […] A Physician on Forcible Feeding” Times (London), February 26, 1913. GALE, TDA. 31 Williams, “Gags, Funnels and Tubes,” 139. 32 A male women’s suffragist, William Ball, was the only suffragist who was transferred to a mental hospital and reported to be “insane” after hunger-striking and being force fed in prison. See “An Insane Suffragist Prisoner,” The Times (London), February 13, 1912, GALE, TDA, and Miller, “A Prostitution of the Profession?” 240-242, for further discussion of this case. 130 newspapers in the United States, which provided an outlet for interested Americans’ speculative comparisons. An increasing nationalism throughout the Progressive Era affected American physicians. By the early twentieth century they had begun to boast about the superiority of American medicine. The growing nationalism in American culture, medicine, and psychiatry was also evident in the diverging responses of medical authorities to the forced feeding of hunger- striking women suffragists in the popular press. The British government’s response to jailed, suffragist hunger strikers served not only as the closest policy precedent to compare similar hunger strikes in the United States to only a few years later, but also served as an opportunity for transnational comparison for American experts seeking to claim superiority over their Atlantic neighbors. The American medical establishment, while overall silent about the British forced- feeding controversy, did have some who supported the practice. The Journal of the American Medical Association (JAMA) included a short editorial piece in the April 12, 1913 edition titled “Militant Suffragettes—A Suggestion.”33 In the anonymous editorial, the author suggested that the solution to the “difficulties encountered by British authorities in the management of militant suffragettes,” who had destroyed public property and committed other “outrages,” was to “declar[e] insane the rank offenders.”34 Radical women’s transgression of gender norms through the destruction of property or undertaking hunger strikes played an important role in finding the 33 “Militant Suffragettes—A Suggestion,” Journal of the American Medical Association 60, no. 2 (April 12, 1913): 1162. 34 To give a more medical reason for considering the suffragists insane, the author argued: “If we define insanity as a condition in which the subject is so mentally out of harmony with the general environment as to be unable to control conduct and to become a public danger, and if we attribute it to some nervous or mental disease affecting the judgement, some of these suffragettes would seem to fall under that head.” A similar statement had been suggested about a year earlier in the New York Tribune. The author wrote: “It has been suggested in responsible quarters that, as refusal of food is prima facie evidence of insanity, the ‘hunger strikers’ be drafted to public lunatic asylums for treatment. Thus, another and more serious menace to the militant suffragists has been devised to reduce them to submission to the prison regime.” “To Push Suffrage Bill,” New York Tribune, March 10, 1912, 4, Chronicling America: Historic American Newspapers, Library of Congress (LOC). 131 women insane; the author stated that “for a woman of cultivation and social standing the evidence [of declaring someone insane] would be much stronger than in the case of an ignorant working man.” The author also used a diagnosis of “sitophobia,” an extreme fear of food often caused by a delusion that led to food refusal, to describe why suffragists would receive better treatment in an asylum than in jail. Overall, the author proposed that a “solution to the problem” of destructive women suffragists was to declare them insane and institutionalize them, which was a suggestion that was extremely infrequent, if not absent, in the British medical and parliamentary debates. This anonymous JAMA editorial was picked up and sensationalized by the Omaha Daily Bee, which titled the short story “Insane Hospital is Place for Wild-Eyed Suffragist Leaders.”35 This title depicted the most prominent women suffragists as insane and more violent than the JAMA editorial by using the phrase “wild-eyed” to describe the women. The author of this article summarized that “suffragists who destroy property should be placed in insane asylums instead of jails, as their actions indicate nervous derangement,” adding the term “derangement,” which was not in the original article and connotated insanity. The author continued to pathologize hunger strikers beyond what the original article asserted, stating that hunger-striking was equivalent to sitophobia, “a mental ailment that should be treated in an asylum for the criminal insane.” The original article did not make this claim verbatim and should not have been quoted as such. This story illustrates how the authority of the medical profession was used to lend credence to an even more sensationalized story that painted militant suffragists as violent and dangerous and hunger striking as grounds for finding someone criminally insane. Much of mainstream newspaper reporting in the United States press about British 35 “Insane Hospital is Place for Wild-Eyed Suffragist Leaders,” Omaha Daily Bee (NE), April 13, 1913, 6A, Chronicling America, LOC. 132 suffragist efforts depicted these women as “insane” rather than as “hysterical,” opposite of some of the major newspapers in Britain. Before militant suffragists used the hunger strike as a political protest tactic in Britain, links between suffragists, militancy, and madness had already circulated in the United States press. One story depicted a woman becoming “insane” after she had been “violent in her room and screamed at the top of her voice all night” and people reported that “she raved over the suffragette question."36 This short piece linked one woman’s insanity to allegedly violent behavior as well as mentally problematic “raving” over woman’s suffrage. A New York Times editorial, “Militant Suffragist Madness,” similarly portrayed these suffragists as unhinged—their actions indicated a “dangerous insane state.”37 One militant suffragist, Kitty Marion, was characterized as “the type which British alienists are now viewing with interest as a psychological freak” because she had purposely gotten arrested and reportedly had “barricaded her cell with the bed slats, fought fiercely with her keepers when they broke down the door, refused food, and finally tried to burn down the jail with herself and other inmates.”38 These determined actions were so out of the realm of possibility for a woman that they were designative of being a “psychological freak.” One of these “freak[y]” actions was the “refusal of food.” As militant suffragists continued their protest actions, the hunger strike became an important tool of political protest, but only further advanced newspapers’ depictions of politically radical women as insane in the United States. Paul’s experience in British prison in 1909 consisted of forced-feeding, which the American press also covered with interest, on the one hand allowing for criticism of forced- feeding but on the other, still stressing the violence done by militant protestors. Major 36 “Suffragist Becomes Insane: Suddenly Goes Mad While Crossing the Ocean,” St. Louis Post-Dispatch, June 14, 1909, 6, Chronicling America, LOC. 37 “Militant Suffragist Madness,” New York Times, November 14, 1909, 12, ProQuest Historical Newspapers (HN). 38 “Militant Suffragist Madness,” 12. 133 metropolitan papers like the New York Times and the Washington Post covered the story of Paul’s return to the United States and her physical condition after enduring forced feeding in British prison. The New York Times reported that Paul said doctors had been “protesting against this method as inhumane, barbarous, and dangerous.”39 Paul’s statement, however, was placed within the context of her violence and law-breaking; one of the article’s subtitles was “SHE’S A WINDOW SMASHER.”40 Although this article did not link Paul’s hunger strike with insanity, it did highlight destructive and criminal behavior. As the U.S. media continued to cover suffragist protests, the connection the press made between women’s activism and insanity became clear. By 1913, even an editor of a small-town newspaper in Oregon felt it was necessary to label all militant suffragists insane. An American woman had reportedly been arrested, jailed, and undertook a hunger strike in England alongside British suffragists; he felt no sympathy for her. He argued that “every woman who advocates and lends her activities and energies to the methods of the English militant suffragette movement is afflicted with a species of insanity.” Their violence and lawlessness were too much; he commented that some of the suffragists “sing hysterically, others claim that to die of starvation for the cause is a martyrdom to be desired; others refuse to eat; they burn buildings; stone their opponents; smash windows; […]—and all in the name of equal suffrage.” This list of “activities”—including refusing food and hunger striking—was seen as improper for both English and American women. The author concluded that jail was not an appropriate place to send them; the militant suffragists “belong[ed] in the insane asylums.”41 The primary 39 “Suffragette Tells of Forcible Feeding,” New York Times, February 18, 1910, 7, ProQuest HN. 40 Suffragette Tells of Forcible Feeding,” 7. For further discussion of the negative impact of press coverage on the suffragist cause due to these events, see Zahniser and Fry, Alice Paul, 98. 41 “Exploiting an American Woman,” Ashland Tidings (OR), April 14, 1913, 7, Chronicling America, LOC. The article appears to be republished from the Eugene Guard (OR). 134 characterization of militant women suffragists in the editorial went beyond mentally unstable and turned into institutionalizable insanity. While jail terms were usually weeks to months in length for similar crimes to the suffragists’, institutionalization in a mental hospital could easily mean years of confinement in comparison. Thus, while this may seem like a small change in rhetoric, it was really one of name-calling to action-based rhetoric, a real threat to radical women. Given these transnational reports about British militant suffragists as well as the increasing power of the American suffrage movement by 1913, U.S. authorities wondered whether American suffragists would borrow the effective protest tactic, and if so, how they would respond. The answer to that question merited a half-page spread in the New York City- based Sun in May of 1913. The article, “Men and Women Forcibly Fed in New York Institutions,” explained that there was a precedent for “what would be done with a militant suffragette who started a militant hunger strike in a New York prison.” That precedent was that for fifty years, in “penal institutions here who could eat and wouldn’t eat have been made to eat” and would continue in the future.42 The author noted that prison officials who had been interviewed on the topic had been reluctant to answer the question directly and some believed the American public would not support a woman being force fed against her will. Ultimately, the author posited “if medical opinion said feed by force the militant suffragette would be fed by force.” He placed the decision to force feed someone solely in the hands of experts and within the realm of medicine— “medical opinion”—rather than the realm of politics or law. By making the solution appear as simple as asking a doctor’s judgement on the matter and following precedent, the article author made the question of force-feeding suffragists like Pankhurst appear straightforward. In this way, the author was likely criticizing the British government’s response 42 “Men and Women Forcibly Fed in New York Institutions” Sun (NY), May 4, 1913, 5, Chronicling America, LOC. 135 to the scandal of forced-feeding militant women suffragists to make it a nationalistic point of pride that the American public would follow medical authority easily and predictably if a similar situation occurred in the United States. Reporters writing about forced feeding therefore often sought the opinions not only of prison officials but also doctors, including psychiatrists. In the same Sun article, the views of two doctors who had experience with mental illness and forced feeding, Peter L. Schenck and S. E. Smith, illustrate the acceptance of forced feeding by medical professionals in the United States as well as the role that gender norms played in the characterization of hunger strikers as insane. Schenck, who worked at the Kings County Hospital (a mental hospital at the time) for almost twenty years before becoming the attending physician at the Kings County Penitentiary, from the mid-1880s to about 1900. The author of the Sun article posited that this employment history in both a mental hospital and prison meant that Schenck had the “most diversified experience, in all likelihood, of present-day physicians who have personally fed prisoners by force” which made him “unusually qualified to relate the accompaniments of a real hunger strike and the methods of subduing it.” S. E. Smith, a psychiatrist and superintendent of Eastern Indiana Insane Hospital and President of the American Medico-Psychological Association in 1914 commented on the British woman suffragists who had previously been on hunger strike. One newspaper from Smith’s home state of Indiana ran an article “Militants Suffer from an Hysteria” based on an interview with Smith. Similar to the reporting about Schenck, the author did not leave out Smith’s professional credentials and stated that he was “recognized as one of the greatest alienists in the United States.” As the President of the professional organization for psychiatrists, what Smith said about suffragists carried significant weight. 136 For these doctors, the gender and race of the women played an important role in how they explained hunger striking as the action of an insane person. According to Schenck, the act of “any woman refusing the sustenance nature demands for the preservation of life” was “insane.” Not sympathetic to the women’s political statements, he also thought that a suffragist’s decision to hunger strike knowing that she would be force fed was a sign of insanity. For example, he asserted that Emmeline Pankhurst was “out of her mind to sentence herself to forced feeding and its attendant pain and unpleasantness.” Though he did not say it directly, it is likely that Schenck felt that “pain and unpleasantness” were better left for men to deal with. Smith felt similarly, but attributed hunger strikes specifically to the largely female disease “hysteria,” which he explicitly referred to as “a form of insanity.” Smith’s assessment of militant suffragists was based largely on their actions, such as window-smashing and hunger-striking, which were “foreign to all normal Anglo-Saxon women.”43 In this way, Smith’s assessment of Pankhurst’s and other radical suffragist protests were not just aligned with perceived gender norms of Progressive-Era, middle- class behavior, but also racial ones. In delineating militant resistance – seen by Smith as violence, law breaking, and downright insanity – he was also alluding to predominant conceptions of black femininity—or, in his opinion, lack thereof. At the turn of the century, racial science and the science of heredity had combined in works like The Female Offender by Cesare Lombroso and William Ferrero to further stereotypes of black women as prone to criminal behavior and more masculine than white women.44 “Normal” white women, on the other hand, were supposed to be restrained and virtuous; if they were of good hereditary stock, they would 43 “Militants Suffer from an Hysteria,” Richmond Palladium and Sun Telegram (IN), May 27, 1914, 2, Chronicling America, LOC. 44 See Kali N. Gross, Colored Amazons: Crime, Violence, and Black Women in the City of Brotherly Love, 1880- 1910 (Durham: Duke University Press, 2006), 134. 137 not participate in criminal activity.45 Smith thus was able to argue that the women’s actions were not only abnormal due to their breaking of gender norms, but also due to their race as Anglo Saxons. In discussing Pankhurst’s and other suffragists’ activism in contrast to mental stability and their whiteness, he framed the women’s movement in the United States and, at the very least, their involvement in it, in a racialized way. For white women like Paul and Pankhurst, they were not just transgressing society’s gender norms, but also their racial ones and for that, institutionalization was possible. Ultimately, as much as hunger striking suffragists understood and articulated their hunger striking as purposeful and political, they likely underestimated the strong view that American medical authorities and institutional administrators would take. Doctors and institutional authorities (whether in prisons, jails, or mental hospitals) did not want to risk their professional credentials or reputation on the chance that they would be found responsible for a hunger striker’s death—even if she died due to “voluntary starvation.” This was especially likely given that this occurred at a time when government investigations into state institutions were common and regularly followed in the press, as was discussed in chapter 2 regarding St. Elizabeths. As Schenck explained: “There is often scandal enough about the ill treatment of institution inmates which does not result in death. How would it be if it could be shown that an inmate had been permitted to commit suicide by starving?”46 By equating hunger striking with suicide, rather than seeing it as a political act of resistance, doctors in the press were able to further pathologize the hunger strike and legitimize the forceful medical response to it. American discussion about the 45 Gross, Colored Amazons, 134-5. 46 “Men and Women Forcibly Fed in New York Institutions,” Sun (NY), May 4, 1913, 5, Chronicling America, LOC. 138 British suffragists’ hunger strikes and speculation over how they would be handled were put to the test less than a year later in New York. The “Matteawan Cure for Hunger Strikers” The first political hunger strike in the United States was not completed by a woman suffragist, but by a female member of the radical labor union Industrial Workers of the World (IWW).47 The IWW focused on the power of worker collectivism rather than on the ballot box and was part of an international growth in anarchism and syndicalism by the turn of the twentieth century.48 In April 1914, police arrested IWW member Rebecca Edelsohn—often referred to in the press as “Reba” or “Becky Edelson”— while she was speaking in New York. In addition, Edelsohn was Jewish and played a small role in the Jewish anarchist women’s movement in the United States during the Progressive Era.49 Although little is known about her background, she had strong ties to the much more famous Jewish woman anarchist Emma Goldman.50 Although she was not a suffragist, Edelsohn’s radical activism and criticism of the U.S. government led to her arrest and subsequent hunger strike. Edelsohn’s arrest came after she had spoken publicly against the United States’ occupation of Veracruz during its intervention in the Mexican Revolution. Reports stated that police charged her with inciting a riot or failure to keep the peace because her speech had caused a public disruption when young people threatened her.51 Edelsohn, on the other hand, saw her imprisonment “as unjust as the burning of ‘witches’ in 47 “An I.W.W. Heroine, Although She Ate,” New York Times, April 28, 1914, 6, ProQuest HN. Sources at the time often abbreviate the union as “I. W. W.” 48 Peter Cole, David Struthers, and Kenyon Zimmer, eds., Wobblies of the World: A Global History of the IWW (London: Pluto Press: 2017), 1, 4. 49 Hadassa Kosak, “Anarchists,” in Jewish Women in America: An Historical Encyclopedia, eds. Paula Hyman, Deborah Dash Moore, and Phyllis Holman Weisbard (New York: Routledge, 1998), 50-53. 50 Buschmann, “Der erste politische Hungerstreik in den USA,” 145-6. 51 The Evening World (NY) reported that she had been “hustled by a mob of irresponsible youths who had heard her denounce the war with Mexico” and that Edelsohn said that the “funny thing” about her imprisonment was that she “was arrested for [her] own protection” only after which the charge was made against her. See “Anarchist Reba in the Workhouse is Still Defiant,” Evening World (NY), July 21, 1914, 3, Chronicling America, LOC. 139 colonial times.”52 She thus placed herself as one woman in a long history of women who were unjustly persecuted for their beliefs. Strikingly, as I argue, her hunger strike and its pathologization by jail authorities and the press also places her within a history of using institutionalization to threaten women who transgressed gender norms. As the popularity of Edelsohn’s case shows, this transgression received national attention when it was linked to radical politics. About two months into Edelsohn’s hunger strike, another IWW protestor named Jane Est had also been arrested in New York for disrupting a church meeting, but prison authorities had quickly sent Est to Matteawan, one of the New York state public mental hospitals which was known for accepting the “criminal insane.”53 Est’s arrest and quick transfer to Matteawan was prime fodder for the sensationalist press. In July of 1914, the two women’s stories quickly became intertwined and muddied, causing a flurry of articles that perpetuated a connection between violent women protestors, hunger-striking, and insanity. After the first political and highly publicized female-led hunger strike in the United States, correction officials as well as doctors in New York had to decide whether forced feeding was an appropriate response to hunger strikes. Despite the criticism the practice had just drawn in Britain, American doctors, including women MDs and PhDs, quickly authorized the forced feeding of these women and drew little public or professional backlash. The New York Times declared that Edelsohn was the “first woman to attempt a hunger 52 Ibid. 53 During the 1906 investigation into St. Elizabeths discussed in chapter 2, White explained that the “criminal insane”— “people with criminal tendencies who have not been convicted of [a] crime”—were sent to Matteawan. White had previously worked at Binghamton State Hospital, another public mental hospital in New York, before accepting his job at St. Elizabeths. See U.S. House, House Special Committee on Investigation of the Government Hospital for the Insane, Report of the Special Committee on Investigation of the Government Hospital for the Insane with Hearings May 4-December 13, 1906 and Digest of the Testimony, 59th Cong., 2nd sess., vol. 1, February 18, 1907, H. Rep. 7644, 834, ProQuest Congressional. 140 strike” in the United States when she began one in April 1914 after police arrested her for protest activities in New York.54 Despite the flurry of press reporting both in New York and nationally about this incident, historians have hardly studied this event, with the exception of Maximilian Buschmann.55 I argue that the United States popular press used and extended the already-present images of women’s activism, hunger striking, forced-feeding, and insanity from earlier reports on militant British suffragists to explain and hyperbolize New York State Corrections officials’ treatment of Edelsohn and Est. Journalists and newspaper editors discussed how the British government treated British hunger-striking suffragists to boast of United States superiority in both government administration and medical science. Part of this superiority relied on outspoken women doctors’ opinions about the legitimacy of forced feeding, which did not happen in Britain to the same degree. Thus, what differed in the case of Edelsohn in New York was that papers seized on the opinions of women doctors in support of forced-feeding women prisoners to legitimize the practice via their shared gender and to, ultimately, invalidate the women prisoners’ political demands. Multiple articles appeared in prominent New York newspapers highlighting the voices of women experts to justify Edelsohn’s treatment. One paper reported that New York Deputy Commissioner of Correction Burdette Lewis attended the Woman’s Medical Society meeting that was happening at the American Academy of Medicine and “appealed” to the fifty women physicians present to ask whether or not he should forcibly feed Edelsohn if she continued to 54 “An I.W.W. Heroine, Although She Ate,” New York Times, April 28, 1914. 55 Maximilian Buschmann is the first historian to study this event, although the work has only been published in German thus far. He uses George Kennan’s 1880s reports of hunger strikers in Siberia as well press coverage of Edelsohn’s hunger strikes to argue that hunger-striking was already understood as a political tactic by the early 1900s rather than a sign of mental illness. However, my argument shows that this was still a time of transition and that popular presentations of hunger striking as insanity still had coercive power, particularly for radical women such as Alice Paul, whose hunger strike came after Edelsohn’s. Maximilian Buschmann, “Der erste politische Hungerstreik in den USA.” 141 hunger strike while in jail.56 The opinions of these women physicians made headlines such as “Women Doctors Back Jail Forced Feeding” and “Women M.D.’s Jeer at ‘Hunger Strike.’”57 Two of these women physicians told Lewis that they “had had much experience in forcible feeding, which was possible without injury under careful medical supervision.”58 Similar statements had been made by British asylum superintendents and physicians during the early years of suffragist hunger strikes. In this case, however, the legitimacy of forced feeding was maintained by physicians not only because they spoke as medical professionals, but also because they spoke as women. There was an assumption that if these women doctors, who were in a way radical themselves for pursuing a medical education in this period, supported members of their own sex to be force fed, then the procedure couldn’t be a simple assertion of male authority over women. These women were not merely doctors—they were “women doctors,” and the combination of their gender and medical expertise was used to invalidate the political activism in radical women’s hunger striking. Women doctors also connected Edelsohn’s hunger strike directly to the British suffragists, and they used that connection to critique the British prison officials who had performed forced feedings. As scientific professionals, these women doctors played an important role in asserting American medical and institutional superiority. One of the most vocal women was the Connecticut physician and second-vice president of the Connecticut State Medical Society, Kate Campbell Mead, who criticized British prison physicians’ handling of the hunger strikers: “The English have bungled things frightfully. […] We can teach England a lot. The 56 “Women Doctors Back Jail Forced Feeding,” Sun (NY), April 28, 1914, 7, Chronicling America, LOC. 57 “Women Doctors Back Jail Forced Feeding,” 7, Chronicling America, LOC and “Women M.D.’s Jeer at ‘Hunger Strike,’” New-York Tribune, April 28, 1914, 12, Chronicling America, LOC. 58 “Women Doctors Back Jail Forced Feeding,” 7. One of the doctors, Jessie W. Fisher, was from the Connecticut Insane Asylum. She therefore likely did have a lot of experience forcibly feeding patients. 142 average striker can stand forcible feeding for forty-eight hours and some six years. We have had experience in our insane asylums, and have got forcible feeding down to a fine point.”59 The mention of insane asylums as the places where forced feeding had been practiced most was factual, but also strengthened the association of hunger striking with insanity. Additionally, the article’s first subheading, “English Prison Physicians, They Say, Made Botch of Suffragettes’ Cases,” highlights the doctors’ nationalist comparison and critique. In the press, many American women doctors both dismissed concerns about the danger of forced feeding hunger-striking women in prison and used this dismissal to bolster an image of American medicine as humane and efficient—a “fine point” compared to that practiced in British prisons. PhD Sociologist Katharine Bement Davis, a woman “doctor” of a different type, exemplified the power of women experts to simultaneously legitimize the forced feeding of hunger strikers and to express United States national superiority in newspapers across the East Coast and beyond. She was the primary female expert featured by the press and held up as the appropriate example of a woman social reformer to compare to the popular images of both British and American militant suffragists.60 Davis was a famous Progressive reformer known for her work as the first superintendent of the New York Reformatory for Women at Bedford Hills, New York, which became the Rockefeller-funded Laboratory of the Bureau of Social Hygiene.61 Her connections and success led to her appointment as the first female New York Commissioner 59 “Women M.D.’s Jeer at ‘Hunger Strike,’” New-York Tribune, April 28, 1914, 12. For further on this doctor, see Toby A. Appel, “Writing Women into Medical History in the 1930s: Kate Campbell Hurd-Mead and ‘Medical Women’ of the Past and Present,” Bulletin of the History of Medicine 88, no. 3 (Fall 2014): 457-92. 60 For more on Davis’s involvement in the Edelsohn case and the role that gender and professional authority played in Edelsohn’s case, see Buschmann, “Der erste politische Hungerstreik in den USA,” 150, 155, 163-172. 61 Estelle B. Freedman, Their Sisters’ Keepers: Women’s Prison Reform in America, 1830-1930 (Ann Arbor: University of Michigan Press, 1981), 116-118. For her involvement in the science of sexuality, social hygiene, and eugenics, see Vern L. Bullough, “Katharine Bement Davis, Sex Research, and the Rockefeller Foundation,” Bulletin of the History of Medicine 62, no. 1 (Spring 1988): 74-89. 143 of Corrections in 1914.62 In this role, she sought to reform women’s prisons in New York; she also became responsible for the treatment of Edelsohn, including the administrative decision to forcibly feed her in jail when she was on hunger strike.63 One Washington Post editorial writer painted Davis as the proper, law-abiding suffragist, writing: “She is frankly a suffragist. She believes that women should have the ballot. She does not believe, however, that they are above the law [...].” In comparison, explained the author, “the lawbreakers who seek to escape by starving themselves must be regarded as mentally unbalanced or recalcitrant […] and be treated accordingly.”64 The press thus designated Davis to be an exemplary suffragist to clearly define what kind of women suffragists would be tolerated. Law-breaking of any sort was not proper, middle-class behavior, especially for a woman. Using the hunger strike as a protest tool while held on criminal charges became a further transgression of normal gender boundaries, and thus was pathologized as “mentally unbalanced” and punished. The turning point in newspaper coverage from classifying Edelsohn’s hunger strike as “mentally unbalanced” to “insane” occurred in July of 1914, a few months after her arrest. On July 21, one New York newspaper ran an article about Edelsohn with the subtitles “MAY GO TO ASYLUM” and “Hint Is Made That She Is Likely to Be Treated as an Insane Person.” The author reported that if Edelsohn continued to refuse food that she would be placed under observation and that the Deputy Commissioner of Correction Lewis said: “If she continues to refuse and her life is endangered then we may have her committed to some other institution 62 “Dr. Davis Dies; 1st Woman to Run City’s Jails,” New York Herald Tribune, December 11, 1935, 20, Chronicling America, LOC; “Katharine Davis Reformer, 75, Dead,” New York Times, December 11, 1935, 23, ProQuest HN. Davis did not stay Commissioner of Corrections long. 63 Forced feeding could be a medical decision, but within the administrative system of the prison, the ultimate decision rested with institutional administrators. In England, the degree of hunger striking led to discussions in the House of Commons, but in the United States the decisions to force feed ended up being local rather than nationally debated in the legislative branch. 64 “A Hunger-Strike Cure,” Washington Post, July 24, 1914, 6, ProQuest HN. 144 where such cases are handled every day and not given much attention. Insane persons who will not eat are forced to eat.” The connection between the refusal of food, endangering one’s own life, and therefore the commitment of someone to an institution for the mentally ill is made explicit by Lewis’s words. Similarly, Davis was quoted, “We don’t propose to let Miss Edelson starve, for that would be inhuman to begin with. I believe we might regard a person as insane who attempts starvation and treat that person as one bereft of her senses should be treated.”65 Davis first argued that to allow someone to stave themselves would be “inhumane.” She then equated hunger striking with suicidal intent and therefore with suicidal insanity, like the rhetoric used by Schenck earlier. U.S. newspaper articles expressed nationalist pride in how the U.S. government and experts, including women such as Davis, were better able to handle radical women protestors on hunger strike than the British government’s earlier failure that included the Cat and Mouse Act. A Washington Post editorial author quipped that “where the whole machinery of the British government failed, this American woman [Katharine Bement Davis] has succeeded” by ordering that the IWW women hunger strikers be force-fed.66 In another instance, when a reporter asked Davis if she would “prefer to have some sort of a cat and mouse act, such as they have in England,” Davis replied that she thought such a law was “ill-advised” and that the simple answer was to force feed hunger strikers.67 These sentiments also appeared in news coverage in Indiana, going one step further in linking hunger striking as a refusal to eat with insanity and institutionalization. After authorities committed Jane Est to Matteawan mental hospital, 65 “Anarchist Reba in the Workhouse Is Still Defiant,” Evening World (NY), July 21, 1914, 3, Chronicling America, LOC. This language depicted people with insanity as insensate, similar to what Williams described in British newspapers and suffragists’ depictions of people seen as insane. See Williams, “Gags, Funnels and Tubes,” 134, 139. 66 “A Hunger-Strike Cure,” Washington Post, July 24, 1914, 6, ProQuest HN. 67 “She Mustn’t Starve: Dr. Davis Will Forcibly Feed ‘Becky’ if Necessary,” Washington Post, July 24, 1914, 4, ProQuest HN. 145 reportedly for her refusal to eat, the South Bend News-Times asserted that “England found a way of dealing with hunger striking suffragets [sic] by the ‘cat and mouse act,’ […] but New York officials have gone the Britons one better.”68 The cases of Jane Est and Rebecca Edelsohn were thus linked, leading to further connections between hunger striking and insanity. Further, the images of militant women hunger-strikers were so strong that the women IWW “agitators” served as a direct comparison to British suffragists for reporters on the East Coast as well as in the Midwest. Given the reporting from U.S.-based newspapers on the suffragists and IWW members, it is clear that in the American context, insanity’s connection with hunger-striking as well as militant women was strong. Although forced feeding could easily become a target of critique during legislative investigations into the management of mental hospitals, forced feeding remained the standard of care for mentally ill patients who persistently refused food. The problem of hunger striking required a rational, enlightened approach, which was readily available in American mental hospitals that were staffed with well-educated and experienced female professionals.69 When papers linked the stories of the two IWW women, they made explicit connections between women protesting, hunger striking, and insanity. Papers reported that Jane Est had been committed to Matteawan either because she had refused to eat or drink or had refused to conform to prison life. The Evening World lead with the headline “Girl Hunger Strikers, One Now in 68 “Must Eat or Go to Asylum New York Officials’ Edict to I. W. W. Hunger Strikers,” South Bend News-Times (IN), July 22, 1914, 1, Chronicling America, LOC. 69 British mental hospitals also practiced forced feeding regularly, but the primary and secondary sources I have examined are silent on the role of female physicians or professionals like Davis in justifying forced feeding in Britain. For example, Elizabeth Williams argued that “medical men played their crucial role” when “the forced feeding of suffrage prisoners was approved by outspoken physicians such as William Morton Harman” but her argument does not include medical women. Similarly, she discussed how one of the main critics of forced feeding suffragists in Britain, C. W. Mansell-Moullin, wrote that in British newspapers that discussed forced feeding, “you always see printed … [the response] of …a superintendent of some exceedingly well-known asylum,…who always declares that he has fed in that way some two thousand lunatics without the slightest trouble.” Williams, “Gags, Funnels, and Tubes,” 134, 138. 146 Matteawan, Other Facing Insane Asylum Unless She Eats,” using two subtitles to highlight the link between the cases of Est and Edelsohn. The paper attributed Est’s institutionalization to her refusal to eat. Thus, according to the paper, Edelson would face a similar fate due to her hunger strike, stating that she “may also be sent to that institution where they have drastic methods of forcing self-starving patients to partake of proper nourishment.”70 Further, the author quoted Deputy Commissioner Lewis as understanding hunger-striking not as a legitimate act of political protest but as an act of self-harm by an insane person. Lewis said, “If the procedure worked in Jane Est’s case […] I am confident it will work in Miss Edelson’s. Starvation is an act of self- destruction, and continued effort to take one’s life is a state of insanity.”71 Ultimately, the author proclaimed that “the New York cure for hunger strike is Matteawan.”72 The pathologization of hunger striking as indicative of insanity allowed for the proliferation of the idea that the “cure” for the use of this new and disruptive protest tool by politically radical women was institutionalization in a mental hospital. This pathologization and the threat of institutionalization delegitimized these women’s activism as part of a radical labor organization whose membership contained elements of anarchism and socialism. Other articles appeared the same day linking the women’s cases further by equating the decision to hunger strike with the need to be institutionalized as an insane person. In the New York Tribune Edelsohn was compared with Est—Est was “another agitator of Miss Edelson’s type” because of their shared connections to the IWW—and Lewis was again credited with saying that “he thought the same method would be followed in Miss Edelson’s case if she could 70 “Girl Hunger Strikers, One Now in Matteawan, Other Facing Insane Asylum Unless She Eats,” Evening World (NY), July 22, 1914, 3, Chronicling America, LOC. This quotation was taken from a subtitle, so all words have been written in the lower case. 71 “Girl Hunger Strikers,” 3. 72 Ibid. 147 not be conquered by other means.”73 The New York Tribune led with the title “Hunger Strike Means Matteawan: Becky Edelson Will be Judged Insane if She Persists in Refusing Food.”74 Because Edelsohn was in prison, she would be committed to Matteawan “as a person criminally insane.” Similarly, the Washington Times in D.C. picked up Edelsohn’s story, printed a picture of Edelsohn, and included as part of the caption: “If She Persists in Refusing to Eat, Be Sent to Matteawan Insane Asylum as a Person Criminally Insane, Under the Law.”75 The image of hunger-striking women as inherently insane was strong enough that corrective reports noting that Rebecca Edelsohn was not committed to Matteawan took several days to take hold in the national press. The New York Times attempted to correct false reports that Est and been institutionalized because she was on a hunger strike and that Edelsohn was facing the same fate. In fact, Est had not attempted a hunger strike but had been “sent to the insane asylum because she harangued other prisoners in a way that indicated that she was unbalanced mentally.”76 In a reversal of earlier statements attributed to Davis, The Washington Post reported that Edelsohn was not going to be sent to Matteawan because Davis did “not regard a refusal to eat as a sign of insanity” and said that Edelsohn had “not shown any sign of mental derangement.”77 Nonetheless, the connection of hunger striking to forced feeding, and then to insanity in popular imagination and the “imagined community” of an increasingly sane and 73 “Hunger Strike Means Matteawan: Becky Edelson Will be Judged Insane if She Persists in Refusing Food,” New York Tribune, July 22, 1914, 1, Chronicling America, LOC. The language here of “conquering” could come from an idea of the struggle as one of war, but indicates the violence Edelsohn faced, particularly from male authorities. 74 “Hunger Strike Means Matteawan,” 1. The story also made it to Indiana. See “Must Eat or Go to Asylum New York Officials’ Edict to I. W. W. Hunger Strikers,” South Bend News-Times (IN), July 22, 1914, 1. 75 “Woman on Hunger Strike,” Washington Times (DC), July 23, 1914, 1, Chronicling America, LOC. 76 “Fast Hasn’t Hurt Becky Edelson Yet,” New York Times, July 23, 1914, 9, ProQuest HN. As noted in Buschmann, “Der erste politische Hungerstreik in den USA,” 155, the Washington Post, on July 23, 1914, also reported a correction to the Jane Est commitment, citing that Davis had said: “The case of Jane Est was different. She also refused to eat, but was insane, in the opinion of the physicians. It was not her hunger strike that landed Jane Est in Matteawan, but insanity.” 77 “‘Becky’ Scorns Food: I.W.W. Woman’s Nerve Still Stronger Than Appetite,” Washington Post, July 23, 1914, 4, ProQuest HN. It is unclear whether Davis actually changed her mind based on the sources consulted here, but the reporting on her opinion did change. 148 superior United States remained strong as some U.S. papers continued to print the sensationalist news about Edelsohn.78 The idea that a “Matteawan cure”—institutionalizing activist hunger strikers with insanity in order to force feed them—existed proved very alluring based on initial reports that were eventually found to be false. Edelsohn’s hunger strike ended with much less drama than the hyperbolic newspaper coverage. She was monitored by Davis during her hunger strike, was not force-fed, and was soon released on bail.79 The next major hunger strike in the United States was Alice Paul’s alongside other National Woman’s Party members. “Fear of Miss Paul Being Held Insane” The threats of institutionalization by reason of insanity that Alice Paul faced in 1917 during her hunger strike in the D.C. District Jail were the culmination of women-led, high- profile, politically motivated hunger strikes in the early-twentieth-century United States. Newspapers on the East Coast and across the country reported on and speculated about Paul’s sanity due to her hunger strike. Editors and journalists relied on the cultural narrative (or “imagined community”) that linked radical feminism to insanity, especially through the hunger strike as a new, disruptive, gender-transgressing political tool. When women suffragists undertook hunger strikes in jail in the United States, the same backlash against the forced feeding of women prisoners did not occur as in Britain. One reason for this is that the suffragist hunger strikes in Britain went on in a much larger scale and for several years. The NWP hunger strike, 78 For the concept of the “imagined community,” see Benedict Anderson, Imagined Communities: Reflections on the Origin and Spread of Nationalism, Revised Edition (New York: Verso, 2006). The Washington Herald (DC) continued to perpetuate the idea that Est had been sent to Matteawan because of a hunger strike and that Edelsohn would be sent there if she continued her hunger strike. “Matteawan Cure for Hunger Strikers,” Washington Herald (DC), July 27, 1914, 3, Chronicling America, LOC. The article led with the headline “Matteawan Cure for Hunger Strikers,” reinforcing the reports and language from the New York Tribune and the Evening World cited earlier. The editorial “A Hunger-Strike Cure” used similar language, even though the Washington Post had already published a corrective story. “A Hunger-Strike Cure,” Washington Post, July 24, 1914, ProQuest HN. 79 It is possible to Edelsohn avoided forced-feeding by eating food secretly during her hunger strike. Many of the papers reported that jail physicians speculated that Edelsohn was eating food secretly snuck into the jail or from other prisoners. For example, “She Mustn’t Starve,” Washington Post, July 24, 1914, 4, ProQuest HN. 149 led by Alice Paul and Rose Winslow, only lasted weeks. Second, most doctors, especially vocal women doctors and social science PhDs, did not criticize the practice of forced feeding prisoners or patients who refused food and often supported it. While some women doctors did object to force feeding hunger-striking suffragists like Paul, papers often focused more on their political activism than their professional credentials and arguments. Overall, journalists from major American newspapers sought the expert authority of doctors to settle the questions of hunger striking as insanity or the safety of forced feeding, and usually found it. While accusations that forced feeding had been used as punishment or caused harm and even death to patients warranted legislators’ attention in the investigations into mental hospitals discussed in chapter 2, suffragists’ allegations about the mistreatment they endured during forced feeding warranted no such attention. One reason for this is that unlike most people in public mental institutions, who had not been convicted of a crime and were understood to be part of a vulnerable population in need of protection, many people saw the hunger strikers as criminals. Whether or not the suffragists met a medical definition of “insane” based on their food refusal, many wanted them punished. Indeed, some doctors who spoke to the press about hunger-striking women appeared to have wanted to punish radical women for their gender and racial transgressions. This short episode in Paul’s long political and feminist career, supported by the strength of her memories about it many decades later, reveals the real and terrifying power that threats against a woman’s sanity held in the early-twentieth-century United States. These threats were powerful because they tapped into the history of the unjust institutionalization of women such as Elizabeth Packard who dared to transgress gender norms. In Paul’s case, jail authorities and doctors asserted that her hunger strike was evidence of insanity, echoing the popular logic applied to Edelsohn. Significantly, these threats ultimately failed when the expert authority of the 150 federal mental hospital’s superintendent, famous and well-respected psychiatrist William Alanson White, was ordered to conduct a mental examination of Paul and found her sane. White, who had served as an expert witness for some of the most famous cases of legal insanity in the United States, was an institutional administrator, psychoanalytically inclined psychiatrist, and Progressive. In the years after Edelsohn’s hunger strike in New York, women suffragists in the United States continued to agitate for the vote. Alice Paul had become famous as a founder of the National Woman’s Party (NWP), a more militant suffragist organization than the long-standing National American Woman Suffrage Association (NAWSA).80 While President Wilson was deciding whether the United States would enter World War I in 1917, NWP members criticized his domestic policy on woman suffrage. She led women’s suffragists in a new and bold protest by picketing for women’s suffrage in front of the White House. D.C. police soon arrested many of the picketing suffragists on the official charge of obstructing traffic, but they were released when their sentences were suspended.81 Paul then decided to send more picketers to the White House on October 20th, 1917, and was again arrested as the “ringleader.”82 After sentencing on October 22nd, 1917, she and the other pickets were sent to the D.C. District Jail.83 In the days leading up to their hunger strike, Paul and the other prisoners quickly realized that the food in the jail was not high-quality and lacked nutrition; jail authorities’ repeated denial of political prisoner status to the women suffragists and their rejection of suffragists’ demands concerning food eventually led Paul to her hunger strike. By late October, the suffragist prisoners 80 See, for example, Anne Firor Scott and Andrew MacKay Scott, One Half the People: The Fight for Woman Suffrage (Chicago: University of Illinois Press, 1982), 33. On the difference between the movements for woman’s suffrage and feminism during this period, see Cott, The Grounding of Modern Feminism. 81 Zahniser and Fry, Alice Paul, 280. 82 Ibid., 281. 83 Ibid. 151 were not allowed to purchase additional food from the prison canteen or receive care packages with food items.84 As her confinement continued, Paul as well as another suffragist, Winslow, grew weaker. Their health had declined to the point where prison authorities offered them fresh milk and eggs, widely used during the period as food for the sick. However, both women refused the food, because they thought that all the suffragists in prison should have access to high-quality and nutritious food.85 The idea that inmates of institutions should be treated equally and served nutritious, quality food echoes arguments made for quality food in St. Elizabeths during the hearings of 1906. That the government did not provide even a basic, nutritious diet to inmates only made the suffragists see more clearly the government’s lack of care for citizens. The NWP New York chairman Alva Belmont, referred to as “Mrs. O. H. P. Belmont,” wired to President Wilson that she protested “against the inhuman treatment of Alice Paul and Rose Winslow, unjustly and illegally detained in Washington jail” and demanded that they “be given the right— granted even murders—to buy the necessary food from the prison store to keep them alive.”86 Jail authorities did not grant these demands. According to Zahniser and Fry, these conditions in United States institutions are what led Paul to realize that the hunger strike, a tool she had learned during her time in England, may also be the “most powerful weapon available” in America as well.87 Because the NWP, like other suffrage groups, relied on the media to publicize their cause, 84 Ibid., 283. 85 Ibid., 285. 86 “Charge Hunger Striker is to be ‘Railroaded,’” Richmond Times-Dispatch, November 10, 1917, 3, Chronicling America, LOC. In her suffragist capacity, newspapers and other “suffragist literature” frequently referred to Alva Belmont as “Mrs. O. H. P. Belmont. She was a New York socialite and ex-wife of a Vanderbilt who helped to finance the NWP. See “Benefactor: Alva Belmont (1853-1933),” Library of Congress, Women of Protest: Photographs from the Records of the National Woman's Party, accessed October 14, 2021, https://www.loc.gov/collections/women-of-protest/articles-and-essays/selected-leaders-of-the-national-womans- party/benefactor/. 87 Zahniser and Fry, Alice Paul, 285. 152 and because suffragists worked in large networks of reformers, it is likely that Paul or other NWP members had heard of IWW member Edelsohn’s successful hunger strike as well as the recent hunger strike undertaken in January 1917 by the radical birth control advocate and sister of Margaret Sanger, Ethel Byrne in New York.88 Byrne reportedly believed that she could not be force fed in jail because it had been found “impracticable in England” and in the United States, there was not “any cat and mouse act” under which she could be released and rearrested.89 She was wrong; the Washington Post reported that Byrne was the first woman to be forcibly fed while imprisoned in the United States.90 The United Press sent out the story nationwide that her supporters feared she faced “death or insanity” because of her hunger strike.91 An editorial writer from Oregon noted that there was “only one excuse for forcibly feeding such a person as Mrs. Byrne, who takes the hunger-strike method, and that is that they are undoubtedly insane, and humanity demands they be protected from themselves.”92 Newspapers did not speculate on Byrne’s sanity nearly as much as Edelsohn’s, however, perhaps because Edelsohn’s case had shown that a person medically declared to be sane could undertake a hunger strike in New York. Nonetheless, Byrne’s case shows how the question was still not settled in popular imagination 88 Cott discusses the impact of the hunger strikes of both the British suffragists and of Byrne as “examples” that Paul followed. Cott, The Grounding of Modern Feminism, 59. 89 “Birth Control Advocate Has Fasted 5 Days,” East Oregonian (Pendleton, OR), Daily Evening Edition, January 26, 1917, 1, Chronicling America, LOC. 90 “Ends ‘Hunger Strike’: Mrs. Byrne, Forcibly Fed, Now Willing to Eat,” Washington Post, January 28, 1917, 3, ProQuest HN. 91 This story was printed or quoted in places such as in the Daily Capital Journal from Salem, Oregon, and the working-class newspaper the Day Book in Chicago. “Birth Control Advocate Makes Doctors Get Busy,” Daily Capital Journal (Salem, OR), January 27, 1917, 1, 4, Chronicling America, LOC and “New York Birth Control Rebel is Fed Forcibly—Mrs. Sanger Explains Fight,” Day Book (Chicago), January 27, 1917, 30, Chronicling America, LOC. Progressive women reformers in Chicago followed Byrne’s incarceration and supported birth control reform but were “equally united in censuring Mrs. Ethel Byrne for adopting English suffragist tactics in protesting her incarceration at Blackwell’s Island.” In “New York Birth Control Rebel is Fed Forcibly—Mrs. Sanger Explains Fight” Day Book (Chicago), January 27, 1917, 30. 92 Daily Capital Journal (Salem, OR), February 02, 1917, 4, Chronicling America, LOC. The author did not think that Byrne deserved being tube-fed eggs unless she was insane, citing the high prices for eggs at the time, which made them a luxury for many. 153 and it adds yet another example of how a woman who protested for causes and in ways considered to be improper or too radical for a white woman faced some speculation as to her sanity. Alice Paul began her hunger strike in the Washington, D.C. District Jail in early November 1917. Within days of the hunger strike’s beginning, Paul’s seriousness became clear to the jail administrators, and especially to the jail physician J. A. Gannon. Gannon and other jail personnel began to use intimidation tactics to attempt to force Paul to stop her hunger strike. They force-fed her and coerced her to undergo mental examinations by psychiatrists who would determine her sanity. White’s finding that Paul was sane was not immediately reported to anyone outside of the jail and President Wilson was informed only a short time afterwards.93 Gannon sent Paul back to the psychopathic ward. He and other jail staff used the specter of institutionalization, through forced feeding in the jail’s psychiatric ward and questioning her about her mental health, to advance their own agenda of reforming women’s behavior to fit the norms. NWP member Agnes Morey told one newspaper that Paul “was a wreck” and that “[t]he fear that she will be sent to the insane asylum has terrorized her.”94 Reportedly, Paul was also given a letter when she was in the psychopathic ward that contained the message: “Why not let this miserable creature starve? The country will be much better off without her and her gang of pickets. They are a rotten lot, are crazy, and should be locked up for life. If they would starve, it would save the expense of keeping them. Let them starve.”95 There was no author indicated, but the intimidation tactic of giving a letter 93 Zahniser and Fry, Alice Paul, 287. Doris Stevens, Jailed for Freedom (New York: Boni and Liveright, 1920), 222-3, 226, HathiTrust. 94 “Charge Hunger Striker is to be ‘Railroaded,’” Richmond Times-Dispatch, November 10, 1917, 3. 95 James Arthur Seavey, “Put to Insanity Test, Alice Paul Says in Letter,” New York Tribune, November 19, 1917, 1, Chronicling America, LOC. The phrase “miserable creature” had also been used to describe famous British suffragist Emmeline Pankhurst. 154 calling Paul and the other suffragists “crazy” alongside dehumanizing language may have weighed on Paul. She also told NWP members of other intimidation tactics—how a nurse constantly “observed” her with an extremely bright, white light and that prison doctors forced her to give blood for a blood test, citing that she was “mentally incompetent,” unable to decide for herself—to attempt to make her feel that she was a “mental patient” like the others on the ward.96 Ultimately, however, White’s authority and his judgement of Paul’s sanity prevailed, as she could not be committed to St. Elizabeths without his agreement. White’s judgement that Paul was sane is representative of his Progressive social views about and psychoanalytic understanding of feminism and the movement for women’s suffrage. Although Alice Paul viewed her treatment by male physicians and administrators at the D.C. District jail—and particularly the threat of institutionalization—as “strong evidence of men’s power over women,” her experience with White, a Progressive psychiatrist, serves as an important counterpoint to the narrative of male doctors punishing female patients, especially those who defied traditional gender norms.97 Historians Adams and Keene have argued that “in [light of] the literature of the developing field of psychiatry” Paul displayed many behaviors of a woman that were seen as indicative of potential mental illness including “the failure to marry and have a family, an overly zealous pursuit of education, public displays of strong opinions, unnatural desires for privacy and independence, and failure to eat regularly.”98 While this is factually accurate, psychiatric theories about mental illness were in flux in the early twentieth century, and White, the nationally-respected head of the federal mental hospital and a frequent medical expert in legal cases, was on the cutting-edge of psychiatry. 96 Stevens, Jailed for Freedom, 223. 97 For this characterization of Paul’s views about “men’s power over women,” see Katherine H. Adams and Michael L Keene, Alice Paul and the American Suffrage Campaign (Urbana, IL: University of Illinois Press, 2008), 203. 98 Adams and Keene, Alice Paul and the American Suffrage Campaign, 204. 155 The significance of White as the expert called into examine Paul should not be overlooked, because he had the political know-how as well as professional experience to stand up to any pressure from D.C. authorities to certify Paul as insane. White had recently served as an expert witness in the highly publicized murder trial of Harry K. Thaw, who murdered architect and socialite Stanford White.99 He was also well-aware of national politics not only as the superintendent of the federal mental hospital but also as a prominent member of the National Committee for Mental Hygiene. Further, as the head of St. Elizabeths, he had already proved his ability to defend himself in Congressional hearings during the 1906 investigation into his administration, as discussed in chapter 2. Despite his success in defending the hospital against accusations of misconduct during the 1906 investigation—including one that doctors and nurses force feeding a female patient unnecessarily—it is also possible that White had little interest in admitting Paul in order to avoid further scandal or to avoid broadening the types of behaviors that would “benefit” from forced feeding in mental institutions. First, admitting Paul, a famous suffragist, would most certainly have brought a flurry of press coverage about her treatment at the hospital. Just as in 1906 (and in later investigations covered in chapter 5), negative press was a thorn in the side of superintendents. Furthermore, with hospital overcrowding only increasing, establishing St. Elizabeths as the treatment center for hunger strikers in D.C. or federal prison would only have stretched the hospital staff and budget thinner, not to mention the potential for additional scandal it could bring. White’s support of Paul and woman suffrage can be understood through his own academic writings as well as his place in the psychiatric eclecticism during the early twentieth 99 See, for example, “Dr. William White Says Thaw is Sane,” The Washington Times, July 10, 1912, 3, Chronicling America, LOC. 156 century.100 White was a Progressive. He believed that legislative reform could change American society for the better; he sought the reform of commitment laws and criminal justice. As a psychoanalyst, he was concerned about how an individual’s environment—including social norms—shaped them mentally. Many of his thoughts on these topics are contained in his work The Principles of Mental Hygiene, which was published in November of 1917, the same month that White examined Paul in the D.C. District Jail.101 Besides explaining the theoretical and scientific bases for mental hygiene and examining the role of mental hygiene in understanding three major groups—"the insane,” criminal, and “feeble-minded”—he also discussed “miscellaneous groups” of people (e.g. prostitutes, inebriates, and homosexuals) who were seen as abnormal members of society as well as “miscellaneous problems” that White thought mental hygiene could speak to. One of these “miscellaneous problems” was “the woman movement.” White thought that woman suffrage was just part of a natural progression of modernity in which women no longer needed to be confined to the home. In fact, he wrote that “the slogan ‘woman’s place is in the home’ serves equally as a distorting rationalization to deflect attention from the real issues and put a premium on leaving things as they are—the dry rot that calls itself conservatism.”102 White dismissed those against woman suffrage and the woman’s movement as irrational, conservative people that had not embraced the benefits of the modern era, including more educational opportunities for women and the ease of buying clothes and other goods from department stores.103 In addition, he believed that women’s economic independence would create 100 Gerald N. Grob, The Mad Among Us: A History of the Care of America’s Mentally Ill (New York: Free Press, 1994), 144. 101 The timing of publishing makes it extremely unlikely that White’s interaction with Paul could have influenced what he had written in the manuscript of Principles of Mental Hygiene before it went to publication. 102 William Alanson White, The Principles of Mental Hygiene (New York: The Macmillan Company, 1917), 237, HathiTrust. 103 White, Principles, 237-238. He wrote, for example, “Released from the drudgery of the housewife by the genius of modern business enterprise, her energies are made available for better and higher things.” White here shows his white, middle-class view of women’s opportunities. 157 better “eugenic mating.”104 The ultimate need women suffragists were trying to fulfill by agitating for the vote, he thought, was in using newly-freed energy to satisfy “self-expression.”105 White’s examination of Paul convinced him that she was intelligent and most likely that she was meant for “higher things.” One suffragist claimed that White had written that Paul was “an unusually gifted personality” and spoke so well about woman’s suffrage to him in the “most admirable, coherent, logical, and forceful way.”106 White thus viewed Paul as an example of a new, modern type of white women’s femininity. As if to counter White’s assessment, however, newspaper reports revealed the continued intimidation that Paul faced when jail doctors and authorities threatened her sanity and consistently perpetuated the connection between radical feminist political action, hunger striking, and insanity. One suffragist recounted that Paul’s release came after it had “began to dawn on the country that she was kept incommunicado . . . that she was in the psychopathic ward . . . alienists . . . hunger-striking . . . forcible feeding. . .”107 Although this treatment led many people— especially other suffragists—to rally behind Paul, others likely doubted her sanity. When Paul faced forced-feeding from the D.C. prison authorities and J. A. Gannon, newspapers, similar to 104 White’s discussion of mental hygiene and the woman’s movement rested on a belief in the usefulness of eugenics—an understanding of human heredity that called for the promotion of having children by “healthy” individuals and the discouraging or prevention of the procreation of “unhealthy” individuals—to create a healthier national population. In 1917, eugenics was very popular with many social reformers and Progressives, including professionals such as psychiatrists, doctors, lawyers, and social workers. White’s argument in support of the woman’s movement took place in this context while at the same time promoting a Progressive view of women’s place in society and in heterosexual marriage. White, like many psychiatrists of the early twentieth century, viewed homosexuality as indicative of mental abnormality. He describes it as a “reaction” which “should be corrected if possible” because it caused “social inadequacy” in an individual. However, the eugenics movement led to “scientific” justification for further discrimination against African Americans, immigrants, and women. It also led to the involuntary sterilizations of women that were unjustly labeled “insane” or “feebleminded,” most famously in the U.S. Supreme Court Buck v. Bell, the case of Carrie Buck in 1924. White himself was against involuntary sterilization. The eugenics movement in the U.S. also provided the foundation for Nazi racial hygiene. 105 White, Principles, 238. 106 Stevens, Jailed for Freedom, 226. 107 Inez Haynes Irwin, The Story of the Woman’s Party (New York: Harcourt, Brace and Company, 1921), 292, HathiTrust. 158 reports about Edelsohn, focused on her hunger-strike and the decision to forcibly feed the suffragist in the context of insanity—in this case the “psychopathic ward.” The existence of intermediate sites like psychiatric wards in prisons enhanced the threat of using a person’s refusal of food in any form as grounds for institutionalizing them because they needed to be force-fed. In an early report from the local D.C. newspaper the Evening Star, jail physician Gannon did not comment directly about Paul’s sanity but stated that “the only danger to these patients’ lives is an apparent suicidal intent, which is prevented by tube feeding.”108 A similar statement had been reported in the case of Edelsohn earlier, when New York Deputy Commissioner Lewis said that Edelsohn would face forced feeding if she continued to hunger strike because “starvation is an act of self-destruction, and continued effort to take one’s life is a state of insanity.”109 Physicians outside of D.C. also stated their opinions on the use of forced feeding as news coverage about the force-feeding of Alice Paul and other suffragists spread. Some quoted in the Philadelphia Evening Ledger cited a long and successful history of forced feeding to justify its use, similar to how some physicians justified the use of forced-feeding in the case of the British woman’s suffrage hunger strikers as explained by Elizabeth Williams. An article headline asked readers, “Forced Feeding, Horror or Not?”110 The subtitle answered the question quickly: “Physicians Call it Harmless and Commonplace Practice of the Profession.” Multiple male doctors in Philadelphia, including one who invented a specific type of stomach tube and a hospital dean, minimized forced feeding as “one of the mere commonplaces of the sickroom” 108 “Pickets Are Fed at District Jail,” Evening Star (DC), November 9, 1917, 2, Chronicling America, LOC. Gannon also stated that jail doctors were “tube feeding” the women rather than using “forcible feeding,” because no force was being used. This rhetorical move was likely meant to medicalize the procedure and prevent accusations of punishment or torture. 109 “Girl Hunger Strikers,” 3. 110 “Forced Feeding, Horror or Not?” Evening Ledger (Philadelphia), November 13, 1917, 11, Chronicling America, LOC. 159 that was “just a matter of hospital discretion,” and was not a cause for “hysteria.”111 By invoking hysteria, the doctor was likely dismissing and even pathologizing suffragists’ outspoken efforts to bring to light what they saw as the unjustified and brutal forcible-feeding of Alice Paul. In contrast to the coverage Katharine Bement Davis received as a socially acceptable, law-abiding suffragist during the Edelsohn controversy, the Philadelphia Evening Ledger reported on other suffragist physicians’ objections to the forced feeding of Alice Paul as part of the “women’s ‘picketing party’” who were “violently” dissenting against the mainstream medical consensus. Sarah Lockery’s opinion was prefaced with her association to Paul as a “close partisan of the National Woman’s Party,” while Caroline Spencer was identified as “an ex- picketer and inmate of Occoquan.”112 Here, unlike the earlier heralding of women doctors that came when their opinions fit the mainstream narrative against hunger strikers, journalists chose to focus not on the expert credentials of these women doctors and their medical opinions, but rather, their political ties to Paul and radical protests. Even a Progressive psychiatrist like White saw Paul as an example of a new, modern woman, some parts of the media, perhaps looking to safeguard medical authority with the U.S. public and to any onlookers abroad, quickly dismissed these suffragist, women doctors’ criticisms of forced feeding based on their politics. In addition to critiquing medical norms and Paul’s treatment in the press, NWP members also contacted the media with accusations that Paul was being “railroaded” into St. Elizabeths hospital by an “insanity plot” by D.C. authorities. The Richmond Times-Dispatch ran an article under the headline “Charge Hunger Striker is to be “Railroaded’” with subtitles that elaborated the point: “Suffrage Leaders Say Officials Intend Sending Miss Paul to Asylum” and “Alleged to Have Said Official Told Her She Was to Be Examined as to Her Mentality—Held 111 “Forced Feeding, Horror or Not?” 11. 112 Ibid. 160 Incommunicado.”113 The Washington Post also ran a short article “Pickets Charge Insanity Plot,” while the Chicago Daily Tribune ran the story “Insanity Threat in Jail Charged by Suffragist.”114 The Los Angeles Times wrote an article sympathetic to Paul and her “inhuman treatment,” but still utilized headlines that sensationalized the possibility that hunger striking suffragists might end up in mental hospitals, such as “Mad House Yawns for Militants,” and “Convicted Picket Says She is Threated with Incarceration in Asylum.”115 These articles were based on the efforts of NWP member Morey who went with Paul’s sister, Helen, to check on Alice Paul and Rose Winslow in jail. Morey reported that Paul said that five physicians forced her to undergo a mental examination and that they had “told me that my mental condition was such it might be necessary to send me to St. Elizabeth’s [sic].”116 Paul, as well as other suffragists, recognized that it was not beyond the realm of possibility that she might be adjudged insane and sent to a mental hospital as a type of state punishment for her protesting, perhaps justified by psychiatrists who viewed hunger-striking as a symptom of insanity. While gender norms had begun to change and women had entered professions that they had been previously been barred from (such as medical practice), the history of the institutionalization of women for defying gender norms still provided the context in which Paul protested and considered potential consequences. Paul had known at least one woman who she had believed was completely sane who was committed to an asylum by her daughter and son-in- 113 “Charge Hunger Striker is to be ‘Railroaded’,” Richmond Times-Dispatch (VA), November 10, 1917, 3. A similar story ran ten days later when the news had reached Oregon with the subtitle “Militant Friends Declare Jail Physicians Threaten to Send Her to Asylum.” See “Fear of Miss Paul Being Held Insane,” East Oregonian (Pendleton, OR), November 20, 1917, 8, Chronicling America, LOC. 114 “Pickets Charge Insanity Plot,” Washington Post, November 10, 1917, 3, ProQuest HN; “Insanity Threat in Jail Charged by Suffragist: Alice Paul Tells of Alleged Plan to Put Stop to Picketing,” Chicago Daily Tribune, November 10, 1917, 5, Chronicling America, LOC. 115 “White with Exhaustion, Alice Paul Tells of Inhuman Treatment,” Los Angeles Times, November 10, 1917, I1, ProQuest HN. 116 “Charge Hunger Striker is to be ‘Railroaded,’” 3. 161 law in an attempt to steal her fortune. Another woman during Paul’s time in Washington came to her for help getting sufficient alimony to survive from her ex-husband who was a high-ranking judge in Illinois. Paul remembered that the woman “was so harassed by being constantly threatened that they would put her in an insane asylum if she made any trouble for this judge” and that she feared the woman would be institutionalized even though she was sane.117 This was one of the contexts that Paul discussed when expressing her belief to historian Amelia Fry, nearly sixty-five years after her hunger strike, that she “owed a lot to that Dr. White because it would have been so very easy for him to have given an adverse decision and I might still at this moment be in the St. Elizabeth [psychopathic ward].”118 Paul also did not believe that her position as the leader of the NWP would have protected her if she had been declared insane by White due to her knowledge of how other women were institutionalized or threatened with institutionalization. The relevance of the history of women’s psychiatric treatment for transgressing gender boundaries was maintained in the United States because of the strong linkage between feminism, insanity, and institutionalization that existed within U.S. Progressivism and modernity. Paul argued, “Well, people are so apt to say, 'Well, this lady unfortunately was very good in her way, but she was mentally unbalanced.’ People are apt to believe it, I am afraid. […] So I could have died in this institution, and be there this moment.”119 Her suffragist friends’ fear that Paul might have been “railroaded” into St. Elizabeths in a form of “insanity plot” by Washington politicians or government employees was not unfounded or without historical precedent and is particularly understandable given how the 117 Fry, Conversations with Alice Paul, 232. This story is reminiscent of Packard’s earlier one, as the rights of married or divorced women came into play here, especially where the husband was a prominent member of the local community. 118 Ibid., 231. 119 Ibid., 234. Underline in the original. 162 press reported on other women hunger-strikers such as British suffragists and Rebecca Edelsohn just a few years prior.120 When Paul explained years later that she knew later how strongly White had written about her sanity, she discussed how he had visited the NWP headquarters and she and other suffragists “got to know him fairly well,” but only in the context of her admiration for him.121 Overall, Paul’s political aims were supported by White, and he did not see a middle-class, white woman’s strong and passionate support of woman’s suffrage as indicative of any mental derangement or social maladjustment. In the context of his psychiatric and psychoanalytic theories about mental hygiene as well as the changing place of women in the United States during the “modern” twentieth century, Paul was sane and a woman fighting for the ability to express herself and achieve something significant. Conclusion Ultimately, Alice Paul’s and Rebecca Edelsohn’s hunger strikes were successful, and neither were ultimately institutionalized in a mental hospital. However, reporting on their hunger strikes illuminated how linkages between women’s radical activity and insanity were made in popular culture and in the “imagined community” of the United States. As the case of Alice Paul shows, concerns about being committed to institutions without cause could be specifically raced and gendered for white women. Because state and national authorities resorted to threats of and the use of forced feeding in response to radical women’s hunger strikes, doctors and psychiatrists were able to publicly express justifications for the use of forced feeding in institutional contexts and at times provided theories linking a hunger striker’s refusal of food with symptoms of a 120 “Charge Hunger Striker is to be ‘Railroaded,’” 3 and “Pickets Charge Insanity Plot,” Washington Post, November 10, 1917, 3. 121 Fry, Conversations with Alice Paul, 231. 163 mental illness. Ultimately, however, American women suffragists and other radical protesters were able to demarcate themselves from the institutionalized “insane” as British suffragists had done. Although these women faced much discrimination because of their gender, they were ultimately able to retain their freedom and ability to refuse medical procedures. Mentally ill people in institutions generally had neither; forced feeding continued for them, even if doctors usually considered it only as a last resort. US newspaper coverage connected British and American militant suffragists in addition to radical IWW women protestors and played a significant part in reinforcing the power of the threat of institutionalization against women who transgressed socially acceptable female behavior. Many articles depicted women arrested for protest activities as violent, defying social norms, and therefore, potentially indicative of mental illness. When combined with the decision to use the hunger strike as a political tactic to protest their incarceration, popular ideas of hunger striking as an act of an insane person rather than a rational, political act of protest became widespread. The discourse generated by prison physicians, psychiatrists, and the media showcase the Progressive reliance on expertise to create medico-legal procedures. Physicians used the common practice of forced feeding in mental hospitals as a precedent for force feeding hunger- striking women protestors in jail. In the case of Edelsohn and Est, however, it is apparent that hunger-striking and insanity were so linked that some news outlets proposed “the Matteawan cure” as a solution for food refusal in prison. Further, articles and editorials used the authority of American experts to show how U.S. authorities and doctors handled radical women protesters better than British ones, advancing a sense of nationalism and superiority in the power of American government and scientific experts. Outspoken women doctors played a significant part in justifying forced feeding in institutions as well as contributed to this shared nationalist critique 164 of Britain, even as they could be misquoted or sometimes became targets of criticism if their opinions did not match the media narrative. Lastly, William Alanson White’s support of Alice Paul was foundational in how her hunger strike was resolved and her ultimate release from jail rather than commitment to St. Elizabeths. Although the jail physician Gannon sent her to the psychopathic ward to be force fed, Paul could not be sent to St. Elizabeths without White’s consent as the hospital’s superintendent. White’s inclusion of “the woman’s movement” in his Principles of Mental Hygiene shows how concern over the mental health of women in the women’s movement was prevalent enough for him to make a comment on it alongside other topics that were “miscellaneous problems” such as patent medicines and social hygiene. His support, based on eugenic arguments but also mental hygiene principles and psychoanalysis, was an integral part of a broad, Progressive reform movement concerning women’s economic independence and their right to vote. He placed his views within the context of a changing modernity that he and other Progressives were a part of. White’s involvement thus shows that although coercive state and psychiatric power over women who defied social norms did exist during this period, psychiatry was not homogenous, as there was an eclectic and competing array of medical theories about mental health and illness in the 1910s that could be used to support social movements. In the next chapter, focus on the institution will return, and the behavior of refusing food is explored further not as a political tactic but as a symptom of mental illness commonly seen by psychiatrists in mental hospitals. I will explore how food refusal was connected to the nutritional deficiency disease pellagra, in addition to how mental hospitals themselves could contribute to pellagra in patients. Chapter 4 will show that for experts both inside and outside mental hospitals, responding to food refusal and overeating led to the classification of the mentally ill as 165 “problems” when it came to their food habits, but also that mentally ill patients became a solution to food shortages during World War I. As state and federal institutions, mental hospitals sought to follow the recommendations and regulations of the Food Administration as part of WWI patriotism. 166 CHAPTER 4: The “Problems” of Feeding the Mentally Ill and the Nation, 1914-1918 Introduction As patient populations in public mental hospitals continued to rise during the 1910s, the most common difficulties in patient care and therapy only became more prevalent. Food— including patient behavior toward it—was at the intersection of these common difficulties. For example, some patients frequently had delusions concerning food, which they experienced as real and often terrifying. Ex-patient and reformer Clifford Beers explained his illness caused “tricks” that “perverted” his senses, causing him to experience the “common delusion” that his food was poisoned. “None of my food had its usual flavor,” he wrote, explaining that salt and sugar tasted the same.1 These types of delusions often led patients to refuse food. Some only rejected foods they thought were dangerous. Others stopped eating altogether. At the other end of the spectrum, some patients had voracious appetites and felt they were not being fed enough. These patients sometimes took matters into their own hands, taking food from other patients. With a foundation established for what the proper diet of the mentally ill was in the 1890s and the early 1900s, mental hospital superintendents in the 1910s began to further examine how patient behaviors around food were symptoms of their mental disorder. Both psychiatrists and dietitians described patients’ food refusal and overeating with the moralistic language of the Progressive Era, agreeing that these behaviors were a problem. Some of them characterized the mentally ill as immoral, irrational, and lacking in self-control.2 While 1 Clifford Whittingham Beers, A Mind That Found Itself: an Autobiography (New York: Longmans, Green, and Co., 1908), 30, HathiTrust. 2 Helen Zoe Veit has shown that the hallmarks of Progressive-Era food reform were the concepts of efficiency, rationality, morality, and self-control. Helen Zoe Veit, Modern Food, Moral Food: Self-Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century (Chapel Hill: University of North Carolina Press, 2013), 4. 167 dietitians and health reformers frequently used this language to describe all types of people— including those who ate the wrong number of calories or threw too much food away—these expectations took on further power in the mental hospital. Psychiatrists in the 1910s often viewed food refusal as just another symptom of mental illness, often deliberately omitting any consideration of its psychosocial contexts. The term psychosocial refers to the interplay of a person’s social environment with their own psyche.3 And with new standards of keeping case files and taking patient histories, medical staff pathologized and recorded patients’ food habits more than ever before. What might be a faux pas outside the hospital, such as eating sloppily, carried new weight inside it. If a patient could not eat in a socially acceptable manner inside the hospital, how were they supposed to fit in outside it? As psychiatrists practicing the “new psychiatry” defined mental disorder not as part of a dichotomy of sane versus insane, but instead as part of a spectrum of adjustment to society to maladjustment, patients’ eating behaviors came under increased scrutiny.4 At the same time, many American psychiatrists participated in debates about the etiology and treatment of a newly endemic disease in the United States called pellagra. As discussed in chapter 2, people suffering from the advanced stages of the disease developed symptoms of dementia or melancholia, including difficulty articulating their thoughts clearly, a lack of desire to do any activities, delusions of persecution, and refusing food.5 While today we know that 3 The word has gone through various transformations in meaning over time since its development in the 1890s. See Rhodri Hayward, “The Invention of the Psychosocial: An Introduction,” History of the Human Sciences 25, no. 5 (December 2012): 3-12. 4 Adolf Meyer, for example, set up the Phipps clinic to be like an agricultural experiment station so that it could be a “living field laboratory for exploring the uses and limits of psychobiology.” At Phipps, food was a “variable in the therapeutic experiment” and psychiatrists there sometimes used food “as an experimental control to test a patient’s reactions.” S. D. Lamb, Pathologist of the Mind: Adolf Meyer and the Origins of American Psychiatry (Baltimore: Johns Hopkins University Press, 2014), 109-110, 196. 5 Daphne A. Roe, A Plague of Corn: The Social History of Pellagra (Ithaca, NY: Cornell University Press, 1973), 4- 5. 168 pellagra is caused primarily by a deficiency in niacin, vitamin B-3, it took until the 1930s for most physicians and psychiatrists to accept that it was a dietary deficiency disease.6 This chapter goes beyond my comparison of the role of pellagra in the investigations into St. Elizabeths and South Carolina State hospital in chapter 2. It shows further how the “problems” particular to feeding the mentally ill in institutions manifested through how psychiatrists and United States Public Health Service (USPHS) scientists—including Joseph Goldberger, the USPHS researcher that first provided evidence that pellagra to a dietary deficiency in 1915—discussed the outbreak of pellagra in the United States during the 1910s. Although pellagra was primarily a Southern problem, its existence in Northern mental hospitals has often been skimmed over in historical analysis.7 Examining psychiatrists’ debates over the etiology of pellagra and their regional variations through pellagra patients’ dietary habits highlights the complex causality of pellagra. Because the biological cause of pellagra is a lack of niacin, the popular and affordable working- class diet in the South of the “three Ms”—meat (fatback), molasses, and (corn) meal—led many Southerners to develop it.8 Social causes also contributed to the disease. In the South, widespread poverty stemming from racism and perpetuated by the sharecropping system that trapped poor farmers, particularly African Americans, in cycles of debt, limited the amount and quality of 6 A diet low in the amino-acid tryptophan also contributes to pellagra because the body can make vitamin B-3 out of tryptophan. 7 Etheridge’s foundational work The Butterfly Caste: A Social History of Pellagra in the South remains the best study. She did discuss pellagra in Northern mental hospitals, but it is not a significant strand of her analysis, as the book’s title indicates. Elizabeth W. Etheridge, The Butterfly Caste: A Social History of Pellagra in the South, (Westport, CN: Greenwood Pub. Co, 1972), 6, 9. Alan M. Kraut also did not spend an abundance of time on pellagra in the North but did provide insightful analysis of the Peoria State Hospital (Illinois) superintendent’s admission that he “misdiagnosed pellagra because he had refused to entertain the possibility that the disease could be contracted in a well-run institution such as his” and that Goldberger was “quite prepared” to believe pellagra was both a Northern and Southern problem. Alan M. Kraut, Goldberger’s War: The Life and Work of a Public Health Crusader (New York: Hill and Wang, 2003), 101-2. 8 Etheridge, The Butterfly Caste, 70-71. 169 food they could buy. In the North where these conditions did not exist in the same way, physicians recorded cases of pellagra primarily in mental hospitals. These cases of pellagra in Northern mental hospitals alongside investigations into Southern hospitals help to reveal how pellagra developed even within institutions that had an overall varied and nutritious diet. Inattention to the eating habits of the severely mentally ill by nursing or other dining room staff could lead to pellagra or other nutritional deficiencies. These complex causes of pellagra within mental hospitals, which could be seen through either a somatic or psychological etiological lens, not only highlight psychiatry in flux but also a particular aspect of “modernity-in-the-making,” one related to the relationship among agriculture, institutions, food, and disease. In the 1910s, somatic and psychological—including early psychoanalytic— understandings of mental illness competed, leading to an eclectic array of theories. Historians of medicine have recently begun to reexamine psychiatry during the late nineteenth and early twentieth centuries and have found that the period was more transitional than scholarship had previously illustrated. Psychiatrist Adolf Meyer developed his theory of psychobiology during this time, which many historians view as the foundation of psychiatry today.9 The development of a theory that brought together the biological and psychological as causes for mental illness made sense because the still-developing profession of psychiatry was not easily categorized as either somatically- or psychologically-oriented in “the fluidity of the era’s modernity in the making.”10 Psychiatrists’ contrasting theories and rhetoric surrounding patient eating habits and the production of food in mental hospitals during the 1910s reveal different aspects of this era’s “modernity-in-the-making” in the complex interaction of Progressive reform, the rise of expert 9 Lamb, Pathologist of the Mind, 101, 248. 10 Naoko Wake, “Homosexuality and Psychoanalysis Meet at a Mental Hospital: An Early Institutional History” Journal of the History of Medicine and Allied Sciences 74, no. 1 (January 2019): 34-35. 170 scientific authority, advances in nutritional science, and psychiatrists’ increasing attention to the psychology of mentally ill patients. In this chapter, I take a novel approach that illuminates the competing theories of mental illness at this time by examining how psychiatrists, neurologists, nutrition scientists, dietitians, and United States Public Health Services researchers discussed and scrutinized the eating habits and behaviors of the mentally ill in institutions. Building on chapter 1, I explore how the interdisciplinary and collaborative investigation of these different medical professionals and government researchers continued placing mentally ill people at the margin of society—in this case because of behaviors surrounding food. This occurred even as the mental hospital itself began to become a “modern” hospital. Examining food, diet, and the rhetoric surrounding patient eating habits reveals how these professionals enacted Progressive reform prior to and during World War I. I argue that, on the one hand, professionals viewed patients and their eating habits as medical “problems” which required separation from society and expert solutions. On the other hand, when the U.S. entered World War I, their attitude shifted, as they viewed patients more as part of society and capable of helping to solve the nation’s food problems through the right mix of patriotism and work ethic. Somatic, psychological, and psychosocial theories of mental illness coexisted during this period, although the balance between them shifted variously depending on region, race, and the sex of patients. World War I one shifted this balance as well, leading to an increasing focus on the psychological and psychosocial aspects of mental disorder. “The Insane Have Their Own Problem”: Patients’ Eating Habits This increasing attention to eating habits by a wide variety of professionals associated with mental hospitals took place in the context of a greater focus on diet in all types of hospitals. In the realm of hospital administration, dietetics experienced slow but significant growth prior to 171 the United States’ entrance into World War I, when the profession took off. Home economists, many of whom had begun to specialized and identify as dietitians, gained a boost in legitimacy and prestige due to their service for the federal government through the Food Administration and their roles in U.S. military hospitals at home and abroad.11 Indeed, home economists who served as specialists in Home Economics for the Bureau of Education noted that the war created a “demand for institution workers [that] has never been so great as during this past year.”12 While their definition of “institutions” included universities, orphanages, boarding houses, and military hospitals, dietitians trained in institutional food service were also needed in mental hospitals.13 While mental hospitals have often been explored as a separate category of hospitals from general hospitals, the two share an important and overlapping history. A shared goal for both general and mental hospitals was to modernize during the first decades of the twentieth century. Although diets had long been considered therapeutic for a variety of ailments, by the 1910s specific therapeutic diets for tuberculosis and other diseases were well-established. One hospital administrator found that doctors were “supplanting medication by the use of special diets given for special purposes under special conditions” at a time when drug therapy was pushed by many doctors.14 Dietitians calculated diets in terms of calories and macronutrients, and with the 11 As Megan Elias has discussed, it is important to use specific, disciplinary terms to refer to home economists. She explained that “home economics, which emerged in this era, was a defined academic area, encompassing (among many subject areas) bacteriology, family psychology, and institutional management as well as nutrition, dietetics, and food science—each a distinct discipline. People who worked in these interconnected fields could be known collectively as home economists but were more likely to identify with their subfields.” Megan Elias, “Making Progress in Food,” The Journal of the Gilded Age and Progressive Era 18, no. 4 (October 2019): 391. See also Harvey A. Levenstein, Revolution at the Table: The Transformation of the American Diet (Oxford: Oxford University Press, 1988), 139, 145-6. 12 Henrietta W. Calvin and Carrie Alberta Lyford, Home Economics. Bulletin, 1918, No.50, Department of the Interior, Bureau of Education (Washington, DC: Government Printing Office, 1919), 21, https://eric.ed.gov/?id=ED541101. 13 Some mental hospitals had hired dietitians before the war, but many, including St. Elizabeths, did not hire dietitians until after the war. Dietitians were among many mostly female professions that gained prominence in the first few decades of the twentieth century. I explore these threads of analysis in chapter 5. 14 John Allan Hornsby, “The Items in Hospital Efficiency,” The Modern Hospital 2, no. 3 (March 1914): 173, HathiTrust. 172 increasing push for specialization in the sciences, diet therapy also began to become a mainstream, specialized branch of medicine. Physicians and neurologists examined feeding institutionalized, mentally ill patients in some of the most prominent textbooks about diet and disease during the 1910s. For example, the fourth edition of Julius Friedenwald and John Ruhräh’s Diet in Health and Disease (1913) included a short section on “diet for the insane” in addition to an appendix of example hospital dietaries.15 In another of the largest medical texts on diet, Dietotherapy: Nutrition in Diet and Disease (1918), one chapter was devoted to “Dietaries for Hospitals and Asylums.” Lists of “special” dietaries appear in the chapter, including those from general hospitals, children’s hospitals, tuberculosis sanitaria, and from at least three mental hospitals, including St. Elizabeths.16 The contents of the diet for “the insane” were not noticeably different from general hospitals; rather, hospital staffs’ and dietitians’ need to manage patients’ eating behaviors was what set diet in mental hospitals apart from other types of hospitals and institutions in the 1910s. As dietitian Lulu Graves stated, feeding the institutionalized mentally ill had “some complications in serving not to be found in other places;” put more bluntly, she thought that “the insane have their own problem.”17 Delusions based on taste, smell, and even sound—like Clifford Beers described in A Mind that Found Itself—set feeding mentally ill patients apart from 15 Julius Friedenwald and John Ruhräh, Diet in Health and Disease, Fourth Ed. (Philadelphia: W. B. Saunders Company, 1913), 14, HathiTrust. The textbook still included a separate section on Silas Weir Mitchell’s rest cure, as it remained influential. See chapter 1 for more about Mitchell and his rest cure. 16 George N. Kreider, “Dietaries for Hospitals and Asylums,” in Dietotherapy: Nutrition in Diet and Disease, ed. William Edward Fitch, Volume 3 (New York: Appleton and Company, 1918), 778-781, HathiTrust. This same volume also included a section written by Casimir Funk on “Deficiency Diseases,” 547-558 which covered beriberi, scurvy, pellagra, and rickets, as well as Tom A. Williams’s “Diet in Mental Disorders,” 609-642. St. Elizabeths also appeared in Friedenwald and Ruhräh’s Diet in Health and Disease and was respected by various medical authorities for its innovative diet, appearing in various lists of special dietaries throughout the early twentieth century. Friedenwald and Ruhräh, Diet in Health and Disease, 723-727. 17 Lulu Graves, “Feeding the Hospital—Various Kinds of Institutions,” The Modern Hospital 4, no. 4 (April 1915): 249, 251, HathiTrust. The quotation “the insane have their own problems” is adapted from the subtitle of the article, so it does not maintain title capitalization. 173 those in general hospitals.18 Because of this, Graves made the suggestion to ventilate hospital dining rooms during meals so “that no disconcerting sounds or disagreeable odors reach the patients, as there are nearly always some who are likely to be affected by these external conditions more than rational persons would be.”19 Continuing from the 1890s, dietitians and hospital superintendents sought to manage the hospital food service and dining environment while many patients’ food refusal, due to delusions or any other cause, ensured that diets for the mentally ill remained a separate medical category in the growing literature on diet in health and disease. At the same time, psychiatrists tried to identify and solve the complex “problem” that patients’ delusions and abnormal eating habits created because this was a period when both somatic and psychological approaches to mental disturbances contributed to the understandings of mental illness.20 This complexity is what allowed St. Elizabeths Superintendent William Alanson White, for example, to stress the importance of psychopathic wards in general hospitals due to the close relationship internal and psychiatric medicine. He argued that there was “a host of conditions that lie on the borderland between internal medicine and psychiatry” which included “fever deleria” but also “that very large group of gastrointestinal cases that have close relationships with the neuroses.”21 In the context of competing somatic and psychological explanations for mental disorder, psychiatrists continued to puzzle over, among other symptoms, patients’ delusions and abnormal eating habits. 18 Graves, for instance, stated that patients “may have delusions about their food which are difficult to overcome and which cause them to refuse to eat.” Ibid., 251. 19 Ibid. 20 For the “psychology of everyday life” and the argument about the shift to a spectrum of normal and abnormal behavior, see Elizabeth Lunbeck, The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America (Cambridge, MA: Harvard University Press, 1994), 46-47. 21 William Alanson White, “Dividing Line Between General Hospital and Hospital for Insane,” The Modern Hospital 2, no. 3 (March 1914): 137, HathiTrust. 174 Neurologists, too, studied food refusal and overeating, including with emphasis not only on their somatic but also on their psychological and psychosocial aspects. The neurologist Tom Williams, for example, thought that “dietetic errors” could cause “mild degrees of mental disturbances,” but he also viewed pathological overeating and fear of food as “psychological factors concerned in diet,” eschewing any somatic causes.22 Like Graves and psychiatrists, he recognized that food was a common target of patients’ delusions or manic obsessions, noting that a “psychological incapacity or refusal to eat” was prevalent in “mental anorexia.”23 Moreover, Williams highlighted the role that religious and cultural ideals of what constitutes a healthy or attractive female body played in patients’ in a mental disorder like this. He wrote: The cause of this reluctance to eat is usually a notion of female patients that eating will keep her normally fleshy. This she objects to on the score that it is a pandering to the body. Of this she is ashamed because it is carnal, and therefore evil, whereas she believes that she should seek to attain the good, which is the spiritual.24 Here, Williams identified one example of “modernity-in-the-making” in the intermixing of both the new cultural ideal of thinness that was a sign of morality and self-control during the Progressive Era, and the older ideal of women’s thinness as a symbol of spiritual purity.25 22 Williams, “Diet in Mental Disorders,” 609, 622. He discussed these eating habits under the medical terms “sitophobia” and “sitomania.” He was a lecturer on nervous and mental diseases at Howard University and a neurologist for the Freedmen Hospital in Washington, D.C. Despite where he worked, Williams did not discuss race or identify any of the case studies subjects as people of color. 23 Ibid., 632. Williams was likely referencing the developing clinical disease of anorexia nervosa, an eating disorder that became prominent in young women in the United States beginning in the 1980s. As a practitioner who had experience primarily with hospitals during the Progressive Era, Williams likely did not see many cases of “mental anorexia,” and therefore did not spend a significant amount of time discussing it in the chapter. It was uncommon for children and adolescents to be admitted to institutions during this period, and historians have found that most cases of early anorexia nervosa occurred in middle-class adolescent women whose parents could afford treatment at private clinics or sanatoria that did not keep thorough records. See Joan Jacobs Brumberg, Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease (Cambridge, MA: Harvard University Press, 1988), 319n14. 24 Williams, “Diet in Mental Disorders,” 632. 25 Although the patients Williams discusses here use spiritual beliefs to explain their anorexia, his description reads as secular and dismissive. Indeed, as Brumberg explains, “the transformation of fasting behavior from piety to disease captures the parallel processes of secularization and medicalization” in the United States. Brumberg, Fasting Girls, 99. 175 Williams thus identified psychosocial causes of mental illness, including religious and cultural pressures, as one of the major causes of pathological food refusal. Because the refusal of food seen in mental anorexia was partially psychological in nature, the cure could be psychoanalytic. The cure for “mental anorexia,” thought Williams, was to change “the point of view of the patient regarding the food and eating [so] that the physician accomplishes the cure of mental anorexia.”26 This is similar to his suggestion that “hysterical food phobias” and feelings of apprehension toward specific foods could be removed though psychotherapy. According to Williams, a doctor’s inability to recognize a “nervous reason” for the avoidance of food and subsequent prescription of drugs to relieve stomach upset could create further stomach pains, leading to a hysteria that could only be “curable by suggestion- persuasion,” a term indicating psychoanalytic influence.27 Here, William’s belief in the power of psychotherapy shows the influence of the mental hygiene movement and the successful efforts of early adopters of psychoanalysis, including William Alanson White, to spread its theories within psychiatry and even neurology. The continuing interdisciplinary study of diet’s role in mental disease produced more knowledge about the role of diet in mental disorder; unlike the 1890s, however, many psychiatrists and neurologists valued psychotherapy as a tool correct some dietary habits in patients with mental disorder. Compared with professionals’ discourse about food refusal, psychiatrists might have held more psychosocially oriented, less somatic views about overeating. Progressive, middle-class values influenced medical ideas about the abnormality of overeating. In popular culture, thinness was becoming a bodily ideal for women. Calorie counting and dieting became popular in the late 1910s not only because to be thin was an aesthetic goal, but also because restricting one’s food 26 Williams, “Diet in Mental Disorders,” 632. 27 Ibid., 636. For case studies showing the use of psychotherapy to remove hysterical food phobias, see p. 637. 176 consumption became a marker of virtuous self-control during the Progressive Era.28 Psychiatrists and dietitians, then, often depicted patients who had large appetites as careless and even animalistic. Graves’s first concern, for instance, was that patients with dementia, epilepsy, or who were in poor physical health would not chew their food properly. They might also eat too fast. These patients, she explained, would “bolt” their food—which meant that dining rooms had to be supervised.29 Physicians and neurologists familiar with mental hospitals also used the common Progressive-Era terms “bolt” or “wolf” to describe how some patients would eat, the latter term conjuring an image of animality as related to the patient.30 While people who ate quickly and sloppily outside mental hospitals were likely shamed by family, friends, or maybe even a public health worker, psychiatrists viewed this behavior inside the hospital as a marker of a lack of self-control and ultimately, then, of a patient’s insufficient readiness to return to the social expectations of the outside world. Aside from those who “bolted” their food, mental hospital superintendents also used the Progressive-Era moral and religious language connected to food to describe patients who either took others’ food or those who ate too much. Doctors labeled patients who took food off another’s plate as a “stealer,” “snatcher,” or “grabber.”31 Like patients who ate too little, psychiatrists thought these patients needed to be vigilantly watched in the dining room. In this 28 Chin Jou, “The Progressive Era Body Project: Calorie-Counting and ‘Disciplining the Stomach’ in 1920s America,” The Journal of the Gilded Age and Progressive Era 18, no. 4 (October 2019): 425-427 and Veit, “The Triumph of the Will: The Progressive Body and the Thin Ideal,” in Modern Food, Moral Food, 157-180. 29 Graves, “Feeding the Hospital,” 251. 30 Williams, “Diet in Mental Disorders,” 619; Henry J. Sommer and P. Saha, A Proposed Basis for a Dietary for Hospitals for the Insane to Meet War Conditions (Hollidaysburg, PA: Directors of the Blair Co. Hospital for Insane, 1918), 7, HathiTrust. Sommer and Saha wrote: “Every Psychiatrist of any experience has over and again seen individuals suffering from Acute Insanity who would “wolf” large quantities of food—sufficient for two or three people—proteins, fats and carbo-hydrates in excess.” These terms were commonly used outside the mental hospital setting as well. 31 See, for example, Robert C. Woodman, “An Experiment in the Feeding and Management of the Patients in a Disturbed Ward,” The State Hospital Quarterly (NY) 3, no. 4 (August 1918): 366, HathiTrust. When New York hospital Superintendent Robert C. Woodman completed an experiment on feeding “disturbed” patients, twelve were “especially bad and were known as the ‘grabbers.’” 177 case, if they weren’t watched, other patients would not get enough food to eat. But the act of snatching food was not only discussed in terms of patients’ lack of self-control; there was a more obvious discussion of patients, including those that were “snatchers,” along moral lines through calling patients gluttonous.32 In one striking case in William’s chapter in Dietotherapy, he diagnosed a woman patient with “recurrent mania due to gluttony.”33 Doctors discovered that she spent “all her money on sweetmeats, and often on more substantial things, which she would eat during the morning, seldom offering any to another person.”34 While the condemnation of gluttony and a lack of control over one’s food consumption was common during the Progressive Era, this condemnation took on more power in mental hospitals. For patients, remaining “gluttonous” could mean remaining in the hospital. Williams’ patient only returned home when “her indulgence was prevented [and] the attacks ceased.”35 “The Problem at Asylums”: Pellagra, Psychosis, and Patients’ Dietary Habits Psychiatrists’ and public health reformers’ attempts to determine the source of mentally ill patients’ disordered eating habits and poor nutritional status coincided with their efforts to understand the etiology of pellagra. Based on their investigations of patient nutrition in a couple southern mental hospitals, United States Public Health Service (USPHS) members Joseph 32 For example, a superintendent from Ontario, Canada reported that many of the hospital’s patients with advanced dementia were “gluttonous and will eat not only the portion allotted to them but that belonging to their neighbors if they can lay hands on it.” J. C. Mitchell, “Food, Service and Conservation in a Provincial Hospital,” American Journal of Insanity 75, no. 2 (October 1918): 203. The AJI and the AMPA were “American” in that they included the United States and Canada in publications. This meant that within psychiatry in the United States, professional ideas had a transnational nature. In addition, sin as an explanation for various diseases has a long history in medicine. See, for example, Peter L. Allen, The Wages of Sin: Sex and Disease, Past and Present (Chicago: University of Chicago Press, 2000). Allen’s discussion about medical concepts of masturbation informed by religious ideas of sin in his chapter 5, which included masturbatory insanity, is particularly relevant. 33 Williams, “Diet in Mental Disorders,” 623. He posited that the mania was due to some kind of “accumulated toxicosis” from eating too much food. 34 Ibid. She also she had tea with different nurses every day where she would “eat abundantly of what was on the table.” The patient, a woman who was the wife of a clergyman, had “recurrent attacks of excitement with a rise in temperature, rapid pulse, disorderly acts, filthy ways, [and] obscene language” that would occur at the same time as her menstrual period. 35 Ibid., 624. 178 Goldberger, C. H. Waring, and David G. Willetts, discussed in 1915 that one reason patients in mental hospitals did not get proper nutrition was “by reason of [food] having been stolen from their plates by another inmate (a ‘stealer’).”36 This statement mirrors the language of Graves and psychiatrists who had discussed the problem of patient overeating, showing how widespread the Progressive-Era moralizing of food was in this period of transitional modernity. In a broader sense, the rise of pellagra to public awareness in the 1910s is a strong example of how eating habits reflected the transitional nature of psychiatric medicine during the era when psychiatrists and mental hygiene reformers grappled with increase of chronically ill patients committed to mental hospitals. While Joseph Goldberger began proving that pellagra was a dietary deficiency disease throughout the 1910s, pellagra continued to be a topic of conversation in professional psychiatric journals because of the mental symptoms that often accompanied it. Psychiatrists wondered: was psychosis or dementia a predisposing cause of pellagra; or did pellagra cause or exacerbate psychosis or dementia? Historians have debated the cause of the epidemic of pellagra in the U.S. South, and most agree that the reign of “King Cotton” combined with Jim Crow laws of the New South created widespread poverty and dietary deficiencies across the South during the Progressive Era. Some scholars have focused on the scientific debates that delayed acceptance of Goldberger’s dietary theory of the disease (which we now know to be accurate), while others have explored the social and cultural aspects of the disease related to the regionalism between the North and South as well as the ways that the gender and race factored into the disease.37 African American sharecroppers 36 Joseph Goldberger, C. H. Waring, and David G. Willets, “How to Treat and Prevent Pellagra,” Farmer and Mechanic (Raleigh), March 29, 1915, 15. 37 Charles S. Bryan and Shane R. Mull, “Pellagra Pre-Goldberger: Rupert Blue, Fleming Sandwith, and the “Vitamine Hypothesis,” The Transactions of the American Clinical and Climatological Association 126 (2015): 39. They are critical of the previous sociocultural scholarship of the disease which include Elizabeth W. Etheridge, “Pellagra: An Unappreciated Reminder of Southern Distinctiveness,” in Todd L. Savitt, JH Young, eds. Disease and Distinctiveness in the American South (Knoxville: University of Tennessee Press, 1988): 100-19; MK Crabb, “An 179 bore the impacts of systems of racial discrimination, leading them to have disproportionately high rates of pellagra. Women were also disproportionately affected by pellagra; in one Census report they made up 69 percent of pellagra deaths.38 One historian has argued that this was because of their cultural role as caregivers, often giving portions of their food to their husbands and children.39 While poverty leading to vitamin deficiency was the most frequent cause of pellagra, the scientific and technological advancement in milling wheat was the catalyst of the pellagra epidemic. A new degerminating method for corn used by the Beall degerminator, which was patented in 1900, led to pellagra in those whose diets consisted primarily of corn meal.40 When the germ was removed from the corn, so was the niacin. The modern industrialization of agriculture and foodways had an unexpected effect on many Americans’ health. I examine pellagra within the context of food, mental hospitals, and the coexistence of somatic, psychological, and psychosocial theories about mental disorder in American psychiatry during the early twentieth century to reveal another layer of complexity in its history. Indeed, embedded in the bigger story of Southern poverty and racism is the forgotten story of the deprivation specific to inpatients of mental hospitals. Although the first case of pellagra in the United States during the twentieth century was recorded by a Georgia physician in 1902, the problem of pellagra came to the attention of physicians only when it was recognized in Southern epidemic of pride: pellagra and the culture of the American South,” Anthropologica 34 (1992): 89-103; and Elizabeth Chacko, “Understanding the Geography of Pellagra in the United States: The Role of Social and Place- Based Identities,” Gender, Place and Culture: A Journal of Feminist Geography 12, no. 2 (May 2005): 197-212. Monographs exploring pellagra’s place in U.S. history, primarily from a social and cultural perspective, include Roe, A Plague of Corn and Etheridge, The Butterfly Caste. 38 Harry M. Marks, “Epidemiologists Explain Pellagra: Gender, Race, and Political Economy in the Work of Edgar Sydenstricker,” Journal of the History of Medicine and Allied Sciences 58, no. 1 (January 2003): 35. 39 Michael A. Flannery, “’Frauds,’ ‘Filth Parties,’ ‘Yeast Fads,’ and ‘Black Boxes’: Pellagra and Southern Pride, 1906-2003,” Southern Quarterly 53, no.3/4 (Spring/Summer 2016): 133-134. 40 Alfred Jay Bollet, “Politics and Pellagra: The Epidemic of Pellagra in the U.S. in the Early Twentieth Century,” Yale Journal of Biology and Medicine 65 (1992): 219. This followed and was similar to the discovery that the new methods used to polish rice led to beriberi in diets that consisted largely of rice. Beriberi is another dietary deficiency disease caused by a lack of thiamine, vitamin B-1. 180 mental hospitals, first by George Searcy at the Mt. Vernon Hospital for the Colored Insane in 1907, and then a short time later by James Babcock, the superintendent of the South Carolina State Hospital for the Insane at Columbia.41 Pellagra was soon recognized at the Georgia State Sanitarium in Milledgeville in 1908, and by 1909 pellagra eclipsed tuberculosis as the leading cause of death at the hospital, causing 16 percent of the hospital’s deaths—seventy three total.42 What often is overlooked in the history of pellagra is that the poor care of patients by either the provision of an insufficiently varied diet or a lack of monitoring their food intake could cause pellagra within the institution regardless of whether the disease was prevalent in the surrounding region or not. Pellagra did not only occur in the South, but also the North. Furthermore, a large category of those with pellagra in the North were those in mental hospitals.43 As historian Elizabeth Etheridge noted, the most surprising early reports of pellagra in mental hospitals came from the Peoria State Hospital in Illinois in 1909 where 130 cases had been reported.44 I highlight the importance of nutrition in institutions, and mental hospitals specifically, through the history of pellagra.45 Thus, while historians of psychiatric institutions have often been critical of the surveillance and social control effected in mental hospitals (and chapter 5 will explore this further with a focus on patient perspectives of a lack of freedom 41 Bollet, “Politics and Pellagra,” 212; Bryan and Mull, “Pellagra Pre-Goldberger,” 23; Etheridge, The Butterfly Caste, 3-4 Goldberger has often been credited with making the argument for pellagra as a dietary deficiency disease and using his power from the USPHS, but historian Charles S. Bryan argued that Babcock should receive more credit for laying the groundwork for Goldberger’s success though his vocal efforts to study pellagra. See Charles S. Bryan, Asylum Doctor: James Woods Babcock and the Red Plague of Pellagra (Columbia, SC: The University of South Carolina Press, 2014). 42 Etheridge, The Butterfly Caste, 5. 43 Grob noted, with little attention to the underlying conditions or racial or gender differences in pellagra, that pellagra was regionally varied and was “generally confined to the South.” He also placed pellagra usefully in the context of the “significant portion of the total institutionalized population […that] were persons suffering from a variety of physical disabilities that also involved behavioral symptoms.” However, he did not engage in depth with the possibility that the institution itself created pellagra. Gerald N. Grob, Mental Illness and American Society, 1875-1940 (Princeton, NJ: Princeton University Press, 1983), 190-191. 44 Etheridge, The Butterfly Caste, 6. 45 For instance, one doctor noted that pellagra “was most prevalent in institutions in which people existed on a restricted, monotonous diet for long periods.” Bollett, “Politics and Pellagra,” 219. 181 regarding food choices in the hospital), poor surveillance of the dietary habits of the mentally ill in and outside the dining room could cause dangerous health outcomes, including death. This focus on mental hospitals makes sense given that a mental hospital was one of the earliest sites Goldberger went to investigate pellagra. The Georgia State Sanitarium in Milledgeville provided the most important experimental setting for these researchers to test the relationship of pellagra to diet as well as mental illness in 1914 and 1915.46 Goldberger found that the institutional diet could cause pellagra if it was not varied enough. The hospital’s diet was not as well funded as other hospitals, including St. Elizabeths, and left much to be desired. The Georgia State Sanitarium had faced a legislative investigation in 1910 similar to those that St. Elizabeths and the South Carolina Hospital for the Insane had endured, with the poor conditions of the hospital food being one of the focuses of investigation.47 In the case of the Georgia State Sanitarium, patients were also served food after the attendants and nurses served themselves first, where Goldberger observed the staff taking the nicest parts of the meat and other prime choices of food for themselves.48 Historian Elizabeth Etheridge described how this situation caused some patients to become “snatchers”: unless a patient was a favorite of the staff, “the easiest way to get more food was simply to steal something off somebody else’s plate, and this was often done.”49 The experiment thus provided a way for these researchers to critique the institutional diet through their findings that pellagra was prevented with more fresh meat and 46 Goldberger, C. H. Waring, and David G. Willets, “A Test of Diet in the Prevention of Pellagra,” Southern Medical Journal 8, no. 12 (December 1915):1043-4, HathiTrust. This was based on a paper presented at the National Association for Study of Pellagra meeting held at the South Carolina State Hospital for the Insane in Columbia, South Carolina on October 22, 1915. The researchers also studied diet in two orphanages before their work at the Georgia State Sanitarium. 47 Etheridge, The Butterfly Caste, 72-3. Etheridge discusses the investigation briefly, writing that through the investigation “an account of mealtime horror could be pieced together” and that one patient went so far as to say that “it would be better to hang than to starve.” 48 Ibid., 72. 49 Ibid., 73. 182 beans in the hospital diet, based on a careful observation of the actual dietary habits of patients. These public health researchers, then, recognized that the eating habits of “the insane” were closely tied to pellagra within the hospitals, leading them to consider the disease in social and psychological contexts. In one newspaper article about the treatment and prevention of pellagra that followed, Goldberger, Waring, and Willets singled out pellagra in mental hospitals as “the problem at asylums,” similar to Graves’ claim that “the insane have their own problem.”50 They asserted that pellagra was caused by a “fault in diet” that had yet to be isolated although this “fault” could occur through the tactics of the aforementioned “stealers” in addition to some patients’ delusional ideas about meat or a dislike of meat.51 Noting that they expected to receive pushback on their ideas among hospital superintendents, they also identified the problems that overcrowding and under-staffing created in the hospital’s food service. Goldberger and his associates aptly summed up their recommendations for mental hospitals: “At asylums for the insane not only should a mixed, well-balanced, varied diet be furnished, but measures must be taken to see that the individual patient actually eats it.”52 Although they would not have phrased it in these words, they argued for more conscience and the continuation of moral treatment in hospitals through increased attention to individual patients’ needs during meals during this transitional period in American psychiatry. Other public health scientists studying pellagra noted how the dietary habits of the mentally ill contributed to the development of pellagra within institutions, using a language of blame directed to certain groups of patients. For USPHS “Special Expert” W. F. Lorenz, a 50 Goldberger et al., “How to Treat and Prevent Pellagra,” 15. This quotation puts a subtitle of the article into lowercase for ease of reading. 51 Ibid. 52 Ibid. This article is placed in a rural periodical in North Carolina, and most likely did not reach hospital superintendents. However, Goldberger had many interactions with mental hospital superintendents about pellagra throughout the 1910s. 183 psychiatrist from Wisconsin who worked with Goldberger in the Georgia State Sanitarium, the types of patients that developed pellagra from an “unbalanced dietary” within the institution were those diagnosed with dementia praecox, paresis, and epilepsy, or those deemed to be “inferiors.”53 Their behaviors or “attitude toward food intake” were the problem, according to Lorenz.54 His judgmental views of the patient are clear, whether through “gluttonous” actions or an “apathetic” attitude toward food: The case of dementia praecox has apparently lost all outside interests. The patient is inactive, seats himself or stands about the ward alone, hides in nooks and corners. His life is vegetative. When directed he may without further assistance proceed to a dining room and there seat himself with the others. He is heedless of what is placed before him; may eat all or none. If all but the gravy has been purloined by a neighboring patient he offers no protest. In a slow, monotonous manner he eats any food that happens to be before him. […] Sometimes the gluttonous paretic may find himself in similar straits. While to all appearance taking a great quantity of food, this food may consist of any one article of diet that is conveniently near and easily handled. The behavior of the depressed, inactive cases at the table will likewise result in either insufficient or monotonous diet if unattended. This possibility of a deranged diet in the instance of a patient devoid of all apparent outside interests, apathetic, indifferent, listless, or affected in his attitude toward food owing to delusions can be readily seen.55 While such a statement shows that patients’ eating habits were carefully observed, what it offered was blame for the patient rather than solutions for their improper feeding. Furthermore, it is notable that in observations like this, a more specific language of blame had developed beyond the dichotomy of mania and melancholia to explain eating habits associated with different diagnoses of mental illness.56 53 W. F. Lorenz, “Mental Manifestations of Pellagra,” Public Health Reports 31, no. 5 (February 4, 1916): 241, JSTOR. 54 Lorenz, “Mental Manifestations of Pellagra,” 241. 55 Ibid., 241-242. 56 This was also due to the newer Kraepelinian diagnostic category of manic-depressive psychosis, which is known today as bipolar disorder. For an excellent overview of both dementia praecox and manic-depressive psychosis, see Martin Summers, Madness in the City of Magnificent Intentions: A History of Race and Mental Illness in the Nation’s Capital (New York: Oxford University Press, 2019), 129-131. See also chapter 1 for my discussion of early-twentieth-century alienists’ discourse surrounding patient diet. 184 Although some of the first reports of pellagra came from superintendents of mental hospitals, public health authorities and statisticians often overlooked pellagra cases and death counts from mental hospitals. This was not lost on contemporary observers. James Babcock, superintendent of the South Carolina State Hospital, argued in 1911 for more attention to and collection of pellagra statistics in mental hospitals, citing USPHS director Rupert Blue’s “probably too sweeping” statement in 1910 that he was “of the opinion that pellagra can be found to-day [sic] in nearly all of the insane asylums and almshouses of this country.”57 This concern did not carry into the first statistical survey done of pellagra in the United States by C. H. Lavinder of the USPHS, however. Lavinder explicitly addressed his decision not to include counts of pellagra in insane asylums in his statistics, citing his fear of duplicating case counts because it was too difficult to determine how many people already reported to have pellagra then ended up in mental hospitals with pellagra.58 While Lavinder’s efforts to avoid over-counting pellagra cases ensured what he believed to be the most accurate statistics, his decision not to report any of the pellagra cases in mental hospitals rendered the responsibility of mental hospitals in preventing pellagra from developing within the institution invisible.59 Hospital psychiatrists, many becoming further aware of the role of diet in health, were still primarily concerned with understanding the relationship between pellagra and the symptoms 57 J. W. Babcock, “The Prevalence and Psychology of Pellagra,” American Journal of Insanity 67, no. 3 (January 1911): 522. Babcock read this paper at the sixty-sixth AMPA meeting in May of 1910. 58 C. H. Lavinder, “The Prevalence and Geographic Distribution of Pellagra in the United States,” Public Health Reports 27, no. 50 (December 13, 1912): 2078, JSTOR. His explanation is as follows: “Undoubtedly many cases of pellagra have developed in the insane asylums of these States, but since I could not determine what percentage of the total did so develop, to have included them would have meant duplicating perhaps the reports already received from individual practitioners, many of whose cases have ultimately found their way into the asylums.” 59 Indeed, working to find the overlap in cases that were admitted to hospitals as pellagrous versus the number of cases of pellagra that developed within institutions may have further highlighted the role mental hospital staff and administrators played in causing nutrient deficiencies in patients through a bad hospital diet or poor patient care. In his work, Bollet stated that “the reported cases never included pellagrins in mental hospitals and thus were always underestimates of the incidence of the disease.” Bollet, “Politics and Pellagra,” 213. 185 of dementia or psychosis that accompanied it. They debated the “psychiatric aspects of pellagra,” which they often linked to patients’ eating habits even when they were not convinced that the disease was dietary in origin.60 Psychiatrists thus understood the complexity of the relationship between pellagra and its mental symptoms. They saw the disease as somatic, psychological, or a combination of both, an example of the eclectic nature of psychiatric debates in this period. One cause of the differing views about pellagra was regional variation, especially between Southern and Northern psychiatrists. Southern psychiatrists as a whole were not quickly convinced that pellagra was a dietary deficiency disease. During his presentation at the American Medico-Psychological Association in 1917, William Sandy, the Medical Director of the State Hospital for the Insane at Columbia, South Carolina, did not want to remark on the etiology of pellagra, noting that it appeared “far from being settled, the advocates of corn, the dietetic and other theories still about equally vehement in their contentions.”61 But he did note that diet appeared to be related to whether a person died from pellagra. After observing patients with dementia praecox died after having recurrent episodes, he found that the “praecox type” were: […] careless as to their habits, eating little unless urged, although provided with sufficient food and a varied diet. Their faulty habits, coupled with insufficient eating, and the general constitutional deterioration which all the former implies seemed to have a real bearing on the return of the pellagra and the fatal outcome.62 Here, Sandy applied similar moralizing language to the “gluttonous” patients discussed earlier as well as the specific language of blame seen in the example of Lorenz—he blamed patients with dementia praecox for their “careless” and “faulty” habits, rather than placing responsibility on 60 See, for example, William C. Sandy, “Psychiatric Aspects of Pellagra,” American Journal of Insanity 73, no. 4 (April 1917): 612. 61 Sandy, “Psychiatric Aspects of Pellagra,” 609. He stated later a similar sentiment, that “the cause and mode of action of pellagra are still largely a matter of investigation […].” Ibid., 613. 62 Ibid., 612. This diagnosis was the precursor to what we today call schizophrenia. 186 the staff for the care of the patients. By the 1910s, moral treatment’s influence had waned in South Carolina and likely other hospitals that faced the pressures pellagra caused; convenience was eclipsing conscience at many hospitals. Additionally, black women were the most likely to die from pellagra at the hospital. 80 percent of all black women’s deaths that year were from pellagra, while in all other groups deaths from pellagra were only about 50 percent of all deaths.63 While many of these patients died within days to two months after admission, seventy patients who died of pellagra had been in the hospital from one to fifteen years.64 Sandy claimed that it was “impossible to prove” whether any patients developed pellagra in the hospital.65 The combined effects of southern poverty, racism, and sexism in the South contributed to the failure of Sandy and other doctors at the South Carolina State Hospital for the Insane to investigate the somatic or psychosocial connection between pellagra and diet within the hospital.66 Indeed, Sandy did not include any case studies in his article. Sandy’s case is interesting, however, because he offers a thread that connects the seemingly Southern story of pellagra in mental institutions to its Northern history. He moved from South Carolina to Connecticut, writing another paper for the American Journal of Insanity about a year later about pellagra at the Connecticut Hospital for the Insane. In the latter article, he shifted his view of the etiology of pellagra more strongly toward diet and presented five case 63 80 percent of black women who died at the hospital that year died of pellagra, while same the rates for black men, white women, and white men were 53, 51, and 52 percent, respectively. Ibid., 611. 64 About 62 percent of cases died within two months of admission that year. 14 percent had been in the hospital one to five years. Ibid., 611. 65 Ibid., 611. 66 Most works on pellagra during this period, like Sandy’s, did not explicitly discuss racial differences in the psychiatric symptoms of the disease. One exception is found in the work of George McCallum Niles, a gastroenterologist from Atlanta, Georgia, who showcased how cultural insensitivity and racist stereotypes could play into discussions regarding pellagra and delusions. When discussing the types of delusions common among patients, he wrote, "With negroes the thought of being bewitched is uppermost in their minds, and they seek strange charms and curious objects, which they think have the power to drive away the evil and torturing spirits. These poor creatures are easily frightened, easily panic-stricken. They seek escape in flight, and hallucinations of poison often make them refuse food and drink to the point of inanition.” George McCallum Niles, Pellagra, an American Problem (Philadelphia: W.B. Saunders Company, 1916), 108, HathiTrust. 187 studies. While patients’ delusions were an “important etiological factor” in the development of pellagra, they were predisposing factors; delusions based on food could create a “faulty dietetic habit” which led to “malnutrition,” the ultimate cause of pellagra, he argued.67 All five cases in the hospital were women who were not from the South, did not eat a diet of mostly corn, and did not have family members that also had pellagra.68 Still, they fell ill. These five cases appear to have changed Sandy’s mind on the etiology of pellagra, but the only patient to survive among the five highlights how socioeconomic status and race played a role in how quickly doctors diagnosed and treated patients with pellagra. The only patient to survive the diagnosis of pellagra in the hospital was a 30-year-old white, Protestant housewife who did not present as the typical pellagra patient. After two years in the hospital and diagnosed with the paranoid form of dementia praecox, doctors noticed pellagra’s characteristic skin lesions across her forearms, knees, and neck. They then launched an investigation into her eating habits. Sandy decided that she had developed pellagra after “persistent dietetic indiscretions” which included “an exclusive diet of bread and sweets, taking practically no meat which she says she is unable to chew and does not like anyway.” Further, her husband visited her in the hospital every week, “bringing fruit, candy, and cakes, so that she has been eating very little in the dining room.”69 After placing the patient on a “rational diet” of eggs, milk, meat and “other elements making up a well-balanced dietary,” the physical symptoms of pellagra disappeared.70 While the support the patient’s family unintentionally contributed to her pellagra by bringing the patient her favorite foods, the doctor’s labeling her as 67 William Sandy, “Pellagra at the Connecticut Hospital for the Insane,” American Journal of Insanity 75, no. 2 (October 1918), 220. 68 Sandy, “Pellagra at the Connecticut Hospital,” 219. 69 Ibid., 213. 70 Ibid., 212-213. 188 a better class of patient than others with dementia praecox in the hospital and the resulting investigation into her eating habits most likely contributed to her recovery from pellagra. Sandy’s other patients did not have this kind of family support, and he did not report their dietary habits beyond that they refused food, ate little, or were tube-fed.71 In the case of one “colored” patient (who was of mixed-race ancestry), doctors did not mention her eating habits, let alone an investigation of them, and the racism that harmed her treatment is apparent. One focus of the case summary was on her “peculiar notion about being white” as a manifestation of her psychosis. Although her case summary indicates that she had been losing weight for months, doctors did not recognize her symptoms of pellagra until it was too late; she died 10 days after receiving “extra diet” for the first time.72 The contrast between these two cases is stark, showing how psychiatrists may not have sought to understand pellagra in black patients through psychosocial causes, even when a case history was taken and when physicians knew that Black patients had been afflicted by the disease at a higher rate than white inmates. In comparison to articles about pellagra in the South, articles about pellagra in the North were usually presented through case studies of a relatively small number that included the use of in-depth patient histories which were able to influence Northern psychiatrists to accept a dietary etiology for the psychiatric symptoms of pellagra. And yet, investigations into patients’ diets were not uniformly 71 The remaining cases were four white females and one “colored” female, the latter who is followed in this paragraph. 72 Ibid., 215-216. This was Sandy’s fourth case of pellagra, and it reveals the ways in which a mixed-race woman classified as “colored” received different treatment for pellagra. The woman was a 42-year-old single cook who had a white mother who doctors labeled as insane and an alcoholic. Her case record stated that she was “stated to have been the result of intimate relations with negro hired man.” She was admitted to the hospital due to a psychosis based on “the idea that she was white.” Sandy’s case summary stated that one of the symptoms of her mental illness was that “she put flour on her face and dressed fantastically as a young girl.” The woman appears to have had syphilis on admission to the hospital, because her blood Wasserman test was positive and she was given 13 mercury injections, after which the Wasserman came back negative. In August, about two months after admission, she had been gradually losing weight until it was noticed in late November that she had “a peculiar roughness on the back of the hands with dark discoloration” with other signs of pellagra. She was given an “extra diet” at that point but died ten days later. 189 applied, especially to those who were racially and socioeconomically marginalized. Compared to psychiatrists in the South, those in the North were more likely to believe that pellagra was a dietary deficiency disease during the 1910s. Northern hospitals, as Sandy experienced, had many fewer cases of pellagra. Doctors were therefore more easily able to obtain a background and clinical picture on a small number of patients. For example, Arthur G. Lane, the senior assistant physician at St. Lawrence State Hospital in New York accepted Goldberger’s theory that an unbalanced diet caused pellagra in 1917.73 At a conference, he discussed four case studies of patients with pellagra. Most patients had long histories of unbalanced diets before coming to the hospital, although one was a “case who developed delusional ideas about her food” while in it.74 Another New York doctor, noted that some of Lane’s cases suggested that patients got pellagra as a result of an “unbalanced diet” due to their delusions or other psychological basis.75 He concluded with a hypothesis: “This would seem to suggest that in cases coming to hospitals for the insane the mental disorder is either entirely independent of the pellagra—except as a remote factor in its etiology—or that only a delirious state occurs, perhaps as really a part of the pellagra.”76 Such acceptance of dietary deficiency theories and a recognition of the role of patient delusions in eating habits led to an importantly nuanced and eclectic understanding of pellagra in New York. Mental hospitals with psychiatrists who were both clinicians and strong researchers thus 73 Arthur G. Lane, “Pellagra in Northern New York,” The State Hospital Quarterly (NY) 3, no. 1 (November 1917): 3, HathiTrust. 74 “Minutes of Quarterly Conference,” The State Hospital Quarterly (NY) 3, no. 1 (November 1917): 43. During the discussion of Lane’s article, another New York psychiatrist, Hoch, stated that one of the interesting points of Lane’s paper was that he “has repeatedly observed the fact that the original mental condition caused the patient to take an unbalanced diet and that it was following this that the pellagra developed. One of the best-founded theories of pellagra is the one which attributes it to inadequate food, more particularly food which does not contain enough of the so-called vitamines.” Ibid., 44. 75 Ibid., 47. 76 Ibid., 47. 190 had the best understanding of pellagra during this period. Due to St. Elizabeths’s high profile among mental hospitals and its location in the nation’s capital, psychiatrist Mary O’Malley advocated for the dietary etiology of pellagra, although very cautiously, based on her research and case studies. O’Malley had worked alongside South Carolina’s James Woods Babcock in 1908, then with D. I. Williams, the superintendent of an asylum in Kingston, Jamaica, and in 1913 had reviewed cases of pellagra with Goldberger.77 O’Malley therefore had the experience working with leaders in the field of pellagra studies and had clinical experience alongside knowledge of nutrition strong enough to argue in favor of pellagra being a dietary deficiency disease in 1916. She explained that researchers had already established that nutrition and pellagra were related, even if the most recent studies could only prove a deficient diet was an “important predisposing factor in the causation of the disease” and a “pellagra-producing or pellagra- preventing food element” had not been found yet.78 Even with these hesitations, her clinical experience taught her that pellagra could “be controlled by a well regulated diet.”79 With very few cases occurring at St. Elizabeths, O’Malley was able to trace “a history of irregularities in diet” similar to how Sandy traced the dietary cause of pellagra in the white woman patient who survived.80 In her study of the twelve cases, she found that seven of the cases had clear “peculiarities and irregularities in diet” while in St. Elizabeths.81 These included refusals to eat, 77 Mary O’Malley, “The Report of Twelve Cases of Pellagra and Its Relation to Mental Disease,” Interstate Medical Journal 23, no. 7 (July 1916): 514. 78 Mary O’Malley, “Relation of Pellagra to Nutrition,” The Southern Medical Journal 9, no. 6 (June 1916): 499. 79 O’Malley, “Relation of Pellagra to Nutrition,” 499-500. She was careful, stating that further studies were still necessary to prove the dietary etiology of pellagra. She stated that “further observation and correlation of data with the greatest scientific circumspection is necessary before the question [of the etiology of pellagra] can be considered as fully elucidated.” 80 She stated that “In the cases admitted with pellagra and in those which the disease made its appearance in the Government Hospital for the Insane it was possible to trace a history of irregularities in diet, and these irregularities were controlled to a large extent by the delusional systems of the individual patients. Some of these cases had a selective attitude toward their food, others required forced feeding, and in all cases the diet had its influence on the occurrence, recurrence, and disappearance of the disease.” O’Malley, “Relation of Pellagra to Nutrition,” 499. 81 O’Malley, “The Report of Twelve Cases of Pellagra,” 526. 191 refusal of certain very nutritious foods (e.g., milk, eggs, and meat), and delusional ideas about food (e.g. poisoning).82 While psychiatrists still speculated about the etiology of pellagra during the late 1910s—and continued to do so until the late 1930s—many agreed that patients’ delusions that caused them to refuse food and peculiar eating habits contributed to the high rates of pellagra observed in mental hospitals. Still, it was rare for doctors to admit that institutional diets and food service could cause dietary deficiency diseases, since that placed responsibility on administrators and staff members. Goldberger had warned of this very thing, but hospital superintendents were slow to accept any responsibility for causing pellagra within their institutions. However, one Canadian psychiatrist noted this in a presentation at the American Medico-Psychological Association annual meeting in 1918: There are none of us probably but have seen patients suffering from the lack of some important article (possibly vitamines [sic]) in their diet that they probably do not care to eat, and those looking after them were not solicitous enough for their welfare to see that they were supplied with the kind of diet that is requisite for good health. Personally, I have seen quite a number of cases of scurvy arise in patients who refuse to eat vegetables. Their peculiarities were not reported, with the result that I have mentioned.83 This psychiatrist observed the importance of the reporting of patient diet peculiarities in identifying and preventing possible cases of dietary disease, whether scurvy as in this case, or beriberi, or pellagra.84 In contrast to many other hospital psychiatrists, he criticized the hospital 82 Ibid. Like her other article on the subject, O’Malley remained cautious and did not declare that pellagra was definitively a dietary deficiency disease, especially because she could not find a clear dietary cause in five patients. She concluded that because pellagra’s “etiology remain[ed] obscure,” that “the diet theory is of sufficient importance to make nutrition a subject for careful study” and that mental hospitals would be prime candidates as places where “experimental investigations of the pellagra problem” could be conducted. 83 Mitchell, “Food, Service and Conservation in a Provincial Mental Hospital,” 209. 84 Beriberi had also been found in some mental hospitals such those in Alabama. See "Note upon the Occurrence of Multiple Neuritis and Beri-Beri in Alabama," Journal of Nervous and Mental Disease 27 (November 1900): 645-48 cited in John S. Hughes, “Labeling and Treating Black Mental Illness in Alabama, 1861-1910” The Journal of Southern History 58, no. 3 (August 1992): 435-460. In addition, during World War I, a Pennsylvania superintendent’s pamphlet about dietaries for the war (discussed further in the next section) included the 192 staff who did not offer adequate care to patients instead of blaming patients who suffered from mental illness. He offered one example of a psychiatrist pushing back against convenience by calling for more conscience; his argument brought focus back to the humanitarian goals of nineteenth-century moral treatment by highlighting the responsibility of superintendents and their staff members to care for this vulnerable population of people when it came to their diet. In this way, he was also suggesting that dietary deficiency diseases in the hospital could be caused by psychosocial factors—e.g., the lack of encouragement to eat a proper diet full of vegetables from a hospital staff member—rather than somatic ones. The eating habits of the mentally ill during this period were thus an important aspect of the understanding of pellagra in psychiatric institutions. Some psychiatrists accepted that an inadequate hospital diet or the hospital staff’s poor surveillance over what patients ate could cause pellagra. Psychiatrists were used to caring for patients who refused food, but pellagra created a complex problem for psychiatrists who sought to understand the mental symptoms of pellagra through the somatic cause of a dietary deficiency, but also the predisposing, psychological causes of patients’ food refusal or harmful dietary habits. “Each Hospital Can Do Its Bit": Mental Hospitals’ Solutions for WWI Food Problems The “problems” of feeding the institutionalized mentally ill, including addressing pathological food habits and the threat of pellagra in institutions, did not disappear with World War I. Instead, the war made it more difficult for institutions to feed patients sufficiently, as superintendents sought to contribute to wartime food conservation efforts and held up patients as sources of labor to solve the nation’s wartime food problem. Mental hospitals had already acknowledgement that “Vitamines are an unknown quantity but are absolutely essential. The want of vitamines causes scurvy or allied diseases.” Sommer and Saha, A Proposed Basis for a Dietary for Hospitals for the Insane to Meet War Conditions, 6. 193 struggled to hire and retain employees due to the demanding nature of caring for and treating the mentally ill, but the war made the labor situation especially difficult. The wartime labor shortage meant that mental hospitals and other state-run hospitals had a difficult time finding enough people to fill necessary hospital staff, including positions on the hospital farms. The problems feeding the mentally ill in the hospital remained while superintendents also turned their attention to doing their part to solve the food problems created by the war by turning to a further use of patient labor. While the United States did not enter World War I until 1917, many Americans were acutely aware of the war and the potential for U.S. involvement. As with any war, supplying sufficient rations to military forces was essential to winning. By the time that the United States entered the war, government officials understood that U.S. food supplies for soldiers and other allied troops had to be managed with utmost care, as food prices were soaring, and allied European nations had been cut off from many of their food supplies. Only three days after the United States declared war on Germany and entered World War I, President Woodrow Wilson created the United States Food Administration and named Herbert Hoover, a “mining engineer turned public servant” as its head.85 The agency’s motto was “Food Will Win the War,” and its goal was to reduce Americans’ consumption of easily shippable pantry staples like wheat so that American farmers could produce a surplus and feed the troops abroad.86 Hoover set up a food administrator in each state, ensuring that Americans everywhere could learn about and participate in food conservation efforts. The Food Administration was thus a typically Progressive creation, as it was based on organized administration, a belief in government power to fix societal problems, and the belief in 85 Veit, Modern Food, Moral Food, 12. 86 Ibid., 14-15. 194 the power of scientific expertise. One branch of the Food Administration, the Food Conservation Division, relied strongly on home economists, helping to legitimize home economics as a scientific profession. The head of the agency and Stanford University president Ray Lyman Wilbur, even set up a section of his division specially for home economics, noting that its staff were “trained specialists.”87 While mandatory food rationing did not take place in the United States during World War I, the Food Administration, along with the help of home economists and dietitians, undertook a public campaign for food conservation. The important role that food played in winning the war was not lost on psychiatrists and hospital superintendents, who quickly began food conservation efforts. During his Presidential Address to the American Medico-Psychological Association in May 1917, Charles G. Wagner explained that “the food question” was “the most important” one that the United States faced after entering the war.88 Similarly, the editors of the professional journal The Modern Hospital expressed concern about food supplies in all types of institutions. Hospital administrators needed to aid conservation efforts while still feeding patients not only a sufficient diet, but one that was exceedingly efficient and economical. As the editors wrote in late 1917, “Economy, which is always an important element in hospital administration, has lately become a patriotic duty as well. The methods used by various hospitals to conserve supplies of food and other articles have therefore a peculiarly timely interest just now.”89 Mental hospitals around the nation thus became part of this larger food conservation effort in reducing the use of foods such as wheat, meat, and sugar that were needed for the war 87 Levenstein, Revolution at the Table, 139. 88 Charles G. Wagner, “Recent Trends in Psychiatry,” American Journal of Insanity 74, no. 1 (July 1917): 1. As one Canadian mental hospital superintendent put it, feeding mentally ill patients remained a problem during the war. He wrote: “The problem of satisfying the hunger of the inmates of a provincial or state hospital at a moderate expense, and with a menu nutritive, varied and palatable, cannot be overestimated.” Mitchell, “Food, Service and Conservation in a Provincial Hospital,” 203. 89 “Institutional Economies for War Time,” The Modern Hospital 9, no. 1 (July 1917): 20. 195 effort. They followed or even went beyond the guidelines set by the Food Administration. Mental hospital administrators worked to solve the food problem by working toward self- sufficiency when it came to their food supplies. Was it not the patriotic duty for state hospitals to strive for self-sufficiency by expanding their farm production to meet the needs of the hospital, therefore reducing the need to purchase in the marketplace?90 Superintendents and the governing boards of state hospital systems were aware of the need for state institutions to “do their bit” in this effort to both conserve food through reduced consumption of items advised by the Food Administration in addition to producing more food at the hospital to maintain an adequate diet.91 St. Elizabeths, a federal mental hospital, was in a prime position to exemplify food conservation for other hospitals and government-funded, public institutions. On November 22, 1917, Wilbur followed up with Superintendent White concerning a dietary survey that White had submitted to the Food Administration.92 Wilbur, a representative of the Food Administration, wrote that the survey seemed “admirable” and that Hoover wanted White to develop his “program” at St. Elizabeths so that it could be “point[ed] to it as an example to be followed in other parts of the United States.”93 Wilbur and Hoover wanted to publicize St. Elizabeths’s conservation efforts during the war.94 Mental hospitals like St. Elizabeths began to play small but significant roles in helping to solve the nation’s food problem. 90 While there are no explicit comparisons of state hospital conservation efforts with victory gardens in the sources that I have examined, the two are extremely similar in their appeal to patriotic duty and promotion of self- sufficiency in food production. 91 The phrase “do their bit” is used in Florence A. Blanchfield, “Responsibility of a Superintendent for Correct Dietary,” The Modern Hospital 9, no. 5 (November 1917): 374, HathiTrust. 92 I was unable to find the dietary survey that White submitted to the Food Administration in 1917 in the archive or otherwise referenced. While the letter and the archive are silent about when exactly this survey was conducted or what it contained, the interest of the Food Administration in St. Elizabeths is significant, nonetheless. 93 NARA RG 418: Entry 47 (Records Relating to a Congressional Investigation, 1917-1919: Box 1, Folder 3) Letter, Ray Lyman Wilbur to William Alanson White, November 22, 1917. 94 Letter, Wilbur to White, November 22, 1917. 196 The Modern Hospital featured articles from three hospitals about their conservation efforts. One of those three articles was focused specifically on food and diet. The assistant superintendent of the Burke Foundation in White Plains, New York, reported that food costs increased forty percent overall and that the cost of meat, fish, and fowl (animal sources of protein) increased by thirty-one percent. However, his administration was able to keep the price of food per capita at only a twelve-percent increase while still maintaining patient health.95 This was done through educating the staff on the basics of food values—which included calories and the suggested amounts of protein, fat, and carbohydrates—as well as through food substitution. For instance, he reported that “meat consumption has been cut nearly in half with extensive use of beans and cheese, peas, peanut butter, etc., for the protein; butter reduced, with cottonseed oil and margarine increasingly used.”96 Many institutions used food substitutions during the war not only to maintain economy in purchasing but also in seeking to maintain a good diet and patient health. This general approach could be found in hospitals of all kinds, but in mental hospitals, the specific “problems” Graves and psychiatrists had pointed to in feeding the mentally ill meant that general discussions about hospital diets were only partially helpful. Take, for example, a look at A Proposed Basis for a Dietary for Hospitals for the Insane to Meet War Conditions, published in 1918. In this pamphlet Henry Sommer, the superintendent of the Blair County Hospital for the Insane in Pennsylvania and P. Saha, the assistant physician there, attempted to set standards for mental hospital diets. Although the modern hospital had made many advances, including in the laboratory sciences, metabolism studies on the mentally 95 Walter E. Wright, “Food Economies at Burke Foundation” in “Institutional Economies for War Time,” The Modern Hospital 9, no. 1 (July 1917): 20, HathiTrust. 96 Wright, “Food Economies at Burke Foundation,” 20. Cottonseed oil was a staple in wartime diets. Helen Zoe Veit has shown that cottonseed oil was a common substitute food during World War I promoted by the Food Administration. See Helen Zoe Veit, “Eating Cotton: Cottonseed, Crisco, and Consumer Ignorance,” The Journal of the Gilded Age and Progressive Era 18, no. 4 (October 2019): 403. 197 ill were still underdeveloped. Sommer and Saha were most concerned about how much protein to feed different types of patients because they believed there was a “peculiar wastage of excessive metabolism for each type of the Insane.”97 They did not have the solution, however, because this problem could “only be solved by a chemist, in a laboratory.”98 Therefore, they proposed a diet by calculating the average weight of all patients and determining the healthy maximum number of calories based on scientific experts’ estimations of other groups of people.99 Thus, more than a decade from the 1904 USDA Office of Experiment Stations study at St. Elizabeths covered in chapter 1, food values for feeding the institutionalized mentally ill had not been calculated. This happened despite the optimism for fast and wide-ranging breakthroughs in medical and laboratory science that existed in the first decades of the twentieth century.100 During the war, however, psychiatrists also began to pay more attention to the psychology of food as a solution, rather than focusing only on the problems patients’ food refusal or overeating caused. Some began to adapt principles of moral treatment expressed by the psychiatrists who wrote about the proper diet for the mentally ill in the 1890s as discussed in chapter 1—e.g., how both a healthy environment and diet were necessary for not only physical but also mental health—under an emerging twentieth-century understanding of individual psychology. Sommer and Saha’s pamphlet, for instance, highlighted the importance of the psychology of patient feeding. To them, paying attention to patient psychology was just as 97 Sommer and Saha, A Proposed Basis for a Dietary for Hospitals for the Insane to Meet War Conditions, 7. They mentioned the dichotomy between “disturbed” and “depressed” patients. They were certain that “one group should have more fat—another more protein and still another possibly more of certain carbo-hydrates, etc., than would be allowed for a mentally sound and vigorous individual.” 98 Ibid. 99 Ibid., 8-10. They relied mostly on Lusk and Chittenden’s studies. These groups of people were all male, including professionals, student athletes, and soldiers. When using the maximum number of possible calories burned, Sommer and Saha calculated that their reduced diet conserved 245,423 calories a day. 100 This optimism and belief in the powers of laboratory medicine, especially developments in bacteriology shine through in Sinclair Lewis’s 1924 novel Arrowsmith (New York: Signet Classics, 2008). 198 important as feeding a properly tabulated diet. Psychology was significant, for example, because “the psychic influence of taste, smell, sight and quantity of food is necessary for a mentally sound individual.” A person whose senses were “disagreeably affected” would be “dissatisfied” and get up from the table where they dined.101 These statements about the importance of psychology to a patient’s taste and satisfaction of food mirror Beers’ comments about his experience of mental illness as well as the comments of Graves from the standpoint of dietetics. Concerns about the psychology of feeding patients—especially given wartime need for food conservation—were also central to a nutrition expert’s opinion of St. Elizabeths’s diet. William Alanson White, for one, felt the effects of the war on his administration acutely. World War I constituted an important turning point in White’s administration of the hospital because the lack of sufficient food became starkly apparent. In his 1919 Annual Report, which covered the second half of 1918 and the end of World War I, White reported that “the question of food arose and caused us many anxious moments as to how we would meet the situation, be able to furnish adequate supplies to our patients, and conform to the rules and regulations of the Food Administration.”102 His concerns about feeding patients during the war led him to seek the opinion of an expert on nutrition, Myer E. Jaffa, a Professor of Nutrition from the University of California, Berkeley, to evaluate the hospital’s diet and food service in 1918.103 101 Sommer and Saha, A Proposed Basis for a Dietary for Hospitals for the Insane to Meet War Conditions, 6. Italics are in the original. They also stated that the psychological value was “in fact as important as the food values and quantity as we are dealing with the Insane.” 102 Annual Report, 1919, Reprinted in the U.S. Department of the Interior, Annual Report of the Secretary of the Interior, Fiscal Year 1919 (January 1, 1919), 792. There were fewer regulations for government institutions and hospitals from the Food Administration, but a desire to be patriotic and “do their part” led superintendents such as White to feel that they needed to reduce their consumption of wheat, meat, sugar, etc. 103 Although he was less widely known than Wilbur Olin Atwater, chemist and first director of the USDA’s Office of Experiment Stations and Harvey Wiley, most famous for his work as the head of chemistry at the USDA, Jaffa was a well-respected and prominent nutrition researcher. He was the first to hold the title of “Professor of Nutrition” in the United States. While at the University of California, he had worked with the Office of Experiment Stations investigating the dietary value of fruits and nuts, among many other nutrition studies. When Jaffa left his post as the director of the California State Food and Drug Laboratory in 1915, he became a “consulting nutrition expert,” which included investigating the food in state hospitals. See Patricia B. Swan and Kenneth J. Carpenter, “Myer E. Jaffa: 199 WWI-era food shortages and constraints, then, sharpened the need for a careful consideration of psychosocial qualities of food, particularly in mental hospitals. Jaffa criticized St. Elizabeths’s menu as not varied enough because it was the same every week. According to Jaffa, a weekly routine was “not good dietetic practice” because patients should not expect the same food every day. “It must not be forgotten that psychology plays a very important part in dietetics,” he stressed.104 However, he also praised the hospital’s food service in the new patient receiving ward—the first place that patients went when they entered the hospital—because the food trays were in good condition and attention had been paid to how they were set up. He explained these features were so important because: [..] first impressions are lasting, and a patient entering an institution for the first time, who comes from a good home, or good surroundings, and is in any condition which might be improved, would receive a set back, in my opinion, if the meals are offered on a tray, the enamel of which was partly removed, and no attention whatever paid to the setting up of the tray.105 St. Elizabeths’s policies were therefore sometimes attuned to the psychology of patient diets. It is especially interesting that Jaffa points to the importance of this presentation for patients that were “in any condition which might be improved,” since the number of insane patients considered incurable was increasing and served as an impetus for the reform of asylums throughout this period. This concern was also reflected in the efforts to prevent incurable cases of insanity from arising though the mental hygiene movement.106 Here, Jaffa’s criticism and praise of St. Pioneering Chemist in Food and Nutrition Science,” Bulletin for the History of Chemistry 21 (1998): 51, 54 and C. F. Langworthy and R. D. Milner, Investigations on the Nutrition of Man in the United States (Washington, DC: Government Printing Office, 1904), 10, HathiTrust. 104 NARA RG 418: Entry 47 (Records Relating to the Investigation of 1919, 1917-1919, Box 1, Folder 3) M. E. Jaffa to William A. White, July 29, 1918. The point that routine in meals is harmful to mental health is particularly interesting in the context of a mental hospital because generally routine and a set schedule was seen as therapeutic and beneficial for patients’ recovery process. 105 M. E. Jaffa to William A. White, July 29, 1918. He also praised one of the dining halls for serving patients only after they were seated at the table. This, he believed, allowed patients to “relish” the food more. 106 One superintendent of a New York state mental hospital argued that “Mental hygiene is as essential as any other form of hygiene” and that as one of several factors, insufficient food was as a predisposing cause of insanity. 200 Elizabeths’s diet and food service was in line with the Progressive-Era ideals of efficient and rational solutions to problems, while also balancing them with patients’ psychology. Progressive ideals had to be negotiated with the new knowledge about the psychology of mentally ill patients. Jaffa’s assessment also highlighted the necessity of hiring a chef to oversee food substitutions in the hospital diet so that patients would more easily accept them. White was concerned about the palatability of the institution’s bread after cutting down on the quantity of wheat flour used by the St. Elizabeths bakery in line with the requests of the Food Administration. Because St. Elizabeths had its own bakery that supplied the bread for the institution, it became White’s job to oversee that his staff reduced wheat flour use. Jaffa placed authority for what food substitutes were used in the chef, stating that the quality of the food substitutes “all depends upon the extent to which the cooperative and patriotic spirit pervades the Chef.”107 Jaffa thus highlighted how chefs, in their preparation of patient food, could balance both aspects of palatability and economy while creating alternate recipes. Although dietitians had begun to become a necessary professional in many institutions, the hiring of credentialed dietitians rather than chefs to oversee the patient diet did not cement until after World War I, as shown by Jaffa’s suggestion that White hire a good chef rather than dietitian. Throughout the war, most hospitals were not able to expand their staff, and the most obvious contribution that state hospitals–and more particularly, their patients—could make in solving the food problem created by the war was the production of farm crops. Psychiatrists used Maurice C. Ashley, “What the State is Doing for the Insane,” The State Hospital Quarterly (NY) 2, no. 3 (May 1917): 251-2, HathiTrust. 107 M. E. Jaffa to William A. White, July 29, 1918. Jaffa further stated that the chef, “He or she, as the case may be, can think up many palatable, savory, economical dishes which will appeal to any patient or invalid as a substitute for part of the bread […].” The underline is in the original. 201 the idea of self-sufficiency to make this point. In Wagner’s Presidential Address to the American Medico-Psychological Association in May 1917 when he chose the “food question” as the most important problem facing the United States during the war. He also explained that members could play a role by “aid[ing] materially in its solution by devoting their energies to the task of making every institution possessed of farm lands largely self-sustaining as regards the products of the soil and the food supplies derived therefrom.”108 The topic was so important that the U.S. assistant secretary of agriculture “and others who expert knowledge qualifie[d] them to speak on the urgent need of strenuous and intensive farm cultivation” held a special session at the annual meeting devoted to the topic.109 Professional journals such as the AJI, Mental Hygiene, and The Modern Hospital featured articles about how institutions could aid in the war effort through agriculture. Similar to Wagner, White, respected as the head of the prestigious federal mental hospital, published an article pushing state hospitals to aid in the war effort through increased farming. This article in the July 1917 issue of Mental Hygiene argued for, among other projects, shifting land use from beautiful green spaces to productive farmland. The first and “most important” practical thing that hospitals could do, according to White, was to be “self- supporting” which, at the time applied mostly to food grown at the hospital. If there was any question about what this meant, White explained, hospitals “should undertake the cultivation of every bit of tillable soil of which it is possessed.”110 White executed this plan at St. Elizabeths. During World War I, an old baseball field was converted into farmland alongside many other 108 Wagner, “Recent Trends in Psychiatry,” 1. 109 Ibid., 2. 110 William Alanson White, “The State Hospital and the War,” Mental Hygiene 1 (1917): 377, HathiTrust. He made his suggestion very clear; he wrote, “I mean this literally.” 202 parts of the hospital grounds.111 Most institutions were built on large tracts of land and operated their own farms where staff and patients raised not only vegetables and fruit, but often also hogs, chickens, and cows.112 Farm labor for able-bodied men who were amenable to the work had long been seen as having therapeutic value for patients. Farming as work therapy was one aspect of nineteenth-century moral therapy that continued through the Progressive Era. Especially given the lack of available labor due to the war, mental hospitals held an existing labor force in the eyes of some administrators and superintendents. In addition, the farms could produce significant monetary value if they were run efficiently, keeping food costs lower than they would be if the food had to be bought in the open market. As one statistician working for the New York State Hospital Commission put it overall, “institution farming has become an important as well as a permanent state industry.”113 Psychiatrists who recognized that the urgent need for labor could be joined with the idea of work as moral treatment decided to strike a balance between convenience and conscience, even if convenience drove this reorientation. How did mental hospitals offer such aid amid the labor shortage? Superintendents were quick to point to patients as a potential source of labor for these expanded farming operations based on the historic use of patients for farm labor as part of moral therapy. Henry Hurd, a psychiatrist affiliated with the well-respected Johns Hopkins Hospital and editor of The Modern Hospital, reported on “State Hospitals and Agricultural Preparedness,” stressing how the farmlands of many state hospitals should be utilized to increase the production of foods due to 111 Thomas Otto, St. Elizabeths: A History (Washington DC: U.S. General Services Administration, 2013), 240. 112 See chapter 1 for an explanation of why mental hospitals had been built on large tracts of land, often following the Kirkbride plan. 113 Horatio M. Pollock, “The Relation of the State Institution Farm to the Cost of Maintenance,” The State Hospital Quarterly (NY) 2, no. 3 (May 1917): 259, HathiTrust. 203 the war. His solution for the lack of laborers for the farm, especially during wartime, was to turn to the patients of the hospitals. He explained, “To cultivate these rich farms a supply of labor is to be had in the hospital itself—a supply which is not in danger of being diminished by enlistments or the lure of high wages in other industries.”114 And to support the use of patients as farm laborers, he pointed to the history of therapeutic labor in mental hospitals and that “the great majority of patients with chronic mental disease are capable of accomplishing a certain amount of farm work under proper guidance and direction by judicious physicians with benefit to themselves in the form of increased mental vigor and self respect.”115 The war and labor shortage therefore opened up an avenue for psychiatrists to reengage with the principles of moral treatment even as American psychiatry continued to transform during the early twentieth century. This characterization of patient work, including farm work, as inculcating self-respect in patients contrasts with the moral, dismissive language psychiatrists used to describe patients’ eating habits during the same period. They labeled patients’ work in producing food as patriotic and a therapeutic practice in self-respect. White, for example, claimed that “that indefinable thrill which a state of war sends coursing through every patriotic citizen” could be used to divert patients’ previously misdirected energies into the useful act of gardening. The status of patients as citizens here highlights the way that relationships to food through its production rather than consumption opened the way for patients to be seen as “productive” and as potentially cured. White also saw gardening and farming for the war effort as “a golden opportunity not only for 114 Henry M. Hurd, “State Hospitals and Agricultural Preparedness,” The Modern Hospital 9, no. 1 (July 1917): 24, HathiTrust. This contrasts with the experience, for example, of public tuberculosis sanitariums during the same period. One state tuberculosis sanatorium director felt compelled to write an article for The Modern Hospital due to interest in his use of prison labor to solve the “sanatorium labor problem” that occurred due to the war and “consequent high price of labor.” Stephen A. Douglass, “The State Sanatorium and the Labor Problem,” The Modern Hospital 11, no. 2 (August 1918): 99, HathiTrust. 115 Hurd, “State Hospitals and Agricultural Preparedness,” 24. 204 bringing great and unexpected help to the country but also for helping the patients to a realization of the great truth that work is not drudgery but opportunity.”116 Psychiatrists therefore pathologized mentally ill patients’ behaviors surrounding food consumption, while deeming food production by the same population to be therapeutic. This contrast between beliefs about food consumption and production by the mentally ill illuminates how food served as a powerful site of tension in “modernity-in-the-making” during the Progressive Era. Food played an important role in the transition to a somatic and psychosocial view of mental illness. But the use of patients for farm labor did not go completely unquestioned, especially through the government bureaucracy. The decision to utilize patients on a larger scale for this farm work was not taken lightly in Hurd’s home state of Maryland. Showcasing a typically Progressive-Era belief in the power of experts and the utilization of government to enact change, the decision was made by experts and various boards related to the Maryland state government, including the boards of trustees for four state hospitals, members of the lunacy commission, the agricultural board of the state, and the governor of Maryland.117 But once this was approved, one Maryland bureaucrat’s plan for using patients as farm labor actually took patients outside of the hospital, opening a door for the abuse of patients as laborers. In many hospitals, African American male patients were most likely to be the first patients used for farm labor. Arthur P. Herring, the Secretary of the Lunacy Commission for the State of Maryland, read and was so inspired by White’s article “The State Hospital and the War” 116 White, “The State Hospital and the War,” 378. While experts also called for more outdoor, physical exercise during this period, I do not think that it had a significant influence on the increasing farm work in the hospital during the war, because farm work had been a feature of mental hospitals since the nineteenth century. White’s statement also shows how, by the time of the Progressive Era, the effects historian Scott Sandage wrote about of the market revolution on the ideology of American success and failure during the nineteenth century remained. White’s comment goes along with Sandage’s statement that “low ambition offends Americans even more than low achievement.” Scott Sandage, Born Losers: A History of Failure in America (Cambridge, MA: Harvard University Press, 2006), 2. 117 Hurd, “State Hospitals and Agricultural Preparedness,” 24. 205 that he wrote to White about his “experiment” with patients during late September of 1917. He explained that he “took a group of fourteen insane negroes from the Crownsville State Hospital in Anne Arundel County to an adjoining farm and cut seventeen acres of corn.” This, he explained, was the first time in Maryland that patients in a state institution had ever worked outside a hospital. He deemed the experiment such a success that he named the group the “Crownsville Corn Cutters Emergency War Squad” and promised their services to other farmers in the area for the next few weeks.118 The use of specifically African American patients from a Maryland hospital reveals how racial discrimination was not only a Southern problem, but also existed elsewhere. Superintendents also saw patients who had traditionally been excluded from doing farm or gardening work, such as women or elderly patients, as an important source of labor for food production projects to aid in the war effort. White proposed that smaller plots of ground not usually seen as worthwhile “could be cultivated by patients from the adjacent buildings who have not sufficient physical vigor to work on the larger farm plots but who could take care of these little patches. Such work is especially adaptable for women patients.”119 Patients who were seen as frail or weak, including women patients, suddenly became able to complete farm and gardening work, albeit on a smaller scale.120 This use of patient labor begs the question: if this type of labor was so therapeutic, why had these patients not been doing it all along? This case, too, opened the doors for the potential abuse of patients. In comparison to the ongoing attention 118 NARA RG 418, Entry 32 (Personal Correspondence, 1906-37: Box 15, Folder H) Letter, Arthur P. Herring to William A. White, October 8, 1917. 119 White, “The State Hospital and the War,” 378. 120 Of note is that women patients had often tended to flower gardens before they turned to food gardens. The nature of the flower gardens as largely aesthetic/beautiful rather than productive shows how very similar patient activities were associated with gender norms and what kinds of labor was valued as more curative. 206 paid to patients’ diets, convenience appears to have overridden conscience with only small traces of moral treatment remaining during the war when it came to patient labor in the hospital. In the relatively short period that the World War I food problem and the regulations of the Food Administration troubled mental hospital superintendents, they sought a way for hospitals as well as patients to “do their bit” in the patriotic war effort. The impact of the war and food conservation efforts in hospitals meant that the problems with feeding patients, expressed by professionals, continued, creating conditions for food experts to secure a place on the hospital staff during the postwar period. Further, patients who had been cast as “problems” or as unproductive, suddenly became valued as solutions to making hospitals more “self-sufficient” through their work that inculcated values of “self-respect” to the patients. In this way, the language used to characterize patients focused more on the characteristics they had or could develop that would make them full citizens instead of keeping them as a distinct problem, separated from society. The possibility of full, social citizenship that came with this labor, however, came with a risk of abuse to patients based on the racial and sexual politics of the era’s “modernity-in-the-making.” Conclusion This chapter has examined a short but complex period in the history of psychiatry and the Progressive Era. Psychiatry was in a moment of transition. Theories about the biological and psychological causes of mental illness as seen through patient eating habits, whether in mental hospitals generally or in relation to pellagra, competed. The rising attention to patients as individuals is seen through the new focus on the importance of psychology in feeding patients as well as the use of psychoanalysis to either explain patient eating habits or treat them, complicating psychiatrists’ effort to make psychiatry a science. Professionals, whether dietitians, 207 USPHS researchers, or psychiatrists used a similar moralizing and often dehumanizing language common during the Progressive Era to discuss patient eating habits, generalizing patient feeding as a “problem.” Expert solutions, they thought, could help to solve this. But at the same time, when food conservation for World War I tightened hospital food supplies nationwide, patients could also be part of the solution. Patients, supposedly patriotic and learning self-respect and the value of hard work through farming, could help to solve the war’s food problem, based on the rhetoric of superintendents. The complex interaction of Progressive reform, the rise of expert scientific authority, advances in nutritional science, and psychiatrists’ increasing attention to the psychology of mentally ill patients coalesced to continue building the modern, twentieth-century mental hospital that stood at the crossroads of somatic and psychological approaches to mental illness. 208 CHAPTER 5: Diet as Care and Therapy: Veterans, Women Professionals, and “Organism as a Whole” in St. Elizabeths, 1919-1937 Introduction Since the hospital’s opening in 1855, soldiers and veterans from the Civil War, the Spanish-American War, and other military engagements who fell ill with severe mental disturbances were committed to St. Elizabeths.1 However, World War I caused the hospital’s connection with the military to grow when many soldiers and veterans suffering from nervous and mental disorders were sent there. At the height of veteran admissions to St. Elizabeths in fiscal year 1919, the Army and Navy sent 1,154 men there.2 St. Elizabeths also established a relationship with the Veterans Bureau when it opened in 1921.3 Although veterans had long made up a significant portion of the patient population at St. Elizabeths, World War I made veteran patients in the hospital more newsworthy and a subject of psychiatric focus and charitable attention from organizations such as the American Red Cross. At the same time, the mind-body holism that many nineteenth-century alienists expressed through moral treatment and early mental hygiene covered in chapter 1 continued in the twentieth century in an evolved form through William Alanson White’s concept of “organism as a whole.”4 White was part of a group of early-twentieth-century “dynamic psychiatrists” who 1 When the famous nineteenth-century reformer Dorothea Dix convinced Congress to appropriate $100,000 for the creation of a mental hospital in D.C. overseen by the Secretary of the Interior in 1852, legislators decided that the hospital would not only serve the citizens of D.C., but also “the insane” from the Army and Navy. See Thomas Otto, St. Elizabeths Hospital: A History (Washington, DC: U.S. General Services Administration, 2013), 5. 2 The Annual Report for 1919 is written for the fiscal year June 31, 1918, to June 30, 1919, thus the number of admissions would have been even higher, had the Army and Navy not stopped sending patients over in February 1919. 3 For a thorough history of the creation of the Veteran’s Bureau and the federal system of veteran care, see Jessica L. Adler, Burdens of War: Creating the United States Veterans Health System (Baltimore: Johns Hopkins University Press, 2017). For mention of St. Elizabeths specifically, see Ibid., 173. 4 William Alanson White, William Alanson White: The Autobiography of a Purpose (Garden City, NY: Doubleday, Doran & Company, Inc., 1938), 265. Keeping with this holistic view of health, he also asserted that “the same laws govern in the psychic sphere as do in the somatic sphere.” Ibid., 269. One of his most clear and concise explanations of organism as a whole can be found in his book chapter “The Significance of Psychopathology for 209 believed that biological, social, and psychological factors all contributed to the development of mental illness.5 This group, explained historian Gerald R. Grob, advanced a “sharp modification in the traditional model of disease,” viewing individual behavior on a spectrum from normal to abnormal, rather than clearly demarcating health from illness.6 Adolf Meyer, who developed psychobiology, was the most famous of this group.7 By 1930, however, White also became a part of what Jack Pressman called the “American School of Psychiatry,” which he described as a marriage between Meyer’s psychobiology and Director of the Medical Division of the Rockefeller Foundation Alan Gregg’s conceptualization of psychosomatic medicine.8 Indeed, White’s “organism as a whole” was central to laying the foundations of the American psychosomatic movement in medicine.9 General Somatic Pathology.” See William A. White, Essays in Psychopathology, Nervous and Mental Disease Monograph Series No. 43 (New York: Nervous and Mental Disease Publishing Company, 1925), 69-92. 5 “Dynamic psychiatry” was a term used during the period. Elmer E. Southard and White’s frequent co-author Smith Ely Jelliffe were also major contributors to this movement. See Grob, Mad Among Us, 142-144; Nancy Tomes, “The Development of Clinical Psychology, Social Work, and Psychiatric Nursing: 1900–1980s” in History of Psychiatry and Medical Psychology: With an Epilogue on Psychiatry and the Mind-Body Relation, eds. Edwin R. Wallace IV and John Gach (New York: Springer, 2008), 658. S. D. Lamb called this group a “psychiatric reform movement” and part of what Meyer had called the “new psychiatry.” She identified August Hoch, Smith Ely Jelliffe, Morton Prince, and William Alanson White as some of the members of this group. See S. D. Lamb, Pathologist of the Mind: Adolf Meyer and the Origins of American Psychiatry (Baltimore: Johns Hopkins University Press, 2014), 101. 6 Grob, Mad Among Us, 142; Lamb, Pathologist of the Mind, 101. For the influence of biology and psychology on White’s views of “organism as a whole,” see William A. White, “The Narrowing Gap Between the Functional and the Organic,” American Journal of Insanity 84, no. 2 (September 1927): 222-223. 7 Historians, except for Gerald Grob, have not viewed the influence of White and Meyer on the development of American Psychiatry as equal. Indeed, historians have called White “a prominent member of the Meyer camp,” and even “Meyer’s heir apparent,” but Grob recognized White as “a figure whose influence equaled that of Meyer.” See, respectively, Martin Summers, Madness in the City of Magnificent Intentions: A History of Race and Mental Illness in the Nation’s Capital (New York: Oxford University Press, 2019), 133; Jack D. Pressman, Last Resort: Psychosurgery and the Limits of Medicine (New York: Cambridge University Press, 1998), Last Resort, 30; Grob, The Mad Among Us, 161. The subject of White’s and Meyer’s comparative influence deserves a project of its own and is an avenue for further study. 8 Pressman, Last Resort, 38. 9 Robert C. Powell, “Helen Flanders Dunbar (1902-1959) and A Holistic Approach to Psychosomatic Problems. I. The Rise and Fall of a Medical Philosophy,” Psychiatric Quarterly 49, no. 2 (1977): 133-152. For further reading on the history of psychiatry and psychosomatic medicine, see Erwin H. Ackerknecht, “The History of Psychosomatic Medicine,” Psychological Medicine 12, no. 1 (February 1982): 17-24, and Z. J. Lipowski, “What Does the Word ‘Psychosomatic’ Really Mean? A Historical and Semantic Inquiry,” Psychosomatic Medicine 46, no. 2 (March/April 1984): 153-171. See also, Pressman, Last Resort, 38. Pressman placed White alongside Edward Strecker, Earl Bond, Charles and Karl Menninger, and Nolan D. C. Lewis as part of the “American School of Psychiatry” that dominated the 1930s in the United States. 210 So, what did White mean by “organism as a whole”?10 As discussed in chapter 2, White’s belief that mind and body were parts of a unified whole can be traced at least as far back as his testimony in front of Congress in 1906 that “mental disease is bodily disease, and is treated along general medical principles.”11 But it was not until the 1920s and 1930s that he fully developed this idea. White dismissed the existence of a mind-body dichotomy, instead arguing that “the organism remains a single entity of which [mind and body] are only aspects, and so ‘mental’ and ‘bodily’ are not two separate categories.”12 He believed that any disease had both somatic and psychic components.13 However, because physicians had historically paid more attention to the somatic factors in disease and Freudian psychoanalysis had opened up the study of the unconscious, White focused most on the psychic components of disease and on the therapeutic benefit of psychotherapy.14 Defining disease in this way—“as a matter of unity and wholeness”—changed the way that some physicians and psychiatrists practiced medicine. As 10 This topic deserves an article of its own. For the purposes of this chapter, I outline the basic concepts of his theory. White likely settled on this phrase after he read William Emerson Ritter’s The Unity of the Organism and the Organismal Conception of Life, Two Volumes (Boston: Richard Badger, 1919). He cites Ritter numerous times in his textbook, Foundations of Psychiatry. See William A. White, Foundations of Psychiatry, Nervous and Mental Disease Monograph Series No. 32 (New York: Nervous and Mental Disease Publishing Company, 1921), 12fn1. Powell explained that the “organismic conception of life” had “reappeared in the 1890s as ‘Gestalt’ or ‘configurational psychology’ and as ‘organismal’ or ‘organismic biology.’” Powell, “Helen Flanders Dunbar,” 140. 11 U.S. House, House Special Committee on Investigation of the Government Hospital for the Insane, Report of the Special Committee on Investigation of the Government Hospital for the Insane, vol. 1, 59th Cong., 2nd sess., 18 Feb 1907, H. Rep. 7644, 904. See chapter 2. 12 White, Autobiography, 265. 13 William A. White, “The Significance of Psychopathology for General Somatic Pathology,” in Essays in Psychopathology, Nervous and Mental Disease Monograph Series No. 43 (New York: Nervous and Mental Disease Publishing Company, 1925), 65, 84. He explained that “The meaning that immediately emerges from looking at mind and body as but two aspects of the organism is that for every situation there is as well a psychic as a somatic aspect, or, as there is no controversy about the latter, that every situation, for our purpose, every disease, has a psychic component, and further, that this component has a history as long and as important for its understanding as has the somatic component.” Ibid., 78. Italics are in the original. 14 Ibid., 69-70. See also White’s engagement with general medicine on this topic in William A. White, “The Message of Psychiatry to General Medicine,” Southern Medicine and Surgical Journal 84, no. 11 (November 1922): 557-563, HathiTrust. 211 White put it, the questions a doctor should ask were no longer “What is the liver, or the kidney, or the stomach doing? but, What is the man doing?”15 In the vein of institutional history, this chapter examines how food’s dual roles in the hospital as care and therapy shifted as part of Progressive reforms in the hospital that both responded to the challenges created by World War I and grew out of Superintendent’s White’s growing articulation of “organism as a whole.” When food at the hospital is placed at the center of the analysis, World War I clearly catalyzed Progressive reform efforts at St. Elizabeths.16 Because food was simultaneously part of humane, custodial care of patients provided by the hospital administration (and ultimately the federal government) and a tool of medical therapeutics, it remained at the nexus of care and therapy for all patients. Food therefore always swung on a pendulum between care and therapy in the mental hospital. Reforming food in the hospital thus included the hiring of professional dietitians, cooperating with the Veterans’ Bureau, and relying on nonprofit organizations such as the Red Cross to supply social workers and volunteers. Dietitians played a particularly important role in changing the hospital diet, since they were versed with administrative and therapeutic knowledge of food and trained student nurses in dietotherapy during White’s tenure as superintendent. While the pendulum swung toward care during the early postwar period, I argue that it had settled close to resting in the middle between care and therapy when White died in 1937.17 15 White, Foundations of Psychiatry, 2. 16 See Pressman, Last Resort, 22-23 for a discussion of how World War I catalyzed the formation of psychiatry as we know it today, founded on Meyer’s psychobiological model. In contrast to World War I, the Great Depression had little effect on the hospital since sufficient appropriations from Congress continued. Gerald N. Grob noted that the institutional care of the mentally ill “remained unchanged” during the interwar period and that “Mental hospitals during this era were among the public institutions least affected by the unprecedented economic depression of the 1930s.” My research supports this through the example of St. Elizabeths. Gerald N. Grob, Mental Illness and American Society, 1875-1940 (Princeton, NJ: Princeton University Press, 1983), 288. 17 Although Jonathan Sadowsky argued against the use of the pendulum metaphor for explaining the history of American psychiatry as focusing on the extremes of psyche and soma through his examination of ECT (Electroconvulsive Therapy) and psychoanalysis, I find it useful to explain the push and pull between care and 212 Examining how the institutional diet and food-related activities developed over the course of White’s tenure as part of the Long Progressive Era reveals a new way of understanding how nineteenth-century moral treatment and holistic views of health continued but also changed in American psychiatry.18 Core aspects of nineteenth-century moral treatment—therapeutic optimism, treating patients as individuals, using work as therapy, and a generous diet—continued through White’s tenure as superintendent.19 However, White’s dynamic approach to health and illness through psychoanalytic principles and his concept of “organism as a whole” put a new spin on moral treatment and nineteenth-century alienists’ holistic conceptions of health.20 Psychological and somatic approaches to mental illness were not generally at odds in St. Elizabeths; the management of food and diet in the hospital shows how interconnected the two therapy in the hospital. By using the pendulum metaphor in this way, I highlight the very dichotomy of the hospital’s organization into a medical and an administrative branch. Food in the hospital reflects the marriage of psyche and soma and the balance between care and therapy in psychiatry. See Jonathan Sadowsky, “Beyond the Metaphor of the Pendulum: Electroconvulsive Therapy, Psychoanalysis, and the Styles of American Psychiatry,” Journal of the History of Medicine and Allied Sciences 61, no. 1 (2005): 1-25. 18 Frank Rives Millikan’s dissertation is the most in-depth examination of how moral treatment continued at St. Elizabeths during the early twentieth century, up to 1920. He asserted that “a persistent concern with the humane provision of shelter, entertainment, and recreation, medical superintendents ensured that moral treatment remained a part of the fabric of asylum life,” especially because few new scientific therapies proved to be highly effective. Frank Rives Millikan, “Wards of the Nation: The Making of St. Elizabeths Hospital, 1852-1920” (PhD diss., George Washington University, 1990), vii and 195-6. 19 For a history of moral treatment at St. Elizabeths, see Millikan, “Wards of the Nation.” Millikan pointed out that White’s reforms showcased a continuation a moral treatment during the Progressive Era due to a “concern for individualized care, for daily living conditions, and for incorporating medical and architectural innovations into the fabric of asylum life.” Ibid., 201. Martin Summers also saw continuation in moral treatment in the hospital. He wrote that the “core principle of moral treatment—the imperative of creating as normal a social environment for the patient as possible—permeated everyday life at St. Elizabeths, even if the staff no longer explicitly reference it as a therapeutic modality.” Summers, Madness in the City of Magnificent Intentions, 154. He also asserted that the therapeutic optimism at St. Elizabeths “did not, by and large, extend to African American patients.” Ibid., 187. My work supports this, as male veterans, most of whom were white, were the focus of occupational therapy and Red Cross volunteer work. 20 This is similar to how Meyer’s psychobiological experiment at the Phipps Clinic put a new “twist” on moral treatment. Lamb argued that the “conflation of medical inquiry and therapeutics represented a twentieth-century and distinctly Meyerian twist in the moral therapies of earlier centuries.” Lamb, Pathologist of the Mind, 203. In addition, Millikan stated that White had a “reputation for reinvigorating moral treatment by introducing psychotherapy, dispersing patients among smaller buildings, and improving patient-staff ratios,” however he does not discuss White’s underlying theory of “organism as a whole” or the context of dynamic psychiatry. See Millikan, “Wards of the Nation,” 201. 213 were.21 Furthermore, the Progressive-Era ideals of economic efficiency and relying on specialized professionals to enact social transformation changed how White and his staff utilized the therapeutic tools of moral treatment, including work and diet. Lastly, women professionals and volunteers—dietitians, occupational therapists, and Red Cross social workers and members—were essential components of postwar reform and therapy at St. Elizabeths.22 The respect for and continued use of scientific and often university-educated professionals to better the hospital is one of the main themes that makes my periodization of a Long Progressive Era possible.23 Historians have long pointed to the end of World War I as the end of the Progressive Era; indeed, as Paul Starr and other medical historians have shown, the debate over compulsory or national health insurance dissipated following the red scare directly after World War I along with many other Progressive ideas.24 However, historians should not fall into trap of periodization based on the war too easily. While World War I and the “end” of the Progressive Era in 1920 provide a seemingly clean demarcation, they can hamper a composite 21 Matthew Gambino has pointed out that in St. Elizabeths “somatic and psychic perspectives on mental illness proved remarkably compatible” as did treatments. St. Elizabeths used hydrotherapy, “shock therapies” of various sorts, and pioneered malarial fever therapy all while White also set up psychoanalysis in the hospital. See Matthew Joseph Gambino, “Mental Health and Ideals of Citizenship: Patient Care at St. Elizabeths Hospital in Washington, D.C., 1903-1962,” (PhD diss., University of Illinois at Urbana-Champaign, 2010), 18, 122, and 137. For an overview of the somatic treatments utilized by psychiatrists in public mental hospitals during the early twentieth century, including hydrotherapy, electroshock therapy, lobotomy, malarial fever therapy, and sterilization see Joel Braslow Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century (Berkeley, CA: University of California Press, 1997). 22 Tomes examined the importance of female social workers and nurses during this period for the development of the “interdisciplinary mental health team” that solidified in the late twentieth century. I add to her work by including dietitians and occupational therapists to the interdisciplinary, Progressive Era team in inpatient psychiatric institutions. See Tomes, “The Development of Clinical Psychology, Social Work, and Psychiatric Nursing,” 657-8. 23 As stated in the introduction to this dissertation, I adopt this term from Rebecca Edwards, “Politics, Social Movements, and the Periodization of U.S. History,” The Journal of the Gilded Age and Progressive Era 8, no. 4 (October 2009): 466. 24 Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 254. John Duffy noted that “the post-World War I years had been a letdown in public health activities, the reverse was true after World War II.” See John Duffy, The Sanitarians: A History of American Public Health (Urbana, IL: University of Illinois Press, 1990), 270. A recent sourcebook, Kevin Hillstrom’s U.S. Health Policy and Politics: A Documentary History (Thousand Oaks, CA: CQ Press, 2012), chapter 4, similarly synthesizes medical historians’ arguments in this vein, periodizing the Progressive Era as 1890 to 1920, ending with the defeat of compulsory health insurance in 1920. 214 understanding of continuity as well as change over time. After World War I, a reformist attitude focused on social welfare continued in some professionals that cared for some of the most vulnerable members of the population—the mentally ill. The growth and increasingly important roles of occupational therapy, social work, and dietetics in St. Elizabeths mental hospital show a continuation of Progressive ideals carried past 1920 and into the New Deal Era that deserve consideration. Furthermore, St. Elizabeths's status as a federal hospital which was subject to repeated congressional investigation allows for further consideration of how a spirit of Progressive reform—seen so clearly in the 1906 investigation into St. Elizabeths and in similar investigations that state hospitals, such as the one in South Carolina, faced in the 1910s—continued into the late 1920s. Nowhere does St. Elizabeths’s federal character reveal itself more than in its care for veterans. One Congressional report on the history of medical care of veterans in 1967 contained a section devoted to St. Elizabeths; the author asserted that “military psychiatry was introduced to this country at St. Elizabeths Hospital, Washington, D.C.”25 By exploring the hospital’s care for veterans, this chapter further highlights the unique place of St. Elizabeths in the history of psychiatry.26 The importance of the role played by St. Elizabeths in the history of the care of mentally ill veterans, and by extension, in the history of psychiatry, cannot be overstated. St. 25 U.S. House, Committee on Veterans’ Affairs, Medical Care of Veterans (CMP-1967-VAH-0122; Date: April 17, 1967), 45, ProQuest Congressional. 26 Unlike military hospitals created under the United States Public Health Service (USPHS), which were transferred to the Veteran’s Bureau in 1922, St. Elizabeths remained a government hospital separate from this system, as it served both civilians and veterans. The Veterans’ Bureau was transformed into the Veterans’ Administration in 1930, as many support services for veterans were consolidated into the single government entity, including veterans’ medical services. This dissertation will not cover the series of changes that the Veterans’ Bureau and Veterans’ Administration faced. For a detailed history of the many changes that took place between the founding of the Veterans’ Bureau and its transformation into the Veterans’ Administration, see U.S. House, Medical Care of Veterans. The tension of federal versus D.C. oversight and funding of the hospital rose during the post-World War II period as different presidents sought to transfer the control and funding of St. Elizabeths to the D.C. government. For this history, see Otto, St. Elizabeths, epilogue. 215 Elizabeths, then, offers a unique case in which war, psychiatry, and federal reform continued to intersect in the Long Progressive Era. The first two sections of this chapter examine the 1919, 1926, and 1929 investigations into St. Elizabeths.27 They mirrored the earlier 1906 investigation into the hospital in how food was a notable concern for investigators. However, these latter investigations focused more on how hospital staff fed and treated veteran patients in particular. The first section shows that the poor conditions of World War I, an increase of interest in veteran patients, and the 1919 investigation prompted reform in the hospital, such as White hiring dietitians to oversee the hospital diet. Section two examines how veterans played an even more central role in the investigation of 1926; White had to continue to remind investigators that although St. Elizabeths was a federal institution, it was not technically a military hospital. Even so, veterans received a better diet than civilian patients—who were still receiving a generous diet—due to payments from the Veterans’ Bureau. The second section also reveals, through the investigation in 1929, that superintendents like White continued to rely on both administrative and medical authority over food in the hospital to defend against allegations of mismanagement, even as food at the time had become more about care than therapy until the pendulum swung back in the 1930s. The next three sections examine food’s role in different types of therapy and therapeutic environments in the hospital managed and undertaken not only by psychiatrists but also by occupational therapists, Red Cross volunteers and social workers, and hospital dietitians. Most of these professionals and volunteers were women, and this chapter illuminates their importance in changing the hospital diet and in providing therapeutic work for and interactions with mentally ill veterans. By the end of White’s tenure in 1937, the hospital diet had the most variety yet and 27 The 1929 investigation has not been discussed by most historians. Some activities related to the investigation took place in 1928, but the congressional hearings took place in February of 1929. 216 most patients had transitioned to choosing what to put on their own plates in the new cafeteria system. In these sections, I ultimately explore what food and its relationship to both the mind and body can tell us about how nineteenth-century moral treatment continued at St. Elizabeths through 1937, but also how moral treatment’s theoretical foundations and therapeutic goals changed to fit White’s Progressive-Era ideals and distinctly twentieth-century conception of holistic health in the “organism as a whole.” “Crazed Yanks Starved”: Veterans, the 1919 Investigation, and Dietitians As chapter 4 began to show, World War I negatively impacted mental hospitals in all areas, including the food supply. Hospital superintendents and physicians took the war conditions and the Food Administration’s rules and regulations seriously. Many took up the cause of food conservation by acknowledging the underutilized farmable land that mental institutions had to offer. Simultaneously, they faced labor shortages not only of attendants, who looked after patients on the ward, but also of medical staff. At St. Elizabeths, the food situation was “serious” during the war because food was difficult to secure, thus reducing the diet.28 All of these factors led to the worsening of patient care, which included less oversight and attention given to patient dining. These conditions led to another congressional investigation into the hospital in 1919. One important outcome of this investigation was that Superintendent White hired dietitians to the hospital staff to reform the hospital diet and food service. To explain this shift in relying of dietitians’ expertise in the postwar period, I explore how U.S. military involvement in the hospital and public and legislative concern for newly admitted veteran patients catalyzed reform of the hospital’s diet and food service through the records of the 1919 investigation. 28 Annual Report, 1919, 792. 217 During World War I, the combined effects of employee vacancies, influenza illnesses in the staff, and a rapidly rising patient population contributed to a lack of sufficient patient care and therapy. The war and the 1918-1919 Influenza Pandemic depleted the hospital’s labor force—especially those working on the wards in close and frequent contact with patients—quite severely. White estimated that the war had caused about 300 employee vacancies out of about 800 total positions in the institution, while 669 patients and 171 employees suffered from influenza, although fatalities were “very few.”29 The greatest number of staff vacancies caused by the war occurred in the ward and kitchen service.30 After a failed attempt in employing men who were considered unfit for military service, White secured some help from the Medical Corps of the Army as well as the Navy. Even so, as White explained, the hospital was not only short- staffed but new workers were inexperienced, which made them half as efficient, therefore contributing further to poor patient conditions.31 Not until the middle of 1919 was White able to hire back old employees as well as new one who were of “an adequate class of help,” which was in part thanks to additional appropriations from Congress that allowed him to offer more competitive wages.32 The war also raised the institution’s patient population, which further contributed to poor conditions. St. Elizabeths continued to accept many U.S. soldiers and veterans who military doctors and psychiatrists from other institutions believed had severe and, usually, chronic mental illness. On October 6, 1917, the U.S. Congress also authorized Superintendent White to receive “interned persons and prisoners of war”—who would be housed in Howard Hall, where the criminally insane and many African American men were also housed—as well as “insane 29 Ibid., 794, 814. 30 Ibid., 791. 31 Ibid., 814. 32 Ibid., 814-815. 218 patients” from the Canal Zone whose “permanent residence” could not be identified.33 The yearly total number of admissions jumped approximately 71 percent for fiscal year 1919 versus 1918. Similarly, the total number of Army and Navy admissions increased by about 95 percent over the same period. Due to overcrowding and the labor shortage, the Army stopped sending patients to St. Elizabeths in February 1919.34 While veterans of the U.S. Armed Forces had been committed to the hospital since the Civil War, the commitment of World War I veterans to the hospital came alongside postwar patriotism and an increase in public concern about their mental and physical wellbeing. In the Washington Post, for example, one citizen criticized veterans’ conditions in the hospital in the early summer of 1919. Although they praised White as “one of the greatest alienists in the world,” they nevertheless thought that "the conditions surrounding army and navy patients at St. Elizabeth’s [sic] Hospital are such as to require immediate remedial legislation by Congress.”35 Aside from hospital conditions, servicemen, their families, and government authorities did not want the label of “insanity” to be easily applied to soldiers and veterans suffering mental troubles from the war. Indeed, the term “shell shock” became popular in art and media to 33 Annual Report, 1918, 691. This same act also authorized the Secretary of War to send Armed Forces veterans to receive care at other public mental hospitals besides St. Elizabeths due to the knowledge that the institution could support a patient population of about 4,000, which was quickly nearing. It is unclear whether the term “permanent residence” refers to legal status or home location in the United States. The phase “interned persons” likely refers to the internment of “enemy aliens”—Germans living in the United States who had not yet become naturalized citizens who government authorities considered dangerous. See Jörg Nagler, “Victims of the Home Front: Enemy Aliens in the United States during the First World War” in Minorities in Wartime: National and Racial Groupings in Europe, North America and Australia during the Two World Wars, ed. Panikos Panayi (New York: Bloomsbury Academic, 2016): 191-215, ProQuest Ebook Central and Adam Hodges, “’Enemy Aliens’ and ‘Silk Stocking Girls’: The Class Politics of Internment in the Drive for Urban Order during World War I,” The Journal of the Gilded Age and Progressive Era 6, no. 4 (October 2007): 431-458. 34 Annual Report, 1919, 802. The Annual Report for 1919 is written for the fiscal year June 31, 1918, to June 30, 1919. In the fiscal year 1918 of the same date range, the hospital admitted 378 people from the Army (354 white males, 22 “colored” males, and 2 white women) and in 214 men from the Navy (210 white males and 4 “colored” males). In the 1919 fiscal year, by comparison, 855 men were admitted from the Army (781 white males and 74 “colored” males) and 299 men from the Navy (292 white males and 7 “colored” males). Army and Navy admissions before and after the war were much less (1917 total of 255 Army and 91 Navy, and 1920 a total of 255 Army and 175 Navy, for example). 35 “Help St. Elizabeth’s,” Washington Post, June 24, 1919, 6, ProQuest Historical Newspapers (HN). 219 describe what psychiatrists came to understand as a psychoneurotic response to war trauma.36 There was stigma associated with being an institutionalized, “insane” patient, including for patients at St. Elizabeths. Many members of the public and their government representatives viewed St. Elizabeths as a large institution only for the incurably insane, not a place for veterans who had suffered a “nervous strain” or “nervous breakdown”—curable conditions—while serving their country.37 Just as the jailed women suffragists in Britain and the U.S. examined in chapter 3 carefully delineated their hunger strikes as distinct from the food refusals of the “insane” in government institutions, veterans and their supporters separated “shell shock” from insanity.38 Although generally only the most severe cases of mental disorder in the Armed Forces were sent to St. Elizabeths, there were some people with neuroses and other acute illnesses who fell through the cracks and were committed to the hospital. The increased admission of solider and veteran patients to St. Elizabeths also drew attention to the different legal commitment procedures for civilians and veterans. While civilian commitments required a judicial hearing to establish a person’s mental status (insanity) and inability to care for themselves, the U.S. Attorney General ruled that “war-risk patients” who had 36 Caroline Cox, “Invisible Wounds: The American Legion, Shell-Shocked Veterans, and American Society, 1919- 1924” in Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870-1930, eds. Mark S. Micale and Paul Lerner (New York: Cambridge University Press, 2001), 288. For the most comprehensive examination of “shell shock” and the developing psychiatric understanding of it during and after World War I, see Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century (Cambridge, MA: Harvard University Press, 2001). 37 See, for example, the statements of Representative John C. McKenzie of Illinois in U.S. Congress, House of Representatives, Committee on Expenditures in War Department, War Expenditures: Hearings Before Subcommittee No. 2 (CAMPS) of the Select Committee on Expenditures in the War Department, 66th Cong., 1st sess., vol. 1, serial 3, July 11-October 31, 1919 (Washington: Government Printing Office 1920), 247, ProQuest Congressional. However, there were few other options for inpatient treatment at the time for soldiers who experienced severe enough symptoms of mental illness while in service or during combat. See Adler, Burdens of War, 208. For popular perceptions and presentations of shell shock as curable and temporary, see Annessa C. Stagner, “Healing the Soldier, Restoring the Nation: Representations of Shell Shock in the USA During and After the First World War,” Journal of Contemporary History 49, no. 2 (2014): 261-2. 38 The American Legion was one organization that sought to improve the care of shell-shocked veterans while also helping psychiatrists to expand their influence outside of the mental hospital. See Cox, “Invisible Wounds.” 220 served in the Army did not require the judicial process prior to commitment. This decision created problems for Superintendent White when some patients and their families alleged sane veterans were being unfairly held in the hospital and took legal action by filing habeas corpus proceedings against the institution.39 Public and familial concern for veterans heightened legislators’ scrutinization of institutions that cared for and treated veterans, including St. Elizabeths. This scrutinization led to another congressional investigation into St. Elizabeths. On August 29th, 1919, Ohio Congressman Charles J. Thompson introduced a resolution in the House of Representatives calling for an immediate investigation into both St. Elizabeths and Walter Reed United States Army General Hospital, a new and prominent military hospital also located in the nation’s capital.40 Thompson had received and compiled complaints regarding poor conditions and abuses at both hospitals from a variety of sources including soldiers and veterans, their families, and Red Cross members. The complaints against St. Elizabeths and Walter Reed centered on poor food, physical abuse, and the confinement of sane soldiers and veterans with insane patients.41 When Thompson’s resolution passed, the investigation began, and the first congressional hearings took place on September 12, 1919. Despite being a civilian institution, St. Elizabeths’s important role in treating some of the nation’s veterans for mental illness led to further scrutinization of its administration through the congressional investigation. Because the focus of the investigation was on the conditions of veterans, the House Committee on Expenditures of the War Department handled it; at the time, 39 Annual Report, 1919, 795. 40 For more information on the Progressive-Era founding of Walter Reed Hospital, see Jessica L. Adler, “The Founding of Walter Reed General Hospital and the Beginning of Modern Institutional Army Medical Care in the United States,” Journal of the History of Medicine and Allied Sciences 69, no. 4 (October 2014): 521-553. 41 Walter Reed’s administration also faced allegations of the unfair treatment or delayed discharge of service members who had been assigned to work at the hospital. 221 the committee had numerous ongoing hearings and investigations regarding not only the conduct of military officers, but also that of hospitals and their administrators. This was a departure from how a new committee had been appointed to investigate St. Elizabeths specifically in 1906. Although fewer witnesses testified in front of congress than in the 1906 investigation into the hospital, a significant portion of testimony in 1919 focused on the food service at St. Elizabeths.42 One of the largest issues in the 1919 investigation was that sane veterans were living alongside “insane” patients, which included veteran patients’ complaints about how the hospital’s food service was set up. The case of James Henry Metz exemplified the struggle faced by service members to get treatment for an acute nervous condition at St. Elizabeths. After twenty-four-year-old Metz suffered what he described as a “little nervous attack due to overwork—practically overwork and improper nourishment” in August of 1918 while he was stationed at Fort Riley, Kansas, he was transferred to St. Elizabeths in November 1918.43 Ultimately, Metz was released from the hospital in February 1919, as doctors determined that he was “not insane since admission.”44 One of his most biting criticisms of the hospital and its food came when he stated that he, a sane man, had to dine alongside insane men: “You could sit beside and insane man that didn’t realize the use of a spoon, which they gave you to eat your meals with, and you can just imagine the table manners; and that is pretty distressing to a man that is used to eating properly.”45 That a “sane” soldier like Metz dined with the incurably insane 42 Eight people testified at the 1919 hearings, and letters from two additional patients were entered into evidence. 43 House Committee on Expenditures in War Department, War Expenditures: Hearings Before Subcommittee No. 2 (CAMPS), 251. 44 Ibid., 253. 45 Ibid., 255. 222 was scandalous, even if St. Elizabeths doctors did discharge him when they were confident he was not insane. Even more scandalous, however, was a local nurse’s testimony that soldier and veteran patients at St. Elizabeths were being starved and beaten by St. Elizabeths staff. Katherine Douglass, a D.C. public health nurse who had visited St. Elizabeths to see her institutionalized brother for almost a decade, became a focal point of the investigation.46 Not only had she helped provide evidence to the Army and Congress in February 1919 that spurred the investigation, but her testimony was seized and sensationalized by the local press to such a degree that Superintendent White had to respond to it directly in his report to the Secretary of the Interior on the matter.47 For example, she claimed that at St. Elizabeths she had eaten “tainted meat and sour oatmeal” from the tray of an Army Captain and that a Lieutenant had not received his allowance of milk and eggs for a month. 48 Even more shocking was her statement that a veteran patient had been “starved out” at the hospital and was only able to get sufficient nourishment when his visiting brother brought him food from outside the hospital for a week.49 Local newspapers highlighted the plight of soldiers and veterans in St. Elizabeths to a greater degree than coverage of the 1906 hearings discussed in chapter 2 through their reporting on the 1919 hearing testimony, especially Douglass’. Newspaper articles also highlighted her 46 Ibid., 237. She had visited her brother, a patient, at St. Elizabeths for nine years when she became “particularly interested in soldiers” in World War I. Her efforts at St. Elizabeths were purely voluntary, though she may also have had connections to hospital volunteering or unofficial charity efforts through her position as a Red Cross reserve nurse (see the following section of this chapter). She thought that 55 percent of soldiers in mental hospitals at the time were curable, and that her free time and skills as a nurse could be used to help them. 47 Ibid., 237. 48 Ibid., 238-9. 49 Ibid., 241. Douglass also took time to explain that she did “not think [the patient’s] ravenous eating was due to his mental condition” and that he took food “in a normal manner, as a normal man would” once he was no longer starved. This was another example of ensuring that veterans were not seen as “insane” due to their mental conditions stemming from the war. As discussed in chapter 4, eating “ravenously” while in a mental hospital was usually pathologized and seen as a symptom of mental illness rather than a response to having had too little food to eat for too long. 223 occupation as a nurse to give further medical credibility to the stories, even though she was not employed at St. Elizabeths. The D.C. Evening Star seized the opportunity to follow the War Department’s “probe” into St. Elizabeths and detailed Douglass’ allegations that soldiers in the hospital were beaten and poorly fed.50 But the most damning report on Douglass’ testimony came from another local paper, the Washington Times, which covered it under the sensationalized headline “Crazed Yanks Starved and Beaten Here, Says Nurse.”51 This article appears to have made a splash at St. Elizabeths, as it was clipped and saved in hospital papers related to the investigation. Superintendent White not only had to respond officially to claims made against the hospital, but also had to consider what, today, we call public relations. White and his administration at St. Elizabeths had to respond, so he promptly drew up a report to the secretary of the interior to defend the hospital.52 Alongside his reports on patients who were the subjects of complaints, he directly responded to critiques about the lack of specific foods during the war and of problems in food preparation and service. White attributed most of these problems to the labor shortage and sheer size of the institution; the hospital served over 50 “Hospital Charges Probe to Continue,” Evening Star (DC), September 13, 1919, 2, Chronicling America, LOC and “Abuses Alleged at St. Elizabeth’s,” Evening Star (DC), September 12, 1919, 1, Chronicling America, LOC. The author stated that Douglass “told the committee that she believes many of the soldiers are not properly fed or properly treated at that institution” and that “she had tasted the food that was being served to a captain and found that the potatoes were not properly cooked and the meat was tainted.” Also, Douglass’ name appears to be spelled differently between her congressional testimony and newspaper entries. For consistency, I have referred to her how her name appears in the Congressional record: Katherine Douglass. Alternative spellings include the first name “Catherine” and last name “Douglas.” 51 NARA RG 418: Entry 47 (Records Relating to a Congressional Investigation, 1917-1919: Box 1, Folder 2), “Crazed Yanks Starved and Beaten Here, Says Nurse.” The clipping in the archive came from “Crazed Yanks Starved and Beaten Here, Says Nurse,” Washington Times (DC), Friday evening edition, September 12, 1919, 1-2, Chronicling America, LOC. The article reported that Douglass, a “trained nurse,” testified that she was “greatly concerned over the ‘distressing condition of the food’” given to “insane soldiers and sailors” in St. Elizabeths. Interestingly, this article’s author did identify veterans as “insane,” breaking with the common sentiment of the time likely in order to further sensationalize the story. 52 This is based on White’s reference to “the information that the statements in the attached papers have been investigated” and the clipping of the newspaper article “Crazed Yanks Starved and Beaten Here, Says Nurse” in the 1919 investigation archival documents. The report exists in carbon-copy form. NARA RG 418: Entry 47 (Records Relating to a Congressional Investigation, 1917-1919: Box 1, Folder 4), William A. White to the Secretary of the Interior. 224 13,000 meals a day.53 White admitted that due to such conditions “it is possible that at times some of the food may not have looked as dainty as we would like to have it.”54 Other parts of the report responded specifically to Katherine Douglass’ claims.55 Indeed, there were times that veterans did not receive the special diets prescribed to them, as Douglass alleged. White was not surprised that some cases slipped through the cracks but made clear that once the physician assigned to the veteran patient’s ward realized the patient was not receiving the proper diet, “the matter was immediately rectified.”56 Although soldiers and veterans in the hospital were the focus of the government investigators as well as the media, the hospital was not officially overseen by the Armed Forces. White therefore used his report to the Secretary of the Interior to highlight what he saw as the “unfair” comparisons between St. Elizabeths and Army and Navy institutions when it came to the “food question.” He argued that when there were possibilities for or actual food shortages during the war, food supplies were restricted and regulated by the Food Administration because of the hospital’s status as a “civilian institution.”57 The War and Navy Departments’ hospitals, White explained, were not subject to this restrictive oversight. Furthermore, while patients at St. Elizabeths were fed in excess of the Food Administration’s per capita allowance, its regulations still meant that St. Elizabeths’s administrators had trouble purchasing canned foods, were pressured into purchasing wheat substitutes instead of flour, and were limited in purchasing 53 William A. White to the Secretary of the Interior, 5. 54 By using the term “dainty,” White indicated that the food did not always live up to middle-class aesthetic sensibilities about what was considered good food, and thus, what was understood to be psychologically healthy for patients. See chapters 1 and 4. Furthermore, Harvey A. Levenstein noted that for middle- and upper-class, non- immigrant women during this period, the term “‘dainty’ was the greatest compliment one could bestow on food.” Harvey A. Levenstein, Revolution at the Table: The Transformation of the American Diet (Oxford: Oxford University Press, 1988), 104. 55 William A. White to the Secretary of the Interior, 3. 56 Ibid., 9. 57 Ibid., 6. 225 sugar based on the food administrator’s issuing of certificates.58 The struggle to supply St. Elizabeths with its usual generous diet for mentally ill patients ultimately illuminated the hospital’s peculiar status as a largely civilian institution that also served the nation’s veterans. White and St. Elizabeths once again came out of a congressional investigation quite unscathed, but the scrutinization of the hospital diet during the investigation prompted White to hire dietitians in 1920 as “an attempt to improve the food” at St. Elizabeths.59 Although the chef continued to be in charge of cooking the food in the institution’s large, industrial kitchens, dietitians took over the planning of menus so that patients’ meals would be “well-balanced” and not monotonous.60 Dietitians also took over the education of nurses from the chef. A special course in dietetics in the Nurses’ Training School at St. Elizabeths was given by one of the St. Elizabeths dietitians, Miss King in the fiscal year 1920.61 Dietitians, who had generally earned college degrees and studied the new science of nutrition, became important professionals in the running of the hospital’s food service.62 58 Ibid., 4. 59 Annual Report, 1920, 32. 60 Ibid. White appears to have followed the advice of what nutrition expert M. E. Jaffa had recommended—creating more variety and using good substitutes—but hired dietitians to oversee this instead of a chef. See the previous chapter. In the 1919 report, White explained that the duties of the chef were to “supervise the care of the kitchens, the cooking, and furnishing of food to the various dining rooms of the hospital.” He had stressed the specialist knowledge that the chef had, stating that he was “specially trained in the work which he does and goes about from kitchen to kitchen inspecting the cooking of the food.” William A. White to the Secretary of the Interior, 3. 61 Annual Report, 1920, 34, 44. 62 It should be stressed that St. Elizabeths hospital was not at the forefront of developing hospital dietetics; this study shows the slow acceptance of the place of the dietitian in a mental hospital working to be respected as a modern hospital (see chapter 4). One historian of St. Elizabeths, Frank Rives Millikan, stated that some changes in the hospital were difficult for White to assess, including “the introduction of new specialists such as college-trained occupational therapists and dietitians.” Millikan, “Wards of the Nation,” 194. However, Millikan’s study of the hospital and White’s Annual Reports end in 1920, the breaking point of periodization that I question. While White valued the social rehabilitation of patients above all else, he recognized that dietitians, among other professionals, had made improvements to the hospital throughout his period as superintendent that continued until 1937. See NARA RG 418, Entry 49 (Records Relating to the American Red Cross, 1917-1936: Box 1, Folder 3 of 3), Letter from William A. White to Eleanor Vincent, April 20th, 1928. When a study of dietitians in the hospital is continued past 1920 and is done in the context of the development of dietetics at St. Elizabeths over White’s tenure, the significant role of the dietitian becomes clearer and more nuanced. 226 The shift in designating the food specialist of the hospital from the chef to the dietitian shows how the university educations and scientific knowledge of food secured dietitians a place in the professional bureaucracy of the modern mental hospital.63 It also showed how female professionals with scientific training—an essential group in Progressive reform efforts—helped to ensure that the hospital continued to be respected not only for its treatment of patients but also for its modern administration. Dietitians played an important role in the R-Building, where the newly established Department of Internal Medicine was located and where patients with serious physical illnesses went. White established this department so that St. Elizabeths would have a scientific and well-equipped medical department like those found in general and university hospitals. When White hired dietitians in 1920, he reported that they were “in charge of the food department” and their efforts had produced “very good results.”64 Most importantly, with the addition of a dietitian to oversee the kitchen, the R-building was “able to furnish any special diet which may be required in the treatment of any type of case.”65 Thus, following the end of the war, the 1919 investigation, and the success of dietitians in the R-Building, White continued to expand the hospital’s focus on patient feeding and added new dietitians to the staff. From 1920, when White hired five dietitians, he kept the number employed steady, growing to seven by the late 1920s.66 The most striking evidence for the cemented role of dietitians in both the medical and administrative work of the institution in the early 1920s is the place of dietitians in the organization chart provided in White’s 1920 Annual 63 As discussed in chapter 4, the rise of dietetics was strongly connected to the rise of the “modern” hospital, and World War I served as a catalyst for the professional legitimacy of dietitians in the eyes of the federal government bureaucrats after the important role dietitians played in the War Department. 64 Annual Report, 1920, 20. 65 Annual Report, 1920, 51. 66 House Committee on the Judiciary, Investigation of St. Elizabeths Hospital: Letter from the Comptroller General of the United States Transmitting, Pursuant to House Concurrent Resolution No. 26, Adopted July 3, 1926, the Report of the Investigation of the Administration of St. Elizabeths Hospital Since July 1, 1926, 69th Cong., 2nd sess., December 16, 1926, H. Doc. 605, 78-79, ProQuest Congressional. 227 Report. The dietitians uniquely reported to representatives from both the administrative and medical branches of the hospital, the administrative assistant to the superintendent and the first assistant physician, respectively.67 The superintendent remained the singular institutional head presiding over both the administrative and medical branches of the hospital, as was articulated and defended during the 1906 investigation discussed in chapter 2. Strikingly, dietitians were the only professionals in the hospital other than the superintendent that had one foot in each branch of the institution. Dietitians thus functioned at the nexus of patient care and patient therapy, similar to the superintendent. They planned diets, which required them calculate the cost of the diets they created. This was connected to food purchasing, an administrative activity. Of course, the creation of diets as well as their oversight of the cooking and serving of food to patients (especially physician-prescribed sick or special diets) meant that dietitians were also involved in the medical branch of the hospital. In 1920, then, the pendulum of care and therapy had settled at the middle, resting point. This change for all patients was, in part, thanks to public and congressional concern over the treatment of veterans in the hospital after the difficult conditions created by World War I. But these administrative changes were also due to White’s continued reliance on scientific expertise, professional credentials, and centralized bureaucracy at St. Elizabeths to make the hospital a better place for patients. Contrary to 1920 marking the end of an era, these Progressive reform efforts persisted through the war and well into the 1920s. Investigations in the late 1920s: Dietary Critiques and Updates Between 1919 and 1926 White and his administration avoided large-scale government investigations and upgraded many of the hospital’s buildings, but patient escapes and claims that 67 Annual Report, 1920, n.p. [follows page 67]. 228 veterans in the hospital were abused continued to cause problems.68 In response to accusations in 1922 that “shell-shocked patients in St. Elizabeths Hospital [were] treated as violently insane” and that the food and general hospital conditions were bad, White, by now used to such complaints, confidently challenged anyone who wished to investigate the hospital to “inspect the hospital yourself and render your own verdict.”69 In 1923, veteran organizations in D.C. also considered requesting that the government check on St. Elizabeths patients after an investigation into the Brooklyn Hospital for the Insane in New York sparked a “nation-wide interest in the welfare of insane patients.”70 Despite these reports, however, an investigation did not immediately occur. Even as more and more patients were admitted to the hospital each year, positive press about major developments at St. Elizabeths also came out. For instance, improvements in the hospital’s food quality and service appeared in local newspapers, including the installation of a “modern milk room” alongside new x-ray equipment in 1922.71 Despite White’s hiring of experts such as dietitians and implementation of other related changes, St. Elizabeths was drawn into another congressional investigation into the hospital’s management in 1926 by the Comptroller General of the United States. A congressman from Texas led the charges against White and the hospital, including that White spent too much time outside of St. Elizabeths as an expert witness and that a Veterans’ Bureau representative had 68 See, for example “Hospital Shake-Up to Follow Inquiry,” Evening Star (DC), September 6, 1920, 1, Chronicling America, LOC, for coverage of patient escapes and police investigation. For coverage of a Massachusetts Congressman’s claims of the abuse of veterans in the hospital, see “Denies Abuse of Veterans in St. Elizabeth’s,” Washington Times (DC), November 26, 1922, 4, Chronicling America, LOC. 69 “Sane Veterans Go in St. Elizabeth’s, Accuser Declares,” Evening Star (DC), November 25, 1922, 1, Chronicling America, LOC. 70 “Vets Plan Inquiry at St. Elizabeths,” Evening Star (DC), July 19, 1923, 5, Chronicling America, LOC. One of the reports of patient abuse from the New York hearings was that a patient was kicked so hard by an attendant as he entered the dining room that “he sprawled six feet along the floor” and that when he “could not eat his meal he was forcibly fed by the attendant, with two other attendants holding him.” The implied use of forcible feeding as punishment here is clear and is similar to accusations about forcible feeding in the 1906 investigation into St. Elizabeths. 71 “St. Elizabeth Hospital Improves During Year,” Evening Star (DC), December 8, 1922, 23, Chronicling America, LOC. 229 written a report in 1924 that criticized the hospital’s diet and food service. The 1926 investigation thus contained many elements similar to the 1906 and 1919 investigations. In all investigations into the hospital, for example, legislators and members of the public voiced concern for the wellbeing of veteran patients; however, the 1926 investigation focused even more attention to the treatment of veteran patients in the hospital as a privileged group of patients than in 1919. During the 1926 investigation, for example, representatives from the Army, Navy, USPHS, and Veterans’ Bureau inspected St. Elizabeths and reported their findings.72 Although White came out of the investigation without major sanctions once again, an analysis of the role of food in the investigation shows how strongly veterans in the hospital influenced food service. It also shows how White and the hospital’s dietitians continued to maintain and update what and how patients in the hospital were fed. The1926 Report of the Special Medical Advisers on St. Elizabeths Hospital covered the hospital diet and was overall supportive of White and the staff of St. Elizabeths.73 This Report formed the medical basis for the Comptroller’s report. The Comptroller thus relied on other medical professionals to assess the value of the St. Elizabeths diet, showing the entrenchment of authority in professionals during the late 1920s. Just as other mental hospital superintendents were called as witnesses in the 1906 investigation, five “eminently qualified, experienced superintendents of hospitals for the insane” were asked and agreed to be special medical advisers for the government.74 The report was also printed in the American Journal of Psychiatry in 1927, the profession’s flagship journal. An investigation into the government mental hospital that had a 72 NARA RG 418, Entry 48 (Records Pertaining to Investigations, 1926-1928: Box 2, Folder V), “Report of Investigation” (Copy), November 16, 1926, 22-24. 73 Newspapers also reported this. See, for example, “St. Elizabeth’s Given Approval of Medical Investigators,” Evening Star, December 1, 1926, 1, Chronicling America, LOC. 74 NARA RG 418: Entry 48 (Records Pertaining to Investigations, 1926-1928: Box 1), “Report of the Special Medical Advisers on St. Elizabeths Hospital.” Reprinted from The American Journal of Psychiatry 6, no. 3 (January 1927): 545. 230 famous superintendent was of interest to psychiatrists across the nation, as much as the psychiatric expertise was of interest to the government and, more generally, the public. As with every prior Progressive-Era investigation, investigators scrutinized food. One out of the seven points of investigation as defined by the Secretary of the Interior, Hubert Work, was whether the food was “wholesome and liberal.”75 By 1926, St. Elizabeths had a total of “seven trained dietitians, 37 cooks, 28 kitchen helpers, 9 bakers, and 26 other employees, in addition to patients and assistance in serving by nurses and attendants” who all worked to feed close to 4,000 patients and 1,250 employees daily from the hospital’s nine kitchens.76 Investigators once again examined the menus, which covered ten-day periods rather than seven to reduce monotony in the diet. The hospital diet had thus changed since the 1919 investigation to follow nutritional and dietetic experts’ advice on not only supplying a wide variety of food, but also creating variance in when the same meals were offered to help patient psychology. Further the food at the hospital was “liberal,” containing many different types of food. For example, the menu for the general diet shows a wide variety of animal protein sources, vegetables, fruits, and desserts. Salmon, mackerel, cod, beef (fried steak, roast beef, pot roast, creamed beef, hamburger, liver, corned beef), veal, lamb, pork (fried ham, shoulder), and chicken made up the animal proteins in various meals.77 Patients at St. Elizabeths in 1926 continued to receive a generous diet which was more than sustenance-level in calories. The head dietitian and chief of commissary oversaw the 75 Ibid., 547. Note here that the term “liberal” is being used to discuss the quantity of food provided rather than a political statement. 76 Ibid., 563. There was also a separate cafeteria that served staff, families, and friends of patients on-site at “cost rate on a cash basis.” Ibid., 564. 77 Eggs also appear on the general menu once as scrambled eggs and twice as soft-cooked eggs, but they did not make up a major part of the breakfasts served for the general diet. This most likely has to do with the use of fresh eggs for sick and special diets of various kinds, which strongly relied on eggs as a major nutrient source. The Medical Advisor’s Report stated that “strictly fresh eggs are furnished the sick patients,” and that many of the eggs used in the hospital were produced at the hospital poultry plant. Ibid., 562. 231 formulation of the general, tubercular, and veteran diets, while physicians prescribed sick and special diets. Calories formed the most general marker of nutrition, as the Comptroller noted that the “general diet is selected with a view to providing, as a means of proper sustenance, an adequate number of calories.”78 However, the general diet, which most patients received, went beyond an “adequate number” of calories. The medical advisers calculated that the average patient ate 3276.47 calories a day, which was “226.47 calories in excess of the requirement of a standard dietary for a man at light, moderate muscular work.”79 The practice of feeding patients more than was scientifically required remained from the early nutrition investigations and rations suggested by physiologist and alienist Austin Flint, Jr., nutrition scientist Wilbur Olin Atwater, and home economist Ellen Richards in chapter 1. An important continuity through the 1910s and 1920s at St. Elizabeths was therefore feeding patients at better-than-sustenance level. While the general hospital diet had improved overall, the diet provided to veteran patients was higher in calories and allowed more room for personal preferences than that of ordinary citizens who had been committed to St. Elizabeths. By 1926, the diets used were a general diet, tubercular diet, general sick diet, special diets, and veteran diets. This existence of a category based merely on veterans’ identity rather than any medical condition shows the privilege given to veteran patients. Indeed, in 1924, the Veterans’ Bureau agreed to pay St. Elizabeths $1.50 per day for each veteran, which was 10 cents more per day than the per capita cost for other patients.80 “No deviation is made in the general diet to suit the individual tastes of patients,” explained the Comptroller. He used the example of eggs to make his point: they were “usually 78 House Committee on the Judiciary, Investigation of St. Elizabeths Hospital, 97. 79 “Report of the Special Medical Advisers on St. Elizabeths Hospital,” 567. 80 NARA RG 418, Entry 48 (Records Pertaining to Investigations, 1926-1928: Box 2, Folder S), Henry Ladd Stickney, “Report of Formal Inspection of St. Elizabeth’s Hospital (Department of Interior) at Washington, D.C.,” April 22- 24, 1924, 4. 232 served scrambled, though there may be a preference on the part of some patients to have their eggs fried or soft boiled.”81 However, veterans, the Comptroller noted, received a “separate menu” that “provides steaks and chops for breakfast, caters to their tastes and desires regarding the manner in which eggs shall be served, and provides one more vegetable and a salad when possible.”82 During this period, then, veterans were given more control over their dietary choices than general patients, and the diet also provided more red meat and vegetables—and was thus more nutrient-dense. A notable change in the menus over the course of White’s tenure was the increasing inclusion of popular Americanized ethnic foods and local cuisine. While many of the patients, especially those committed from D.C., would have been working-class, the dietitians planning the menus had an eye to middle-class cuisine and popular dishes of the period. This food would have appealed to the middle-class dietitians.83 “American chop suey” appeared on the “General Diet” menu in 1926, showcasing a concern for patient feeding that went beyond preparing a diet that would be purely nutritious; patients likely found food like this to be new and interesting, or perhaps delicious.84 An old and established local dish, Chicken a la Maryland, also appeared on 81 House Committee on the Judiciary, Investigation of St. Elizabeths Hospital, 97. 82 Ibid., 98. 83 Andrew P. Haley has argued that by 1920, the middle class replaced the upper class as the class which shaped American culture most, which can be seen in the middle class’s cosmopolitan and democratic influence on American restaurant and culinary culture. Andrew P. Haley, Turning the Tables: Restaurants and the Rise of the American Middle Class, 1880-1920 (Chapel Hill: University of North Carolina Press, 2011), Introduction. 84 “Report of the Special Medical Advisers on St. Elizabeths Hospital,” 564. The dish “American chop suey” was not standardized during this period. Anne Mendelsohn wrote that, initially, “the term embraced anything from a purportedly Chinese chop suey with extra broth to any long-cooked meat stew, with little rhyme or reason.” In the early 1930s, she reports, the casserole version of “American chop suey” became popular, which usually included macaroni, some form of tomatoes, and ground meat. See Anne Mendelson, Chow Chop Suey: Food and the Chinese American Journey (New York: Columbia University Press, 2016), 131. Andrew Coe, however, stated that “By the 1920s, chop suey and chow mein had claimed a place in the national diet alongside ham and eggs, coffee and a slice of pie, and the Sunday pot roast. For those who were not part of the mainstream culture, eating Chinese food offered one way to join it, to prove one belonged” in Chop Suey: A Cultural History of Chinese Food in the United States (New York: Oxford University Press, 2009), 198. Therefore, having “American Chop Suey” on the General Dietary at St. Elizabeths in 1926 meant that patients in the mental hospital, many who had spent 10 or more years in the hospital, would get a chance to have a dish that had become part of American mainstream cuisine that they may have missed. 233 the menu, which patients from D.C. would most likely have been familiar with. The dish is made up of fried chicken, often accompanied by white, cream gravy.85 The introduction of this dish may have been an attempt by hospital dietitians to Americanize some of St. Elizabeths’s patients who were not native to the United States. Traditional, Anglo-American white cream sauces had become especially popular at the turn of the century with home economists, because they considered the bland flavors less disruptive to the digestive system compared with the spices used in ethnic cuisine.86 At the same time, these dishes from the hospital diet in 1926 suggest that patients could try new and unfamiliar foods while institutionalized while also experiencing the social reform and Americanization goals that hospital dietitians may have held for immigrant patients.87 These popular dishes also prepared patients who were eventually discharged for life outside of the institution.88 85 The matter of “authentic” Chicken a la Maryland, as with many dishes, has never been decided and was debated by Americans throughout the twentieth century (and probably still to this day). I have based what St. Elizabeths most likely offered on a quotation of the recipe from a 1931 Sun (Baltimore) article that sought to firmly establish what the dish was: “chicken dipped in egg and flour, seasoned with salt and pepper and then fried in lard. It is served with cream gravy and fried mush […]” in Peter Bryce, “Maryland Chicken Vs. A La Maryland,” Sun (Baltimore), August 7, 1960, E1, Chronicling America, LOC. 86 See Levenstein, Revolution at the Tables, 104, 157, and Helen Zoe Veit, Modern Food, Moral Food: Self-Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century (Chapel Hill: University of North Carolina Press, 2013), 129. 87 Many patients in the institution were immigrants. Of the 644 patients admitted to St. Elizabeths for the first time in the fiscal year of 1926, 108 patients, about 17 percent, were born outside of the United States. The most common countries these patients were born in (with 6 or more patients tallied) were Germany, Greece, Ireland, Italy, Poland, and Russia. Many additional patients had parents who were born outside the United States and were first-generation U.S. citizens. Of these 108 patients, almost half (51) had resided in the United States for fifteen years or more, fourteen had resided in the U.S. for ten to fourteen years, seven had resided in the U.S. for five to nine years, thirteen had resided in the U.S. for under five years, and twenty-three patients’ time of residence in the U.S. could not be ascertained by staff. The report does not give data on patients’ English fluency. Annual Report, 1926, 16, 18. 88 A popular fruit, pineapple, which the hospital did not produce, also appeared on the menu in 1926. The 1926 menu also shows that the hospital’s food gained in variety through the growth in food processing and transportation. St. Elizabeths had long been producing some fruits in its orchards, including apples, peaches, and pears, but the 1926 menu featured pineapple, which was not grown at the hospital. Most likely, the pineapple bought and served at the hospital was canned and shipped from Hawai’i using modern canning technology and transportation. For a history of the pineapple canning industry, see Richard A. Hawkins, A Pacific Industry: The History of Pineapple Canning in Hawaii (London: Tauris Academic Studies, 2011). Ads in D.C. for pineapple in newspapers were for canned pineapples. See, for example, an A&P ad for four different sizes and preparations including sliced, “tidbits for salads” and grated, of Del Monte pineapples, Evening Star (DC), January 22, 1926, 16, Chronicling America, LOC. Having pineapple on the menu was not nutritionally necessary due to the variety of other fruits the hospital 234 Despite these changes to the hospital menus, the pendulum between patient care and therapy had moved further toward care when it came to food’s role in the hospital during the mid-1920s. The constant pressures of convenience in a large, public mental hospital like St. Elizabeths led created an environment that made it difficult for conscience to improve patient care. In contrast to the 1920 Annual Report, the organizational chart included in the Special Medical Advisers’ Report in 1926 classified the Office of the Head Dietitian under the Administrative Division of the hospital next to the Commissary Service, and not also under the Medical Division. The Chief of the Commissary and the Head Dietitian worked together, according to the chart, to prepare menus for the institution.89 Thus, when it came down to organization, dietitians no longer occupied a place between the medical and administrative divisions of the hospital, and their role was classified as one more of patient care rather than of medical therapy. White also faced a congressional investigation again in late 1928 and early 1929, though the focus of the investigation was not overall mismanagement of the hospital or the treatment of the patients.90 Notably, food in the hospital was always scrutinized, no matter the investigation. In this case, the investigation was focused on the “matter of quarters, subsistence, and help allowed to certain employees” of St. Elizabeths which some congressmen believed to be against the law.91 White and other members of the medical staff had always gotten a salary in addition to offered, but shows how even simple, popular foods with the American public were made accessible to patients in this period. 89 “Report of the Special Medical Advisers on St. Elizabeths Hospital,” 548. 90 Historians of White and St. Elizabeths have tended to overlook this investigation, though its beginnings were reported in the local press. See, for example, “Blanton Attacks Head of Hospital for Insane,” Washington Post, January 14, 1928, 22, ProQuest HN. Note that the article misnames White as “Charles A. White,” but that House representative Thomas L. Blanton of Texas was one of the most vocal opponents of White, going back to the 1926 investigation. 91 House Committee on Expenditures in the Executive Departments, Subcommittee on St. Elizabeth’s Hospital, Quarters and Allowances at St. Elizabeths Hospital, 70th Cong., 2nd sess., February 27 and 28, 1929, 1. 235 housing and food provided by the hospital. However, when the government created Veterans’ Bureau Hospitals and their administrators took salary deductions to pay for their room and board, some politicians protested the status quo at St. Elizabeths. The investigation also focused on financial matters, with a large amount of time spent discussing the amount of money that White and his administrative assistant, Monie Sanger, spent on coal. While this investigation was largely an attack on White and a look into obscure legal statutes, its accompanying hearing testimony reveals how food so often became a point of critique in matters of hospital administration. Where food was, there was also opportunity to critique either patient care or administrative mismanagement of hospital finances. In a similar way to the 1906 investigation, White created part of his defense through asserting authority over food from both medical and administrative positions. The medical oversight of patient food at the hospital became White and Sanger’s primary defense as to why generous subsistence at the hospital should be furnished for the superintendent and first assistant physician. Sanger stated that White ate the same food patients had because it was “the superintendent's business to find out what food is furnished the patients, and by having the same food furnished him, he can better judge whether proper food is being furnished to the patients.”92 If Superintendent White was not present, then it became the duty of the first assistant physician to stand in for him, including his judging of the food. This detail is significant: First Assistant Physician Arthur P. Noyes was head of the medical division of the hospital, while Assistant to the Superintendent Monie Sanger was head of the administrative division. Thus, eating and judging the same food supplied to patients fell under the White’s medical rather than the administrative authority. 92 Subcommittee on St. Elizabeths, Quarters and Allowances, 60. 236 Oleomargarine, a battleground between health and economy in the 1906 investigation of St. Elizabeths, appeared yet again in 1928, but this time White’s appeal to administrative economy shut down discussion quickly. Questions about the butter substitute’s healthfulness came from Wisconsin congressman John C. Schafer, a member of the investigation subcommittee. He asked White and Sanger about the use of oleomargarine in the institution, leading to a bit of a heated exchange: Mr. SCHAFER. Do you use oleomargarine? Mr. SANGER. We use oleomargarine; yes, sir. Mr. SCHAFER. In lieu of butter for bread? Mr. SANGER. Yes, sir. Mr. SCHAFER. Do you do it because you think oleomargarine is more satisfactory to the patients— Mr. SANGER. More wholesome and keeps better. Mr. SCHAFER (continuing). Or does economy enter into the question? Mr. SANGER. Probably both, but it is considered more wholesome and keeps better, and there is less opportunity of a consignment going wrong and cause complaints. Mr. SCHAFER. Do you think it is as good to feed a sick man butterine or oleomargarine, instead of butter? Mr. SANGER. I am not a medical man. Doctor WHITE. They make a magnificent oleomargarine now; but, if this committee wants us to buy butter and will see that we get the appropriation, we will be tickled to death to buy it.93 Both Sanger and White were versed in the long-held rationale for using oleomargarine instead of butter in the institution—it was understood to be nutritionally equivalent to butter, did not spoil as easily or as quickly, and cost less. White, as indicated by his final response, felt that Schafer’s questions were laughable. It is likely that had White been purchasing butter for the use of all patients at the hospital, he would have been accused of misspending government money.94 93 Ibid., 68. 94 Most likely, as a congressman from a Midwest, heavily dairy-producing state, Schafer did not like oleomargarine. This exchange is almost identical to the exchanges that took place in the 1906 investigation, except that White was far more confident in his role as superintendent. 237 Balancing food costs, the hospital diet’s nutritional quality, and lay ideas about what foods were healthy remained an administrative challenge central to large institutions. Lastly, St. Elizabeths staff relied on a mix of administrative and medical authority surrounding food-centered occupational therapies to defend against allegations that the hospital’s truck gardens were “doctors’ gardens” used to funnel food directly to doctors rather than to the institution. Woolley, the clinical director of the male service in the hospital’s medical division, who presided over and conducted research on much of the occupational therapy in the hospital, explained that patients raised the vegetables in the garden surrounding Howard Hall, that the gardens were not used by doctors, and that any food picked was immediately sent to the storerooms.95 To further clarify the use of the gardens, he explained that they were “used as a means of occupational therapy for the benefit of the patients in Howard Hall” by twenty to thirty patients.96 From the administrative side, Sanger inserted that while doctors did not take any of the food, some patients were given it to “get the benefit of what they raise.” Because the gardens were labeled as “truck gardens” it is possible that patients had the option to sell their yields in order to earn a financial benefit rather than keep them for a nutritional one.97 The importance of occupational therapy at St. Elizabeths beyond congressional investigations of the hospital is the focus of the next section. Moral Treatment or Modern Therapy? Food and Occupational Therapy Labor, especially on the institution’s farm, had long been a part of the experience of the institutionalized mentally ill. Nineteenth-century alienists and superintendents saw farm work as therapeutic under moral treatment. At St. Elizabeths, Superintendent William Whitney Godding 95 Subcommittee on St. Elizabeths, Quarters and Allowances, 128. 96 Ibid. 97 Ibid. 238 had established a farm colony for that purpose in 1892, which came to be known as “Godding croft” during White’s tenure at the hospital.98 Historian Ben Harris has argued that the revival of nineteenth-century moral therapy after 1910 came in the form of a the “work cure” that arose in the Northeast United States, particularly in New England.99 According to Harris, this revival “did not last, as Freudians came to dominate psychiatric thought and the optimism of the 1910s was replaced by another wave of therapeutic pessimism.”100 The creation and existence of occupational therapy programs in St. Elizabeths, under the authority and guidance of White, himself a strong supporter of American psychoanalysis, shows that while a wave of therapeutic pessimism did eventually occur, optimism—and what I argue are the continuing forces of Progressivism—accelerated after World War I and remained strong through the 1920s, continuing into the 1930s. Occupational therapy became a welcome addition to St. Elizabeths’s therapeutic offerings because its therapists, like White, also took a “holistic approach to health care.”101 In fact, Adolf Meyer had included occupational therapy as part of his “therapeutic experiment” in psychobiology at the Phipps Clinic in Baltimore.102 White’s leadership of St. Elizabeths showed a similar therapeutic experiment applied to a much larger hospital. In St. Elizabeths’s case, the continuation of that experiment into the post-World War I period shows how work as therapy 98 Millikan, “Wards of the Nation,” 134. 99 Ben Harris, “Therapeutic Work and Mental Illness in America, c. 1830-1970,” in Work, Psychiatry, and Society, c. 1750-2015, ed. Waltraud Ernst (Manchester: Manchester University Press, 2016), 65. Much of the foundational history of psychiatric institutions focused on the Northeast as well. See, for example, Ellen Dwyer, Homes for the Mad: Life Inside Two Nineteenth-Century Asylums (New Brunswick, NJ: Rutgers University Press, 1987), Elizabeth Lunbeck, The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America (Princeton, NJ: Princeton University Press, 1994) and Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum Keeping,1840-1883 (New York: Cambridge University Press, 1984). 100 Harris, “Therapeutic Work,” 56. 101 Virginia Anne Metaxas Quiroga, Occupational Therapy: The First Thirty Years, 1900 to 1930 (Bethesda, MD: The American Occupational Therapy Association, Inc., 1995), 13. 102 Lamb, Pathologist of the Mind, 171-2, 162, 204. 239 continued after World War I, although professionalization made it more systematic and Progressive ideals of economic efficiency and self-sufficiency guided the therapy more than ever before.103 Part of the developing modern treatment for mental illness was thus the rising use of occupational therapy. As noted in the previous chapter, occupational therapy as a new medical specialty was already on the rise by the time that the United States entered World War I. Like dietetics, occupational therapy became a profession during the 1910s and was made up of mostly women.104 Its first professional association, the National Society for the Promotion of Occupational Therapy, was founded in 1917.105 During the war, many psychiatrists supported the idea that the mentally ill could be used as farm laborers for food conservation efforts while also receiving the added benefit of the therapy that came with taking one’s mind off depressing, anxious, or delusional thoughts. The use of occupational therapy in mental hospitals continued to expand after the war was over. Alongside making crafts, patients often did food-related work for their occupational therapy such as farming, animal husbandry, and cooking.106 At St. Elizabeths, occupational therapy officially became part of the hospital as its own department in July 1919.107 In the fiscal year 1920, White created positions not only for dietitians 103 Virginia Anne Metaxas Quiroga describes occupational therapy during World War I as “a practice field between acute illness, the domain of physicians and nurses, and return to economic self-sufficiency, the responsibility of vocational educators.” Quiroga, Occupational Therapy, 146. 104 Ibid., 14-17. Quiroga explained the male physicians involved in occupational therapy lent it medical authority, usually serving in administrative roles such as president of the association or on governing boards of training schools and similar institutions. 105 Ibid., 14-15. 106 Many scholars have pointed out the impact of the Arts and Crafts movement on twentieth-century American culture as well as occupational therapy. See Jackson Lears, No Place of Grace: Antimodernism and the Transformation of American Culture, 1880-1920 (Chicago: University of Chicago Press, 1981), chapters 1 and 2, Jennifer Laws, “Crackpots and Basket-Cases: A History of Therapeutic Work and Occupation,” History of the Human Sciences 24, no. 2 (2011), and Ruth Levine Schemm, “Bridging Conflicting Ideologies: The Origins of American and British Occupational Therapy,” The American Journal of Occupational Therapy 48, no. 11 (November/December 1994). At. St. Elizabeths, the Knights of Columbus helped to teach veteran patients how to make toys as part of occupational therapy. See Gambino, “Mental Health and Ideals of Citizenship,” 102n89. 107 Annual Report, 1920, 23. 240 but also for 11 occupational therapy aids and a superintendent of occupational therapy aids.108 Occupational therapy, in the words of White, was “of distinct therapeutic value, serving to arouse and stimulate the interest of many patients.”109 Ideally, each patient received individualized treatment tailored to their strengths and current abilities. The hospital’s inclusion of occupational therapy soon became part of a larger milieu of therapies based on work and recreation, which looked very similar to nineteenth-century moral treatment.110 St. Elizabeths psychiatrists recognized continuities between moral treatment and occupational therapy, but also articulated changes. Clinical Director Mary O’Malley credited nineteenth-century French psychiatrist and one of the founders of moral treatment, Philippe Pinel, with “the suggestion of employment as a remedy in mental diseases.”111 William Kenna, a medical officer at St. Elizabeths as part of the United States Public Health Service, pointed out that patient work in hospitals been viewed as therapeutic since the 1830s, so that occupational therapy was not altogether modern. “What we can emphasize,” he wrote, “is that in the present day development of this form of therapy, recent occupational activities are less aimless and desultory in their character and more systematic in their application.”112 To Kenna, then, the efficient and purposeful way that occupational therapy was structured was a departure from earlier moral therapy. 108 Ibid., 50, 34. 109 Ibid., 50. 110 As Millikan argues, “Because of the hospital’s historical roots, moral treatment in various guises remained a powerful ideal, resurging periodically after lapsing into routine.” Millikan, “Wards of the Nation,” 203. Further, “White earned a reputation for reinvigorating moral treatment by introducing psychotherapy, dispersing patients among smaller buildings, and improving patient-staff ratios. These initiatives revealed a persistent tradition of concern for individualized care, for daily living conditions, and for incorporating medical and architectural innovations into the fabric of asylum life.” Ibid., 201. 111 Mary O’Malley, “The Psychiatric Approach to Occupational Therapy,” Archives of Occupational Therapy 3, no. 6 (December 1924): 447. 112 William M. Kenna, “Occupational Activities at St. Elizabeths Hospital,” Archives of Occupational Therapy 3, no. 5 (October 1924): 355-6. 241 Farming exemplifies one type of work central to occupational therapy at mental hospitals that became modernized and “systematic” in the eyes of psychiatrists while in practice remaining much the same as in the nineteenth century. Farming, in fact, featured prominently in White’s Presidential Address to the American Medico-Psychological Association in 1925. In the first section of his speech, he sought to “pay tribute to the hospital superintendents of one and two generations ago,” because he felt guilty about how he viewed them in his earliest days as a psychiatrist before he became a superintendent.113 He admitted that he may have “made fun of these sturdy gentlemen because they published annual reports of state hospitals in which were pictured the prize pumpkin at the county fair and the tallest corn raised in the state.”114 White went on to explain that it was unfair to criticize nineteenth-century superintendents for their lack of scientific knowledge, praising them instead for their “humanitarian instinct” which led to a focus on the patient as an individual as a member of the hospital “family.”115 Patient farming revealed the tension between the past and present of work therapy: “[The old-fashioned superintendent] believed in teaching the simple occupations, particularly farming, for he believed in getting close to nature, in working outdoors in the sunlight and fresh air, in raising the food that was to be eaten; and in commenting upon these various ideals I cannot but wonder in passing whether our very intelligent college graduates who have come into the hospital under the designation of occupational therapists have added very much that is of value to these original conceptions.116 Such a discussion shows how many aspects of moral treatment as practiced by the “old- fashioned superintendents” in the mid-nineteenth century continued well into twentieth. While 113 William A. White, “Presidential Address,” American Journal of Psychiatry 5, no. 1 (July 1925): 2. He stated that he wished “to make amends for a state of mind the only excuse for which was ignorance and lack of experience.” 114 White, “Presidential Address,” 2. White further stated that “The pumpkin and the corn in the annual report are symbolic, perhaps, of the simple, uncomplicated, and, if you will, unscientific thinking of the old-fashioned superintendent,” 3. His own reports on the hospital’s vegetables and certified, tuberculin-free Holstein cow herds, however, were not so different, although they had the veneer of agricultural science in the early twentieth century. 115 Ibid., 2-3. 116 Ibid., 3. He did believe that occupational therapy had an “interesting future” in the hospital. Ibid., 4. 242 White still heralded modern, scientific therapeutics as the future, working outdoors and raising a portion of the hospital’s food supply—just as patients did under moral treatment—remained at the foundation of farming as occupational therapy in the twentieth century. One major difference between moral and occupational therapies, was the latter’s focus on economic efficiency through self-sufficiency. One of the primary ways that occupational therapy was defined by St. Elizabeths psychiatrists was through a lens of economic independence; patients, particularly male veterans, were expected not only to readjust socially, but also to readjust economically.117 Psychiatrists had long regarded financial stress as an exciting cause of mental illness. Thus, while they considered work in and of itself to be therapeutic, psychiatrists also recognized that patients who learned skills for a job that could provide financially outside the hospital would have a lesser chance of relapse and readmission.118 Assigned to St. Elizabeths as an advisor for the newly created Vocational Training Center for veterans at the hospital in 1920, William Kenna understood the program as one not founded on therapeutics, but rather “on the conception that patients during their stay in the hospital may be properly surveyed and, in a preliminary way, trained along the lines of future economic helpfulness subsequent to their discharge from the hospital.”119 Job training in the hospital, carried out through occupational therapy or vocational training for veteran patients, was therefore both therapeutic and 117 Kenna, “Occupational Activities,” 355. Matthew Gambino noted psychiatrists’ same focus on “self-reliance and economic independence” as “masculine virtues” when discussing how physicians assessed patient improvement after malarial fever therapy. Gambino, “Mental Health and Ideals of Citizenship,” 145. 118 An example of this can be seen in the duties ascribed to Red Cross psychiatric social workers in Annual Report, 1930, 6. One aspect of their case work was to “secure information about, and to effect the adjustment of financial problems in the patient’s home which are connected with or incident to the patient’s mental breakdown.” 119 William M. Kenna, “The Therapeutic Value of the Training Center at St. Elizabeth’s Hospital, Washington, D.C.,” Medical Record 100 (November 26, 1921): 939, HathiTrust. Kenna also noted the economic problems that faced patients once they were out of the hospital: “As a rule, when a patient leaves the hospital, he goes into an atmosphere of fairly consistent disinterest and enters a social environment where a process of economic attrition is again resumed. Here and there some effort at post-hospital assistance is made; but it is mostly of an advisory nature; and mere advice in this world of constant financial strife is not accepted as a substitute, or as collateral, for that mystifyingly evasive substance termed ‘coin of the realm.’” 243 prophylactic.120 Its prophylactic power came from it being an “economic measure” of how well a patient could earn a living after being discharged.121 Like Kenna, St. Elizabeths Assistant Physician Lois Hubbard focused on the economic aspects of occupational therapy, but her work was not restricted to veteran patients. All “progressive” mental hospitals, she thought, emphasized the “value of work,” and two out of the three purposes she gave for patient work centered on the patient’s economic potential.122 If rehabilitated, the patient could “take his place in the community once more as an economic asset.” If the patient did not get well enough to leave the hospital, their work could at least make them “economically useful to the institution.”123 For Hubbard, work for patients was meant to create an economically valuable citizen, whether inside or outside the hospital setting. A patient’s ability to be economically productive, then, determined how psychiatrists at St. Elizabeths viewed the progress of their therapy in the hospital. To be lazy or unproductive meant that a patient was not mentally fit to adjust to life in the community. Race factored into how vocational and occupational therapy ended up taking place in the hospital. Though there was little explicit discussion of racially segregated labor in administrative documents, it appears that black male veterans were especially assigned to farm work and more menial tasks such as clearing land.124 In many of Superintendent White’s annual reports, 120 Although there are differences between vocational training and occupational therapy, they had similar goals at St. Elizabeths. Occupational therapy served as pre-vocational training for those veterans who went on to vocational training. See Kenna, “The Therapeutic Value,” 939. For the blurry boundaries between vocational training and occupational therapy during this period, see Quiroga, Occupational Therapy, 115-116, 156. 121 Kenna, “The Therapeutic Value,” 940. 122 Lois D. Hubbard, “Congenial Occupation for the Mentally Ill” Hygeia 6, no. 4 (1928): 225. While the title of the article highlights occupation, Hubbard referred to “ergotherapy” rather than “occupational therapy,” as she saw ergotherapy as the “technical name” of the type of therapy. This term was not common. 123 Ibid. 124 NARA RG 418, Entry 49 (Records Relating to the American Red Cross, 1917-1936: Box 2, Folder 3) Herbert Woolley, Monthly Report of the Veterans Department, St. Elizabeths Hospital, October 11, 1922. Not much is said in the record about racially segregated occupational therapy in general, however. Menial tasks in agriculture were often assigned to African American patients; see also chapter 4’s discussion of Maryland’s “Crownsville Corn Cutters Emergency War Squad.” 244 vegetables harvested appear in the table “Articles Made in Occupational Therapy Department” under the category “garden truck.”125 Vegetables included tomatoes, beets, string beans, radishes, lettuce, sweet corn, cucumbers, and eggplant. Most of these garden truck vegetables came from patients in occupational therapy at Howard Hall, who were likely primarily African American.126 In 1921 there were roughly 572 African American male patients at St. Elizabeths, and about 169 were veterans.127 It is likely that many of the vegetables produced at the hospital came from the labor of these patients, whether veteran or civilian. The working class and rural backgrounds of many veterans also influenced the types of job training they received. In general, Kenna believed that industrial, mechanical, and agricultural courses were the most beneficial to veteran patients, especially given the rural background and incomplete primary educations of many of them.128 Although the Veterans’ Bureau had originally hoped that veterans would receive white-collar pre-vocational training, explained Kenna in 1924, this did not completely come to fruition. Leaders of the vocational programs realized they had “shot above the mark” when they tried to train many hospital veterans for white-collar jobs. Many veterans, they argued, saw better therapeutic results when they were assigned “to occupations of a less pretentious nature” such as “weaving, toys, wood- working, farm and poultry projects and other crafts.”129 Progressive ideas about the importance of efficiency and economy, underpinned by the power of science as practiced by experts in an organized administration shined through in newspaper articles about occupational therapy and vocational training for veterans in St. 125 Annual Report, 1921, 12. 126 Subcommittee on St. Elizabeths, Quarters and Allowances, 128. 127 Annual Report, 1921, 30. 128 Kenna, “The Therapeutic Value,” 941. 129 Kenna, “Occupational Activities,” 356. Indeed, Kenna noted, a special class had to be created for the “‘white collar’ types” that did not appreciate the blue-collar occupational training such as “in the somewhat more laborious farm occupation.” Ibid., 357. 245 Elizabeths.130 The combination of the everyday quality of occupational therapy—their good- quality products could be easily admired by anyone who knew good food—alongside an intense public interest in the rehabilitation of “shell-shocked” war veterans created opportunities for papers to publish human interest stories. In D.C., this was also combined with the attention that local papers, especially the Evening Star, paid to events concerning St. Elizabeths. One article, “Veterans at St. Elizabeths Aided in Recovery by Modern Science,” outlined how veterans obtained “restoration” from their work done in the hospital through a relationship between St. Elizabeths medical staff and the Veterans’ Bureau.131 Each department in one office, the author wrote, was “under the direction of an expert.” For the author, agricultural work’s benefits to patients were clear: Today there are a many men whose condition is greatly improved because of this particular treatment. They are taught why trees are pruned, why the ground is tilled and how to economize in the matter of shade trees. For instance, the planting of apple, pear and other similar trees not only provides shade, but also revenue. In the olden days men representing mental cases were allowed just to sit around, and a peculiarity was that the great majority of them sought out dark corners in which to hide themselves. With present-day methods they more speedily regain a healthier condition.132 The author highlights how this work was both therapeutic as well as lined up with the ideals of economy and efficiency. Trees did not just produce shade; fruit-bearing trees could be used to “economize” a landscape, by producing “revenue.” Further, unlike the “olden days,” patients were not allowed to be lazy or “sit around,” but were instead, through this modern and scientific treatment with work, given opportunities to restore their health. 130 See, for example, “Advance in Treating Mental Diseases,” Evening Star (DC), July 13, 1924, 4, Chronicling America, LOC. 131 James A. Buchanan, “Veterans at St. Elizabeths Aided in Recovery by Modern Science,” Evening Star (DC), April 1, 1923, 3, Chronicling America, LOC. 132 Ibid. 246 The championing of scientific experts extended to St. Elizabeths’s poultry farm and its director, Pat Flaherty. The article referred to Flaherty as the “genius of chickendom,” and “a man with an executive mind, a person devoted to research work, the domain of a genealogist, the work-shop of an inventor, the quarters of a keen lover of statistics and a practical poultry man.”133 Veterans learned about caring for a poultry farm from Flaherty, including collecting eggs from hens, testing eggs, marking eggs, understanding the pedigree of chickens, incubating eggs, hatching chicks, and tagging chicks with a band on their ankles with an identification number. This therapy, then, connected an old kind of labor—poultry raising—with the modern, scientific practice of it, thus instilling in patients the values of modern, science-driven American society.134 Psychiatrists’ vision of appropriate work was tied also to the Progressive-Era gender roles for the middle-class. In comparison to male patients in the hospital, female patients’ occupational therapy did not focus as much on their potential economic output, but rather on their potential roles as wives or caretakers.135 Women patients in the industrial department of therapy were encouraged to do “general housework,” which included traditionally female activities such as 133 Ibid. 134 Ibid. Interestingly, purely working with animals proved to be the greatest draw for many patients. The poultry farm was a “magnet” for patients who “appear[ed] to receive greater benefits when handling something of an animate nature.” Patients were so devoted, in fact, that some soldiers and sailors were “so engrossed in their work that half of the time they kick at having to leave their feathered playmates and to respond to mess call.” For the reporter, the veterans’ choice to forego food was indicative of their devotion to their work, enjoyment of the chickens, and the effectiveness of this type of work as restorative—or as the physicians at St. Elizabeths would have thought, therapeutic. This statement is made with the caveat that a continued refusal of food or obsessive focus on work in lieu of meals would not have been seen as a healthy or restorative behavior. In addition, the therapeutic nature of caring for animals—and particularly farm animals—for mentally ill patients was not widely recognized during the early twentieth century, but research on the subject has picked up in the late twentieth century to the present. See, for example, Bente Berget, Oivind Ekeberg, and Bjarne O. Braastad, “Animal-assisted therapy with farm animals for persons with psychiatric disorders: effects on self-efficacy, coping ability and quality of life, a randomized controlled trial,” Clinical Practice and Epidemiology in Mental Health 4, no. 9 (2008): 9. 135 While the practicalities of life meant that a gendered division of labor could not always be maintained in patient work around the hospital (men also worked in dining rooms and kitchens), it was men only that worked outside on the hospital’s farm and with the poultry. See also, Gambino, “Mental Health and Ideals of Citizenship,” 104. 247 “taking care of pantry and dining room, running errands and helping care for feeble patients,” among others.136 Herbert Woolley, a senior assistant physician at St. Elizabeths, explicitly delineated men’s from women’s occupational therapy work; when it came to arts and crafts, men made a larger variety of handmade crafts while women were to focus primarily on work with textiles.137 Some women utilized the opportunity to make crafts as one way to participate in middle-class domesticity that they had never had the opportunity for outside of the hospital. Indeed, Hubbard observed that “some women who have spent their lives in the midst of household drudgery welcome the opportunity of learning to make dainty embroidered articles and attractive baskets.”138 Such an opportunity to make something “dainty”—a term commonly used to describe desirable food as well—revealed the adulation of middle-class pleasures in what doctors saw as appropriate work for women in the hospital to undertake. This was a step toward a more respectable femininity. For some St. Elizabeths psychiatrists, even chronic patients who would likely never be discharged could benefit from occupational therapy by becoming more useful to the institution. Much like their nineteenth-century predecessors, these psychiatrists hoped that occupational therapy would at least distract patients from morbid or apathetic thoughts, redirect their “destructive energy,” and perhaps slow down their mental deterioration.139 Herbert Woolley, the clinical director of the male service, thought occupational therapy “may result in the patient becoming a useful institutional citizen, making an adjustment to the hospital level, even though 136 Hubbard, “Congenial Occupation for the Mentally Ill,” 226. 137 While men did make braided, cloth rugs and weave, women weaved but also sewed, crocheted, and embroidered. Herbert Woolley, “Treatment of Disease by Employment at St. Elizabeths Hospital,” The Modern Hospital 20, no. 2 (February 1923): 198, HathiTrust. 138 Hubbard, “Congenial Occupation for the Mentally Ill,” 226. This quotation is used and cited in Gambino, “Mental Health and Ideals of Citizenship,” 111-112, but not analyzed with regard to the word “dainty” and class- based language. The term dainty appears throughout this dissertation, usually in reference to serving patients “dainty” food. 139 Woolley, “Treatment of Disease,” 198 and O’Malley, “The Psychiatric Approach,” 448. 248 he shows but little improvement from a psychiatric standpoint.”140 Mary O’Malley, also a clinical director at the hospital, observed this in practice. She asserted that occupational therapy created changes on the wards that were “little less than marvelous,” although she noted that the work that had been done was only an experiment only benefitted a small percentage of patients.141 White’s belief in “organism as a whole” and in the power of psychotherapy also influenced how psychiatrists at St. Elizabeths understood the efficacy of occupational therapy. O’Malley, for instance, thought that the primary means of awakening patients’ interest in an occupation was “the transfer.”142 In psychoanalysis, transference occurs when a patient projects their positive or negative emotions about another person onto someone else, usually their analyst.143 However, White and O’Malley also believed that transference was not only something that happened during psychotherapy; as White explained in Foundations of Psychiatry, transfers were “the phenomena of all personal relationships.”144 In treating patients as a whole with a focus on their psyche, psychiatrists could see a patient’s interaction with an occupational therapist as therapy. Despite all the efforts being made at the hospital and psychiatrists’ best intentions, however, occupational therapy was not a cure for chronic mental illness. St. Elizabeths, like many hospitals across the nation, continued to be overcrowded with chronically ill patients. 140 Woolley, “Treatment of Disease,” 198. 141 O’Malley, “The Psychiatric Approach,” 448, 451. 142 Ibid., 449. 143 White, Foundations of Psychiatry, 116. In an article, White also detailed how he thought that all the “cures” of earlier periods, including those of “diet,” “magnetism,” “rest,” etc., were only seen as curative by physicians because of the psychoanalytic “transfer” that had gone on between the physician and their patient. See William A. White, “The Dynamics of the Relation of the Physician and Patient,” Mental Hygiene 10, no. 1 (January 1926): 10. 144 White, Foundations of Psychiatry, 116. O’Malley explained that transfer between the occupational therapist and patient was “not used in exactly the same manner as psychoanalysis but the mechanism at the foundation of the interest which the occupational aide awakens is the same as that of the cure made by the psychoanalyst.” O’Malley, “The Psychiatric Approach,” 449. 249 Patient work at the institution, whether through occupational therapy or simply “healthful employment,” continued through the course of White’s tenure as superintendent. This was true even as more than 600 veterans were transferred out of St. Elizabeths to other Veterans’ Administration institutions in the mid-1920s.145 Farm work continued too, and White began to suggest that further appropriations for additional farmland would be needed in 1929.146 One major impetus was roads which were being built through the institution’s current farmlands to increase access to Washington, D.C. In 1932, these requested appropriations became more urgent, according to White, because the hospital’s population continued to grow and therefore required more land, “not only to provide economical feed for its dairy herd and for the patients, but in order to provide, from a therapeutic standpoint, more work for the patients.”147 The hospital’s economic efficiency remained closely bound together with patient’s potential economic independence through therapy. By the end of White’s tenure, the farm—supplied with patient labor—had become productive over time, but occupational therapy did not improve overall patient recovery rates. In 1904, the hospital had 2,492 patients, which more than doubled to a total of 5,390 patients in 1936.148 The output of the hospital farm from the 1904 Annual Report versus the 1936 Annual Report provide brief yet useful metrics of how the farm grew over White’s tenure as 145 The overall number of veterans transferred out was significant, alleviating some overcrowded conditions in the hospital for at least a couple of years. In the fiscal year of 1926, more than 100 patients were transferred out by the Veteran’s Bureau, while in 1927, more than 500 were. Annual Report, 1926, 10 and Annual Report, 1927, 7. However, the patient population continued to grow rapidly following these transfers, eclipsing the gains made from the transfers. 146 Annual Report, 1928, 3, and Annual Report, 1929, 3. White stated that “the chief function of the farm department, aside from its primary function of furnishing healthful employment to patients, is to furnish foodstuffs for the hospital” 3. 147 Annual Report, 1932, 17. 148 Annual Report, 1904 and 1936. This was about a 116 percent increase in the patient population over 32 years. 250 superintendent. In many instances, the amount of different foods produced outpaced the doubling of the patient population over this period:149 Article of Food 1904 1936 Percent Change gallons of milk 96,290 283,841 195% pounds of fresh pork 53,303 125,794 136% dozens of eggs 4,408.5 13,934 216% pounds of chicken 1,021.5 3,952 287% bunches beets 9,256 29,021 214% bunches carrots 852 31,775 3629% pumpkins 642 812 26% pounds of grape 14,703 5,375 -63% heads of lettuce 14,650 28,679 96% Table 1- Articles of Food Produced at St. Elizabeths in 1904 versus 1936 Milk production as well as fresh meat from the piggery and the poultry barn show substantial production rises over these years, which can be attributed to the benefits of advances in agricultural science and industry that White invested in during this time. The farm vegetables were also cultivated more widely and successfully over these years. Patients, it is not to be forgotten, provided most of the farm labor and were central to feeding the hospital at a low cost. Despite the greater production of food and the implementation of occupational therapy at St. Elizabeths, patient recovery rates declined overall from 1904 to 1937 as the population of the hospital grew, leading to overcrowding.150 Even as aspects of the old moral treatment remained 149 Annual Report, 1904, 193 and Annual Report, 1936, 388. Note that these are selected, and not a complete comparison, but are a representation of the larger trend. I selected these items because the units of measurement are the same between the two periods. Many food items had different measurements. The calculations for percent changed have been rounded to the nearest whole number. 150 For example, the total discharge rate from the hospital in 1904 was about 12.8 percent. 58.75 percent of patients discharged were “recovered,” 32.50 percent were “improved,” 8.5 percent were “unimproved,” and 0.25 percent were found to be “not insane.” 7.65 percent of all patients under treatment died in 1904. In comparison, the total 251 at the hospital through occupational therapy, there was still a limit to the therapeutic optimism and economic aims found in the staff’s academic articles, as recovery rates in a growing chronic patient population. Food, Psychosocial Health, and Red Cross Women Similar to the public’s focus on veteran treatment in the hospital that served as an impetus for investigation in 1919, St. Elizabeths’s treatment of World War I veterans— sometimes referred to as “shell shocked” in the media—drew charitable attention to the hospital during the post-war period.151 Organizations such as the American Red Cross focused on providing entertainment and socially healthy activities for St. Elizabeths patients, particularly for veterans.152 Physicians and nursing staff at the hospital often could not find the time to provide these types of activities, especially directly after the war, because the hospital was still understaffed while White sought to replenish its labor force. Red Cross workers—largely women who were volunteers and social workers—filled an important gap in providing a therapeutic environment for patients during the postwar period. Unlike the female, suffragist hunger strikers who faced threats of institutionalization due to their radical activism discussed in chapter 3, these women participated in Progressive-Era efforts to make people’s lives better by adhering much more closely to traditional gender norms. One quotidian but powerful way women volunteers discharge rate in 1937 was about 7.6 percent. In this year, 33.67 percent of patients discharged were “recovered,” 31.43 percent were “improved,” 33.67 percent were “unimproved,” and 1.22 percent were found to be “not insane.” 5.12 percent of all patients under treatment in 1937 died. Calculations are my own from the corresponding Annual Reports. I calculated the rates using the total number of patients “under care and treatment” for the year. 151 The media’s use of the term “shell-shocked” to describe World War I veteran soldiers in the hospital appears to be overgeneralized. During his written report in the 1919 investigation, White explained that “usually the statement that there were shell-shock patients under treatment in this hospital arises from this who are either ignorant or uninformed and usually the term shell-shock is used by the laity as an entirely different meaning from that when used by physicians.” See William A. White to the Secretary of the Interior, 8. 152 Gambino, “Mental Health and Ideals of Citizenship,” 101. 252 helped to provide therapeutic experiences to veteran patients was through food, whether in the form of gifts or as dinner parties. St. Elizabeths psychiatrists viewed social and physical activities as therapeutically valuable. As part of his conception of “organism as a whole,” White believed that mental disease occurred “at the level of integration between the individual and society”—where the psyche interacted with the environment—and that it therefore existed at the “psychosocial level” the person.153 Thus, White thought the Red Cross’ activities contributed to patients’ integration back into society, as the hospital was a place that not only cared for the chronically mentally ill but also strove to treat patients with therapies backed by science that would allow them to return to society as productive and socially well-adjusted citizens.154 The Red Cross unit thus became very integrated into the hospital during the 1920s—Superintendent White called it the “social center of the institution” in 1924.155 Red Cross workers organized dances and outdoor athletic events for patients. One St. Elizabeths psychiatrist noted to the press that some of the least responsive patients—including some that had even refused to eat—actually “indulged in various games” with the Red Cross workers.156 Similarly, in a letter to the chairman of the District chapter of the 153 William A. White, Medical Psychology: The Mental Factor in Disease (New York: Nervous and Mental Disease Publishing Company, 1931), 113. 154 “Lauds St. Elizabeth Work of Red Cross,” Evening Star (DC), January 11, 1924, 15, Chronicling America, LOC and Gambino, “Mental Health and Ideals of Citizenship,” ii-iii. 155 “Lauds St. Elizabeth Work of Red Cross,” 15. Gambino has noted how the Red Cross building became a “masculine social space” particularly because of the number of young-women volunteers that interacted with white male veterans, who came to dominate use of the space. See Gambino, “Mental Health and Ideals of Citizenship,” 116. Also, the Red Cross paid for and built a long-awaited entertainment space and social hall—simply named the Red Cross Building—in 1920 that White had been unable to convince Congress to appropriate funds for. See Annual Report, 1920, 23. The same year that the Red Cross Building was erected at St. Elizabeths, a temporary building was also erected for the use of the Knights of Columbus. Like the Red Cross, the Knights of Columbus distributed treats to the patients at the hospital, although their service at the hospital ended in 1927. Their “distribution of comforts,” such as fruit and candy, was one of their main contributions to the hospital and its patients, and eventually became a weekly occurrence. Their other contribution was to provide patients in the hospital with vocational training in industrial work such as carpentry and toy-making. See Annual Report, 1924, 9. “Soldier Patients at St. Elizabeth’s Get Gifts,” Washington Herald (DC), November 8, 1919, 10, Chronicling America, LOC. 156 “Brain-Dulled Patients Yield to Red Cross,” Evening Star (DC), November 29, 1919, 3, Chronicling America, LOC. It is notable that a focus on the Army and Navy patients was not lost; the article mentioned that “the Army and 253 Red Cross, White stated that many St. Elizabeths patients “suffer[ed] from an inability to freely associate with their fellows,” and that the activities provided by the Red Cross helped to combat that symptom of mental disorder.157 While Red Cross entertainments frequently included dances and athletic events, the important role of food in Red Cross workers’ contributions to encouraging patients’ psychosocial health has been largely overlooked by historians.158 Gifts of food items that Red Cross workers provided to patients were one category of these contributions. Foods gifted to patients most frequently included cakes, oranges, apples, candy, and ice cream.159 The Red Cross’s distribution of fruit, candy, and ice cream to patients became an organized, weekly occurrence.160 Between July 1921 and July 1922, for instance, the Red Cross distributed 1,800 pounds of candy, 2,000 gallons of ice cream, sixty cases of oranges, seventy-five cases of apples, thirty bunches of bananas, and twenty-five baskets containing other fruit to mostly veteran patients.161 Through the Junior Red Cross, eighth-grade students at local schools supplied veteran patients at St. Elizabeths and other D.C. hospitals with jelly, jam, preserves, marmalade, grape juice, and pickles made in their domestic science classes.162 Some foods were also given as gifts for holidays. For Easter in 1925, for example, the Red Cross Navy patients were largely away for the day, enjoying festivities in Washington, and the inspiration of their military example was therefore lacking.” 157 “Lauds St. Elizabeth Work of Red Cross,” 15. 158 Otto does mention briefly how the Red Cross supplied patients with fruit, candy, and ice cream, but does not analyze this fact. See St. Elizabeths Hospital, 238-243. For other historians’ discussions of the Red Cross at St. Elizabeths during this period, see Gambino, “Mental Health and Ideals of Citizenship,” 101-118 and Millikan, “Wards of the Nation,” 183. 159 It is important to note that the only non-food items often included on this list of “gifts,” were cigarettes/ “smokes.” This dissertation does not explore the role of cigarettes in mental hospitals, but important scholarship on this topic has been done. See Laura D. Hirshbein, Smoking Privileges: Psychiatry, The Mentally Ill, and the Tobacco Industry (New Brunswick, NJ: Rutgers University Press, 2015). For the foundational work on the history of tobacco, medicine, and industry, see Allan M. Brandt, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America (New York: Basic Books, 2007). 160 Annual Report, 1922, 4. 161 NARA RG 418, Entry 49 (Records Relating to the American Red Cross, 1917-1936: Box 1, Folder 3 of 3) John N. Zydeman, “Annual Report of the American Red Cross,” July 1, 1921, to July 1, 1922. 162 “Reed Soldiers Get Gifts from Pupils,” Evening Star (DC), November 23, 1919, 9, Chronicling America, LOC. 254 distributed a chocolate easter egg to veteran patients.163 These gifts of food items allowed veterans in the hospital to have their own treats to enhance their hospital diet. They also enhanced veterans’ ability to celebrate holidays with a tasty, nostalgic treat. While the hospital did serve dessert, the gift of having a food item to oneself or the comfort of a treat was likely special to patients, especially those who did not have family nearby. Supper parties hosted by the Red Cross were important for creating social opportunities outside of the hospital setting. Volunteers took some patients to supper parties off the hospital grounds on a weekly basis.164 Between July 1921 and July 1922, the Red Cross hosted thirty special supper parties that entertained 1,734 patients.165 Hospital authorities did allow other organizations to take veterans out of St. Elizabeths for supper parties and other entertainments, however. Veteran patients, along with other disabled World War I veterans from D.C. area military hospitals, even attended a garden party and supper hosted at the White House by President and First Lady Harding in 1922.166 Just like sporting events and dances were meant to keep patients’ minds away from morbid thoughts, supper parties provided a healthy social activity for veterans. Women Red Cross members as well as other women volunteers connected to local charities also provided a sense of home and even motherly attention through the food they brought to veterans at St. Elizabeths. One Red Cross volunteer, Mrs. Bertha Winnie Eldred, made it her mission to “bring home to the soldiers” who had no friends or family able to visit 163 NARA RG 418, Entry 49 (Records Relating to the American Red Cross, 1917-1936: Box 1, Folder 3) Report of John N. Zydeman, The American Red Cross Field Director at St. Elizabeths Hospital on April 1, 1925. 164 Annual Report, 1922, 4. 165 Zydeman, “Annual Report of the American Red Cross,” July 1, 1921 to July 1, 1922. Most of these patients were likely white, male veterans who had earned parole. As Matthew Gambino has calculated for the year 1926, 19.7 percent of all white male patients had parole as compared to 8.3 percent of black male patients. See Gambino, “Menth Health and Ideals of Citizenship,” 109. 166 “The Chief Executive and Mrs. Harding to Be Hosts for 2,000 Disabled Veterans of the World War,” Evening Star (DC), June 7, 1922, 8, Chronicling America, LOC. 255 them. She brought homecooked food to them, including baked biscuits, cakes, and candies, which they ate “ravenously.”167 Women volunteering for the Trinity Community House, a local D.C. welfare organization, likely saw their efforts similarly. On one occasion, the women “were on hand in aprons and kitchen apparel of all sorts cooking up and serving a great big dandy fine supper for those soldiers and sailors” at St. Elizabeths.168 A newspaper editorial played to the gender norms of the period, stating that these women “had gone into the work of doing for St. Elizabeth’s [sic] patients what the doctors themselves cannot do—that is, to add the friendly and the motherly touch.”169 Through providing home-cooked meals and treats to veterans, many women volunteers adhered to the traditional vision of the domestic woman and nurturing mother, through which they hoped to help to heal “shell-shocked” soldiers facing, as one historian has termed it, a “crisis of masculinity.”170 While the role of psychiatric social workers at St. Elizabeths related to food has been difficult to glean from the archives, they also played an important part in the activities of the Red Cross at the hospital. Three psychiatric social workers worked there.171 Not only did they help to keep patients’ medical records up to date and monitor patient parole, but they also served as an important link to the outside world for patients by connecting them with family and friends.172 For example, when a Marine Corps veteran’s mother, a “Slavic peasant immigrant,” visited the 167 Committee on Expenditures in War Department, War Expenditures: Hearings Before Subcommittee No. 2 (CAMPS), 232. 168 “Agricultural Department Women Aid Trinity,” Washington Times (DC), October 27, 1919, 20, Chronicling America, LOC. 169 “Ibid. Later that year, the organization provided entertainment and church visit, complete with an oyster supper, to “one hundred and thirty shell-shocked soldiers” from the hospital. See “St. Elizabeth Soldiers Are Dined, Go to Church,” Washington Herald (DC), November 24, 1919, 2, Chronicling America, LOC. 170 I have applied Elaine Showalter’s discussion of a World War I “crisis of masculinity” to shell-shocked soldiers directly. She argued in her book about hysteria as a historically “female malady” that shell shock was “male hysteria.” She wrote that “shell shock was related to social expectations of the masculine role in war” and that the “Great War was a crisis of masculinity and a trial of the Victorian masculine ideal.” See Elaine Showalter, The Female Malady: Women, Madness, and English Culture, 1830-1980 (New York: Pantheon Books, 1985), 171. 171 Annual Report, 1930, 6. 172 Ibid., 6. 256 hospital from out of state to try to get her son discharged, social workers ensured that she had housing and food.173 The archival record also shows that these social workers were likely reading academic articles while at the hospital, which gives a glimpse of the way they may have approached issues concerning food with patients. An article by Grace Dorman Raynes, a psychiatric social worker at Grafton State Mental Hospital in Massachusetts, was torn out of a journal and saved in the institution’s archive. In it, Raynes discussed the challenges of psychiatric social work, including food. “Food can cause profound misunderstanding between people,” wrote Raynes.174 Psychiatric social workers, who were generally white, middle-class women, recognized that cultural differences in food preferences between themselves and some of their patients of different ethnicities or social classes could create problems. But food did not only present obstacles for social workers; it could provide comfort for patients and help them to adjust to life in a mental hospital. In one of Raynes’s examples, a female Chinese patient who feared and distrusted the hospital staff appeared to be won over when her social worker “collected a good, hot, Chinese dinner from the patient’s family and brought it back to her” while completing the interviews necessary for the woman’s case history. In another, an “astute” social worker had read a hospitalized, old woman’s case file; she discovered that the woman was “of a very genteel family, but reduced to the utmost poverty,” 173 NARA RG 418, Entry 49 (Records Relating to the American Red Cross, 1917-1936: Box 1, Folder 1) Margaret Hagan, “Narrative Report as of October 30, 1936.” See “She Wanted Her Boy.” Even though the social workers continued to provide help, the picture of the woman in the eyes of the Red Cross Field Director was of a simple and irresponsible person: “She took it for granted that there would be agencies wherever she went who would not let her starve and it was impossible, and we did not attempt it of course, to illuminate her own responsibility to her.” This interaction took place during the aftermath of the Great Depression, which did not seem to strike the Field Director. 174 Grace Dorman Raynes, “The Ones Who Have to Stay,” Reprinted from The Survey, February 1934, clipping, in NARA RG 418, Entry 49 (Records Relating to the American Red Cross, 1917-1936: Box 1, Folder 1). She remembered a time that a fellow social worker thought Jewish houses were “dirty because they sometimes smelled of garlic.” The implication was that Raynes understood ethnic cooking to be culturally different and that having what today is called cultural literacy led to better social work. 257 and loved doughnuts and coffee. The social worder was able to contact the patient’s friends, who were “still game enough to contribute the small amount needed to give her coffee and doughnuts on occasion between meals, the happy moments in an otherwise—to her—stale and unpleasant existence.”175 For some patients, having contact with psychiatric social workers meant an understanding of their individual backgrounds, which included the foods that they traditionally ate. Those foods brought them comfort and aided their psychosocial health through knowing that their friends or family cared for them. It is likely that the psychiatric social workers at St. Elizabeths incorporated those ideas into their own work and humanistic philosophies of care and therapy, even if they primarily benefitted veteran patients. Nurses’ Training, Dietotherapy, and “Organism as a Whole” in the 1930s In the years following the last investigation into the hospital during White’s tenure as superintendent, major developments were made to the hospital’s food service. In 1929, the category “Diet” rather than the more administrative term “Food Supplies” or “Kitchen Supplies" made its first appearance in the hospital’s Annual Report, and it remained a category until White’s successor took office.176 The variety of the hospital diet continued to expand. The addition of an ice cream machine in the hospital around 1926 meant that ice cream was “added to the regular dietaries as a dessert, at least once a week for all the patients.”177 Canned fruits and fowl became regular menu items.178 Previously, patients had only been able to eat ice cream if it had been donated and were only served chicken and turkey on Thanksgiving and Christmas.179 Throughout the 1930s, White reported that the hospital “continue[d] a study of the diet.”180 175 Ibid. 176 Annual Report, 1929, 2. 177 Annual Report, 1928, 2. 178 Annual Report, 1928, 3 and Annual Report, 1929, 3. 179 Annual Report, 1929, 3. 180 Annual Report, 1930, 4. See also Annual Report, 1931-1936. The first sentence of the diet section is always the same. 258 The Nurses’ Training School at St. Elizabeths brought instruction in dietotherapy to students while hospital psychiatrists continued to stress the importance of careful management of mentally ill patients’ diets. One St. Elizabeths psychiatrist asserted in 1927 that “the fundamental rules of diet apply as well to the mentally ill patient as to anyone else and the same or greater care should be taken concerning proper balance and vitamin content.”181 Indeed, the discovery of vitamins and the existence of dietary deficiency diseases such as pellagra made patient nutrition more difficult to manage. By 1931, dietotherapy had become a course.182 The dietotherapy courses, run by the “Dietary Department,” consisted of a lecture and laboratory course in “Nutrition and Cookery,” including forty-six hours of instruction, and a course “Diet in Diseases,” which was sixteen-hours of lecture and recitation including six weeks of practical work in the diet kitchen.183 Although there was no specific diet for mental illness featured, students still experienced the challenges discussed in chapter 4 that came with feeding an institutionalized, mentally ill population. Despite these advances, White’s choice to shift the dietitians to the administrative branch of the hospital during the mid-1920s harmed the department’s ability to train student nurses in dietetics and dietotherapy. Administrative convenience likely spurred the move since the kitchens were scattered throughout the hospital grounds and the only office space that the head dietitian occupied was near the main storeroom and the chief of the commissary. The most up-to- date diet kitchen was not installed in the hospital until the opening of the new Medical and 181 Lois D. Hubbard, “Diet Problems of Mental Patients: Feeding the Violent and the Depressed,” Hygeia 5 (April 1927): 195. 182 United States Department of the Interior, Ninth Annual Announcement of the St. Elizabeths Hospital School of Nursing, 1931 (Washington, DC: Government Printing Office, 1931), 6-10, ProQuest Congressional. 183 Department of the Interior, Ninth Annual Announcement of the St. Elizabeths Hospital School of Nursing, 1931, 6. 259 Surgical Building in 1931.184 Housing the dietitians in an administrative rather than medical section of the hospital resulted in a conflict between White and the Nurses’ Examining Board of D.C. in 1932. The Executive Secretary of the Nurses’ Examining Board of the District of Columbia, Bertha E. McAfee found the dietetic department was not educating student nurses properly, and implied that the course was in danger of being de-accredited. Nursing students, she claimed, were not being taught how to calculate and prepare therapeutic diets. They also weren’t going into the wards to follow up on patients enough. Further, she had discussed the situation with Herbert Woolley, the Clinical Director of the Male Service at the hospital, and another doctor during her visit to the institution. For MacAfee, diet was medical. It was a part of hospital therapeutics. Thus, when on her visit she “received the impression that under the present set up of having this department under the administrative rather than the medical service,” she felt that there was “little hope of any improvement.”185 After she received a response from Woolley, she explained the problems with the training even further, outlining a five-point summary of the requirements for student nurses’ training in dietetics, stressing again that she was “still of the opinion that if this department were directly responsible to the medical and surgical division, 184 Congress appropriated $875,000 for the building and besides functioning as a general hospital with eye, ear, nose and throat, dental, dermatological, neurological, and gynecological clinics among others, it also housed the nursing school and contained “not only class rooms but model wards and diet kitchen.” See Annual Report, 1930, 5. The Washington Post heralded the building and its equipment as “of the most modern nature,” stating that “the wiping out of the distinction between sane and insane in hospital treatment will arrest the attention of hospital authorities and insane experts the world over.” See “St. Elizabeths Hospital,” Washington Post, October 25, 1928, 6, ProQuest HN. 185 NARA RG 418, Entry 7 (Administrative Files ca. 1921-1964: Box 29, Folder St. Elizabeths Training School for Nurses) Letter from Bertha E. McAfee to William A. White, July 12, 1932. In the letter, McAfee wrote to White: “I am sure you readily understand what an important part diet plays in disease at the present time and the value of this education to the student nurse.” 260 better correlation and cooperation would be possible.”186 White’s decision to place the dietitians under the administrative rather than medical service was therefore not an inconsequential one. It appears that Woolley and St. Elizabeths dietitians responded to McAfee’s concerns, as the Training School continued to function and the courses taught to student nurses by the hospital dietitians continued according to the Annual Reports.187 White’s Annual Report for 1932 noted that “the nurses during their training receive actual practice in the diet kitchens of the Medical and Surgical Building,” and that “the work this year was given for the first time in the new dietetic laboratory in the Medical and Surgical Building.”188 Notably, the phrasing of “actual practice” in the report mirrored the language used by McAfee in her letter. During White’s tenure in the 1930s, menus were still calculated to ensure the proper number of calories and macronutrients without too much monotony, but his increased concern about the appeal of food to patients was a striking departure from discussions about the hospital diet in the previous reports. In 1931, he asserted that it did not matter “whether the physician administers a drug, prescribes a dietetic or hygienic regime or performs a surgical operation, the influence of these measures upon the patient’s psyche should never be lost sight of.”189 Dietetics had firmly secured its place in the hospital’s therapeutic milieu for White; it was a representation 186 NARA RG 418, Entry 7 (Administrative Files ca. 1921-1964: Box 29, Folder St. Elizabeths Training School for Nurses) Letter from Bertha E. McAfee to H. C. Woolley, August 19, 1932, Most important were the “actual preparation of proper diets for special cases, such as diabetic, nephritic, anemic, etc., as well as experience in the selection and computation of diets” and that “each student should prepare at least four therapeutic diets daily.” Underlines are in original and indicate the strength of McAfee’s demands. 187 NARA RG 418, Entry 7 (Administrative Files ca. 1921-1964: Box 29, Folder St. Elizabeths Training School for Nurses) Letter from Herbert C. Woolley to Bertha E. McAfee, August 22, 1932. 188 Annual Report, 1932, 4. The timing of this in the Annual Report should be of note. Technically the report covers the fiscal year ending on June 30, 1932, and this correspondence happened after that. However, it is possible the report was written and submitted sometime in the fall and thus included changes in response to McAfee’s letters. A publication by Nolan D. Lewis with a date of November 1932 appears in the report. 189 White, Medical Psychology, 134. In 1935, when explaining “organism as a whole,” he also wrote that “therapy in every instance, whether it be surgical, mechanical, medicinal, dietary or what not, [is] administered by and through a personality.” William A. White, “Emotions and Bodily Changes (Special Review),” The Psychoanalytic Review 22, no. 4 (October 1935): 443, ProQuest. 261 of something, like a drug, that was usually regarded as somatic but still had psychological impacts on patients. White’s vision of the “organism-as-a-whole” also influenced the psychiatrists at St. Elizabeths. Lois Hubbard, echoing White in her 1927 article “Diet Problems of Mental Patients: Feeding the Violent and the Depressed,” asserted that mental illness was “a disorder of the entire individual and not merely of the mind.”190 She went on to explain that diet was one way that the body of an individual received attention in mental hospitals while “the mind received care and treatment” there.191 Even with White’s own focus on psyche, Hubbard reminded practitioners that both psyche and soma had to be treated. Thus, White’s view that body and mind could not be separated was adopted by many of the hospital’s staff, ensuring that dietary treatment held a firm place in the mental hospital’s therapeutics. By the late 1920s and early 1930s, the pendulum between care and therapy had swung back toward the middle-resting point, with greater attention once again paid to food as therapeutic. One of the dietary studies being conducted at intervals was to see “what foods may not appeal to the patients so that substitutes may be furnished.”192 On this line, more varieties of leafy greens were grown on the hospital grounds and there was an effort to supply the hospital with fresh greens all year round.193 A similar effort was taken regarding the raising of root vegetables that were best eaten in winter months, including parsnips, carrots, and beets.194 Beginning in 1931, there was recurring attention to how patients’ food could be “served in a more appetizing manner.”195 Besides adding variety to the general diet, the largest expression of 190 Hubbard, “Diet Problems of Mental Patients,” 195. 191 Ibid. 192 Annual Report, 1929, 3. 193 Annual Report, 1931, 3. 194 Annual Report, 1932, 3. 195 Annual Report, 1931, 3. 262 respect for patients’ food choices came when the hospital began cafeteria service. Although the cafeteria system was also economically efficient—dietitians in charge of the various hospital kitchens reported that under the cafeteria system, food waste had been reduced by about 40 percent—cafeteria service still provided patients with more agency over their food choices in an institution where many aspects of their individual agency were limited.196 Cafeteria service began in the hospital in 1932 when the Toner building kitchen was converted into a cafeteria that served 150 to 175 patients and allowed patients to choose which foods they wanted to eat. White reported that patients enjoyed the cafeteria service and had “not hesitated to express their approval of the improvement in the manner in which the food is served.”197 Indeed, the cafeteria service in Toner was so popular that patients from other buildings requested and were granted permission to use it.198 Patients were given a choice of meats, vegetables, salads, and desserts, which covered most of the dietary categories except for dairy and eggs.199 The hospital had so much success in cafeteria feeding that by 1935, the cafeteria system had expanded to serve 3,500 out of approximately 5,300 patients. In 1936, 3,500 patients were served by full cafeteria service while an additional 1,000 had cafeteria service in modified form.200 Cafeteria service became one powerful example of how White put his concept of “organism-as-a-whole” into practice at the hospital by placing further emphasis on patients’ psyche. While moral treatment strictly regimented patient diets, White’s emphasis on psyche 196 See Annual Report, 1936, Reprinted in the U.S. Department of the Interior, Annual Report of the Secretary of the Interior, Fiscal Year 1936 (January 1, 1936), 391. 197 Annual Report, 1935, Reprinted in the U.S. Department of the Interior, Annual Report of the Secretary of the Interior, Fiscal Year 1935 (January 1, 1935), 385. 198 Annual Report, 1932, 4. 199 Annual Report, 1932, 4. 200 Annual Report, 1936, 391. One of the primarily African American male buildings, West Lodge, appears to be one of the last to transition to cafeteria service. Ibid., 400. 263 over soma in this instance illustrated his commitment to treating the whole person, even when it came to diet.201 He did not hesitate to report the happiness of the patients with this new system of feeding, as hospital staff reported its therapeutic effects were apparent. White noted that during the cafeteria service, “It was a surprise to see the large number of patients belonging to the chronic and deteriorated groups who were able to get along with this type of service.”202 Hospital physicians were used to trying to persuade patients to eat. If they didn’t eat, physicians tube fed them.203 In 1924, for example, 199 patients were tube fed for a total of 7,330 tube feedings that year.204 The chief dietitian noted the changes that the cafeteria brought to some women tube-fed patients, reporting to White that two patients who had been tube-fed for several days and were then transferred to another building with cafeteria service “chose their food and ate their first meal of their own election in their new surroundings.”205 The cafeteria service, through allowing patients to choose their food, thus proved therapeutic in some cases.206 Conclusion The challenges posed by World War I only catalyzed the development of St. Elizabeths’s institutional diet and the administration’s reliance on college-educated professionals to create and serve that diet. The Great War also led to an increase in farming at the institution, which 201 The cafeteria method of food service likely had its flaws. Some patients probably did not benefit from this experiment in choosing their meals from the standpoint of proper nutrition. As discussed in chapter 4, mentally ill patients could have eating habits that, if not kept track of, could lead to dietary deficiency diseases like pellagra. 202 Annual Report, 1935, 391-2. 203 Doctors rarely, if ever, referred to it as “forced feeding,” as they believed the procedure to be a medical necessity and treatment. See chapter 3 for further discussion about the use of “tube feeding” versus “forced feeding.” 204 Annual Report, 1924, 17. I calculated these percentage figures based on the data provided. The statistics on tube- feeding are not reported in other Annual Reports. It is unclear why, in this year, statistics on patient feedings were given. It is of note, given my analysis of Alice Paul and the forced-feeding of suffragists in chapter 3, that white women were most likely to be tube fed. Out of tube-fed patients that year, 66.33 percent were white women; 16.4 percent of all white women patients in the hospital that year were tube fed. Further evidence and data are needed to assess why white women were tube-fed at higher rates than other demographic groups of patients. 205 Annual Report, 1936, 391. 206 The cafeteria system was also seen as economically efficient, as dietitians in charge of the various hospital kitchens reported that under the cafeteria system, food waste had been reduced by about 40 percent. See Ibid., 391. 264 helped to speed the development of the hospital’s farm during the postwar period along, creating more variety in food for the patients. Regardless of the problems with employees and administration exposed by patient escapes as well as accusations about the poor treatment of veterans in St. Elizabeths featured in local newspapers, the hospital continued to modernize not only its kitchens, agricultural operations, and diet, but also the essential scientific and medical operations in the hospital with the appropriations provided by Congress. The staff at St. Elizabeths, including the more recently hired dietitians, had vastly more credentials and education than when White had become superintendent in 1903.207 For White, the “old days” of the asylum had passed, and St. Elizabeths as he saw it in 1937 was the modern mental hospital that he had worked so hard to build. White was also remembered at his death in 1937 as a true Progressive by his colleagues. Winfred Overholser, who became the St. Elizabeths superintendent following White’s death, commented on White’s legacy. He said that White was “the most eloquent, forceful, and progressive psychiatrist in this country, and he had achieved for Saint Elizabeths, always a highly regarded institution, an enviable position in the ranks of mental hospitals.”208 Harry Stack Sullivan, a psychiatrist who worked under White at St. Elizabeths for one year and then went on to become a leader of American psychiatry, psychoanalysis, and interdisciplinary work with social scientists during the interwar period, felt similarly to Overholser in his assessment of White’s legacy.209 In Sullivan’s foreword to the collection of the first William Alanson White 207 White, Autobiography, 130. 208 As cited in Arcangelo R. T. D’Amore, ed. William Alanson White: The Washington Years, 1903-1937 (Washington, DC: U.S. Department of Health, Education, and Welfare, 1976), 9. 209 Sullivan came to St. Elizabeths as a liaison officer for the Veterans Bureau in November of 1921, which was a major turning point for his career, according to historian Helen Swick Perry. See Helen Swick Perry, Psychiatrist of America: The Life of Harry Stack Sullivan (Cambridge, MA: The Belknap Press of Harvard University Press, 1982), chapter 22. He became an expert in schizophrenia after taking a new job at the Sheppard and Enoch Pratt Hospital in Towson, Maryland. Sullivan became known as an expert in schizophrenia, and his work to promote life histories of patients and to help craft the field of interpersonal psychoanalysis made him a pioneer. See Naoko Wake, Private 265 Memorial Lectures, he stated that White “was a leader, a champion of progressive developments” in psychiatry.210 Indeed, White and Sullivan had both been representatives of the American Psychiatric Association during the Colloquium on Personality Investigation (1928 and 1929), which was a significant interdisciplinary event for psychiatrists and sociologists.211 Investigating St. Elizabeths through White’s whole tenure allows us to see how a Long Progressive Era manifested at the hospital, with reforms catalyzed by World War I. Even as many therapies that made up a part of moral treatment remained, White put his own spin on them through the hiring of professionals, a focus on economic efficiency and independence, and his concept of “organism as a whole.” Following the development of not only White’s psychiatric thought but also his administrative management through the end of his tenure as the superintendent of St. Elizabeths in 1937 shows how Progressive ideology continued to grow and impact mental hospitals and their patients well beyond World War I. A food-focused history allows us to see the ways in which White’s commitment to the care and treatment of patients until his death in 1937 contained many aspects of nineteenth-century moral treatment and mind-body holism. On the other hand, using food to view the development of not only dietetics but also occupational therapy, social work, and charitable volunteer efforts show us the wide variety of ways that therapy could take place in the hospital even if it wasn’t curative for the increasing number of people with chronic mental illness who ended up there. As White once wrote, “And even if, roughly speaking, the institutional psychiatrist is no more able to cure his patients than he was Practices: Harry Stack Sullivan, the Science of Homosexuality, and American Liberalism (New Brunswick, NJ: Rutgers University Press, 2011), chapter 1 and Naoko Wake, Roger Frie, and Pascal Sauvayre, “The Roots of Interpersonal Psychoanalysis: Harry S. Sullivan, Interdisciplinary Inquiry, and Subjectivity” in Culture, Politics and Race in the Making of Interpersonal Psychoanalysis: Breaking Boundaries, eds. Roger Frie, and Pascal Sauvayre (New York: Routledge, 2022). 210 D’Amore, William Alanson White, 10. 211 Wake et al., “The Roots of Interpersonal Psychoanalysis,” 28. 266 twenty-five years ago, he approaches them not with interest and with some considerable measure of understanding.”212 Although he only names psychiatrists here, it is clear that many female professionals and volunteers of different specialties in the hospital also approached patients in this way. Of course, further studies could show ongoing continuities and changes in psychiatry and Progressivism after 1937, but this study ends chronologically with White. When viewed through a sociocultural-informed institutional history, the transitional nature—part change and part continuity—of the first few decades of the twentieth century in psychiatry as well as in American modernity are clear. 212 William A. White, Twentieth Century Psychiatry: Its Contribution to Man’s Knowledge of Himself (New York: W. W. Norton & Company, 1936), 28, HathiTrust. 267 CHAPTER 6: “I feel that I really need something to eat”: Patient Perspectives on and Challenges to Institutional Food and Medical Authority in the Long Progressive Era Introduction St. Elizabeths hospital, under the Progressive and psychoanalytically inclined administration of William Alanson White, served as a relatively receptive institution to patient expression. For White, the “patient’s point of view” and their confidence in the physician or psychiatrist treating them formed an important aspect of treatment.1 He thought that patients had long “been crying out to be understood”; it was only with an understanding of the mental mechanisms underlying patient psychology developed during the early twentieth century that psychiatrists had “been able to turn an understanding ear to what [patients] had to say.”2 Taking up this spirit, this chapter departs from the focus of earlier chapters on psychiatrists and other scientific experts to turn an historical ear to patients’ perspectives of food and diet at St. Elizabeths during the Long Progressive Era. Food was not only necessary sustenance or medical therapy that hospitals provided for patients. It held meaning connected to patients’ identities and personal beliefs beyond a concern for sustenance. Patients’ perspectives about food further illuminate the complex balance between custodial care and medical treatment in the mental hospital. Patients had agency and many used food as a tool to shape their hospital experience. I argue that patients’ food preferences, when they differed from the hospital diet, disrupted a simple dichotomy of care and therapy. Individual preferences for different food complicate the psychiatric perspective of administrative and therapeutic understandings of food in the institution that this dissertation has focused on thus far. 1 William Alanson White, The Principles of Mental Hygiene (New York: The Macmillan Company, 1917), 77, HathiTrust. 2 White, The Principles of Mental Hygiene, 67-8. 268 Furthermore, these preferences and doctors’ responses to them show that food was a site where the convenience and coercion of the Progressive-Era mental hospital could give way to doctors’ conscience and subsequent decision to provide individualized treatment.3 Consequently, the dietary reforms put into place throughout White’s tenure as St. Elizabeths superintendent did not always work in the quotidian interactions between patients and doctors. Two St. Elizabeths patients, Jacqueline Page, a local D.C. woman, and James Kalter, an Army veteran and Austrian immigrant, are the focus of this chapter and its analysis.4 After their commitments to St. Elizabeths, both patients spent the remaining years of their lives in the hospital as two of the thousands of “chronic insane” that filled St. Elizabeths and state mental hospitals during the early- and mid-twentieth century. While neither patient recovered from their mental illness or was able to negotiate for their release, both used food to navigate their institutional life and their interactions with doctors. Notably, Page’s and Kalter’s stories demonstrate how patients with alternative beliefs and values about food—whether an adherence to a vegetarian diet or to naturopathic medical ideas which included a focus on “natural” foods— struggled with gaining acceptance from their doctors but did sometimes win tolerance for them. Page’s and Kalter’s perspectives also highlight how food could be intimately connected to patients’ beliefs about freedom and American “civilization” during the Long Progressive Era. These beliefs related to the racial, gender, and socioeconomic backgrounds of Page and Kalter 3 I am using the categories that David Rothman created in Conscience and Convenience: The Asylum and Its Alternatives in Progressive America (Boston: Little, Brown and Company, 1980). 4 With care about confidentiality and the sensitivity of mental hospital patient records, I have changed the names of the two patients in this chapter, keeping the initials the same, although the records are open to the public. The case file numbers that are cited throughout are accurate for scholarly research and citation purposes. In this, I follow Matthew Gambino’s precedent. See Matthew Joseph Gambino, “Mental Health and Ideals of Citizenship: Patient Care at St. Elizabeths Hospital in Washington, D.C., 1903-1962,” (PhD diss., University of Illinois at Urbana- Champaign, 2010), 310. The case files used in the chapter both come from NARA RG 418, Entry 66 (Case Files of Patients, 1855 - ca. 1950). The first is Case 15330 in Box 261. The second is Case 21807 in Box 320. Each case has two folders, a medical folder, and a correspondence folder. The folder is identified in each citation. 269 which informed not only how they experienced food within the mental hospital but also how they understood their place within American “civilization.” As a white, likely middle-class, woman, Page’s rhetoric is similar to that of the woman suffragist hunger strikers examined in chapter 3 in her focus on demanding her rights from the government and the doctors who were on its payroll. Kalter, on the other hand, an Austrian immigrant man who was a U.S. Army veteran, often evinced the kind of “manliness and civilization” which President Theodore Roosevelt was known for.5 Patients’ actions surrounding something as quotidian as diet are thus able to reveal tensions in the relationship of the mental hospital to American “civilization,” freedom, and government during the Progressive Era. While one approach to exploring the patient perspective of food in mental hospital would have been to create a composite of many patient voices, I chose to focus on two patients. I took this approach because their own writings about food and health contained in their case files are exceptionally rich and detailed. In addition, a close and in-depth analysis of some of their writings during their institutionalization allows me to more fully represent Page and Kalter as unique individuals rather than just clinical cases.6 This approach mirrors the humanitarian and Progressive goals of psychiatrists and nurses in mental hospitals to treat patients as individuals, even when many failed to realize these goals amidst a growing chronic patient population and overcrowding in many public hospitals during the early twentieth century. Furthermore, focusing on these two patients still allows the analysis to cover almost the entire length of White’s tenure of 1903 to 1937, which is the basis for this dissertation’s 5 Gail Bederman, Manliness & Civilization: A Cultural History of Gender and Race in the United States, 1880-1917 (Chicago: University of Chicago Press, 1995), chapter 5. 6 Geoffrey Reaume, “Keep Your Labels Off My Mind? or ‘Now I Am Going to Pretend I Am Craze but Don’t Be a Bit Alarmed’: Psychiatric History from the Patients’ Perspectives,” Canadian Bulletin of Medical History 11, no. 2 (1994): 416. 270 chronology. Page was admitted to St. Elizabeths in 1905, and she remained there until her death in 1930. Many of Page’s objections to hospital food and the leeway doctors eventually gave her regarding her diet occurred before World War I food restrictions. Kalter, on the other hand, was committed to St. Elizabeths in 1915 and spent the rest of his life in the hospital he died in 1934. This chronology allows for the patient perspective for the changes and continuities traced in chapters 1 through 5. The perspectives of Page and Kalter provide the final piece to the complex history of food in the mental hospital during the last five chapters of this dissertation. Page’s and Kalter’s perspectives come from their own writing preserved in case files, which provide an imperfect but rich source base for understanding their hospital experience. Case files are created by doctors for an administrative record and medical purpose. Thus, most patient writings kept in case files served as proof of troublesome behavior, if not of outright evidence for mental illness. Despite doctors’ original purpose for keeping patients’ writings, patients’ handwritten letters, commentary, and even a typewritten poem, still illuminate their voices.7 In the following pages, I therefore provide these patients’ perspectives more than their doctors’ diagnoses and evaluations of their conditions. Although I center Page’s and Kalter’s perspectives in this analysis, I do not assess the validity of their diagnoses or whether these patients should have been released. Rather, I endeavor to reveal how these two patients understood food in relationship to their institutionalization and how they asserted and negotiated for their dietary preferences to create a better place for themselves within the institution. 7 Historians have shown that patient records are one important part of reconstructing clinical activities but have also cautioned against seeing case histories as displaying some type of pure form of “clinical reality.” See Guenter B. Risse and John Harley Warner, “Reconstructing Clinical Activities: Patient Records in Medical History,” Social History of Medicine 5, no. 2 (August 1, 1992):186. With this caution in mind, patient voices in the form of patients’ own writings are rare and provide one of the best sources with which to understand how patients thought and felt about their experience of mental illness as well as their experience in an institutional setting. 271 This chapter’s analysis proceeds in two sections. One section is devoted to each patient. In the first section, I explore Jacqueline Page’s perspective about her hospitalization, food, and American “civilization” through her letters to her doctors and an original, typewritten poem titled “Dinner.” In the second section, I examine James Kalter’s perspective about healthy food, proper health American “civilization,” and the role he desired for himself in the hospital. I use his letters to doctors and government officials, a handwritten business card that declared him to be a “hygiene physician,” and bits of his undated commentary about health. Jacqueline Page Page was admitted to St. Elizabeths on May 17th, 1905, and she remained there until her death on December 5, 1930, at the age of sixty-six. At the time of her involuntary commitment, Page was forty-one years old, widowed, and living with her parents in Washington, D.C. She had no occupation and was white. Page’s path to St. Elizabeths began when she became angry with her father, left home, and reportedly spent three nights wandering the streets and two local parks. She eventually made her way to the White House steps during a severe thunderstorm to seek protection from the elements, where authorities arrested her. After she was institutionalized, her family offered her support and often visited. They were likely middle-class based on the quality and quantity of this support. While her patient history did not identify any abnormalities of her father, doctors wrote that her mother was “extremely nervous and unreasonable,” and her sister was “rather peculiar and at times unreasonable in her dealings with the hospital in regard to patient.”8 Her family’s involvement in Page’s care frequently included bringing her food from outside the hospital. Descriptions of Page’s relationship with food contained in her case file are unique due to 8 Case 15330: Medical, History (December 4, 1913). 272 the number of them as well as their length. There are several letters she wrote that staff kept alongside admission information, case notes summaries, ward notes, and other medical test results. The file also noteworthy because although it is quite thick in comparison to other files of the period, there is no mental examination or official diagnosis contained in the file.9 The closest to an official diagnosis of Page’s condition was that of “undifferentiated psychosis, paranoid type.”10 Most patient files from St. Elizabeths during this period include descriptions such as “eats well” or “takes meals in dining room,” but Page’s file stands out for doctors’ detailed descriptions surrounding food and eating behaviors. For example, in February 1906, Page was noted as having “peculiar notions about her eating, and will not eat meat of any kind.”11 In less than year of after her institutionalization, Page’s preferred vegetarian diet had come to the attention of her doctors and was not well-received. During her early institutionalization, Page wrote letters to her doctors to let them know what she was unhappy with at the hospital. These letters often included her demands for food that met her dietary preferences. In August 1906, Page wrote a letter to one of her attending doctors in which she “insist[ed]” on her “right to fit food supplied by this place” even as she was arranging to have her mother visit to supply her with “all necessary food.” Having the type of food that she desired constituted, for her, the conditions necessary to “have some degree of comfort and convenience” in the institutional environment.12 The letter, which spanned twenty- five pages, also detailed the other injustices she felt were being done against her and alleged that her doctors were part of a conspiracy to keep her in the hospital. When the ward notes were 9 This is supported by the summary of clinical history written upon her death. The unidentified author states that “No official mental examination is on file but early notes record numerous delusions and hallucinations.” Case 15330: Medical, “Synopsis of Clinical Record For Pathologist.” 10 Case 15330: Medical, Conference Report (January 14, 1919). 11 Case 15330: Medical, Case Notes (February 1906). The specific day was not recorded, only month and year. 12 Case 15330: Medical, Letter to Dr. Hough (August 23, 1906). 273 typed into case notes, Page’s condition was noted as: “The hallucinations do not appear to be so vivid but she is exceedingly delusional. (See letter of August 23, 1906, in case history).”13 In her next letter, Page explicitly proclaimed her vegetarian identity in continuing her attempts to communicate—and demand she be provided with—her dietary preferences to her doctors. Only about three weeks after her previous letter, she delivered her “Letter of Demand” to her doctor and Superintendent White. One of her primary demands was as follows: I demand now here again in the name of all humanity and of every civilized government in the world that in addition to my right of freedom as described I be furnished while awaiting your final action with a sufficient quantity of clean food appropriate for a vegetarian of twenty years standing, decently and respectfully served.14 The letter asked her doctors to release her from the hospital since she had been institutionalized against her will—her “right of freedom.” It thus illuminates how she viewed her institutionalization as carceral and contrary to U.S. law and culture. Page’s rhetoric in this letter—her demands and appeal to her rights as a US citizen while institutionalized—was similar to that of white, middle-class women suffragists a decade later, as examined in chapter 3. New York NWP chairman and prominent funder Alva Belmont protested the “barbarous and inhuman treatment” of Alice Paul and other jailed suffragists and “demand[ed]” that they “be given the right” to buy prison food from the commissary.15 Page appealed to humanitarian and reform ideals when she referenced “all humanity” and “every civilized government in the world.” She implied that her treatment in the federal government’s mental hospital was not, in fact, civilized. Unlike Paul and the other jailed suffragists who were eventually released, Page was never 13 Case 15330: Medical, Case Notes (July 15, 1906). The date of this is correct because the case notes summaries were created from the ward notes, so it is likely that when they were summarized from the ward notes, the letter written later could be referenced. 14 Case 15330: Medical, “A Letter of Demand” to Dr. Hough and Superintendent William A. White (September 6, 1906). 15 “Charge Hunger Striker is to be ‘Railroaded,’” Richmond Times-Dispatch, November 10, 1917, 3. 274 discharged from the hospital. But contained within these demands was also an important declaration of her vegetarianism, which was a personal dietary choice and a part of her identity that she used to assert her agency in the hospital. Today, the assertion that a person has the right to choose their own diet—for religious, health, or other reasons—can usually be taken for granted in the United States. In the early twentieth century, Page’s assertion of the “right to fit food,” which for her consisted of a vegetarian diet, was not a right that was established in public institutions during this period. As discussed in chapter 3, for instance, Alice Paul and other jailed suffragists found the prison diet poor and were not allowed to purchase food from the canteen or bring in food from outside to supplement their diet before they undertook their hunger strike. In Page’s case, her self- identification as vegetarian in 1906 was still uncommon, although vegetarianism was on the rise during the Progressive Era. Unlike vegetarians coming from the nineteenth-century tradition who were seen as politically radical for support of abolition, women’s suffrage, and other causes, advocates of vegetarianism in the Progressive-Era physical culture movement associated a vegetarian diet with good health, exercise, and strength, and found a fair degree of social acceptance in the United States.16 However, orthodox physicians were generally hostile to vegetarianism, because they saw the movement as encroaching on their expert authority over health.17 Page’s struggle to get psychiatrists at St. Elizabeth to respect her vegetarian diet can therefore be viewed as a struggle over medical authority between doctor and patient. Page’s dietary demands in her letters were not taken seriously by her doctors, who pathologized her refusal of meat rather than viewing it as a legitimate dietary preference. Notes 16 Adam Shprintzen, The Vegetarian Crusade: The Rise of an American Reform Movement, 1817-1921 (Chapel Hill: University of North Carolina Press, 2013), 195, 202-3, 208. 17 Shprintzen, The Vegetarian Crusade, 208-9. 275 from the week after the “Letter of Demand” was written reveal that Page was “very much disturbed at times” and would “not eat meat[;] becomes very much disturbed when she find[s] meat on her plate.”18 Her doctor’s use of “disturbed” here indicates that doctors took Page’s reaction to her food as being one of clinical importance, rather than an act that was within what doctors deemed reasonable bounds when her food preferences were not respected. The hospital diet, as examined in chapters 2 and 5, was not formulated to be vegetarian. The general patient diet in 1906 for Tuesdays included a breakfast of “fried mush,” peach sauce, and fried shoulder for “working patients,” and dinner included beef potpie, turnips, steamed pudding, sauce, and coffee.19 Hospital diets focused on meat because it was high in protein and turn-of-the-century nutrition experts like Wilbur Olin Atwater believed protein to be the most important part of a healthy diet.20 Page, however, continued her demands for her preferred vegetarian diet and her doctors quickly became tired of them, deciding to give her special accommodations. Ward notes reveal that Page still refused to eat “meats of any kind,” was eating mostly the food her family and friends brought into the hospital for her rather than hospital food, and was on a “Special Diet.”21 The term “Special Diet” was a catch-all that allowed doctors to prescribe an alternative menu for the patient for the day, which usually consisted of milk and eggs, considered to be two of the most important and nourishing foods.22 While Page may have received a special diet simply 18 Case 15330: Medical, Ward Notes (September 15, 1906). 19 House Special Committee on Investigation of the Government Hospital for the Insane, Report of the Special Committee on Investigation of the Government Hospital for the Insane, vol. 1, 59th Cong., 2nd sess., February 18, 1907, H. Rep. 7644, 524. 20 Harvey A. Levenstein, Revolution at the Table: The Transformation of the American Diet (Oxford: Oxford University Press, 1988), 57. While there are many sources of plant-based protein, diets at the time still focused on the larger amounts found in animal sources. See chapter 1 for more discussion of Atwater. 21 Case 15330: Medical, Ward Notes (April 14, 1907). 22 For further reading on the important place of milk in the American diet, culture, and economy, see E. Melanie DuPuis, Nature’s Perfect Food: How Milk Became America’s Drink (New York: New York University Press, 2002). 276 because she had been transferred to the Oaks ward from J Building because her doctors suspected tuberculosis, however, the special diet may have been linked to her continued dietary requests. Nevertheless, rather than forcing Page to eat the general hospital diet, doctors allowed her family to bring her food on their frequent visits and provided her with a special diet for a time, which essentially allowed her to practice her vegetarian diet. Although Page continued to be an “irritable” patient, the hospital staff sought to alleviate her complaints by allowing her to be responsible for many aspects of her diet. In 1910, she was allowed to use her own dishes to eat from and she washed them herself, “tend[ing] entirely to her own needs.”23 In 1911 and 1912, doctors noted that Page, thinking only of herself, took food from other patients without consideration for their own “right” to the food and at times threw whole plates of food onto the floor or at attendants when the food did “not please her.”24 Because Page continued to protest the food, doctors made further allowances. In 1915, she asked the hospital staff for bread to make butter sandwiches because she had been brought butter from home. One of her doctors noted that “this request was granted and it seemed to make her more agreeable with the physician for a time.”25 In this case, the physician deemed it more important to make Page “agreeable” than for her to be a part of the ward routine. While giving into Page’s demands can on one hand be seen as taking the easy road of convenience, doctors were also following their conscience by treating Page as an individual. Page likely felt that doctors had listened to her requests and respected her personal choice. The back and forth between Page and her doctors over her dietary choices served as a negotiation and one way that Page controlled her and Kendra Smith-Howard, Pure and Modern Milk: An Environmental History since 1900 (New York: Oxford University Press, 2014). 23 Case 15330: Medical, Ward Notes (September 3, 1910). 24 Case 15330: Medical, Case Notes (January 15, 1911), (September 18, 1911), (September 25, 1912). 25 Case 15330: Medical, Case Notes (April 15, 1915). 277 personal freedom through what food she did and did not choose to put into her body based on her dietary beliefs. When given the opportunity to express herself in 1927, Page took to poetry to display her critiques about the quality and quantity of the hospital’s food in a poem titled “Dinner – June 20, 1927”: The tray, it was smeared with spilt chopped-up meats, The full saucer of rice was too salty to eat, The preserve dish of tomato had meat spilt in it, And something at one side that looked much like spit, But I tried, and did swallow a fair taste of it. Three slices of bread the one buttered below— (That I do not want butter, they certainly know). Two mugs two-thirds full each, one soup I don’t taste, The other was milk that I dared not to waste. I broke the clean slices of bread up in it, The whole of the two, save the tiniest bit. Some chocolate ice-cream which seemed full of big grits, Which proved to be chocolate in hard seedy bits. There were more than a dozen, though perhaps not two, To spit them out of each mouthful was all I could do. And to cap the whole thing, which in some ways seems fit Not even a spoon with which to eat it, But I used my own spoon which I keep for such need, And ate what I could though without any greed. In spite of all this taste and looks of the stuff, I did hope I’d get almost — almost enough. But now I am through (this you may repeat), “I feel that I really need something to eat.” 26 She complained that the tray was had bits of meat on it or in vegetable dishes and that the soup was tasteless. Page also appeared to dislike the “butter” at the hospital—which was likely oleomargarine which patients during the 1906 investigation into the hospital claimed was like “axel grease”—instead probably preferring the butter that she had been brought from home before. She stated that she was not even provided with a spoon with which to eat her meal; she 26 Case 15330: Medical, “Dinner – June 20, 1927” (June 20, 1927). 278 had to use her own. Furthermore, she asserted she ate “without any greed,” thus positioning herself as a moral and proper eater, unlike patients who might be referred to as gluttonous by their physicians as highlighted in chapter 4. Read within the context of the mental hospital, her assertions in this poem can be interpreted as Page’s argument that she was displaying self- controlled and rational behavior in response to a hospital diet that did not meet her preferences and was of poor quality both nutritionally and aesthetically. To end the poem and her discussion of her dinner, Page simply asserted, “I feel that I really need something to eat.” While Page was vegetarian for the vast majority of her institutionalization, there may have been a time late in her institutionalization that she did not practice it, even as she continued to obtain the diet she wanted. Her doctor noted in 1928 that she was “much pleasanter and more comfortable than she used to be, [and] eats every sort of food instead of confining herself to vegetables.”27 The fact that her doctors specifically mentioned this in her case file shows how peculiar, and likely pathological, they found her vegetarian diet to be throughout almost her entire institutionalization. Page may have eaten meat as an attempt to convince doctors she had recovered from her mental illness, she may have chosen to change her dietary preferences and eat meat willingly, or she may have simply been worn down from more than two decades of consistently asking for a vegetarian diet. Nonetheless, she soon became very “disagreeable” again and often complained about the food in the dining room, and she continued to purchase “luxuries which she [did] not find on the table” with money from her sister in the last years of her institutionalization before her death.28 Ultimately, the last line of Page’s poem reflected her feelings about the food and food service at St. Elizabeths and the way that she utilized food to control her experience of the 27 Case 15330: Medical, Case Notes (May 10, 1928). 28 Case 15330: Medical, Case Notes (October 15, 1929), (April 10, 1930). 279 hospital and level critiques against her doctors and the administration. Page’s story, then, reveals how food, something that each patient must have every day, could be negotiated. The carefully planned and expert-approved hospital dietaries were not always effective or possible when dealing with the dietary preferences and personalities of patients in a large mental hospital. James Kalter Jacqueline Page’s experience is contrasted by James Kalter’s, because Kalter’s challenge to doctors’ authority through food came primarily as a challenge to their professional authority and the “orthodox,” scientifically based medical system. Although he worked as a male nurse during his time in the U.S. Army, he claimed titles such as “Hygiene Physician” when writing to his doctors or federal government officials outside of the hospital. Kalter, like Page, expressed his complaints about the hospital food through letters, although he did so by creating a fictitious background of public health and naturopathic medical authority for himself. Like Page, Kalter was diagnosed as “paranoid” although his official diagnosis simply stated, “Paranoid State.”29 Unlike Page’s patient background, doctors did not write much about Kalter’s history in his case file.30 James Kalter, an Austrian immigrant and U.S. Army veteran, was committed to St. Elizabeths on January 8, 1915, and spent the rest of his life in the hospital until his death on March 15, 1934. He had served in the U.S. Army during the Spanish-American War, where many of his physical troubles began but where he also found a calling as a medical practitioner. In one letter where he reflected on his past experiences, he explained that he traveled to Chickamauga Park in Georgia because he had heard of the typhoid fever outbreaks in the Army camp there 29 Case 21807: Case Notes (December 26, 1933). 30 This appears to have been because he was transferred to St. Elizabeths with another case file from his first mental examination in Philadelphia on December 5, 1912, which was not included in the archival materials. 280 (Camp George H. Thomas) and thought that he could help. The outbreak was not small; by its end, 761 soldiers at the camp had died from the disease.31 Further, he asserts that he told the War Department that he could show them “how to cure Thyphoid [sic]” and that his methods had served as an impetus for doctors in the camp to change old methods “into modern ones.”32 Based on his writings, Kalter likely gained an interest in hygiene, sanitation, and dietetics from his experiences at the camp amidst the typhoid outbreak. Improved sanitation and hygiene (e.g. hand-washing, clean latrines, clean drinking water, and fresh food that was prepared with sanitary measures) were the best prevention and treatment for typhoid fever at the time, as it was spread through bacteria primarily found in human feces.33 An interest in sanitation, hygiene in all forms, park beautification, and public health solutions remained with Kalter through the rest of his life and played an important role in his interactions with his psychiatrists at St. Elizabeths. Another lifelong interest developed when the decline of Kalter’s physical health while in the Army and the lack of therapeutic success he experienced led him, like many other people in the past and in the present, to seek healing outside of the orthodox Western medical paradigm. Kalter recollected that while stationed at the Field Hospital at Chickamauga during the war, he had become “sensitive against Sun rays,” injured his spine due to these rays, and sustained “severe (body) burning or disfiguring of the Face.”34 After his injuries, he was given an honorable discharge from the Army for disability, and thus retained the right to a pension as an Army veteran. According to Kalter, the injury lasted “in spite of all sorts of possible + 31 Bradley S. Keefer, Conflicting Memories on the River of Death: The Chickamauga Battlefield and the Spanish- American War, 1863-1934 (Kent, OH: Kent State University Press, 2013), 188. 32 Case 21807: Correspondence, Letter to White House Secretary Rudolph Forster, May 17, 1919. He noted that still, “orthodox Medical Docktors dont like to change their Practice of administering Drug’s” further indicating his naturopathic leanings and pitting himself against “orthodox” doctors. 33 According to Keefer, poor quality food was part of the “Camp Thomas disease narrative,” and many soldiers, members of the public, and service groups such as the Red Cross blamed the typhoid outbreak partially on poor food. See Keefer, Conflicting Memories on the River of Death, 189-193. 34 Case 21807: Correspondence, Letter to White House Secretary Rudolph Forster, May 17, 1919. 281 (impossible) scientific Treatment’s appleyed [sic] for Years.”35 The lack of results from regular and “scientific,” medicine spurred him to seek natural remedies for his ills, and he turned to naturopathy and other alternative medical systems that included a focus on diet to help heal his body and his mind. Kalter’s belief alternative medicine, which included a “natural” diet, became a point of conflict with his doctors in St. Elizabeths. Minimally processed, wholesome food was a central feature of Kalter’s ideal version of a healthy life, just as some critics of the diet—particularly oleomargarine—at St. Elizabeths had argued in the 1906 investigation hearings discussed in chapter 2. Among complaints that he was not receiving his military pension in a letter he sent from St. Elizabeths to the Department of the Interior in 1917, Kalter revealed what he thought would be best for his recovery: “I feel that I am in need to go to some Place in the Mountains where I can recuperate, by living close to Nature […] that I can make myself useful after gaining strength by cultivating some Land, planting Nuts + Fruit Trees, raising diff. sorts of Berrys, Herbs, Roots, + Teas + other wholesome Food.”36 Kalter was not released from St. Elizabeths, but he would take these beliefs about food with him throughout his time there. Kalter’s clash with medical authority began as soon as he entered St. Elizabeths due to his beliefs in alternative and patent medicine as well as in himself as a knowledgeable medical healer. He read magazines such as The Naturopaths and The Chiropractics in addition to newspapers, and often mailed out requests from the hospital for different natural remedies and patent medicines to try.37 When Kalter first arrived at St. Elizabeths, the primary physician and psychiatrist overseeing his case was John Lind, who did not support the “cults” that Kalter 35 Ibid. 36 Case 21807: Correspondence, Letter to the Secretary of the Interior, May 1917. The specific date is illegible. 37 Case 21807: Case Notes (May 5, 1915) and (August 23, 1915). Sometimes the doctors approved these mailings, other times they did not. 282 subscribed to.38 During a conversation in August of 1915, Kalter told Lind that “the only way he can get well and cure all disease is by adhering entirely to nature and subsisting entirely on nuts, fruit, and water.”39 Kalter had likely proposed a strict fruitarian diet, which was even less popular than vegetarianism at the time.40 Lind saw “cults” such as vegetarianism as illegitimate compared to the “real developments” of the 1906 Food and Drug Act and the discovery of vitamins, and was especially critical of Kalter’s proposed alternative diets and interest in alternative medicine.41 Much of Kalter’s case file is filled with notes about his various naturopathic medical beliefs as one aspect of his delusional system as understood by the medical staff. This system included money-making schemes based on his overtly unrealistic understanding of his abilities, finances, and professional credentials. Although Kalter proposed his alternative diet and engaged with discussions about it with his physician, he did not get any special accommodations from Lind at the time. Unlike Page, he did not have a middle-class family network that was able to purchase and bring food to him inside the hospital to satisfy his ideal diet; he instead chose to make do with the hospital diet while also planning for his economic future once he left the hospital. Kalter believed in the importance of work and saw himself as a professional who could earn a living inside or outside the hospital. He believed that his experience prior to coming to the hospital allowed him to 38 Case 21807: Case Notes (August 23, 1915). 39 Case 21807: Case Notes (August 23, 1915). 40 One example of a fruitarian diet in 1907 consisted of the fruit of trees, bushes, plants, grasses, and nut trees with some “earth fruits (like potatoes)” and a small number of vegetables. “A Fruitarian Diet,” Tazewell Republican, January 24, 1907, Chronicling America, LOC. 41 Lind’s dislike of food fads and alternative medicine was so strong that he published an article in The New York Medical Journal titled “Dietetic Fads and Fancies” in 1917. Most of the article focuses on the “dietetic cults” of “vegetarianism, excessive mastication [Fletcherism], and fasting,” and argues that the “real developments” and representation of “progress” in dietetics beginning in about 1906, included “the Food and Drug Act in 1906, Allen’s fasting treatment of diabetes, and the vitamine discoveries.” John E. Lind, “Dietetic Fads and Fancies,” New York Medical Journal 105, no. 17 (April 28, 1917): 793-795, continued New York Medical Journal 105, no. 19 (May 12, 1917): 889-892. 283 suggest improvements within the institution as an expert consultant. While his doctors, such as Lind, explained this behavior as “compensate[ing] himself for his condition as a patient in a hospital of this sort by making himself a great healer,” Kalter saw himself as a legitimate healer and businessman. He went so far as to create handwritten business cards—or “advertising cards” as he called them—to hand out or send to people he thought may get him a job.42 Part of the expertise he developed for himself included food and diet. An undated copy of his advertising card reveals his internal system of beliefs based heavily on Progressive ideals, including food reforms and the creation of a strong national citizenry. He introduces himself with the title “H. Ph.,” which stood for “Hygiene Physician,” and as a “Practitioner of modern Sciences + Pioneer Since 1893.”43 These “modern sciences” he was able to offer as a Hygiene Physician included: Art healing, beautyfeying + congenial living, according to true american Ideals! Prevention + Cure of all kind of Ailments, Perfection of Man + Woman, by employing scientific Principles of […] Hygiene, Sanitation, Food Reform’s, etc. Training of Boy’s + Girl’s, raising of strong, intelligent, + really healthy Children, to become prosperous, progressive, + successfull American Citizen[s].44 Kalter’s card touches on almost every type of Progressive-Era health reform. He included food reforms, which comprised a lot of the content of his discussions with doctors as well as his attempts at challenging doctors’ authority. Informed by his experiences as an Army nurse and the many newspapers and magazines focused on health that he read, Kalter believed that his knowledge could help to build the future America many Progressives idealized. His use of the term “progressive” shows how strongly he sought to associate himself with the reform efforts of the period, even as he took the subversive action of claiming credentials for himself that he did 42 Case 21807: Case Notes (September 18, 1915). 43 1893 likely refers to the year that he enlisted in the Army. 44 Case 21807: Correspondence, Handwritten Copy of Advertising Card, Undated. Incorrect punctuation and misspellings have been maintained from the original. 284 not have. Kalter’s business card was thus one expression of his attempts to challenge the authority of his physicians, or at the least, create what he believed would be a respectful and authoritative career for himself as a Progressive reformer. Kalter’s attempts to be a part of Progressive reform within the hospital but also in the U.S. government reveal not only the authority of scientific experts in this era, but also how even mental hospital patients had a role to play in these reform efforts. Perhaps inspired by delusions of grandeur and/or simply cognizant of the power of credentials in getting doctors and government officers to take a letter seriously, Kalter gave himself what he thought was an appropriate professional title in order to attract attention to his plans for hospital and public health improvements. His most frequently used title was “Hygiene Physician.” A “prolific letter writer,” Kalter tried to contact the President of the United States, the White House Secretary, the War Department, the Navy Department, the Department of Justice, and the Department of the Interior about his plans for improvements to the hospital and its public health measures.45 For example, in a letter to the Secretary of the Treasury, he said he could employ “Hygiene Principles, sanitary measures, Dietetics, etc.,” at St. Elizabeths.46 That Kalter sought to claim authority from dietetics is significant, as it shows that a discipline dealing with food specifically was of interest to him. Furthermore, it is likely that he had picked up on the growing authority of dietetics during World War I. Although his doctors did not believe that he was a “hygiene physician,” they allowed Kalter to act out this idea. He brought “meals to one bed patient” while caring for their room, conversed with other patients, and helped in the dining room during this 45 Case 21807: Case Notes: (May 25, 1916), (September 21, 1920), and Correspondence. Physicians attempted to stop Kalter from sending many of these letters, but he found ways around them. This led his doctors, at one point in 1918, to transfer him to a different building where he “could be better watched” to stop this behavior. See Case 21807: Case Notes (24 January 1918). 46 Case 21807: Letter (August 12, 1920). In 1919, he had suggested similar contributions to his attending doctor, who stated that he thought he was “versed in hygiene, sanitation, dietetics, etc.” See Case 21807: Case Notes (June 19, 1919). 285 period.47 Kalter thus contributed to other patients’ wellbeing and care that hospital staff members might not have had time for, especially as the hospital’s patient population continued to grow after World War I. For Kalter, this likely also gave him a sense of purpose and feeling that doctors, at least in a small way, granted him some authority and a role in making the hospital a better, healthier place. Unlike many of the professional articles about patient feeding, clinical records like Kalter’s show that at St. Elizabeths there was a notion that patient-to-patient care and interdependence could be not only practical, but therapeutically useful. This picture of patient interdependence and care helps to broaden our understanding of what Progressive reform centered on food in the hospital looked like beyond what the hospital staff did. In contrast to Page, Kalter routinely attempted to prove to physicians that he was self- sufficient and would economically be able to provide for himself after he left the hospital. This difference likely had a lot to do with gender norms; both Kalter and St. Elizabeths psychiatrists expected that men who were released from the hospital would be able to financially provide for themselves, highlighted most strongly in the role of occupational therapy in the hospital after World War I, as discussed in chapter 5. Kalter wrote letters to his doctors at St. Elizabeths that were usually focused on hospital improvements, but also highlighted his own desire to find a job and healthy life for himself outside of the hospital. Although psychiatrists throughout his commitment to St. Elizabeths understood Kalter’s “medical inventions based on hospital management,” “schemes” for the improvement of the hospital, and claims of being a “great healer,” “physician,” or “Public Hygiene physician” as manifestations of his mental illness, he was able to create a sense of purpose for himself and to assert some control over his and other 47 Ibid., and Case Notes (February 15, 1919). 286 patients’ health through food.48 At various points during his institutionalization, Kalter attempted to get more and better food than he had received at the hospital. In an undated note, he implicitly asked his doctors for specific foods based on his preferred diet, stating that a hospital doctor had “admitted that the most needed things I should have is fresh Fruit, green [leafy] Vegetables, Spinach, etc.”49 There is no indication in his case file that these requests were fulfilled. Perhaps in response to not getting diet that he wanted, Kalter attempted more than once to “appropriate” food from other patients’ special diets.50 It is likely that because he was a well-liked and generally cooperative patient, doctors did not label him instead with the more moralistic terms “snatcher” or “grabber” discussed in chapter 4 that were common in academic and newspaper articles.51 Kalter also attempted to leverage the medical and scientific knowledge and skills he believed he had to buy himself the food which he desired. In a letter to one of his attending doctors, John Lind, Kalter suggested improvements to the hospital, which he believed would “elevate Medical Science to the highest standard of Efficiency.”52 Furthermore, he was willing to guarantee that any funds he would receive from his proposed work would be deposited except for those he would use for paying off his debts and “that little for furnishing [his] own food.”53 Here, Kalter displayed his desire for his “own” food outside of what the hospital provided, and his plans to acquire that food if possible. Despite his best efforts to appeal to doctors’ authority and to convince them he could earn extra income, Kalter was not able to secure a special diet or purchase food from 48 Case 21807: Case Notes (May 25, 1916), (January 9, 1915), (May 5, 1915), (December 30, 1915), (June 19, 1919), (May 9, 1928). 49 Case 21807: Medical, Undated Note. 50 Case 21807: Ward Notes (June 8, 1921). 51 It is also possible that he was treated more kindly or given the benefit of the doubt more often because he was a veteran. However, this does not come out explicitly in doctors’ case notes. 52 Case 21807: Case Notes (January 15, 1916). 53 Case 21807: Case Notes (January 15, 1916). 287 outside the hospital without family or friends to help him like Page had. Kalter’s beliefs in the importance of food and in his expertise about food coalesced when World War I brought the problems of food and labor into the hospital. Chapter 4 detailed medical superintendents’ responses to the problems of World War I food conservation needs as well as the ways in which they viewed patients—through their labor—as solutions to this problem. Given his interest in healthy food as well as his status as an Army veteran, Kalter was struck with the spirit of patriotism and worked to be part of the solution to food conservation. From Kalter’s writings, it is clear that the hospital’s food conservation efforts did reach patients and those patients could be aware of food conservation goals. Seeing himself as a “Hygiene Physician,” Kalter used food as one means to gain professional credibility, and likely, a way to leave the hospital. During the war, Kalter offered to aid in the hospital’s food conservation efforts and drafted plans for turning the hospital’s uncultivated grounds into gardens. In a 1917 letter to the Secretary of the Interior, he showed his knowledge of the scope of food conservation efforts as well as the goals specifically for institutions. He explained that he knew: that some Farm-Property in the tradition is needed in order to supply this + probably some other Institution’s with Fruits, Vegetables + Grains’ I permit myself to make a Suggestion, which I believe would not only serve the demand but would also be a practical Improvement , because it would greatly hasten the Aim’s + Effort’s of the Administration here to make the Institution self-supporting […].54 In this same letter, he also displayed his knowledge of the justification behind occupational therapy. He suggested the use of patient labor from “inmates” who were “willing, able,” and in a position to be useful in farming, and that this work would also “help to improve the health” of patients. He thought that areas of the hospital grounds that had been dumping grounds could be 54 Case 21807: Correspondence, Letter to Secretary Lane. The letter is dated January 1916 but received January 31, 1917, and returned to St. Elizabeths on Feb 2, 1917, so it is likely the original year was incorrect. 288 turned into gardens for fruits, nuts, and vegetables.55 Further, he asserted that veterans could do much of the work of creating and cultivating the gardens, as some had already made “a small beginning” by planting some vegetables. In a similar letter to White House Secretary Rudolph Forster written in 1919, he proposed a plan to clean up the hospital grounds by “planting Nut + Fruit Trees, Berrys [sic] of all sorts, some Vegetables + fixing up the Sidewalks [into] a veritable Garden spot.”56 Although his letters were returned to the hospital, Kalter had attempted to use his knowledge of food conservation and occupational therapy in institutions to secure work and professional credibility. These efforts likely, in his mind, might have helped him to secure his release from the hospital because he was aware of the importance of economic self-sufficiency, as discussed in chapter 5, to doctors’ decisions on whether to release patients. Amidst the changes to the hospital and the institutional diet during the war, Kalter also continued to assert authority over his own health by identifying himself as a professional and expert. He wrote his own catchphrase in pencil on an article of the Literary Digest of May 17, 1919, stating that the “highest Civilisation [sic] the World will have reached, when once Everyone will be his own Physician.”57 Here, Kalter promoted an individualistic view of health and medicine, which went even further than the ideal of individual treatment in mental hospitals seen, for example, through the increasing attention paid to individual psychology in feeding patients. In an undated writing, he proclaimed, “The strength of a Nation depends on the health, 55 Case 21807: Correspondence, Undated letter, “Private Matters,” on YMCA war-time stationary. 56 Case 21807: Correspondence, Letter to White House Secretary Rudolph Forster, May 17, 1919. 57 Case 21807: Correspondence (undated). This use of “civilization” is especially interesting when put into the context of his previous letter to Forster where he also mentioned that “Call’s are still going out for Frontiersmen, Pioneer’s + Crusaders in order to advance against disease, Ignorance, poverty, Injustice, greed + tyranny etc. + for bringing about Civilisation, higher [Americanisation] + good Citizenship, […].” This view is largely in line with historian Gail Bederman’s assessment of Theodore Roosevelt: “As he saw it, the United States was engaged in a millennial drama of manly racial advancement, in which American men enacted their superior manhood by asserting imperialistic control over races of inferior manhood. To prove their virility, as a race and a nation, American men needed to take up the “strenuous life” and strive to advance civilization—through imperialistic warfare and racial violence if necessary.” Bederman, Manliness and Civilization, 171. 289 Efficiency, + Patriotism of its People! Health is Wealth!” And this good health, for Kalter, included, among other things, “proper Food [and] Drink.”58 As Kalter remained in the hospital, he continued to seek to improve the hospital and the diet of patients, although he began to develop complaints about stomach pain and indigestion. In 1926, he still had “all sorts of little complaints about the Hospital management” and likewise continued to assert that he was a “Public Hygiene Physician” in 1928.59 In fact, Kalter felt that his services as a Hygiene Physician at the hospital should be paid for with the Army pension he felt he had not received from the federal government.60 He also tried to help other patients by diagnosing their illnesses and advising them about their food.61 Even in 1929, a doctor recorded that Kalter said “the ‘food’ could be improved, may suit others, but not me. I have a delicate system.”62 For brief episodes through the 1920s and 1930s, Kalter claimed that his food was poisoned, which led to more conflicts between him and his doctors. Kalter’s doctors thought that his ongoing complaints of stomach pain were delusions rather than somatic in origin. As chapters 1 and 4 discussed, a common delusion patients experienced was that their food was poisoned. Doctors thus had to be careful in how they treated patients to ensure that they ate enough nutritious food. In Kalter’s case, doctors did not adjust the planned hospital diet for him by giving him special diets. Rather, they placated his complaints in another way—by giving him soda mints, even though they thought the mints were physically unnecessary. Because soda mints were supposed to aid indigestion, Kalter took them every day throughout much of his institutionalization in St. Elizabeths because he thought he was “unable 58 Case 21807: Correspondence (undated). 59 Case 21807: Case Notes (July 8, 1926, and May 9, 1928). 60 Case 21807: Case Notes (May 9, 1928). 61 Case 21807: Case Notes (February 8, 1930). 62 Case 21807: Case Notes (January 11, 1929). 290 to digest his food without them.”63 Doctors then, while they did not shift the food given to Kalter, did allow him some autonomy. Overall, Kalter’s story, different but similar to Page’s in many ways, shows how negotiations around food and diet in the hospital reveal the persistence of conscience in the era of convenience in psychiatry. Conclusion The writings and cases from Jacqueline Page and James Kalter presented in this chapter provide a window into the lives and thoughts of two patients centered on food in psychiatric institutions and the intersections of food, individual freedom, and discourses of civilization within the mental hospital. St. Elizabeths patient case files are important source bases for illuminating the patient perspective of their care and treatment with the institution. For Page and Kalter, their alternative diets—vegetarianism and a “natural” diet informed by alternative medical systems—were central to their experiences within St. Elizabeths and their interactions with their doctors. In different ways, both were able to obtain accommodations from their doctors which allowed them to be more comfortable within the hospital environment. On one hand, Page shows a white, middle-class, and female perspective of freedom within the institution, particularly centered on her vegetarianism. Doctors viewed her food preferences as part of her delusional system, but also as things that could be accommodated to make her life in the hospital easier and more comfortable. Her family brought outside food to her, and doctors prescribed a special diet for her at times. As much as food was planned at St. Elizabeths, Page’s experiences show that patient preferences for a particular diet—one aspect of individual psychology—were important facets of twentieth century psychiatry but also opened a space for patients to criticize the hospital and the lack of freedom they were experiencing as 63 Case 21807: Ward Notes (February 16, 1923). 291 involuntarily committed inmates of a public institution. In her “Letter of Demand,” Page critiqued what she saw as uncivilized conditions relating to her commitment and diet in the hospital as part of a broader struggle for freedom that “civilized governments” across the world, including the United States, idealized. James Kalter’s experiences and use of food and diet within the hospital differ sharply but show how he used his knowledge of Progressive-Era public health reform language—including food reforms and dietetics—to influence his place within the hospital. His history as a veteran who was proud of his country and lived through a typhoid outbreak influenced his view of a healthy diet and life as well as the discourse of civilization that he used. Patient preferences ultimately disrupted a dichotomy of care (as administration) and therapy (as medicine), or a clear domination of convenience and coercion over conscience and treatment. Patients, when they were treated as individuals, did leave traces of agency in the hospital setting. While both patients did spend the rest of their lives in the institution, they gained a degree of freedom when it came to food. Each used their own beliefs about healthy food to meaningfully express themselves and shape their experiences within St. Elizabeths. 292 CONCLUSION Winfred Overholser, who was appointed as St. Elizabeths superintendent after the passing of William Alanson White in 1937, faced a new set of challenges upon the United States’ entry into World War II. Unlike the regulations that the hospital faced during World War I from the Food Administration, the hospital had to carry out rationing during World War II. Dietitians were central to this effort and the hospital staff may have felt the administrative burden of food more acutely than at any point in time examined in this dissertation. St. Elizabeths also welcomed sociologist Erving Goffman during the 1950s as the location for his case work that formed the foundation of his famous book Asylums. In his work, food comes up frequently as an aspect of mental hospital discipline, the struggle between patients and their physicians, and in the adaptations of patients to their material and social lives in the hospital.1 Put most simply, food never left the hospital. In Goffman’s work on St. Elizabeths, many of the same complexities that psychiatrists had long faced in feeding the institutionalized mentally ill remained. In the 1950s, clear continuities can be seen in how psychiatrists theorized the best practices for feeding the mentally ill. In Psychiatric Services, clinical director Paul Haun stated: With the regression common to all illness seen most strikingly in mental afflictions, food takes on once more the profound symbolic value it had in earlier periods of development. A tasteless, skimpy meal slapped on a chipped plate and eaten with a tarnished spoon is deficient in far more than proteins, vitamins and minerals. […] The vast healing potential of love, which will never be measured in grams or in mice units, can find expression in the patience of a counter-man, in the smile of a dietitian, and in the humble comfort of good food.2 1 Erving Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (Garden City, NY: Anchor Books, 1961). 2 Paul Haun, “Food and the Mentally Ill,” Psychiatric Services 5, no. 10 (December 1954): 8-9. 293 Here, it is striking that the sentence describing the need for patients to be served meals that were liberal in quantity, appetizing, up to nutritional qualifications of the period, and in ways that were aesthetically pleasing reads almost as if it had been written during the 1890s. Although the doctor is more versed in psychoanalytic terms such as “regression” and “periods of development” as well as words from nutrition science such as “vitamins” than most of the authors that I cite in from 1890s to the 1930s, the foundations of patient feeding are the same. Haun also points to the importance of the dietitian to food service as well as the “comfort of good food,” both themes that I have explored throughout this dissertation. But the therapeutic optimism psychiatrists like William Alanson White had for the care and treatment of chronically ill patients during the “Long Progressive Era” did eventually turn to a wave of therapeutic pessimism that culminated in a wave of deinstitutionalization in the 1960s and 1970s. This movement was fueled by academic literature like Goffman’s Asylums, Michel Foucault’s Madness and Civilization and Thomas Szasz’s The Myth of Mental Illness, by the widespread adoption of psychoanalytic therapy by the middle-class in small, private clinics, and by popular representation of the horrors of life in the mental hospital.3 Similar to the sensational and muckraking journalists of the Progressive Era, there were various newspaper exposés that revealed abuse in mental hospitals. However, literature and film played a particularly important part in convincing the public that mental hospitals were irredeemable. Similar to the popularity of Clifford Beers’ A Mind that Found Itself in the early twentieth century, historians have pointed to Mary Jane Ward’s 1946 novel The Snake Pit and in particular the 1948 movie of the same name produced by 20th Century Fox as central to changing popular opinion about the 3 Nathan Hale Jr. labeled the two decades between 1945 and 1965 as the “‘Golden Age’ of Popularization” for psychoanalysis. See Nathan Hale Jr., The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans, 1917-1985 (New York: Oxford University Press, 1995), chapter 16. 294 merits of institutionalization.4 Ken Kesey’s 1962 novel One Flew Over the Cuckoo’s Nest similarly contributed to negative attitudes.5 The place of food and diet in these and other important literary and film representations of mental hospitals during the late twentieth century is a fruitful avenue for further research. As stated earlier in this dissertation, the very mundanity of food gives it power as an analytical lens and as something that is fundamental to the human experience. Food, as a continuous part of being human, lends itself well to investigations that defy strict periodization or place. The investigation into food as both administrative (an aspect of care) and as therapeutic (an aspect of medicine) in St. Elizabeths thus serves as a starting point for further investigation and comparison of food in psychiatry, as well as for food in other state-run institutions, particularly those of a carceral nature. Where there is food in institutions in the United States, there has always been criticism. and it is likely that criticism will continue as food becomes entangled with a range of theories, practices, and policies brought about by a new generation of reformers in the twenty-first century. 4 See Anne E. 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