The Year Neurology Almost Took Over Psychiatry

In December 1880, the emerging profession of neurology almost absorbed psychiatry, which had established itself four decades earlier. The final confrontation was the culmination of an extremely bitter three-year battle, and the outcome was very much in doubt as representatives of each side prepared to testify before the New York State Senate Investigative Committee on Asylum Management. One possible outcome would be the recommendation that neurologists be given administrative control of the state asylums and, effectively, of psychiatry. Other states watched New York's battle closely and seemed likely to follow its lead.

The events of 1880 and their antecedents are little-known to contemporary psychiatrists and neurologists. Understanding these events, however, is relevant to the present, since psychiatry and neurology are moving ever closer together. Increasing numbers of psychiatrists are also taking training in neurology. In Bethesda, Md., the administrative offices of the National Institute of Mental Health (NIMH) and the National Institute of Neurological Diseases and Stroke (NINDS) share the same building, and some NIMH and NINDS laboratories share common space. Some professionals believe it is just a matter of time before NIMH and NINDS merge into a National Institute of Brain Research. Psychiatry and neurology may ultimately become a single profession.

Like many professional turf battles, the neurology-psychiatry imbroglio was based on big ideas and even bigger egos. The leader of the fledging neurologists was 48-year-old William Alexander Hammond, M.D., a large man, "pompous and arrogantwith a voice so powerful that [he] could be heard upwind in a hurricane" (Haymaker, 1953). Like most of the emerging neurologists of his time, he acquired his skills treating war injuries during the Civil War. He had become Surgeon General of the Union Army, but in 1864 was charged with "irregularities in granting contracts for hospital supplies" and court-martialed (Werman, 1973). He then established a private practice of neurology in New York City, charged high fees and became very wealthy. He was one of seven founders of the American Neurological Association in 1874 and was appointed to the first professorship of nervous and mental diseases in the nation.

The leader of the more established psychiatrists was 51-year-old John Perdue Gray, M.D., known for his 300-pound girth and said by some to be "autocratic," "powerful and manipulative," and "an enduring hater" (Rosenberg, 1968). In 1844, he was one of the 13 founders of the Association of Medical Superintendents of American Institutions for the Insane (AMSAII), which later became the American Psychiatric Association. He was also superintendent of the Utica State Lunatic Asylum in New York, editor of the American Journal of Insanity (now the American Journal of Psychiatry) and an advisor to government officials, including President Lincoln.

The battle between the psychiatrists and neurologists was for control of the state insane asylums, with the accompanying patronage system of jobs, and the teaching of mental disorders in medical schools. The psychiatrists claimed that they had been running the asylums for more than half a century and were best qualified to do so. The neurologists countered that the psychiatrists were incompetent, failed to do research on psychiatric disorders and focused almost exclusively on the administrative aspects of their jobs. Furthermore, the neurologists believed themselves to be the true experts on all brain disorders, including various forms of neuroses. Neurologist George Beard, M.D., coined the term neurasthenia in 1869, and many neurologists were practicing forms of what today would be called psychotherapy. In short, the neurologists claimed, "the study of insanity should be considered a subdivision of neurology" (Spitzka, 1878a).

Hammond and Gray initially clashed during the 1871 trial of David Montgomery who was accused of killing his wife. Gray testified that Montgomery, who had epilepsy, was insane at the time. Hammond argued that the defendant was "perfectly sane" and that Gray's testimony was a product of his "want of practical experience with epilepsy or insanity" (Echeverria, 1873). Hammond won the case.

The feud continued to simmer until 1878, when neurologist Edward Spitzka, M.D., a close associate of Hammond's, publicly attacked the psychiatrists. The asylum superintendents, said Spitzka (1878b), were selected "on grounds of nepotism and political favor," showed only "apathy and ignorance manifested by [their]dereliction of scientific duty," and were mostly concerned "over the prizes gained by their hogs and strawberries [from the asylum farms] at agricultural fairs." Spitzka also attacked Gray personally, calling him an "indifferent, superficial man, owing his position merely to political buffoonery" and accused him of having "harmoniously confused, if not falsified, the [asylum's] financial statements."

The psychiatrists' reply was delivered two months later at their association meeting by Eugene Grissom, M.D., (1878) an asylum superintendent who had been Gray's medical school classmate and close friend. Dispensing with any pretense of civility, Grissom attacked Hammond as a criminal, an atheist and a "prisoner of the fountain of justice." Grissom focused much of his attack on Hammond's high fees, calling him "a Judas Iscariot to humanity, selling the blood of his children for thirty pieces of silver." Grissom concluded, "Now at last we shudder as we recognize that the false expert is no man at all, but a moral monster, whose baleful eyes glare with delusive light; whose bowels are but bags of gold, to feed which, spider-like, he casts his loathsome arms about a helpless prey." Grissom's presentation was reported to have been "greeted with thunderous applause" (Spitzka, 1878a).

Two months later, Grissom's presentation was published in the American Journal of Insanity. Hammond promptly sued Gray for libel, both as an editor of the journal and because Gray was widely assumed to have written Grissom's paper. Medical and lay publications widely reported the increasingly personal fight. Because of this interest, the rules of the New York Neurological Society were suspended to permit newspaper reporters to attend the October 1878 meeting, at which Spitzka was scheduled to reply to the Grissom and Gray charges (Blustein, 1979).

In his presentation, Spitzka (1878a) briefly took the high ground, deploring Grissom's "purely personal attack" and "its language exceeding anything which has yet appeared in a professedly medical publication." However, he then attacked the asylum superintendents as "shallow pretenders and ignorant indifferentists," who had led psychiatry to the "slough of despond into which it has sunken in every scientific and administrative respect." Furthermore, according to Spitzka, one prominent superintendent was under official investigation for extravagances and looseness in financial accounts, another was accused of falsifying asylum death certificates to hide patient abuses by the staff, and two others had been dismissed for being repeatedly intoxicated. Simultaneously, Hammond published an open letter in which he defended his high fees and suggested that Grissom himself might possibly be insane.

The neurologists appeared to be winning the battle. The New York Times reported favorably on Spitzka's call for asylum reform, the Connecticut Medical Society invited Hammond to speak, and the Michigan legislature opened an inquiry into the management of its state asylum. Most significantly, the New York legislature appointed a board to investigate the asylums.

Throughout 1879 and early 1880, the neurologists continued the attack. Since the asylums were increasingly overcrowded, it was not difficult to find areas to criticize. In 1879, the neurologists, together with social workers and laypeople interested in asylum reform, organized a National Association for the Protection of the Insane and the Prevention of Insanity (NAPIPI). This organization provided yet another venue for attacking the psychiatrists. As one neurologist later wrote in the NAPIPI newsletter, the average asylum superintendent was more interested in "the growth of cabbagethan [in] morbid growths within the encephalon" and "the location of turnip or potato patches interest him more than the localization of cerebral lesions" (Ayres, 1884).

Finally, in December 1880, the New York State Senate Investigative Committee held hearings. The hearing room was described as "overflowing with witnesses and interested spectators," including many representatives of the media. Hammond cited his usual litany of shortcomings of the asylum superintendents and drew laughter, according to the New York Times (The Care of the Insane, 1880), when he proposed that psychiatrists not be permitted to be asylum superintendents and recommended instead that "a lay superintendent [be] appointed to raise turnipsand entertain the friends of visitors." Spitzka, following Hammond, accused the superintendents of committing perjury in their attacks on him. The psychiatrists, predictably, defended their integrity and their record.

The hearings would emerge in historical retrospect as the turning point in attempts by the neurologists to oust the psychiatrists from the asylums. There appear to be at least three reasons for this. First, the legislators and the public in general were growing tired of the bitter and unseemly personal attacks and counterattacks by both groups of professionals. Second, the neurologists criticized the psychiatrists without offering an alternative plan for asylum management. As summarized by Blustein (1981) in an article about this conflict, the neurologists "failed to establish themselves as the sole authorities on the treatment of the insane, and even appeared to be somewhat irresponsible and sensationalist."

The most important reason, however, was probably the fact that the psychiatrists had friends in the legislature. Friends and relatives of state legislators looked to the psychiatrists to get their mentally ill family members admitted to overcrowded hospitals. In addition, the asylum superintendents controlled all the jobs in the asylums and could offer these to the friends of helpful state legislators. The New York State Senate Investigative Committee was thus stacked against the neurologists. As Hammond himself summarized it, the commission "could not have been more favorable to the superintendents if the latter had themselves, as was very likely, selected the names of the appointees" (Blustein, 1981).

After 1880, the neurologists never again mounted a serious threat to the asylum superintendents. Their position was further weakened in 1881 when President James Garfield was shot by Charles Guiteau. At Guiteau's trial, Gray was the chief prosecution witness, and he argued that Guiteau had been perfectly sane when he shot the President. Spitzka, Hammond and other neurologists argued that Guiteau was affected by "reasoning mania" and thus was insane. The vast majority of the public, as well as the jury, sided with Gray. Guiteau was found guilty and was hung on June 30, 1882. On autopsy, evidence was found of what today would be diagnosed as brain syphilis; thus, the neurologists won the battle, but they had lost the war.

Hammond and Spitzka went on to have successful careers as prominent neurologists. Gray, ironically, was himself shot to death by one of his patients two months after he had testified regarding Guiteau's sanity. And Grissom, whom Hammond had suggested might be insane, did indeed become insane from brain syphilis and, in 1902, committed suicide "by firing a pistol into his brain" (Werman, 1973).

References:

References

1.

Ayres S (1884), Our asylums and our insane. American Psychological Journal 1:341-347.

2.

Blustein BE (1979), New York neurologists and the specialization of American medicine. Bull Hist Med 53(2):170-183.

3.

Blustein BE (1981), "A hollow square of psychological science": American neurologists and psychiatrists in conflict. In: Madhouses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian Era, Scull AT, ed. Philadelphia: University of Pennsylvania Press, pp241-270.

4.

Care of the insane, The. New York Times. Dec. 8, 1880, p2.

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Echeverria MG (1873), Criminal responsibility of epileptics as illustrated by the case of David Montgomery. American Journal of Insanity 29:341-425.

6.

Grissom E (1878), True and false experts. American Journal of Insanity 35:1-36.

7.

Haymaker W, ed. (1953), The Founders of Neurology: One Hundred and Thirty-Three Biographical Sketches Prepared for the Fourth International Neurological Congress in Paris by Eighty Four Authors. Springfield, Ill.: Charles C. Thomas, p297.

8.

Rosenberg CE (1968), The Trial of the Assassin Guiteau: Psychiatry and Law in the Guilded Age. Chicago: University of Chicago Press, pp63,73,190.

9.

Spitzka EC (1878a), Merits and motives of the movement for asylum reform. J Nerv Ment Dis 5:694-714.

10.

Spitzka EC (1878b), Reform in the scientific study of psychiatry. J Nerv Ment Dis 5:201-228.

11.

Werman DS (1973), True and false experts: a second look. Am J Psychiatry 130(12):1351-1354.