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E.C. Seguin was one of the early, influential 19th-century neurologists who participated in the development of neurology as a specialty in the United States. Born in France, but raised from early childhood in the United States, Seguin published widely, developed a high-profile New York City practice, and was named Clinical Professor of Diseases of the Mind and Nervous System at the College of Physicians and Surgeons (New York) in 1874. Typical of the era, he studied neurologic disorders, but also several conditions that today would be considered in the realm of psychiatry. One of his seminal papers was titled “The treatment of mild cases of melancholia at home” (1876). Contrary to the widespread practice of isolating patients in either rest homes or asylums, Seguin introduced and formalized treatment of depression within the household. Against this academic backdrop, Seguin returned home on October 31, 1882, to discover that his own wife, afflicted with long-standing depression and treated at home, had committed suicide after murdering their 3 children. The grim dichotomy between the confidently written paper and the reality of the treatment failure is a neurologic lesson in humility regarding diseases and their unpredictable outcomes.
Edward Constant Seguin (1843–1898) was a celebrated 19th-century New York neurologist.1,2 He was among the first American professors of neurology and a founding member of the American Neurological Association.3,4 Typical of the period, Seguin treated patients with neurologic as well as psychiatric diagnoses. One of his most important papers,5 “The treatment of mild cases of melancholia at home” (1876), justified keeping some patients with depression in the secure environment of their family, rather than the usually advocated approach of isolation, either in rest homes or asylums. Twelve years later, Seguin faced his own personal medical tragedy when his wife, having experienced depressive episodes, murdered their 3 young children and committed suicide at home.6 This article discusses the grim dichotomy between academic wisdom and personal misjudgment in a particularly salient, even sensational, example from early neurologic history.
E.C. Seguin was born in Paris in 1843 and moved with his family to the United States during childhood.1 His father, Edouard O. Seguin, was an established international medical authority on developmental disabilities.2 In 1864, Seguin graduated from the College of Physicians and Surgeons, later the medical school of Columbia University (appendix e-1.1 on the Neurology® Web site at www.neurology.org7–11). Seguin was known for his painstakingly detailed methods of observation and documentation.2 He developed an active teaching curriculum at the College of Physicians and Surgeons, attracted a faithful following of patients, and entered into the hierarchy of New York City medicine. He served as a founding member and an early president of the American Neurological Association.
Seguin's work covered several areas that today would be allocated to psychiatry, though at the time, the budding field of neurology still dealt with such entities.12,13 In 1876, he published “The treatment of mild cases of melancholia at home,”5 describing patients with depression managed at home with supportive family surveillance and expert physician guidance instead of the usual admission to asylums or private rest homes. Seguin summarized the unifying features of the successfully treated cases, the guidelines for determining whether patients could safely stay at home, and the treatment strategies for this option. He emphasized that “psychic pain” dominated the clinical picture, with patients experiencing low-spirited attitudes with loss of interest or self-confidence and a “negative state” of listless inactivity. Patients typically feared being unable to control dangerous impulses or having paralyzing inertia, so that daily activities, even eating or dressing, were unduly burdensome. In some subjects, impulses led to fitful, socially unacceptable bouts of kicking or stomping.
Seguin emphasized that the decision to treat patients at home was a “momentous one” (p. 26) and that only some patients were appropriate for this treatment. The decision to elect this cautious alternative to asylum or rest home therapy depended not only on the patient's emotional state but also on the family resources available for the patient's supervision and daily treatment. Three primary criteria favoring opting against home treatment and admitting the patient to a treatment center were strong delusions or hallucinations, serious refusal to eat, and high risk of suicide. In these cases, severe melancholia was diagnosed, and Seguin believed that families, no matter how well organized, could not be charged with the responsibility of caring for their relative safely. These patients, he stated, needed medical admission for more intense surveillance and, usually, pump feedings for nutrition. Additionally, even when a case of melancholia was mild, if depression was tightly linked to the current home environment, removal to an institution must be recommended.
Treatment at home necessarily involved a team of family, friends, and staff, including professional nurses, all coordinated to implement “kind, firm and judicious management” and incessant watchfulness for any suspicions of suicide plans. The hallmark of the physician's care must be kindness, engagement, and positive encouragement. An authoritative tone and manner could also be used, and families relied on the doctor's clear orders to ensure that the patient followed prescribed activities. Seguin also discussed improved nutrition, exercise, and tonics, as well as sleep aids, including opium, cannabis, and alcohol, on the premise that they “improve the nutrition of the brain, render the circulation in it more active, and thus expedite cure” (p. 20). Engagement in activities was paramount, and these diversions were tailored to the individual patient. Reading aloud, games, outings, and manual projects were all possibilities and should involve multiple people whom the patient trusted: “Your common sense, and medical knowledge, together with a knowledge of the patient's habits, will guide you safely in these matters” (p. 23).
Seguin emphasized that this home treatment was a long one, requiring patience by the doctor, patient, and family. Further, Seguin stated that the treatment required faithful and persistent involvement of the family and their staff in order to be successful, cautioning physicians that, without this anchoring, medications or physician treatment would prove useless.
The essay introduced and formalized a treatment that had likely been widely used before but without academic discussion. In providing a codification of his approach, Seguin officially lent his medical authority to an option anchored in keeping psychiatric patients in their home environment, in sharp contrast with the isolation approaches of asylums and rest therapy, the latter advocated by his colleague S. Weir Mitchell.14 Written with very precise detail, this treatise served as an influential model for the evolving field of American psychiatry and was publicized in journals including the Journal of Nervous and Mental Disease.15
Although never mentioned in the article, Seguin likely had personal experience with treating melancholia at home at the time he wrote his article. On October 31, 1882, Dr. Seguin returned home from his medical rounds to discover that his wife, Margaret Amidon Seguin, and 3 children were dead. The events leading to this tragic outcome were reported in local newspapers the next morning and on subsequent occasions as information was unveiled. The November 1 front-page story of the New-York Tribune16(p1) included this statement: “While the relations of Mr. and Mrs. Seguin were of the most affectionate kind, the lady had been subject for some time to fits of melancholia.” In the afternoon of the preceding day, Dr. Seguin called on his patients and left his wife at home. She visited her brother, Dr. Robert Amidon, a few doors away in downtown New York City and returned home. Dr. Amidon later went to his sister's home, and the staff told him that Mrs. Seguin had taken the children out. He visited later to find that she had not returned, and upon further questioning, the chambermaid admitted that she had not actually seen the mistress leave. Searching the house, she had noted that the door of a spare room on the top floor was locked. Kicking the door open, Dr. Amidon discovered the bloodied and lifeless bodies of Mrs. Seguin and her 3 children, aged 6, 5, and 4 years. In the mother's hand, a 32-caliber Remington pistol was clenched with 3 shots fired. Two other pistols were in the room as well, one an 11-inch barrel pistol that had been used and the other a double-barreled Derringer, loaded but not fired. The children were bound, dressed in finery, and blindfolded. The unsuspecting father arrived home at 7 pm and, upon learning of the tragedy, slumped in a chair, remaining silent and staring into space. No suicide note was found, and the origin of the guns was not reported (appendix e-1.21). Seguin himself issued no public statement and deferred to his brother-in-law, who managed the reports to the police and press:
Mrs. Seguin had been subject to attacks of depression for some time; for several days this had been noticeable. I should call them the “blues” although some physicians might term the symptoms somewhat those of insanity. To my own mind, however, Mrs. Seguin had no symptoms of insanity, although I must acknowledge that this sad act seems that of an insane woman. I had never considered my sister at all affected by insanity, however.16(p1)
Further details on motives, planning, or prior signals of serious psychiatric illness were not unveiled.17,18 The popular press included “A Mad Mother's Crime”18 with a dramatic pictorial image of Mrs. Seguin in the act of her deliberate executions (figure). Dr. William Welch, a former student and current colleague of Seguin, summarized the irony of the tragic situation:
I met him and his wife and three children about two days before the tragedy. They seemed then very happy. It is the most awful calamity which I ever heard of—an additional horror is given to it among doctors by the fact that Dr. Seguin has been particularly prominent as an advocate of the home treatment of insane patients as opposed to asylum treatment, and also as an advocate of non-restraint. Mrs. Seguin's attacks of melancholia could hardly have escaped his notice.19
With little documentation of the Seguin family routine, it is impossible to know exactly how Seguin implemented the home management of his wife's long-standing depression. The regular and frequent daily visits by Mrs. Seguin's brother logically fit within Seguin's advice for careful family surveillance. The household staff was attentive to the locked room, a detail that might have been overlooked in a household without prescribed orders for monitoring. Dr. Amidon confirmed that when he discovered his sister missing, he first feared that she had thrown herself in Central Park pond, suggesting established suicidal concerns. In this light, the warning by Seguin in his article5(p12) takes on a haunting irony in that the seriousness of his wife's disease eluded even the expert: “I would have you feel that every depressed patient may commit self-destruction. The minutiae of this watching and care I cannot enter into; they will readily occur to you.”
Seguin's choice to treat his wife's depressive illness at home was likely influenced by his clear knowledge of other available treatment options. Between 1879 and 1880, Seguin had published a searing, multipart commentary20(ptIV,p73) on the status of psychiatric asylums in New York, concluding, “It is fair to say that, in the present state of psychiatry in America, to be pronounced insane by physicians, by a judge, or by a jury, means imprisonment for months, years, or for life.” Along with other major American neurologic figures, including T.A. McBride, E.C. Spitzka, L.C. Gray, and W.A. Hammond, Seguin had been active in the New York Neurological Society and an official state legislative committee to petition the New York government on asylum reform.20 In the private sector, several private rest homes were available in the United States and Europe, but these facilities were based on the concept of complete isolation from prior social contacts. Given the very young age of his children and Seguin's social prominence in New York society, such options may have been viewed as disruptive and compromising.
In spite of his obvious misjudgment on the severity of his wife's illness, Seguin did not completely stop publishing on psychiatric issues in his later years. In later writings, there is no evidence, however, of revamping of views, and he remained highly critical of asylums when he reviewed the state of psychiatric care in asylums after a visit to Spain.21 However, one of his last writings,22 a series of essays on the treatment and management of neuroses, later translated into French with a foreword by Charcot, did not include a discussion of melancholia or depression (appendix e-1.323).
The neurologic community acknowledged Seguin's tragedy, and the New York Academy of Medicine published the following24(p146):
Whereas, Dr. EC Seguin, an honored fellow of this Academy, has been stricken with a domestic calamity so overwhelming as to paralyze him with despair, and so heart-rending as to command universal compassion; therefore
Resolved, That the Academy of medicine offers to Dr. Seguin the expression of its profound and respectful sympathy and commiseration…it will cherish the hope that Dr. Seguin may recover the spirit and the strength to return to his home and to take up his work in the sphere in which he has already achieved wide and well-merited renown.
Over the next months, Seguin traveled to Europe, but he returned to New York and resumed his career with continued publishing, teaching, and practicing of clinical neurology. In the introductory comments to his collected works, Opera Minora (1884),25 he wrote about the 2-year transition to work, stating: “An apparently unlimited interruption having taken place in my professional life, the idea occurred of reprinting my various medical contributions for private circulation.” Socially, he also reinvested and married again, in fact, twice, and became President of the American Neurological Association in 1889. He maintained an active association with August Forel and spent time working with him in Switzerland, maintaining an active correspondence with him as late as 1893.26
In his Last Will and Testament,23 signed August 28, 1896, 18 months before his death, Seguin donated his medical materials to the New York Academy of Medicine and the College of Physicians and Surgeons in New York and all personal possessions to his third wife. The document includes no mention of the final disposition of the pistols used in the tragic event or any items related to his first wife or their children. He directed that he be buried in Woodlawn Cemetery, Bronx, New York, by the side of “my dearly beloved children and my father.”23(p1) Although he made no mention of his first wife, in fact she had been buried 14 years earlier in the same family plot, and his final resting place was immediately beside her.27
In the context of neurologic practice and expertise, Seguin's personal tragedy is an historical lesson in the needed humility of modern physicians as they approach diseases with unpredictable outcomes. Current examples of parents or caregivers murdering children and then killing themselves emphasize that the Seguin story is not an isolated sensational event of the past, but, instead, an example within the neurologic and psychiatric fields of the limits of expertise and the need for further study. A large medical literature,28 including official guidelines, also exists on the dangers of misjudgment when physicians treat family members.
The authors thank Anna Maman Hylton, MA, for providing French-to-English translations of Seguin's correspondence.
Supplemental data at www.neurology.org
Dr. Goetz: conception, design, data collection, writing of first draft, review, and critique. Dr. Harter: conception, design, data collection, revision of first draft, review, and critique.
No targeted funding reported.
The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.