MILLEDGEVILLE --- The first patient came to Georgia's first insane asylum on Dec. 15, 1842, chained to a horse-drawn wagon. Tilman Barnett, described as violent and destructive, diagnosed as a "lunatic, " never left.
Barnett, a 30-year-old farmer from Bibb County, died six months later of a malady termed "maniacal exhaustion." Thus he became not only the first patient but the first casualty in the long and often dark history of one of the nation's most notorious mental institutions, known now as Central State Hospital.
That history played out in a seemingly endless cycle: good intentions, not enough money, poor psychiatric and medical treatment, too many patients with too few caretakers, abuse and neglect, expose and scandal, and, eventually, high-minded but fleeting reforms.
Only now, after 170 years, is the cycle breaking.
By the end of the year, Central State will operate only one hospital unit: a 184-bed secure facility that evaluates and treats criminal defendants who are mentally ill.
The state is shutting down the rest --- massive buildings that once warehoused 13,000 patients at a time --- to comply with a federal mandate to overhaul the way it provides psychiatric services. Across the nation, large institutions such as Central State, where abuse and neglect killed or injured hundreds, perhaps thousands, across the decades, are giving way to programs that treat patients in their communities.
Closing most of Central State, once the nation's largest psychiatric hospital, is "a huge symbol" of changing attitudes about people with mental illnesses, said Larry Fricks, a longtime patients' advocate.
"When we were growing up in Georgia, they used to say, 'If you don't behave, we'll send you to Milledgeville, ' " Fricks said recently. "Everyone knew what that meant. ... That was like a death sentence."
In its last days, though, Central State seems far less imposing.
Many of the 200 buildings on the 2,000-acre campus have become ghosts of their own pasts: windows shattered, porches sagging, roofs collapsed. Pine saplings sprout from the red-tile roof of the once-majestic Jones Building, where surgery was sometimes performed without a doctor present. Wild vines smother the brick walls and sunlight streams through the exposed ceilings of the Walker Building, where new patients waited as long as a year before getting psychiatric treatment.
"No trespassing, " small signs warn. "Unsafe building and grounds."
The hospital's grim history remains in plain sight in at least two places. One is a small museum in the hospital's former train depot. Among the relics on display are straitjackets that restrained patients, stainless-steel picks that were used to perform frontal lobotomies, and electroshock machines that dispensed what doctors jokingly called "the Georgia Power cocktail."
The other tangible link to the past can be found in the dozens of acres that hold the graves of more than 25,000 patients. Because so many patients lived at the hospital for so many years, often forgotten or shunned by their families, the hospital ran a mortuary and employed carpenters whose sole job was building caskets. For more than a century, the hospital buried its dead beneath small metal stakes, each emblazoned with a number that corresponded with a patient's file. No names. No dates of birth or death. No symbols of lives outside the hospital.
For grounds keepers, the markers amounted to a nuisance when they mowed the cemeteries. In the late 1960s, they simply pulled stakes from the ground --- at least 10,000 of them --- and tossed them into the woods.
Isolated in life, each grave's occupant would be forever anonymous in death.
On Nov. 4, 1834, when the General Assembly convened in Milledgeville, then Georgia's capital, Gov. Wilson Lumpkin made an impassioned plea on behalf of "the lunatics, idiots and epileptics."
"Every government possessing the means should without hesitancy provide suitable asylums for these most distressed and unfortunate of human beings, " Lumpkin said.
Legislators approved his proposal three years later. Construction took five more years. Finally, in November 1842, the Georgia Lunatic Asylum opened in the tiny community of Hardwick, on the outskirts of the capital. Six weeks later, a Milledgeville newspaper reported that a "sad procession" had brought the first patient, Tilman Barnett, chained to his wagon by his wife and other relatives.
Slowly at first, the hospital's registry of admissions shows, others followed: Samuel Henderson, 47, a farmer from Cobb County driven insane by "religious study, " who spent his final 11 years at Milledgeville. Juliana Mayer, 23, a "pauper, lunatic & epileptic" from Savannah, troubled by "disappointed affection, " who died of consumption after 9 1/2 years. Daniel Ashmore, 30, of Liberty County, who arrived "demented" from "intense application to study" and died in his sleep four years later.
Patients were admitted for "intemperance, " "religious excitement, " "domestic unhappiness, " "ill health and jealousy." One early patient was described as "rather idiotic."
Of the first 50 patients, 29 died without ever leaving. Records list causes of death as dysentery, chronic diarrhea, convulsions, and "general paralysis."
Just eight of the first 50 were pronounced "cured."
At the end of the hospital's first decade, the U.S. Census recorded 108 patients. Ten years later, census takers counted 283; they included two physicians, a lawyer, a bank officer and seven "lunatics of the same family."
The hospital admitted only white patients until 1866, a year after the Civil War ended. By 1870, according to census documents, one-sixth of the patients were African-Americans. But census workers listed some only by a first name; they called one 37-year-old patient, merely, "Negro Man." For another 80 years, black and white patients would live in separate buildings, receive treatment separately and even occupy segregated cemeteries after they died.
Renamed the Georgia State Sanitarium in 1897, the hospital grew rapidly at the turn of the century, as did the scope of its challenges.
The hospital held an average of 2,880 patients a day in 1904, and problems were rampant. In their annual report to the governor, the hospital's trustees pleaded for $10,000 to build a tuberculosis hospital; the disease killed 121 patients that year. They also requested a new water supply; contaminated water from Camp Creek apparently caused an outbreak of typhoid fever among patients. And, foreshadowing problems that would plague Georgia's state hospitals into the 21st century, they told the governor that more money was imperative.
"The very end for which the sanitarium was established is largely defeated by the rigid economy necessary to bring its cost to the state within limits, " the trustees wrote. "If the sanitarium is designed to be merely an asylum, a home for the insane, where they are to be cared for at the least possible cost to the state, well and good. If, however, it is designed not only as a home but a hospital as well, where everything modern science can devise is brought to bear upon its patients in the effort to restore them to health and reason, then its work assumes a different character."
But in the same report, the hospital's superintendent, Dr. Theophilus O. Powell, tried to dispel the gloom. Caring for the mentally ill, Powell wrote, "should not be regarded as a burden, but a divine privilege."
One hundred years after its founding, the Milledgeville hospital found itself at the center of a supposedly progressive cause: the forced sterilization of patients.
In 1937 Georgia became the last of 32 states to enact a eugenics law, which targeted those who "would be likely, if released without sterilization, to procreate a child, or children, who would have a tendency to serious physical, mental or nervous disease or deficiency."
Physicians, politicians, editorial writers and others promoted sterilizations as "scientific" and "humanitarian."
One Atlanta doctor gave a speech supporting sterilizations as a way to suppress the state's "poor white trash" who might otherwise need to be euthanized.
The law permitted sterilizations at what by then was called Milledgeville State Hospital, as well as at the Georgia Training School for Mental Defectives in Gracewood. A state Board of Eugenics decided which patients would be sterilized; its chairman was the Milledgeville hospital superintendent, who initiated many of the sterilization requests.
Dr. Thomas Peacock, the superintendent from 1948 to 1959, wrote a medical journal article in 1951 touting the "prophylactic value" of forced sterilizations. The practice, he said, was "protecting patients from psychotic episodes induced by pregnancy, and shielding children from mental trauma by psychotic parents."
In theory, patients could appeal sterilization orders. But academic researchers later concluded that few comprehended their legal rights or the nature of the sterilization procedure. In 1956, a lawyer for the Medical Association of Georgia argued that because no case had gone before the state's appellate courts, the eugenics law was "being administered very wisely."
The idea of controlling procreation among certain groups remained popular in Georgia even after the atrocities of eugenics-obsessed Nazi Germany came to light after World War II. In fact, sterilizations spiked in the post-war era, to about 200 a year between 1955 and 1960. Georgia ended the practice in 1963 after sterilizing almost 3,300 people, the fifth-highest total of any state.
Another 44 years passed before state legislators addressed the forced sterilizations. They adopted a nonbinding resolution that expressed "profound regret."
By the mid-20th century, the hospital campus took on the appearance of a pleasant small town. It had a post office, police and fire stations, a dentist's office, churches, a beauty shop and an auditorium that booked musical acts and professional wrestling matches. A patients choir recorded an album: Handel's "Messiah."
Behind the hospital's closed doors, however, the population swelled to the point that many buildings became human warehouses. Each employee was assigned to care for 100 patients at a time.
Photographs from the 1930s and 1940s show patients lying in long rows of cots, tightly spaced in barracks style, or sitting unsupervised and disengaged in dayrooms. A newspaper photo from the 1940s shows men in suits staring at a little boy, perhaps 5 or 6, who is locked inside a small metal cage. The boy stares into the middle distance, avoiding eye contact with the men on the other side of the bars, or with the camera.
Disturbing episodes occurred with regularity, according to a history that Peter Cranford, a psychologist at the hospital, wrote in 1952.
In 1950 alone, Cranford wrote, three patients died nearby after escaping. Another hanged himself with a bed sheet. One patient beat another to death. When a patient in the maximum-security unit vomited on the floor, Cranford wrote, two employees ordered him to clean up the mess with a towel --- and then forced him to eat the towel. The patient choked to death.
Hospital officials, particularly Superintendent Peacock, denounced the articles as the work of "communist-loving" journalists. But Nelson's reporting, which won a Pulitzer Prize, spurred numerous reforms.
By the late 1960s, Georgia was opening six other regional psychiatric hospitals. Thousands of patients left as Milledgeville became Central State, and its slow decline began.
At the beginning of the 21st century, many of the antebellum buildings on Central State's campus stood empty and decaying. Only a few hundred patients remained.
Still, abuses continued.
The Atlanta Journal-Constitution reported in 2007 that as many as 136 state hospital patients had died under suspicious circumstances during the previous five years. Forty-two were patients at Central State.
Some choked to death while eating without supervision. One died while hospital employees restrained him face down on the floor. Others died from poor or even nonexistent medical treatment.
The newspaper also found more than 190 instances in which the state confirmed patient abuse by hospital employees. One Central State case evoked an episode from nearly five decades earlier: A patient alleged that an employee forced her face to the floor where she had vomited, then yanked her away by the neck. The patient was 10 years old.
In response to the newspaper articles, the U.S. Department of Justice opened an investigation of civil-rights violations at all seven of Georgia's public psychiatric hospitals. To avert a possible federal takeover, the state eventually agreed to widespread changes, including more money for patient care, in and out of institutions.
Except for the criminal-justice facility, all that remains open at Central State is a nursing home for people with developmental disabilities and mental illnesses. It will close by the end of the year.
The state has eliminated hundreds of jobs at Central State and is leaving behind a sprawling, mostly unoccupied campus in a town that has long been synonymous with a hospital that will no longer exist.
State hospital administrators "did not look into the future and think outside the box, " said state Rep. Rusty Kidd, I-Milledgeville. "You wake up one day and the buildings are old and the treatment modalities have changed. We're stuck with a lot of stuff there."
Kidd sponsored legislation that created an agency to transform the hospital grounds into something else: maybe a college campus or a state-government office park or even a corporate headquarters or research facility. Early on, officials have received few nibbles, but they remain optimistic.
"We look at it as the greatest single opportunity Milledgeville has to define itself, " said Mike Couch, executive director of the Central State Hospital Local Redevelopment Authority.
Couch is a Milledgeville native. His mother used to be the director of nursing at the state hospital. He is protective of Central State's image and doesn't see its notoriety making the property a tough sell.
"We're trying to leverage what it is, " Couch said --- a facility with "a noble history."
But it also has 25,000 graves and dozens of vacant, dilapidated buildings, each with its own story to tell. So it seems fair to wonder whether Milledgeville's past will ever fade from the present.
"There's a lot of history there, " said Larry Fricks, the patient advocate. "You just can't put it in a good light."
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This story is partly based on material housed at the Georgia Archives, including reports by state hospital trustees and records of early admissions.