Fulton State Hospital was not only Missouri’s first state mental asylum but also the first such institution west of the Mississippi. In tracing its founding and evolution over a century and a half, this book sheds light on both a neglected aspect of the state’s history and the development of mental health care in America. It acknowledges the noble aspirations of Fulton State Hospital—as well as its failures, throughout much of its existence, to transform those aspirations into realities. This institutional history of the hospital traces the debates surrounding its creation (as the State Lunatic Asylum) in a time when mental illness was barely understood. Although the Fulton hospital was initially conceived as a treatment facility, it quickly transformed into a primarily custodial institution. It existed as a self-sufficient establishment until the mid-twentieth century, dependent on patient labor and even producing its own food. But for the most socially disadvantaged and for the severely delusional, life at Fulton was anything but therapeutic. The book describes not only the lofty goals of professionals dedicated to treating the mentally ill but also an institution once clouded by overcrowding, financial mismanagement, political cronyism, and wrongful confinement. It considers segregation within the hospital, where the first black doctor was hired in 1960 and where racism nevertheless continued to flourish, and it describes how, even after the 1921 Eleemosynary Act, the patronage system continued to plague Fulton for two more decades. The authors reveal changing attitudes toward new treatments in the mid-twentieth century as psychotherapy and drugs became common, and decisions at Fulton regarding patient care are described within the context of progress in Europe and the eastern United States. The book addresses the complexities facing the physician-superintendents who supervised both medical therapies and administrative matters, depicting ongoing tension between hospital finances and state support and showing the difficulties state institutions faced in a “low tax/low public service” environment. As Fulton State Hospital enters the twenty-first century, clients have become active in the development of institutional policies—a far cry from the warehousing of patients a hundred years ago. In tracing these seismic shifts in mental health care, this book offers an eye-opening exploration of how one state has sought to care for its citizens.