CHAPTER 4

The Census of Insanity Tests Its Status as a Disease of Civilization, 1807-1851

And if it is not without some surprise that we will find proportionately more insane in Norway than in England or France, we gain at the same time a proof that the result derives from the same general laws that rule the development of minds among all peoples.

— Étienne Esquirol (1830)

Nobody concerned with the treatment of mental illness believed that the number of people in institutions was a valid measure of insanity in the population at large. It was the work of the census to make such determinations, tallying the insane wherever they were found. The diagnosis of lunacy or idiocy was especially uncertain when disconnected from the medical-legal processes of commitment to an institution, even if a village idiot or lunatic was part of ordinary life. Worse, asylum statistics of admission were radically incompatible with those of discharge. At least until the mid-nineteenth century, many asylums showed cure rates of 50% or higher, sometimes, as we have seen, much higher. Yet it seemed that every new asylum rapidly filled to overflowing, and the numbers of known insane increased in lockstep with the capacity of the institutions. Some new patients appeared to be cured, but those who remained were lingering, often-hopeless cases who drove down cure rates, discrediting that noble, humane mission of mental medicine. Counts of the insane were as protean and ill-behaved as madness itself, refusing to converge to any credible number or even to expand or contract along with total population and other plausible variables.

Census counts both reflected and stimulated anxieties about the effects of modern life on the quality of populations and were invoked on both sides of debates on state action. Whatever its imperfections, a census appeared necessary for the very practical purpose of planning asylum facilities. Beyond that, census results bore specifically (if unreliably) on vital issues of public health. Was the apparent increase of insanity real, and what could explain it? Would the costs of care for the insane continue to grow without limit? Most crucially, what were the causes of insanity, and how were they evolving with the progress of civilization? Inevitably, and increasingly, heredity was at issue in these counts, which were invoked more and more to justify the selective control of human reproduction.

Civilization Causes Insanity

Some of the earliest counts of the mad arose from a 1773 British law requiring registration of persons admitted to lunatic houses of all sorts. These reports enabled the semiofficial Literary Panorama in 1807 to print and ponder the diverse ratios of insane to total population. The returns were too erratic to inspire confidence. They showed, for example, seven insane out of 440,000 inhabitants of four counties around Cambridge, smaller by a factor of 24 than the ratio in Lancashire. Yet they could not simply be ignored. “It passes uncontradicted that the lunatic affection is a disease increasing in its frequency in this country.” The journal proceeded immediately to a list of possible causes, all of them “moral” or environmental rather than medical or physical, and some hinting at social critique. Should the growth of insanity be attributed

to the increase, or decrease, of marriages? to the propagation of disorders destructive to generation, and to morals?—to the depreciation of money, and consequent difficulties of support?—to the introduction of foreign luxuries and a mode of life less conducive to general health, than that of former ages?—to a more diversified system of education which injures the body in very early life, before it is able to support the requisite exertion?—to prevalent glooms arising from the unhappiness of the times?1

Figures for “lunatics in each county held in gaols, houses of correction, and workhouses” were allied also to a medical-social vision. The journal printed these numbers in a table to advance its dream of an organized system of asylums, each to hold about 300 patients. The best authorities doubted that the variability indicated by these tallies was real, however. Dr. Andrew Halliday, the most prominent writer on insanity numbers of his day, assumed that mental illness was a simple fact of nature, proportional to population. In a letter printed with the 1807 report, he proposed to distribute asylums across the counties not according to the number of registered insane, but so that each asylum would serve the same total population. In 1814, Richard Powell of the Royal College of Physicians published a table of registered admissions in five-year intervals from 1773 and argued that all the numbers were too low to be credible.2

Halliday was a forceful advocate for public mental hospitals, not least for the inspections and statistics they would provide. He accused madhouse keepers of exploiting ignorance to their own advantage by abusing the insane until the disease became permanent. A decade before Farr, he insisted that asylums should be opened to public observation. In 1828, another moment of acute parliamentary concern, he pronounced it curable. Halliday traveled all over Europe, from Sweden to Spain, gathering data and regretted having to make do with printed reports on faraway India. It was time, he thought, for England to bring its register of admissions up to the French standard of accuracy, since correct tallies formed the indispensable basis for a rational system of asylum care.3

The urge to count the insane incorporated a new acceptance of public responsibility for them and for the health of populations more generally. At the same time, many were anxious that the apparent increase of insanity could be real. Pinel had emphasized revolutionary excess as a cause of insanity, and a chart he drew up at Bicêtre in 1793 attributed a third of his cases to “events connected with the revolution.” Esquirol’s table of moral causes for his private establishment in 1816 attributed 18% to political events, still a high number.4 In his medical dissertation of 1805, he worked out an appealingly pessimistic explanation of the epidemic of madness. He spoke of perfectibilité as the curse as well as the glory of human life, since this capacity for improvement is attended by moral disorders linked to love, anger, vengeance, and ambition. Artificial needs and desires that do not conserve our bodies are the fruit of developing moral faculties. Fluctuations of commerce, enthusiasms of exaggerated religion, and the inflammation of love by theater and novel reading all chip away at mental balance. In combination with hereditary susceptibility, these can easily lead to lunacy.5

In 1816, Esquirol provided a numbered list of moral causes alongside the physical ones. So many persons gone mad due to failed love affairs, family deaths, business reversals, abuse of alcohol, masturbation, and the pressures of work and study moved him to reflect on the tumults of modern life. His statistics revealed a heightened vulnerability to insanity in sedentary occupations. The unstable lives of merchants and courtesans must be still worse. He credited Alexander von Humboldt for an observation on the rarity of insanity among the savages of America, and a book of travels by John Carr, A Northern Summer, for its rarity in Russia. In France, he declared, insanity occurs mainly in cities. He concluded, invoking Rousseau, that civilization as such was not the cause, but that by multiplying sensations and providing the means of excess, it occasioned an increase of mental disorder. His thesis became familiar in a less nuanced form: madness is a disease of civilization.6

Esquirol returned to these questions in 1830 in response to a Norwegian census organized by the physician Frederik Holst. Like so many in his profession, Holst had been granted state funding for an alienist Wanderjahr, on which he reported in 1820 and 1823. He was most impressed by the hospitals of Paris, where he followed Esquirol’s course on mental illness. His count was part of the 1825 Norwegian census, but he delayed publication until 1828 because he did not accept the competence of priests to classify forms of insanity on the census sheet. Esquirol praised this work extravagantly in a review. There had been various incomplete or unsatisfactory enumerations in England, Bavaria, and France, he wrote, but here at last was a proper count, “the most complete statistics of insanity that we have.” The statistics required for rational administration of hospitals for the insane, and for a scientific reckoning of its modern increase, had to be based on a census like this one.7

Holst, rather exceptionally, combined two variables in his table: cause (beginning with heredity: Arveligt Anlæg) on the left axis and disease form (as well as sex) along the top. This arrangement required extra work to sort out the cases as well as the inspiration to seek statistical relationships of this kind.8 He was, however, most concerned by the gross figures, concluding sadly that his numbers demonstrated an increase of insanity in step with the advance of civilization. Esquirol could scarcely disagree, and in his review, again invoked Humboldt, now for the categorical claim that insanity was unknown among the indigenes of South America. He also cited Philadelphia physician Benjamin Rush as a witness to the rarity of insanity among savages. Rush, in fact, claimed no personal experience among primitive peoples but relied on the testimony of travelers. “Baron Humbolt informed me, that he did not hear of a single instance of it among the uncivilized Indians in South America.” Humboldt probably spoke with Rush in 1804 as he was returning from five years of travel in Latin America. Esquirol almost certainly extracted this comment, which became famous, as well as Carr’s, from Rush’s Medical Inquiries and Observations. Rush also referred to Dr. William Scott, a member of Lord Macartney’s embassy to the Emperor Qianlong in 1793–1794, who had “heard of but a single instance of madness in China.”9

The authority of these travelers, recited again and again, inspired a little ethnographic industry to give evidence on the question of whether madness really did arise from the denaturing processes of civilization. Non-Europeans figured here as authoritative witnesses. Amariah Brigham wrote in an 1845 asylum report that insanity was rare among Indians and Negroes, then, generalizing, declared it uncommon in China, Persia, and Hindostan as well as Turkey and Russia.10 An eighty-year-old Cherokee chief, described by a missionary-physician as intelligent, was reported in the AJI as saying that he never witnessed a case of madness among his own people to compare with those he saw in a Philadelphia hospital. Unnamed “Amistad Negroes” remarked after seeing the Connecticut Retreat in the early 1840s that insanity like this was very rare in their country. Their leader, Joseph Cinqué, with greater precision, said he had seen one case.11

The Literary Panorama had proposed already in 1807 to examine quantitatively some basic questions of causation by comparing lunacy rates in manufacturing and agricultural districts. “Though we acknowledge, freely, that more correct returns are wanting to justify inferences, yet we cannot refrain from directing the attention of the inquisitive and especially of medical practitioners to these queries.” Esquirol, chiseling in the same vein, suggested a comparison with Halliday’s work on England and Wales and T. R. Beck’s on some US states. If others prepared statistics with the same care and detail as in Norway, they would be precious for “philosophical and medical study of mental maladies” and provide valuable comparative results for different climates and customs.12

In the event, Holst’s ratio of insane to total population, 1:551, was uniquely high: higher than Halliday’s most recent numbers for England and Wales, higher than the 1825 results for New York, higher even than an 1821 figure from Scotland. Only the department of the Seine showed a greater ratio, and this, Esquirol explained, was meaningless because so many migrants came to Paris for treatment. For France as a whole there were as yet only round, hence speculative numbers: 30,000 insane in a population of 30 million, or 1 in 1,000. He thought Norway’s excess of insanity paradoxical. How could a land of mountains and fjords, of shepherds, fishermen, and tillers of the soil, outpace England and France in this disease of civilization? But Holst had anticipated the objection and hinted at the answer. An excess not of lunacy, but idiocy, accounted for the elevated Norwegian numbers, and idiocy, as Esquirol taught, is most common in mountains. The figures for Scotland, just a notch behind Norway’s at 1:573, admitted the same interpretation.13

If the increase of these numbers over time reflected something real, the reasons for worry were not limited to budgetary ones. The idea of insanity as a disease of civilization hinted already at a threat of degeneration, the dark side of progress, and cast a shadow over faith in human reason. In 1831, the liberal Bonapartist and Montpellier-trained physician Claude-Charles Pierquin accused Esquirol of a fundamental error amounting to a logical contradiction. There must be something wrong with the evidence. Travelers had failed to notice insanity among the hordes barbares precisely because it is so ordinary, and only against a background of enlightenment does madness stand out. To counter Humboldt’s authority on the mental stability of primitive peoples, Pierquin invoked the ethnographic experience of the Baron Jacques-François Roger, recently governor of Senegal and a member with Pierquin of the Société Universelle de Statistique. Roger had told him in a letter that furious madness was almost unknown in Senegal. This was not from any deficit of insane people but owed to their utter freedom from constraints, even of bulky clothing, and to the admirable tolerance of their generous nation. Since the mad were never tormented in Senegal, they were rarely violent. Monomania, always difficult to diagnose, was scarcely distinguishable there from ordinary religious practices. Dementia, Roger went on, appeared if anything to be more common in Senegal than in civilization, but this impression, too, was an illusion, a result of the charity bestowed on these unfortunates. People with dementia, entering a village, could expect a warm welcome and generous provision, in accordance with Islamic custom, so they had no reason to conceal their condition. Some, indeed, feigned madness in order to live well without working.14

Pierquin included an array of proofs that civilization is opposed to insanity. He noted, for example, that in counts of the institutionalized insane by profession, the highest numbers are given for domestic servants, seamstresses, day laborers, and the like, who make the least use of intelligence. (It seems he did not think to adjust the absolute numbers for relative frequencies of different occupations.) He argued that level of instruction was much more fundamental to insanity than all the little causes from Esquirol’s table, and that the greater prevalence of insanity in Norway than Scotland could be simply explained by the superiority of Scottish schooling. Holst’s numbers, in sum, reflected the commonness of idiocy and dementia in ignorant societies in contrast to mania and monomania in educated ones. It all made sense against the background of another, much hotter debate of the era, which obsessed Pierquin, on the relation of education to crime. He took the enlightened view that crime and insanity were not caused by education but cured by it and that citizens of Paris, the most enlightened in the universe, were the least insane or criminal. Its prisons were indeed filled to overflowing, but with foreigners.15

The work of recording demographic, commercial, agricultural, and judicial numbers intersected less than we might expect with asylum statistics, but censuses of the insane are another matter. Adolphe Quetelet took up the points of debate between Esquirol and Pierquin in his most important book, Sur l’homme (Treatise on Man), which appeared in 1835. For his chapter on mental alienation, Quetelet relied on Esquirol’s review of the Norwegian census. He also thanked Esquirol for unpublished asylum data. He endorsed the typical result of asylum statistics, contested by Pierquin, that insanity tends to erupt at the age of most vigorous intellectual development, when persons are in their twenties and thirties. He rejected Pierquin’s bundling of crime and insanity with ignorance, and he endorsed the distinction between idiocy and mental alienation as the explanation for high insanity figures in Norway. In short, he supported Esquirol on every point. Mental alienation is an attack on intelligence in its seat, provoked either by its too intense exercise or by an excess of passion and sorrow.16

Esquirol held resolutely to his views, reprinting his old papers and reports in 1838 as the summation of his life’s work. Even in 1805, the link between madness and civilization was scarcely shocking. Insanity had long been associated with leisure and luxury, not least in England. This, as Andrew Scull has shown, was an understanding that mattered, since images of insanity as a tragic disease attacking respectable people were routinely mobilized in campaigns for public asylum systems. As soon as they succeeded, however, the experience of such systems began to undermine in a very concrete way the association of madness with luxury and cultivation. As these institutions filled to overflowing with pauper patients, families with resources began to avoid them. Under these conditions, insanity came to be interpreted as an affliction of the poor.17 In 1872, one of the commissioners in lunacy for Scotland, Sir James Coxe, presented statistics showing a massive expansion of insanity, especially among institutionalized paupers, as a basis for reversing Esquirol’s assessment. Far from being a disease of civilization, insanity was nurtured by poverty and ignorance. He put great stress on social conditions that led to the increase of asylum populations. Institutions for the insane, he thought, had very little power for good or for evil, and many so-called cures owed instead to the recuperative power of nature. He had seen many patients cured at home who would have rapidly become incurable in an asylum. Not purgatives, hypnotics, narcotics, and tonics, but hygiene and mental cultivation were the best that asylums could offer their patients.18

Counting and Being: Alienation as a Medical Specialty

The growth of asylum systems and of the knowledge that supported them appears haphazard until about 1840, when, in short order, the forces of professional and bureaucratic order marched onto the stage. Alongside the new journals of mental medicine, societies of asylum doctors took form, beginning with the (British) Association of Medical Officers of Asylums and Hospitals for the Insane in 1841. Still more significant were new laws requiring public asylum systems in much of Europe and North America. A simultaneous surge of census activity gives evidence of heightened public attention to the social problem of insanity. While the Norwegian census of insanity in 1828 preceded such legislation there, the counts of the early 1840s appear as efforts to gather systematic data for an accelerating institutional expansion. None of these counts, however, seemed quite satisfactory.19

The first American census of the insane, part of the 1840 US census, used a complex new paper form with an array of brave new questions. This was social politics on a census card, summed up in the entries for persons “at public charge” and for those over twenty who could not read or write. The card included a jumble of little spaces for the blind, the deaf and dumb, and insane and idiots, all divided between “white persons” and “colored persons.” The deaf and dumb of the white race, but not the colored, were partitioned into three age categories. A space was set aside for black insane and idiots, and two more for white ones at public and at private charge. The tangled process of recording, combining, and copying to get totals for each state brought forth absurd results on race and insanity, and then a scandal.

Almost immediately upon the release of census results in 1841, its readers noticed massively higher rates of insanity among blacks living in the northern states than had ever been found for any population anywhere. In the free northern states as a whole, 1 in 163 blacks were shown as insane or idiotic, almost ten times higher than in the South. In Maine, with only a few black inhabitants, this ratio rose to the astonishing level of 1 in 14. By 1842, the Massachusetts asylum doctor and medical statistician Edward Jarvis had uncovered damning inconsistences, such as towns that tallied no colored residents at all and yet, in a separate entry, showed one or more insane ones. The entire population of the all-white Worcester asylum was entered as colored. Historians have reconstructed the mistakes, mainly of copying, that produced these implausible results. Each page of the printed census has about seventy-five lines, and it is barely possible to follow the entries for a town or county across facing pages. The discrepancies involving free blacks were not even on adjacent pages, and the population tables for all the states included over 100,000 numbers, excluding blank spaces. Checking for consistency could not have been easy, unless a reader was impressed or startled by the totals, and avoiding errors was not a high priority in this bungled operation.

Advocates of slavery eagerly embraced the rhetorical opportunities offered by this unexpected result. Even Jarvis briefly considered the possibility that high levels of black insanity might be a result of their sudden exposure to the pressures and choices of commercial society. His subsequent demand that the published numbers be corrected went nowhere, partly from a reluctance of the census officials to admit mistakes, but mainly because champions of the peculiar institution were so entranced by seeming evidence that the mind of the African could not bear up to freedom.20

A French naturalist and political anarchist of Spanish and Cuban background, Ramon de la Sagra, assayed these numbers and proposed some explanations in the first issue of the AMP. “Profiting from these tables that have just been published by the government of the United States on the population there, I have carried out a great number of comparisons and statistical calculations with proportional numbers that I have deduced from absolute numbers furnished by the census.” The proportion of insane among the free colored, he observed, is without equal in Europe, “to the point that some expert statisticians in a famous academy have cast doubt on the exactitude of the document.” That was the American Statistical Association, of which Jarvis was a founding member. While it would be no surprise, Sagra continued, if slave owners should downplay problems of mental health, the federal government had no reason to exaggerate the insanity of colored people in the North. The numbers, he concluded, must be correct, pointing to a serious problem of American civilization. The elevated rate of black lunacy must owe to the disdain and contempt of Northern whites, who appeared to him even more culpable in regard to race relations than slaveholders. He also got in a few jabs on the severity of religion in America, whose puritanism, lack of public amusements, and disorderly exaltation of Methodist meetings heightened madness in both races.21 This was just the sort of thing that refined American critics liked to say about their own culture. John Butler of the Connecticut Retreat was moved by this census to deplore the circumstance “that in no section of the world is insanity more prevalent” than in New England and the upper Midwest. “We are too much obsessed with business, leaving too little time for recreation, social intercourse, literature, and science.”22

The first French census of the insane, published in 1843 as a sixty-five-page section in the Statistique de la France, consisted mainly of tables on the operation of asylums. Its charge had been to count patients in private establishments or kept at home as well as the inhabitants of public institutions. A summary table at the end combined the departmental figures into national ones, giving mental alienation by profession, by presumed cause, and by condition: idiots, epileptics, and mad (fous). While the data was mainly bureaucratic, the issues at stake extended to civilization itself, as was made clear in debates at the Académie des Sciences. Alexandre Moreau de Jonnès, the first head of the revived French census, appeared there on 10 July 1843 to discuss its bearing on the great moral questions of the day. There were a lot of false numbers about, he intoned, mentioning first some very early British figures on insanity. The American census of 1840, with proportions mad as high as 1:14, was alarming for a different reason. He did not mention that this figure was only for a tiny racial minority in one state or that Jarvis had challenged it. Instead, he condemned in quasi-religious terms the terrible degradation of the human species implied by so much madness.

Moreau de Jonnès was concerned primarily with matters closer to home. The figures for insanity in France had risen steadily during recent decades to 32,000, implying about one insane per thousand inhabitants. That number, like every assertion that insanity must increase with the advance of civilization, was baseless. His office, he modestly declared, had at last solved the problem of counting insane persons outside as well as within institutions. The correct figure was 18,350, a ratio to population of 1:1,900 or 1:2,000, and it was not increasing.23 But what was this methodological innovation of the new French census? A week later, the alienist Alexandre Brierre de Boismont offered proofs that the new numbers were purely institutional figures, by-products of the new French law for care of the insane. There had been no true census at all. The mad in départements with no asylum as yet would have been missed, as would those residing at large or in other kinds of institutions. A well-conducted recent census of Belgium had found 1.22 insane per 1,000 population, and Parchappe’s authoritative count in the Lower Seine gave a ratio almost as high. The correct number for the insane in France could not be lower than 30,000.

Moreau de Jonnès denied everything. The Belgian census was flawed, and his critic did not understand the French one, which did not depend on the asylum law at all. It had been rigorously planned and executed using all the resources offered by a public authority, and it in no way supported the pretended increase of insanity with civilization. His tables showed a dominance of physical causes by a ratio of 7:3, while all the moral ones were such as could be found already in the Bible. In short, these causes of insanity included nothing specific to modern life.24

Moreau’s tally, vigorously debated at home, also attracted attention abroad. Brigham declared such a count to be beyond the capabilities of the French census, since physicians alone were competent to draw up medical statistics.25 To alienists in German lands, by contrast, it seemed, even if flawed, a daunting achievement of centralized authority, accenting the tragedy of poor, fragmented Germany. “The lunacy statistics of Germany are fractions of no whole,” lamented Heinrich Damerow. German disunity implied the incoherence of its statistics and the impossibility of any coordinated asylum system, even within the Prussian state.26

Abandon Hope: Recording an Epidemic

In reality, there was as yet no established model for tracking and enumerating the insane at large. Thurnam had the advantage of a relatively homogeneous population and of access to informal networks of information. Relapsed patients were likely to return to the Retreat, whereas patients in state asylums might circulate through poorhouses and prisons as well as diverse asylums. Tallying the mentally ill in the context of a national census provided a basis for approaching big questions of social medicine. It appeared increasingly that state asylums were accelerating the increase of the recognized insane without relieving the pressure of mental illness in society. As Scull observed, “It remains perhaps the most paradoxical feature of the entire reform process that the adoption of a policy avowedly aimed at rehabilitation and the rise of a profession claiming expertise in this regard should have been accompanied by a startling and continuing rise in the proportion of the population officially recognized as insane.”27 At the same time, outcomes for these patients went into a tailspin. Physicians complained that so many incurable patients deprived them of space to house the very ones who could benefit from treatment.

Samuel Smith in Ohio, who had warned of just such an outcome, gave republican arguments for a ban on private institutions. Not only was luxury an obstacle to cures, but the availability of a private alternative tended to undermine support for medical facilities so desperately needed by the poor. Lacking state assistance, lunatics without means would drag their families into destitution or, if left at large, endanger the public. Finally, “it is the duty of the Commonwealth jealously to guard the rights and liberties of her citizens,” which is only possible within “state Institutions under proper control.” Smith vehemently opposed the custodial asylum on the ground that only the prospect of curing some patients can keep up morale among the staff and encourage decent care for the hopeless ones. His state, still close to the frontier, was, he said, mostly free of the destitution that plagued other societies. Yet insanity and its causes seemed to increase unremittingly, even in Ohio.28

A growing pessimism about cures undermined sympathy for the insane. At Worcester, George Chandler complained of Irish patients smuggled into the state and brought to the asylum with dubious claims that their long-festering illnesses were new. Laid low by drunkenness, their prospects of recovery were bleak. They were filling places needed by “our native population.” His report for 1854 recalled fondly the days when Worcester was a model, drawing visitors from near and far to witness its excellence. While other asylums had experienced “changes and improvements, amounting to revolutions” in the pathology and treatment of the insane, Worcester was now packed to the gills with patients no longer drawn from an educated, intelligent class of yeomanry but from one without refinement or culture, “and not much civilization even.” Such an institution must degenerate, bringing a revival of private hospitals and the evils that always come with them.29

As cure rates declined, asylum officers battled to preserve their status as places to treat and cure insanity rather than merely to warehouse it. Some recited Dante’s line “All hope abandon, ye who enter” to protest the elimination of medical care for patients deemed hopeless. In his 1845 textbook, the noted Berlin alienist Wilhelm Griesinger worried that the segregation of chronic patients from those undergoing active treatment might create places “where ‘Lasciate ogni speranza’ is written on the brow.”30 In Quebec, supporters of a new asylum imputed to its predecessor institution the dismal condition described by Dante.31 Critics of the proposed Willard Asylum in New York, designed to house chronic pauper patients cheaply by withholding treatment, complained in 1865: “Truly over the gateway to such institutions should Dante’s inscription to the portals of hell be written.” The next year in Toronto, it was again quoted as a protest against a custodial hospital.32 It was impossible now to do without asylums, yet the dream of humanity and hope was giving way to darkest hell. Having set the train of generous asylum care in motion, it was hard to climb off as it careened out of control.

By the 1860s, the hope of cures was clearly receding, but this pessimism did not mean giving up on medical science. Ironically, the failure of medicine to control the growth of asylum populations brought new resources for recordkeeping and statistical study. Alienists labored to create a foundation of data for the investigation and relief of hereditary causes.

It is tempting, but mostly incorrect, to suppose that the growing fixation on heredity was an evasion of responsibility for medical failure. If anything, asylum doctors were moving in the contrary direction, reciting statistics to prove that inherited insanity was not less curable. Maximilian Jacobi’s experience at Siegburg during the 1830s is revealing on this point. At first he referred to the high frequency of inherited insanity along with the poor condition of many patients as impediments to successful treatment. The responsible committee of the Rhine Province Landtag agreed, praising him for curing about 57 of 270 patients even though 69 were incurable and 50 more, “on account of hereditary Anlage, or for other reasons, presented at the time of admission greatly diminished hopes of a fortunate success.” Jacobi’s report for 1833–1836 emphasized the disadvantage of treating 183 patients “who, because of hereditary or congenital Anlage, the long duration of their illness, or earlier and as yet fruitless attempts at cure, offered as good as no hope . . . for a successful treatment.” In 1840, he pointedly omitted heredity from the list of factors tending to reduce cure rates.33 The first doubts that modern asylums could halt and reverse the growth of insanity coincided with the initial appearance of statistics on the curability of hereditary patients. The numbers were taken as showing that a hereditary Anlage increased vulnerability to recurrence or relapse but did not imply incurability. New tables showed hereditary insanity to be, if anything, more readily curable than nonhereditary. In 1847, AZP’s associate editor C.F.W. Roller referred scathingly to the ignorance of an author who had invoked a hereditary Anlage to excuse medical failure, in opposition to “the most rigorous observations.”34

This view became, for a time, a consensus. Heredity is “among the most prevailing causes of insanity,” was how William Malcolm summed up the statistics in his 1849 report for Perth, Scotland. “I by no means find the disease is less easily cured when this is the case.”35 B.-A. Morel, not yet a famous degenerationist, cited statistics to support his enduring faith in curability. He celebrated a new asylum at Maréville, with its great population of 760 patients, as an “inexhaustible mine of riches” for science. He even denied that expanding asylum populations reflected any real increase of insanity.36

Better Hospitals and Rising Insanity

Beginning about 1852, Edward Jarvis bravely undertook to separate social from medical sources of rising asylum numbers. Although the insane appear ever more numerous, he remarked, “it is impossible to demonstrate, whether lunacy is increasing, stationary, or diminishing, in proportion to the advancement of the population, for want of definite and reliable facts.” A determination would require at least two accurate censuses of the same population. Such were nowhere to be found. The French census of 1843 was manifestly incomplete, while British counts were vitiated by their limitation to asylum patients. Jarvis respected the 1850 US census, but the one in 1840 had been a fiasco. An excellent new Belgian count would provide information on the growth of insanity when it had been repeated. He also praised the Norwegian census of 1828, which he knew from Esquirol’s review, but he seemed unaware of subsequent Norwegian counts.37

In 1855, he reported on a census of the insane in Massachusetts, which had been authorized to assess the need for a third state asylum. In contrast to prior tallies in his own and other states, which relied on untrained officials, the commission for this one sent an inquiry to every physician in the state requesting medical information on all insane persons. There were enough physicians, Jarvis thought, to carry out a valid census: the “whole Commonwealth is, in detail, under the eye of the medical profession.” The result, 2,632 insane and 1,087 idiots, would provide guidance in the future, once the exercise had been repeated.38

For now, he had no choice but to reason in reverse, from causes to statistics. Starting with a list of 176 physical and moral causes extracted mainly from the Worcester hospital reports, he surmised their direction of change. Civilization makes sensibilities more keen and passions more powerful and abiding, he reasoned, creating vulnerability but allowing the affections to become more permanent, providing stability. Religious enthusiasm waxes and wanes. Education, the greatest benefit of civilization, brings, alas, no sufficient increase of wisdom to guide cerebral action. The evidence from all sources, he concluded, supported Esquirol’s assessment of a disease on the rise.39

In Britain, many informed commentators suspected that the increase of insanity was an artifact. According to a British statistical report from 1861, “the great increase which has taken place in the number of Patients in Asylums is limited almost entirely to Pauper and criminal Patients.”40 It appeared that the abundance, quality, and cheapness (to patients) of asylum care might provide the real explanation. Alternatively, the demands of modern life may have raised the bar for effective participation in society, driving the less able to asylums.

The British census first counted the insane in 1851, but only those in asylums.41 Other numbers derived from registration processes at various sorts of institutions: county asylums, licensed houses, hospitals, poorhouses, and private homes. Since numbers from different sources remained distinct in the reports, they could be investigated separately. For example, pauper patients as tallied by the Commissioners in Lunacy were compared with those given in reports of the Poor Law Board to show that increasing pauperism, by itself, could not explain the alarming growth of pauper insanity. There were several ways for asylum patients to increase without any real increase of insanity. For example, life will be prolonged when “destitute and diseased persons” are placed in “well constructed, well regulated” establishments, “specially adapted for their protection and treatment.” Asylum professionals, of course, liked to emphasize this one. The apparatus of data circulation could also have an impact. A simple example is the introduction of automatic registration of new patients, which of course made for higher patient numbers. A more consequential shift of recording practices was the requirement for inspectors at workhouses to include in the returns for lunacy “all persons receiving relief on account of mental infirmity.” Some of these reclassified individuals were promptly sent to asylums.42

There was always a possibility that some cause, perhaps one as vague as “civilization,” was stimulating the increase of a bona fide mental disease. “Degeneration,” though less specifically medical, also implied a decline of human quality or resilience. The extraordinary growth of asylum populations was almost as alarming and just as expensive even without causes like these. The very tangible consequence of relentlessly growing populations of patients and prisoners drove these painful debates about causes. A series of reports from 1875 to 1877 of an expert commission set up by the Lancet, a medical journal, held that the problem was not really a medical one at all. “If the moment a new asylum is opened, with all the best modern appliances, it be filled with patients withdrawn from the licensed houses, and treated as an almshouse for the aged and infirm paupers who happen to be eccentric and troublesome in the neighbouring workhouses, it will be necessary to go on building asylums until no inconsiderable portion of the pauper population is returned as lunatic.”43

The insane asylum as a restful, ordered place grew up in part as the remedy for a disease linked to modern hustle and bustle. It was, in a way, a backward-looking remedy in an age of industry and progress.44 It had much in common with communitarian utopian visions of this period, and it did not seem to be working. Hence, the problem had to be confronted outside the walls of institutions. Asylum doctors were already aware of this, and census investigations revealed more fully the social dimensions of insanity. Its medical character remained elusive, and no one could say if civilization was its deepest cause. It was, in any case, expensive and deeply disturbing. The work of the census intensified this frustration. The terrible increase of the insane was a sink for public expenditures, one that medicine seemed powerless to reverse. “Hereditary predisposition doubtless exists in a far greater number of cases than is generally supposed,” wrote Richard Dunglison in 1860.45 The census might even be mobilized to explore and to depict this power of hereditary causation.