Historical Analysis of Dix Asylum (1865-1920)

Lived Experience
UNC_OpioidResearch_illustrations_studies__DixAsylum

What we are studying

We are analyzing the admissions ledger entries  from what was originally called the Insane Asylum of North Carolina, but what was better known as the Dorothea Dix Hospital in Raleigh, North Carolina (1856-2012). The ledgers start with the admission of the first patient on February 22, 1856 and are organized in the order of admission. A revision of the state’s open records law in 2016 made these and other state records created more than 100 years ago available to the public at the State Archives of North Carolina for the first time. More than 7000 patients were admitted between 1856 and 1920. The decision to close the hospital was made in the early 2000s, the last residential patient was transferred in 2012, and the hospital permanently closed. The City of Raleigh purchased the 306 acre site from the state in 2015 for $52 million and committed to transform it into the city’s defining green space—a “destination park.”  All patients being analyzed in this project have passed away, and these are de-identified data from public records. Currently we are cleaning and processing the OCR data from the physical ledgers and creating variables for historical and epidemiologic analysis. In addition to descriptive statistics and data visualizations, we will also examine opioid use during this period of history.

Why it matters

When it opened in 1856, the NC Hospital for the Insane, as it was called, was an expression of a transformative understanding of mind, brain, and body. The “moral treatment” approach, as it was called, was based upon the creation of new therapeutic environments—asylums in the original meaning of that term. Madness was reconceived as a disease of the brain, and “attacks” of insanity were believed to be triggered in susceptible individuals by a wide range of “supposed causes,” including “religious excitement,” “domestic trouble,” “war,” and grief.

Alcohol and opioid addiction were treated at the hospital.  Whiskey was the most profitable use for corn in 19th century North Carolina. When prohibition was enacted in 1908, production and consumption simply went underground.  “Bootleggers” supplied “blind tigers” in many towns. Opium and alcohol were (unlisted) ingredients in patent medicines readily available without prescription at local drug stores.  Doctors dispensed morphine for a wide range of ailments.  Asylum doctors gave opium to patients suffering from types of mania.

One of the most common supposed causes was “ill-health.”  In women, madness was connected to reproduction: “uterine trouble,” “puerperal illness” (pregnancy, childbirth, and post-partum depression) and menopause. More than 150 different supposed causes were noted across the more than 60 years covered by available records. Patients were categorized by the “form” (diagnosis) their madness took: melancholia, mania, and dementia being the most common. Epilepsy was regarded as a form of madness. Ledger entries chart new forms entering the diagnostic lexicon at the end of the 19th and beginning of the 20th century: anxiety, depression, dementia praecox. The entries follow each patient from admission to discharge (cured, improved, not improved), transfer, “elopement” (escape), or death.  Patients with acute illnesses might stay for six months or more; patients with chronic, recurrent, or uncurable maladies might stay for decades.

The transcribed and digitized admissions ledgers for Dix Hospital represent the first comprehensive, searchable database for a 19th century American insane asylum. It is also the only index to the original records. Through them the emergence of modern psychiatry can be traced: asylum superintendents were the first psychiatrists. Based on patterns they saw in the ledgers, they attempted to discern the etiology of madness and determine whether some people were constitutionally disposed to attacks of insanity. From the beginning, the ledgers show a persistent interest in heredity, for example, which is amplified in the early 20th century, laying the groundwork for the eugenics movement.

By the end of the 19th century, madness was widely regarded as an effect of the modern age: urbanization, industrialization, rapid and unmanageable change. Suicide, for example, was thought to be most prevalent among middle-class urban men, and rare among women of all classes. The population from which Dix Hospital drew in the 19th and early 20th century, however, was overwhelmingly rural: the largest city in North Carolina in 1900 was Wilmington, with only 25,000 residents.  The ledgers consistently note “suicide”—what we would now call suicidality—giving us an opportunity to examine suicide in this very different demographic. There is a burgeoning secondary literature on the 19th century international asylum movement and the understandings of mental illness upon which it was based. The Dix ledger database provides us with a rare opportunity to “field test” the arguments made in these studies in relation to region, rurality, and culture.

The database also allows us to track patients through other recently uncovered records. What were called general casebook records began to be kept in 1887 and continue throughout the period of record availability. These printed intake forms contain more than 100 fields, documenting patients’ family and personal history, physical condition, and “manifestations” of the mental illness for which they were admitted. The numerical identifier assigned each patient in the admissions ledger is continued in the general casebook entries, creating a sub-set of some 5,500 patients documented in both sets of records between 1856 and 1920.  Staff meeting minutes and unredacted patient interviews from 1916-17 have been copied, for which the database also provides a key.

There is a long and deep connection between the hospital and the University of North Carolina at Chapel Hill. Generations of psychiatrists, psychologists, psychiatric nurses, and social workers who trained at UNC did rotations at Dix, some of whom went on to serve on the Dix staff.

How we are studying it

The primary source material was an intake/discharge ledger, which has been digitized and de-identified for our analysis. We are cleaning and formatting the data, and will be making data visualizations to allow others to develop hypotheses for further research. In addition, interview transcripts, staff meeting notes, genealogy records, and newspaper archives are available to provide context and details, but are being analyzed separately.

How to use the results

Our quantitative analysis is primarily for developing hypotheses that can be examined using primary sources from the era. Preliminary data visualizations are being posted here.

Who is conducting and supporting the study

The original records were uncovered in the State Archives by a  a team led by Robert C. Allen (the James Logan Godfrey Distinguished Professor of American Studies and Co-Director, Community Histories Workshop at The University of North Carolina at Chapel Hill), and Sarah Almond (Program Coordinator, Dorothea Dix Park History Initiative and Assistant Director, Community Histories Workshop at the Center for Urban and Regional Studies, UNC-Chapel Hill).  Their initial research in 2017-18 was part of the planning process for Dorothea Dix Park, supported by a gift from the City of Raleigh.  The ledgers were transcribed and digitized by four honors students at the University of North Carolina at Chapel Hill: Thomas Burnett, Hannah Frisch, Keely Curry, and Dani Callahan. Data analysis is being conducted by Nabarun Dasgupta and Katie Huber. We are grateful to generations of taxpayers in North Carolina for supporting public universities. This study has been registered with the University of North Carolina  Institutional Review Board.

Nabarun Dasgupta
Epidemiologist, Factotum