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.