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A well-established interpretation associates the nineteenth-century psychiatrist Pliny Earle's deflation of high cure rates for insanity with the onset of a persistent malaise in patient treatment and public health policy during the Gilded Age. This essay comes not to praise Earle but to correct and clarify interpretations, however well intentioned, that are incomplete and inaccurate. Several points are made: the overwhelming influence of antebellum enthusiasm on astonishing therapeutic claims; the interrogation of high “recovery” rates begun decades before Earle's ultimate provocation; and, however disruptive, the heuristically essential contribution of Earle's challenge to furthering a meaningful model of mental disorder. In spite of the impression created by existing historiography, Earle, a principled Quaker, remained committed to “moral treatment.”
Nay, I'll ne'er believe a madman till I see his brains.
Feste, a clown
Shakespeare, Twelfth Night, Act 4, Scene 2
During a long life, Pliny Earle (1809–92) was a young physician at the foundation of Western psychiatry but in later years a controversial critic of claims of high recovery rates, which he had earlier touted.1 He was one of thirteen asylum doctors present at the creation of the Association of Medical Superintendents of American Institutions for the Insane (AMSAII) in Philadelphia in 1844, and the last of these framers, “the Nestor of psychological medicine,” to die.2 Among other activities, he was physician at the Friends' Asylum in Frankford, Pennsylvania, from 1840 to 1842; at the Bloomingdale Asylum near New York City from 1844 to 1849; and in 1853 at the New York City Lunatic Asylum at Blackwell's Island. During the Civil War he cared for deranged Union soldiers at the Government Hospital for the Insane near Washington, D.C., and then over the period from 1864 to 1885 he was superintendent of the state hospital for the insane at Northampton, Massachusetts. He studied in Paris, published widely in specialized journals, and traveled extensively in Europe, writing about mental hospitals from the British Isles and Central Europe to Italy and the Ottoman Empire, as well as the Caribbean. Well established in the profession, Earle launched an iconoclastic revision of cure rates starting in 1876 that had profound reverberations. Earle's metamorphosis from faith to doubt is a revealing case study in the transformation of psychiatric paradigms from the expansive Antebellum Era to the constrictive Gilded Age.
Prominent colleagues, medical societies, and influential journals across the Atlantic world initially endorsed his revision, if begrudgingly. As an editorial in Alienist and Neurologist characteristically put it in 1883, “Dr Pliny Earle contributes another of his dispiriting articles on the curability of insanity, which are all the less welcome since we can find no flaw in his reasonings, and are compelled nolens volens to accept his conclusions.”3 More recently commentary has been mixed. In the first substantive history of mental illness in the United States, the journalist Albert Deutsch charged in 1937 that “once the cult of curability was dealt a death-blow, however, a period of reaction set in, the unfortunate effects that are still seen today.”4 Also outraged by the plight of the mentally disordered, Boston psychiatrist Sanford Bockoven projected the current malaise backward on Earle, unlike Deutsch who singled out “the psychiatry fraternity” for a “vicious cycle of fallacies.”5 Bockoven wrote disparagingly in 1956: “Belief in the incurability of mental illness, which Dr Earle had sold the medical profession, was a barrier to the adoption of much needed corrective measures which has not yet been torn down.”6 Three years later, psychiatrist Eric Carlson and Lillian Peters echoed that “J.S. Bockoven has well pointed out the negative influence of this work and has demonstrated that Earle himself misused statistics in order to prove his point.”7 And the eminent scholar Gerald N. Grob concluded, “By and large the criticism of Bockoven seems justified.”8
This essay comes not to praise Earle but to correct and clarify interpretations, however well intentioned, that are incomplete and inaccurate. Several themes will be highlighted that are broadly entangled with the nascent effort to create a persuasive psychiatric paradigm during the nineteenth century. First, although Deutsch did not scapegoat Earle, he did accuse the “psychiatry fraternity” of a “white lie” in claiming unprecedented recovery rates during the antebellum period. A fuller explanation should place the early asylum movement in the context of a romantic reform with its own inherent contradictions that rose fully to consciousness during the Gilded Age. Second, the effort to create a sustainable model of the mind, including diagnosis and prognosis, was necessarily instable for an inchoate discipline, and intellectual provocations such as Earle's were essential to the creation of meaningful knowledge.9 Third, Bockoven's quest to discredit Earle pivoted on the interpretation of a statistical study at Worcester State Hospital and on a gratuitous ad hominem attack that overlooked a wide-ranging and long-standing discussion that Earle and others had tentatively pursued even before the post-bellum era. Furthermore to blame Earle for the subsequent woeful policy on mental illness is to claim too much and to explain too little. Rather than shoot the messenger, this essay places this provocative psychiatrist in the framework of his New England Quaker roots and the therapeutic revolution of the nineteenth century.10
Let us begin with Deutsch's linkage of the “psychiatric fraternity” with the fallacy of the “curability craze.” He wrote that this first generation of asylum superintendents proclaimed a “false optimism” that was “woven with the warp of error and woof of short-sighted opportunism.”11 It is clear that the newly created asylums of the Atlantic world reported unprecedented recoveries of the mentally ill during their first decades. According to Earle's debunking in 1876 and subsequent reprise of recovery rates, these included: 90 percent at the Hartford Retreat for the Insane during 1824–33; 90 percent at the Vermont Asylum in 1849; 99 percent “radically restored” at the Mount Hope Institution at Baltimore in 1845; and 93 percent at the Western Lunatic Asylum in Virginia during 1836–44.12 During the same period, John M. Galt at the Eastern Asylum in Virginia, Luther V. Bell at the McLean Hospital outside Boston, and William M. Awl at the State Hospital for the Insane at Columbus, Ohio, asserted as Bell put it, “all cases, certainly recent [underline in original] … recover under a fair trial.”13 George Man Burrows in Greater London and Samuel Tuke at the York Retreat in England also reported similar figures.14
Furthermore, Eli Todd (whose success in Hartford gained international repute thanks to the publicity of Captain Basil Hart, an English visitor) explained that “mental disorder is as definitely a manifestation of disease as is a fever or a fracture.”15 His close friend Samuel Woodward at the Worcester State Hospital continued in 1835, “In recent cases of insanity, under judicious treatment, as large a proportion of recoveries will take place as from any other acute disease of equal severity.”16 Writing from Paris three years later, Earle hailed the Hartford Retreat for the Insane as the most successful institution of its kind in the western world. “It was left for the physicians of the present age,” he proclaimed, “to demonstrate that as great a proportion of patients suffering under acute mania may be cured as of those of any other disease.”17 As superintendent of the Bloomingdale Asylum in Upper Manhattan, Earle (decades before his iconoclasm) joined his peers in hailing a recovery rate of insanity in its early stages at between 75 and 90 percent. “There are but few diseases,” he wrote in 1844, “from which so large a percentage of the persons attacked are restored.”18
What is lacking in Deutsch's muckraking exposé is the temporal dimension. What was happening in Earle's time? Why the enthusiasm? Why the break with tradition? Was there something more than professional aggrandizement or snake oil hucksterism at work? As historian Gordon S. Wood asked rhetorically, “Is it true, as some historians of medicine now contend, that medicine, far from tending toward absolute truth, reflects and interacts with culture, society, and politics?”19 Indeed, the belief in high rates of cure was integral to the optimism of the Enlightenment during an age of reform. Assumptions of rationality, egalitarianism, natural law, liberty, and progress were widespread. Revolution in the United States, France, and Saint-Domingue, abolitionism, penal reform, women's rights, and Jewish emancipation marked deep fissures within the Ancien Régime. Historian Lynn Hunt has identified this era with the origins of the doctrine of universal human rights.20
In their own transoceanic sphere, physicians William Battie in England, Philippe Pinel in France, Vincenzo Chiarugi in Italy, and Benjamin Rush in the United States espoused humane treatment of the afflicted and proclaimed that insanity was curable. The creation of the early asylums rested on the credo that if treated early, insanity was reversible, an astounding assertion. Human nature, it was assumed, was malleable. Physician and philosopher John Locke posited in An Essay Concerning Human Understanding (1690) the premise of classical liberalism, that consciousness itself was a tabula rasa and subject to amelioration in beneficent environments. Pinel's famous treatment morale was given its American idiom by Todd in 1824 as the “the law of kindness” in patient care.21 The Society of Friends' asylums in Philadelphia under Thomas S. Kirkbride and Thomas Eddy in New York City derived from Quaker William Tuke's York Retreat that opened in 1796. The Hartford Retreat for the Insane, founded by doctors, borrowed its name from Tuke's pioneering English institution. Psychiatric literature—treatises, case studies, and annual reports—provided diffusion of knowledge and international collaboration. Americans, such as Amariah Brigham and Pliny Earle, were early psychiatric visitors to Europe with the latter making three substantial sojourns.
The intersections between early psychiatry and other philanthropy were abundant. Quaker antislavery and psychiatric endeavors converged, as we will see later in Earle's family. Pinel's celebrated unchaining of the mad during the 1790s at the Bicetre and Salpetriere in Paris shared an iconography with English abolitionist and potter Josiah Wedgewood's 1787 cameo, “Am I not a Man and a Brother,” in which a kneeling black slave implored with uplifted hands to be unshackled.22 The linkage between antislavery and psychiatry is extraordinary, because for the first time in world history systematic efforts were made to eradicate the evil of slavery and to cure the affliction of insanity. As the times were radically new, perceptions were utopian, fraught with great expectations.
Fundamental alterations in theology added propulsion to the new order of the world, including that of early psychiatry. What scholar Nathan O. Hatch calls “the democratization of American Christianity” rested on an altered soteriology that rejected Calvinist predestination for Arminianism, a former heresy that taught that a graciously enabled faith opened the way for redemption.23 Evangelicals—Baptists, Methodists, Presbyterians, and Congregationalists—created a united front to catechize humanity, including Jews and Turks. Methodists opened hospitals and their “good news” spread from the slums of England to the quarters of southern slaves. Guided by the “inner spirit,” Quaker benevolence was a wellspring for mental asylums and antislavery organizations on two continents. The outpouring of the spirit during the Second Great Awakening was ubiquitous, whether in the frontier exuberance at Cane Ridge or the more staid New Haven theology. The dynamism of a transformative market revolution and expanding political democracy was complemented after 1800 by what scholar Harold Bloom called the formation of an “American religion,” a post-Christian culture of unlimited possibilities.24
The Concord essayist and Chautauqua lecturer Ralph Waldo Emerson marveled in 1841, “What a fertility of projects for the salvation of the world.”25 Not only Transcendentalism, but perfectionism, prohibition, and phrenology gained proponents. Set in the context of belief in Manifest Destiny, mesmerism, Methodism, millennialism, and Mormonism, would faith in the curability of insanity seem outlandish? Psychiatric epidemiologist Edward Jarvis remarked in 1843 that the astounding cure rates at Woodward's Worcester hospital were “among the brightest of these tributes to humanity.”26 Beyond Michel Foucault's “great confinement,” Erving Goffman's “total institutions,” and David Rothman's “social control,” asylum medicine was an integral part of what historians Alice Felt Tyler and John Thomas described as “freedom's ferment” and “romantic reform.”27 Conversion and curability, moral suasion, and moral treatment overlapped and intersected. “The realm of causation in medicine,” Charles E. Rosenberg adds, “was not distinguishable from the realm of meaning in society generally.”28 While the Reverend Thomas Gallaudet taught deaf mutes, physician Samuel Gridley Howe educated the blind, and Dorothea Dix reclaimed the insane, William Lloyd Garrison and Frederick Douglass demanded immediate abolition and Karl Marx and Frederick Engels proclaimed “the proletarians have nothing to lose but their chains.”29 The Old Hero Andrew Jackson—in John William Ward's words “a symbol for an age” of democratic change (at least for white men)—moved from log cabin to White House.30
Growing contradictions during the Gilded Age that subverted the expansive claims of antebellum asylum physicians eventually became apparent to Earle's relentless intellect. This “man of independent opinion,” as the British Journal of Psychiatry characterized Earle, had Quaker roots in New England where he was born in 1809 in rural Leicester (west of Worcester, Massachusetts).31 His dynamic mother, Patience Buffum Earle, though not formally educated, taught her children to read. An elder in the local Friends' meeting, she was from a prominent Quaker family in Rhode Island, Roger Williams's refuge for dissidents from Puritan Massachusetts. Her brother Arnold Buffum—Pliny's uncle—was an early coadjutor to William Lloyd Garrison, as well as first roving lecturer and president of the New England Anti-Slavery Society that had been founded in a Boston African American church in 1832. He broke with Garrison over the adoption of “non-resistance” later in the decade and helped form the crusading Liberty Party in 1840. His nephew Thomas Earle—Pliny's brother, Philadelphia attorney and journalist—ran for vice-president on the abolitionist ticket with apostate Alabama slaveholder James G. Birney in that formative year. Elizabeth Buffum Chace—Arnold's daughter and Pliny's cousin—was herself a prominent abolitionist, feminist, and prison reformer. In addition, two other of Earle's brothers were radicals: John Milton Earle was editor of the antislavery Worcester Spy; and William Buffum Earle was a leading antislavery agitator in Worcester County.32 As his friend Franklin Sanborn—himself a radical abolitionist and one of the “Secret Six” who escaped arrest in Canada after funding John Brown's 1859 raid—described him, Pliny was “an early Abolitionist” with firsthand observation of slavery in the South and Cuba.33 In addition to family, his notable antislavery contacts in the United States included Theodore Weld, the Quaker Grimke sisters Angelina and Sarah, James G. Birney, and an English Quaker antislavery circle that included Joseph Sturge, a founder in 1839 of the British and Foreign Anti-Slavery Society.34
Less radical politically than his brothers, Earle translated Quaker philanthropy to medicine, not abolitionism. He had a practical and technical side: as a youth he worked the family farm and learned an exacting machinist trade in his father's shop. The entrepreneurial, Quaker father—descended from an original incorporator of the Rhode Island colony—combined agriculture with producing “cards” for the burgeoning textile industry of his customers Samuel Slater, Moses Brown, and William Almy, innovators of the factory system in the United States. Leaving behind the yeoman and artisanal background of his parents, the younger Earle and his siblings acquired formal education with new generational opportunities afforded in the accelerating market revolution after the Panic of 1819. Earle studied at the Friends' School in Providence in 1826, and then followed his older sister Sarah as a teacher there from 1829 to 1835. As a pedagogue, his numerical description of the woeful orthography of his charges in 1833 closely anticipated his questioning of cure rates more than four decades later: “When my spelling-class consisted of twenty-one, I put the name of the twenty-four United States to them. They spelled on their slates; and I found more than two hundred mistakes—an average of ten apiece.” Another class of twenty-seven misspelled fifty common words a total 391 times. And, as he would later do with patients repeatedly discharged as cured, he noted, “One youth of seventeen made forty-three errors.”35 The empirical ruler for assessing student performance would later crack the knuckles of asylum physicians.
Instead of abolitionist agitation, a constellation of factors drew him to early psychiatry. Quaker benevolence was foremost. Until age thirty Earle wore plain attire befitting a Friend, when the newly minted physician became a la mode. As his influential mother observed, “It makes but little difference what Pliny wears, long as he retains his integrity.”36 Her maternal aphorism reflected strict but loving child nurture based on persuasion and reason that internalized spiritual values, exacting morals, good works, and middleclass aspirations. Quaker asylums in England and Philadelphia were renowned by 1830 when the young man mixed school teaching with a two-year apprenticeship with Rhode Island's leading physician Usher Parsons in Providence. Over the century, he formed close relationships with Samuel Tuke, his son James, and grandson Daniel Hack Tuke, lineal descendants of William Tuke, founder of the archetypal Quaker Retreat at York. Like his brother Thomas, Pliny relocated to the Quaker hub of Philadelphia for medical studies from 1835 to 1837 at the University of Pennsylvania, where co-religionist Thomas Kirkbride, famous for the eponymous plan of asylum architecture, graduated five years earlier.37 After an intervening European tour following graduation, he was assistant physician at the Friends Asylum at Philadelphia from 1840 to 1842.
Earle's inclinations and curiosity are revealed in letters as the nearly twenty-four-year-old traveled to medical school in the autumn of 1835. At Hartford with its landmark asylums, he praised the Retreat for the Insane, modeled after the York Retreat, for its “delightful prospect.”38 At the Asylum for the Deaf and Dumb, he marveled at the remarkable Julia Brace, blind and deaf since a childhood bout with typhus, who threaded a needle. He described its inspirational founder, Reverend Thomas H. Gallaudet, as a man with “a face that beams with benevolence.”39 At Yale he attended lectures by Benjamin Silliman, one of the nation's first professors of science, and nearby at the Grove Street Cemetery, the former machinist paid homage to renowned inventor Eli Whitney, who, like Earle, studied at Leicester Academy.
Not unlike Eli Todd whose father and sister suffered mental debility, a similar situation may have predisposed Earle's choice of career.40 A cousin Rebecca Spring remembered that Earle's sister Mary had a “terrible illness” that left her insane; she eventually died in an asylum.41 Abolitionist Samuel May, Jr., a family friend and Unitarian minister in Leicester, related that Earle's brother Jonah “had less than his equal of the mind and capacity of the family” of nine children.42 Earle never married, and Mrs. Spring recalled, “Later he was interested in a lady of Salem, and she in him, but he told me he could not marry her on account of there being insanity also in her family.”43 A close cousin, Mary, died insane early in life.44 In an 1838 dinner discussion, with Samuel Tuke in London about the “cause of such preponderance” of insanity among Friends, he pinpointed the “extreme cultivation of ties of consanguinity.”45 In a publication of 1848, Earle, not unlike other colleagues but with personal resonance, identified heredity in the etiology of insanity.46
Fresh out of medical school in 1838, Earle boldly announced his professional coming of age with a prescient essay on the state of asylum medicine in a major journal. “Remarkable improvements have been made within the last half century in the treatment of insanity, but,” he cautioned, “our knowledge of its causes and pathology have not advanced with equal rapidity.”47 He surveyed the data on the predisposing causes of insanity—inheritance, temperament, complexion, age, sex, social relations, and education—and found little concrete evidence. The precipitating cause was also nebulous with nearly two-thirds of identified psychosocial factors unknown. “It is extremely difficult,” he continued, “nay absolutely impossible, as the reports fully indicate, for the superintendents of lunatic hospitals to ascertain either the proximate or the immediate causes of the diseases of many of the patients.”48 Nonetheless he was as ebullient as his colleagues in rejoicing that “as great a proportion of patients suffering under acute mania may be cured as of those of any other acute disease.”49 Yet, his message was mixed, hinting at a conundrum that he would confront head-on forty years later. He averred, “Diseases of the nervous system are peculiarly liable to relapse” in spite of the “more enlightened philanthropy” of “moral treatment” in hospitals.50
Furthermore, a hegemonic Cartesian dualism qualified his and his associates' lifelong assumption that it was “a fundamental error” that “the mind itself is diseased, instead of the organ through which it is manifested.”51 In other words, the autonomous mind, or to the point the transcendental soul, was not deranged, but the brain was afflicted with a pathological, but ill-defined, lesion. This Quaker iteration of antebellum theology provided Tukes, Kirkbride, and Earle a spiritual calling to asylum medicine, but the mind–body differentiation blocked an understanding of the gestalt of neuroanatomy. Rather than scientific innovation, Earle's métier was analyzing asylum data, the Tukes' humanitarianism, and Kirkbride's architecture. The twenty-nine-year-old doctor, who had yet to run an asylum, complained of the “diversity in the methods of collecting similar statistics.” In a statement that would define his legacy, he recommended, “If a common formula for the statistical part of the reports [underline in original] could be adopted by all the asylums, this objection would be removed, and our knowledge of the disease, of its causes, duration, curability, etc., would be more rapidly advanced.”52
After two years spent in Europe after graduation, Earle published a study “with copious statistics” of thirteen asylums. The 1839 foray into international psychiatric epidemiology reaffirmed for him the legitimacy of high cure rates. “I would direct the attention of those who are interested in the question of the utility of Lunatic Asylums,” he wrote in language similar to Dorothea Dix's landmark report to the Massachusetts legislature of 1841, “to the results of treatment as exhibited in the tables of recent and chronic cases, and request them to compare the condition even of the ‘incurables’ with that of hundreds, may it not be said, thousands, in our country, who are pining, famishing, dying in garrets, cellars and dungeons, clothed in rags, and, in too many instances, confined by chains.”53
Earle's experience at the Friends' Asylum further prompted in 1843 a heuristic essay, “Curability,” which, like the 1838 essay, shows the continuity of his critical thought. His discussion is not alien to the profession today, particularly the iterations of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Earle's axiom was that too many “variables” made it “evident that the adoption of a fixed standard of intellectual and moral integrity, or of sanity [underline in original], is beyond the bounds of possibility.” The corollary was “in many cases it is a point of greatest difficulty to determine when a perfect restoration is affected.”54 He quoted Amariah Brigham, then superintendent at the Hartford Retreat and one of the most creative intellects in the discipline, “By recovered we usually mean complete restoration of mental powers,” yet some people so identified could be, Brigham qualified, “very eccentric” or without “their former mental vigor.”55 The general protocol at most institutions, such as the precedent setting York Retreat, Earle explained, was that “recovery” was not equivalent to cure, but assessed functionality.
Not one to genuflect to what Francis Bacon called the idol of authority, Earle faulted the hasty generalization of the recently deceased Jean-Etienne Dominique Esquirol, one of the fathers of psychiatry, that France achieved more recoveries than occurred in England. “General truths can never be obtained,” Earle continued in Baconian fashion, “from data so limited and so partial.”56 Applying his analytical litmus test, he contradicted Woodward, then a pillar of the profession at Worcester State Hospital—as he would sensationally during the 1870s—that statistics show “the difficulty of effecting cure increases progressively with advancing years,” not vice versa.57 He joined revisionists who in 1840 no longer reported the distinction between recent and chronic cases, which facilitated the reporting of high recovery rates of recent cases by isolating others as “chronic.” Not only, as Deutsch made clear, was such reporting de rigueur in the heady atmosphere of asylum building and career promotion, but, as Earle analytically put it, “perhaps no utility can result from the continuance of a custom which can never terminate in absolute mathematical certainty.”58 In spite of a plethora of problems with psychiatric precision, Earle remained a positivist: “However imperfect so ever may be our data on the subject, at present, still no inconsiderable amount of good may eventually accrue from pursuing it.”59
The collection of statistics on insanity was part of the mandate of the thirteen superintendents, including Earle, who gathered in Philadelphia in October 1844 to form the AMSAII, the nation's first medical specialty. Woodward, the first president of the Association, was adamant, as he wrote Earle two years earlier, that “the statistics of insanity have done great good, and the extensive and enthusiastic movements in favor of the insane in the United States have been produced by comparing the results of institutions and looking to the success of the best as given in the published statistics.”60 Underlying his commitment to high recovery rates at Worcester, he conveniently assumed that recurrences of mental disorder were not relapses of the original disorder but independent, analogous to sequential infections of respiratory illness. Unlike Woodward (who died at sixty-three in 1850), a younger, more analytical cohort (Pliny Earle, Edward Jarvis, and Isaac Ray) started to question the assumptions of the founding generation. In 1848 Earle noted that before his tenure at Bloomingdale—which by necessity accepted acute alcoholics and the insane—an inebriate was admitted nineteen times and discharged as “cured” [underline in original] seven times and as “relieved” [underline in original] five times.61 Earle added that among the insane “relapses or recurrences of the disease” were so common between 1821 and 1844 that 467 cases out of 2308—about one-fifth—were readmissions.62
The Boston-based Edward Jarvis, the foremost statistician in the profession, observed in 1854 that the claims of mental hospitals—now the preferred term among professionals to emphasize amelioration—had raised public expectations. Jarvis, a specialist on the United States census, did not find an increase in insanity per se at mid-century. In contrast, Earle, and notably Brigham, attributed widespread anomie to the nascent industrial revolution in the United States that foreshadowed sociologist Emile Durkheim.63 Jarvis perceptively continued, “Consequently more and more persons and families who … formerly kept their insane friends and relations at home … now believe, that they can be restored or improved or, at least made comfortable in these institutions… .”64
Isaac Ray, a founder of forensic psychiatry, in 1856 derogated the overflowing statistics in hospital reports, as “a useless array of numbers.”65 Physicians “lower the dignity of their calling by statements calculated to win the popular favor [rather] than to advance the true interests of science.”66 Foreshadowing Earle's expose by exactly twenty years, Ray elaborated, “Ninety per cent of recoveries in recent cases was not an unfrequent result of a year's operation, and the public was taught to believe that it had only to establish hospitals for the insane, in order to cure every case as it occurred, and thus prevent any further accession to the accumulating mass of incurables that crowded the receptacles of pauperism and crime.”67 With decades of experience at hospitals in Maine and Rhode Island, Ray declared “The public found it had been deceived.”68 Seven years later in a major address to the profession significantly titled “Doubtful Recoveries,” he summed up his caveat “I have thus pointed out some of those conditions and incidents which throw doubt on a question of recovery, and therefore require to be carefully and intelligently considered.”69
Similarly, Earle sought greater certitude, because “science is lost at once in mazes of uncertainty and ignorance, whenever it attempts to fathom mind itself.”70 Among the most published of his colleagues, he analyzed European asylum data, wrote about cholera in Malta, examined data on the pulse rate of the insane, and self-dozed with increasing amounts of conium maculatum, concluding that the widely prescribed materia medica had imprecise effects, though not for Socrates in a fatal draught of “hemlock” in Plato's Phaedo.71 He made some cursory statements about phrenology, but he was not a promoter nor were other superintendents.72 In a meta-analysis of phlebotomy in treating insanity, he ridiculed Benjamin Rush, a copious bleeder of a previous generation, that leeches would “find but a small amount of their favorite fluid” in his depleted patients.73 “The question is not,” he averred, “shall we never [underline in original] bleed, but shall we always [underline in original] bleed in such enormous, not to say outrageous, quantities?”74 In a study of inheritance well before Gregor Mendel, he investigated twenty examples of color blindness in the Buffum side of the family and found that eighteen were male, a sex-specific characteristic.75
During what Mark Twain and Charles Dudley Warner derided as the Gilded Age, blatant contradictions in American society spurred African Americans, feminists, proletariat, and farmers to action. So too in psychiatry, Earle, inquisitive and empirical, challenged the validity of the reported high cure rates of insane asylums over the last century in which he was an elite figure. With Quaker fortitude, if not provocation (akin to the radical abolitionist tradition of his family), he questioned a central tenet of the professional paradigm. A conjunction of several factors, in addition to his character, prompted the expose, a foreshadowing of progressive muckraking in general. Historian Gerald N. Grob clearly sets the context: “The creation of asylums in the early nineteenth century rested on the assumption that mental disorders, identified early and treated promptly, were curable. Many insane persons—whether treated or ignored—failed to improve or recover, and the duration of their illnesses was often measured in decades rather than weeks or months.”76 The insane were one of the largest dependent classes, and with one-half in public hospitals, the cost of care was the largest item in state budgets. Beginning a twenty-year-long superintendence in 1864 at the State Lunatic Asylum at Northampton, Earle alerted in 1877 that the public asylums in Massachusetts were “overflowing.”77
Earle posited two causes for this trans-Atlantic phenomenon. First, he agreed with a Scottish colleague that “the patient is sent to the asylum because he cannot be conveniently kept at home.”78 With more asylums more families and local officials relocated the persistently afflicted to state institutions. And more speculatively, he suggested in keeping with the nineteenth-century sociology of anomie and alienation that “the diseases of the brain and nerves must [underline in original] become more and more permanent.”79 Long-term overcrowding meant lack of beds for recent cases, which structurally undermined the premise that prompt hospitalization facilitated recovery. In an era rife with peculation, such as “Boss” William Tweed's notorious graft and the Credit Mobilier scandal, Earle lambasted the nearly $2,000,000, with abundant cost overruns, spent for five hundred patients at a new asylum at Danvers, Massachusetts and excoriated a similar “elephantine monument” of Victoriana erected at Poughkeepsie.80 Earle and his ally Franklin Sanborn at the Massachusetts State Board of Charities charged that the excessive cost of “palace hospitals” did not, as architects, politicians, and patronage appointed superintendents promised, promote more recoveries, however much statistics were manipulated.81 Earle remained devoted to the original imperative of smaller hospitals (no more than 250 beds) and personal care during the grandiosity of the Gilded Age.
What the existing historiography fails to appreciate is that Earle's challenge to nineteenth-century psychiatry was not to discredit “moral treatment” per se. Instead, he sought greater precision and more accuracy, in physician reported data on mental aberration, which was essential for beneficent public policy and humane patient care. His sensational expose of the claims for high “recovery” rates was a corrective, not a rejection, for patient-centered care, the essence of moral treatment and his own sense of Quaker philanthropy. As early as 1838, the newly minted physician stated, “If a common formula for the statistical part of the reports [underline in original] could be adopted by all the asylums … our knowledge of the diseases, of its causes, duration, curability, etc., would be more rapidly advanced.”82 His revision was a long-term quest that a conjunction of contradictions crystallized into consciousness.83
In a variety of publications starting in 1876 and continuing for more than a decade, Earle relentlessly questioned psychiatric epidemiology. The major motif of his oeuvre was that the failure to differentiate the number of cases of mental disorder from individual patients inflated recovery rates. “By the way in which they are generally published,” he averred, “the uninitiated reader has no reason even to suspect that the number of persons recovered [underline in original] is not equal to the number of recoveries [underline in original].”84 To cite one of numerous examples, at the Friends' Asylum at Frankford, 87 patients contributed to 274 recoveries.85 At the Bloomingdale Asylum prior to Earle's tenure, one woman was admitted fifty-nine times over twenty-nine years and discharged recovered forty-six times.86 And at Worcester, one patient was pronounced recovered seven times in one year.87 He cited a cumulative table at the Hartford Retreat that showed more than one-third of patients were readmissions.88 “Following the example of my predecessor,” Earle admitted, referring to Bloomingdale, “I reported these recoveries in the tabulated statistics without any textual explanation.”89 By 1845, in his own reports he listed readmissions separately in an effort at transparency.
Earle remembered that during “earlier periods of a great philanthropic enterprise”90 a cascade of enthusiasm created the popular impression that “insanity is largely curable.”91 “Both reason and common sense were sacrificed to that desire” to produce “enormous percentages of recoveries.”92 He particularly faulted the influential Samuel B. Woodward at the Worcester State Hospital during the 1830s, whose “very elaborate reports, abounding in statistics” codified curability into the 80 and 90 percent range. Earle observed that Woodward “came directly from the atmosphere of the Hartford Retreat, where the British traveler Basil Hall had publicized the amazing healing power of the charismatic Eli Todd. First-generation superintendents in the United States and Europe, including Earle during the early 1840s, felt the pressure to comply.
Now more circumspect of earlier wisdom, the sixty-seven-year-old Earle pointed out the statistical errors and fallacious conclusions of the profession. In addition to the number of recoveries exceeding the number of patients treated, “many institutions” excluded mortality and obdurate “recent” patients to improve outcomes.93 Recoveries based on discharges, not admissions, furthered inflated results. There were hasty generalizations; for example, at the Hartford Retreat in 1827 based on too small a sample of 23 patients only one was not a success. The word “recovery” itself was nebulous: it was usually synonymous with improvement, but to the public and politicians it implied cures, even permanent ones. Luther V. Bell of the McLean Asylum outside Boston worried that all recent cases recovered at an Ohio facility meant “there is infinite danger that the public mind may arrive at such views and expectations as to the curability of insanity.”94 Furthermore, Earle added in 1882, “The extreme liability to relapse of a large proportion of the cases recovered from insanity is now very generally known.”95 The determination of what constituted “recovery” also varied with the diagnostician. Earle cited a difference of 22 percent in recoveries reported by two different physicians at the McLean Asylum during the decades of the 1860s and 1870s.96 Public institutions, such as Bloomingdale, housed scores of alcoholics, who professionals asserted were not “entitled to the mantle of insanity,” but with sobriety after a binge were tabulated as “recoveries from insanity.”97
Contrary to Todd and Woodward who compared insanity to other maladies, Earle's riposte was “there is about as close analogy between pneumonia and insanity as there is between a broken bone and a broken promise.”98 Henry P. Stearns at the Hartford Retreat added that insanity to “a very marked degree” may reoccur like other diseases.99 The dictum of Superintendent William H. Stokes in 1845 at the Mt. Hope asylum near Baltimore that 90 percent of recent cases recovered within a year unless something prevented it raised Earle's hackles: “Ninety-nine cases in a hundred of any [underline in original] disease may be cured unless something [underline in original] prevents.”100 And in rebuttal to fellow statistician Edward Jarvis's apothegm that “in a perfect state of things” treatment of early-stage insanity was highly restorative, Earle quipped, “‘In a perfect state of things’, the writer might better have said, ‘there would be no insanity… .’”101
In what has remained his historical signature, Earle documented falling recovery rates over the last half century. Based on a survey of twenty institutions, he concluded in 1876 that of total admissions “the recoveries of persons [underline in original] cannot be more than about thirty in the hundred.”102 He added two years later that recoveries based on admissions at asylums in England and Wales during 1859–74 were 34 percent.103 Earle made clear that he was not the first to substantially question asylum statistics, although he brought the interrogation to a crescendo. Forty years earlier, Samuel Tuke, an exemplar of mental health reform treatment, called for “useful statistical comparisons as to the effect of treatment and other circumstances on the health of the patients, and in regard to the cure of this greatest of human maladies.”104 Isaac Ray of the asylum in Augusta, Maine in 1842 alerted that “nothing can be made [underline in original] more deceptive than statistics, and I have yet to learn that those of insanity form any exception to the general rule.”105 At mid-century his successor, James Bates, was skeptical of that “marvelous fiction” of extraordinary recovery rates “received with wondrous admiration” by a gullible public: “if figures can not [sic] lie, they may mislead, by disguising the truth.”106 In 1848 Andrew McFarland of New Hampshire's asylum expressed skepticism about “establishing infallible percentages from extremely loose and insufficient premises.”107
John Thurman, head of the Quaker York Retreat in England, in 1845 concluded in a detailed analysis of data from 1796 to 1840, “In round numbers, then, of ten persons attacked by insanity, five recover, and five die, sooner or later, during the attack. Of the five who recover, not more than two remain well during the rest of their lives, the other three sustain subsequent attacks, during which at least two of them die.”108 In spite of the correction, none argued against, what Earle called the “public necessity,” “beneficent blessing,” and “utility of hospitals.”109 He—with the concurrence of colleagues—added with characteristic humanitarianism, “A recovery is none the less desirable, and none the less valuable to the person, or to the society, so long as the person remains well, because it is of limited duration.”110
A number of prominent colleagues in the British Isles and the United States endorsed Earle's reforms. A pamphlet by William A.F. Browne, a distinguished Scottish specialist, echoed the concern about the failure to identify readmitted patients.111 The Massachusetts State Board of Health, Lunacy and Charity—in 1863 the first of its kind in the nation—led in adopting Earle's recommendations for asylum reports in 1879 as did the British in 1882, unlike the staid AMSAII. Franklin Sanborn, the Massachusetts official, concluded that “it is no longer possible to have those absurd results so gravely and confidently stated.112 In the Bay State, the category of “cause of recovery” was dropped, because, as Sanborn explained, “it will be exceptional that the true cause will be known, or, if known, truly stated.”113 Daniel Hack Tuke, a scion of the renowned family associated with the York Retreat, lauded his fellow Quaker in the same year in a detailed essay.114 In a major survey of North American psychiatry in 1885, Tuke wrote, “Doctor Pliny Earle has carefully studied the curability of insanity, and has done good service by pointing out the fallacy of counting all the recoveries of a single case as if they represented so many recovered insane persons.”115 And two years later an entry in a leading publication noted that “leading hospitals” had abandoned the old statistical format.116
Isaac Ray, a co-founder of the Association of Medical Superintendents of American Institutions for the Insane, took issue with Earle on two points: that the frame of reference of the physician and that conflating cases with clients were the prime factors in inflating cure rates. Instead the first director of the Butler asylum in Providence pointed to the admission of more chronic patients and the surge of mental instability due to a disruptive industrial revolution with “diminishing the proportion of recovery” of an earlier time.117 In actuality, both septuagenarians actually agreed more than they differed. “The original fault was in undertaking,” Ray reflected—and his colleague could not agree more—“to give statistical expression to an order of occurrences largely conjectural” that had the “inevitable tendency to mislead the reader [of asylum reports] respecting the curability of insanity.”118 Henry P. Stearns added that the Hartford Retreat had seen a 20 percent increase in intractable senile dementia during 1875–85 compared to 1850–60. “There exists,” he explained, “a tendency to remove such members of families to asylums, to a much larger degree than formerly.”119
How has the curability crisis in asylum medicine that became full borne during the late nineteenth century with Earle, its midwife, been explained in the historiography? According to Bockoven, whose interpretation has reigned since 1956, “Although an avid proponent of moral treatment, [Pliny Earle] was paradoxically, one of the strongest forces in discrediting its results.”120 The way Bockoven—who reasonably equated moral treatment with contemporary psychotherapy—explained the apparent paradox was through an ad hominem argument. He wrote that Earle suffered “mood swings;”121 had an “over protective father who fostered dependency”;122 “hid from view” his “purist criteria of recovery;”123 and that he “sold the medical profession” on therapeutic nihilism since insanity was incurable.124 The result—“whatever Dr Earle's underlying purpose”—was a cruel custodianship of the mentally disordered “which has not yet been torn down.”125 At worst in this rendition, a duplicitous Earle is the ideological progenitor of the notorious “snake pits” and “Titicut Follies” of the post-World War II era.
Bockoven's “paradox” pivots on a longitudinal study at the Worcester State Asylum by Superintendent John G. Park in 1893, one year after Earle's death. In his survey of 984 individuals based on their only or last admission, he found that nearly 58 percent discharged as recovered were never again institutionalized, which Park thought confirmed Earle's thesis that the rate of recoveries was overblown. In contrast, Bockovern, Carlson, and Grob, as the latter put it in 1994, found the 58 percent statistic “did not by any means discredit earlier claims about curability,” which were validated by figures from other institutions and contemporary experience.126 No wonder, it appears, Bockoven called foul, pointing to Earle's pernicious influence on the profession! In a more sophisticated but complimentary account to Bockoven's, Grob concluded that “to acknowledge failures and shortcomings, however, is not to imply absence of achievements,” a statement that does not preclude Earle, because he remained committed to the Quaker ideal of humane treatment.127 More to the point, Grob judiciously added that Park's longitudinal study “indicates the half-full or half-empty cup perception.”128 All well and good, but what is missing is an understanding of the “half-empty cup” persuasion promoted by Earle.
Why did Earle in 1876 modify his earlier enthusiasm? He had written in the Bloomingdale Report of 1845: “When the insane are placed under proper curative treatment in the early stages of the disease, from seventy-five to ninety percent recover.”129 “The glamour of Arabic numbers,” however, faded; he concluded after decades of experience that these astounding asylum statistics were misleading.130 Even as Bockoven, Carlson, and Grob judge Park's 58 percent as an endorsement of remarkable achievement, that statistic is units of ten less than the 75–90 percent recovery reports, let alone the 90–100 percent recoveries, claimed from the 1820s to the 1840s. Deutsch is at least partly correct to point to the inflation due to peer pressure and institutional rivalry. But that “vicious cycle of fallacies,” as he bluntly described the “cult of curability,” was more an epiphenomenon of the excess of romantic reform of the early antebellum era.131 The zeitgeist—the embrace of enhanced moral ability, human plasticity, personal regeneration, and social melioration—inflected the sensibility of the first generation of asylum doctors, as it did evangelicals, abolitionists, feminists, perfectionists, transcendentalists, prohibitionists, utopianists, adventists, among other romantics.132 Over the next half century, this euphoria of exceptionalism necessarily waned in the aftermath of a cataclysmic Civil War with 750,000 dead, as robber barons, corrupt politicians, white supremacists, and patriarchs flexed their muscles.133
The swelling number of chronic cases that Earle confronted at Northampton after 1864 forced a reevaluation of his earlier estimate. From the beginning asylums were overburdened by demand that worsened over time: beleaguered families shed their traditional welfare role; selectmen saved money by transplanting town wards; and the numerous indigent—augmented by the periodic “panics” of laissez faire capitalism, exploitation of labor, skewed distribution of wealth, social dislocation, urbanization, population growth, and influx of famine Irish—overwhelmed capacity.134 Class based psychiatry came full force with the well-to-do at elite private institutions and the numerous poor, chronically ill, in custodianship at monolithic, public hospitals, such as the 2000 residents in 1900 who overflowed the hallways at the Middletown facility in Connecticut.135 In a survey of 2856 patients at the Hartford Retreat for the Insane from 1824 to 1877, Henry P. Stearns in 1882 concluded that 30–50 percent had previously been hospital patients at the Retreat or elsewhere.136
Historian Norman Dain has put the statistical cul-de-sac succinctly: “… psychiatrists continued to collect data that they themselves often recognized as valueless. For most of them this pursuit served as a means of proving the scientific nature of their institutions and—when recovery rates were involved—their success in curing patients.”137 Within the convention, Earle pointed out numerous flaws: the failure to segregate persons from cases; the need to identify re-admitted patients; tracking how many times patients were readmitted, including at different institutions; counting repeated “recoveries” of undisclosed re-admissions; the inflation of “recovery” rates; the exclusion of mortality and inclusion of inebriates in calculations; conclusions drawn from too small a sample; and the different frames of reference of superintendents. Although fundamental questions about the statistics of mental disorder arose decades earlier from multiple commentators, Earle systematically brought to the fore in 1876 the imprecision and lack of transparency in “the glamour of Arabic numbers.”
The crisis in asylum medicine was more fundamental than faulty measurement and dubious conclusions. Moral treatment had no overall theory; insanity remained an ontological mystery, except for the shamanism of phrenology. Earle particularly faulted Woodward whose statistical format became normative. Without empirical grounding, Woodward claimed in 1842 that a reoccurrence of mental disorder after one year was not a relapse but an independent event, such as multiple occasions of respiratory illness. He self-interestedly faulted “numerous recommittals” to the volition of the afflicted, for which “the institutions for the insane are blameless.”138 He enthused that “the statistics of insanity have done great good.”139 The next year—in data that Dorothea Dix would promote to policy makers—he compared the immense cost savings in the treatment of twenty-five “old” and twenty-five “new” cases. Earle's investigation in 1879 found that of the twenty-five alleged “recoveries”—that purportedly saved over $2000 in charges compared to the “old” cases—eighteen had more than one attack, while ten proved to be permanently insane.140 Earle also charged that Woodward and others conveniently excluded “unpreventable” deaths from calculations.141
Earle's conclusion that “the old claim of curability in a very large majority of recent cases is not sustained” had wide repercussions.142 The descriptive pronouncement of “recovery” was arbitrary, interpretative, and nebulous. For first-generation asylum founders, the elastic definition allowed astounding percentages to instantiate a new medicine. Astonishing statistics of “recovery” in impressive numerical tables abrogated the predestined fatalism of insanity, the inhumane stigmatization of the mad, that was incongruent with antebellum reform and Enlightenment rationality. The perceptive French visitor Alexis de Tocqueville observed during the 1830s that Americans believe that “man is endowed with an indefinite faculty of improvement.”143 With a mix of enthusiasm, charisma, and promotion, the early asylum doctors created a public impression that “recovery” equated cure, a permanent, final victory over a dread affliction, not unlike that of William Lloyd Garrison and early radical abolitionists who initially believed that “moral suasion” alone would cause southern planters to leave off the sin of slavery. In practice, “recovery” meant some degree of improvement, a return to a level of functionality, which, however measured, was no small achievement. Nonetheless, mental disorder remained more obdurate—and white supremacy more intransigent—that these heroic crusaders imagined.
Contrary to what might be thought, Earle did not during the fin de siècle enlist in the eugenic juggernaut, part of the hegemonic ideology of Gilded Age capitalism. The octogenarian, the last of his cohort, remained imbued with Quaker ideals of a divine inner spirit that had directed Earles and Buffums to the abolitionist crusade. He retained a faith that “Mind is eternal,” “superior to the bodily structure,” and cannot be diseased and die.144 Indeed, the Christian dualism of the spirit and the somatic impeded theoretical breakthroughs among asylum doctors at a time of a fundamental change in late nineteenth-century medicine, including the emergence of neurology, not to mention the contemporary psychodynamic formulation of Sigmund Freud, an agnostic Jew.145 In addition, patient rights groups, not unlike the proletariat agitation of the era, attempted to reign in the power of the superintendents.146 Earle did back limited reforms, such as renaming the venerable AMSAII to the American Medico-Psychological Association whose mission included scientific research and a provision to admit assistant physicians to membership.147 In most respects, he remained wedded to tradition.
Earle was committed to the ideal of the humanitarian hospital, even as he believed that assertions of earlier high cure rates were misleading. His vision of the “psychopathic hospital of the future” called for “a comprehensive curriculum, a complete organization, a perfect systemization and an efficient administration.”148 He may have been the first to give formal lectures (rather than sermons) to patients about their affliction, and the first to establish a school for male patients. He had employed occupational therapy since the early 1840s. He believed manual labor was “among the most potent and curative means,” but it was “never required of a patient except with his cheerful volition,” otherwise an exploitation not unlike antebellum slavery ensued.149 Indeed, his emphasis on manual labor offended the well-to-do at Bloomingdale Asylum, and under pressure from the board of governors that was compliant to the wealthy, he resigned his position. At Northampton gardening and farm work proved therapeutic and remunerative in good Yankee fashion with enhanced nutrition as a bonus.
Sports—baseball, billiards, and bowling—were normative at the Northampton Asylum as were illustrated travelogues and talks on science. Since a disturbing deception of a deluded patient at the Friends' Asylum in 1840, Earle pledged that in the future honesty with patients “shall be straight forward work.”150 Early in his career, he disposed of the tranquilizing chair, routine venesection, muffs, confined bath, cold douche, and most physical restraint. In medical matters, the superintendent nevertheless remained in charge of administrating cathartics, emetics, and the stomach pump with or without informed consent. His self-experiment with conium maculatum that produced “cerebral oppression” hopefully tempered the use of noxious drugs.151 Sanborn found that Earle excelled in the “virtual recoveries” of chronic patients who were then boarded out in rural Massachusetts homes.152 Earle favored a limit on patients at 250 so “the superintendent can obtain a sufficiently thorough knowledge of every patient.”153
Before Earle took over Northampton in 1864, the hospital was plagued with deficits and staff problems. It was a receptacle for chronic and pauper cases; the formidable Dorothea Dix lambasted it. Unlike the extravagant hospital construction of the day with excessive expenditures, Earle made the institution financially self-sustaining, increased its valuation, gained the praise of the trustees, extended occupational therapy, improved nutrition, and lowered the death rate. The new professional journal Alienist and Neurologist praised him at his retirement as “a model official.”154 At his death the same journal eulogized about Northampton that “the so-called ‘moral treatment’ of the patients was amplified, made more diversified, and extended over a greater portion of the year than any other American hospital.” And without apparent irony added it was “a first class curative institution.”155
Ample evidence indicates that Earle—in spite of his heuristic correction to “the glamour of Arabic numbers”—did not embrace therapeutic nihilism, but remained a persistent practitioner of moral treatment and an efficient administrator, hallmarks of traditional asylum medicine. After all, there was a religious imperative to do good works, because, as he put it in 1886, “the pathology of the disease is unknown.”156 A onetime machinist at the cusp of the textile industry in New England, Earle sought greater accuracy, more transparency, in asylum reports. He was tamping down antebellum enthusiasm about curability, not throwing out the baby with the bath water. As he put it in 1883, “the long perused methods of reporting the statistics of the hospitals of the insane was so imperfect, in some respects, as to deceive rather to enlighten the mind of the reader.”157 Earle's biographer and his ally at the Massachusetts State Board of Charities, Franklin Sanborn, accurately memorialized his friend as “a man of independent opinion,” who hailed from a principled Quaker family in the vanguard of humanitarian reform.158 Although the historiography has long painted Earle as the poster boy of fin de siècle pessimism, this essay argues that the thesis is not compelling. Instead look to the dehumanization of massive corporate capitalism with its reigning ideology of laissez faire, social Darwinism, eugenics (though not integral to psychiatry), rugged individualism, diminution of the commons, antagonism to public services, and bogeyman of socialized medicine that continues to make the United States an outlier in the provision of health care. And the fundamental epistemological problem in measuring outcomes persists.159
1No complete, modern biography of Earle exists. Franklin Benjamin Sanborn, Memoirs of Pliny Earle, M.D. (Damrell and Upham, 1898) is less a biography than an idiosyncratic eulogy to his deceased friend and colleague. See, however, Constance M. McGovern, “The Early Career of Pliny Earle: A Founder of American Psychiatry” (M.A. thesis, University of Massachusetts, 1971).
2[No author], “Obituary. Pliny Earle,” Brit. J. Psychiat., 1892, 38, 479.
3C.H. Hughes, ed., “Editorial,” Alienist Neurol., 1883, 4, 493. Endorsement of Earle's revisionism included these contemporaries: Daniel Hack Tuke, “On the Best Mode,” Brit. J. Psychiat., 1880, 26, 375–3; Tuke, The Insane in the United States and Canada (London: H.K. Lewis, 1885), 61; E. N. B., “Recent Works on the Treatment of Insanity,” Am. J. Med. Sci., 1887, 94, 191; Henry P. Stearns, “Statistics of Insanity: Relative to Re-Admissions to the [Hartford] Retreat,” Essays on Insanity, Etc., Etc. (Hartford, CT: n.p., 1882), 2–10; [No author], “Obituary. Pliny Earle,” 479–80; “In Memoriam,” Alienist Neurol., 1892, 13, 572; and Sanborn, Memoirs, 392.
4Albert Deutsch, The Mentally Ill in America (N.Y.: Columbia University Press, 1946), 157.
5Deutsch, The Mentally Ill, 133.
6J. Sanbourne Bockoven, “Moral Treatment in American Psychiatry,” J. Nerv. Ment. Dis., 1956, 124, 297–8. See also Bockoven, Moral Treatment in American Psychiatry (N.Y.: Springer, 1963).
7Eric Carlson and Lillian Peters, “Dr Pliny Earle (1809–1892),” American Journal of Psychiatry, 1959, 116, 588. Dr Carlson founded in 1958 what is now The Institute for the History of Psychiatry at Weill Cornell Medical College in New York.
8Gerald N. Grob, The State and the Mentally Ill: A History of the Worcester State Hospital in Massachusetts, 1830–1920 (Chapel Hill: University of North Carolina Press, 1966), 232–5. See also Grob, The Mad among Us: A History of the Care of America's Mentally Ill (N.Y.: Free Press, 1994), 36, 101–2, 327–35. In a contentious scholarly field, Grob's extensive historiography is noted for its balance and judiciousness.
9Roy Porter wrote: “Medicine has been constantly remaking itself, demolishing old dogmas, building on the past, forging new perspectives, and redefining its goals.” Roy Porter, ed., “Introduction,” in The Cambridge Illustrated History of Medicine (Cambridge: Cambridge University Press, 1996), 15. See Stuart Firestein, Ignorance: How it Drives Science (N.Y.: Oxford University Press, 2014); and the classic Thomas S. Kuhn, The Structure of Scientific Revolutions, 2nd ed. (Chicago: University of Chicago Press, 1970).
10See Charles E. Rosenberg, “The Therapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth-Century America,” Perspect. Biol. Med., 1977, 20, 485–506.
11Deutsch, The Mentally Ill, 157.
12Pliny Earle, The Curability of Insanity: A Series of Studies  (N.Y.: Arno Press, 1972; originally 1886), 40, 42, 50.
13Earle, Curability , 27–9.
14Earle, Curability , 19–20.
15Todd quoted in Charles C. Burlingame, “Connecticut's Part in the Development of Psychiatry in America,” in The Heritage of Connecticut Medicine, ed. Herbert Thoms (New Haven: Waples-Bullis, 1942), 155.
16Woodward quoted in Earle, Curability (1876), 23.
17Pliny Earle, “Researches in Reference to the Causes, Duration, Termination, and Moral Treatment of Insanity,” Am. J. Med. Sci., 1838, 22, 347.
18Pliny Earle, “The Curability of Insanity,” Am. J. Insanity, 1876–1877, 33, 511.
19Gordon S. Wood, “The Bleeding Founders,” NY Rev. Books, July 10, 2014, 61, 43. For a recent example of anachronism in medical historiography, see Jeanne E. Abrams, Revolutionary Medicine: The Founding Fathers and Mothers in Sickness and Health (N.Y.: New York University Press, 2014).
20Lynn Hunt, Inventing Human Rights; A History (N.Y.: W.W. Norton, 2007). See Henry May, The Enlightenment in America (N.Y.: Oxford, 1976).
21Report of the Physician of the Connecticut Retreat for the Insane, from the Opening of the Institution on the 1st of April 1824 to the 1st of April 1825 (Hartford: P.B. Goodsell, ), [broadside].
22Mary Guyatt, “The Wedgwood Slave Medallion: Values in Eighteenth-Century Design,” Journal of Design History 2000, 13, 93–105.
23Nathan O. Hatch, The Democratization of American Christianity (New Haven: Yale University Press, 1989).
24Harold Bloom, The American Religion: The Emergence of the Post-Christian Nation (N.Y.: Simon and Schuster, 1992). See Paul K. Conkin, American Originals: Homemade Varieties of Christianity (Chapel Hill: University of North Carolina Press, 1997).
25Ralph Waldo Emerson, The Selected Writings of Ralph Waldo Emerson, ed. Brooks Atkinson (N.Y.: Modern Library, 1950), 449–50.
26Edward Jarvis, “Insanity in Massachusetts,” North Am. Rev., 1843, 56, 187.
27Michel Foucault, A History of Insanity in the Age of Reason, trans. by Richard Howard (N.Y.: Vintage Books, 1965); Erving Goffman, Asylums (N.Y.: Anchor Books, 1961); David Rothman, The Discovery of the Asylum: Social Order and Disorder in the New Republic (Boston: Little Brown, 1961); Alice Felt Tyler, Freedom's Ferment (N.Y.: Harper and Brothers, 1962); John L. Thomas, “Romantic Reform in America, 1815–1860,” American Quarterly, 1965, 17, 656–81; and more recently Ethan J. Kytle, Romantic Reformers and the Antislavery Struggle in the Civil War Era (N.Y.: Cambridge University Press, 2014), 9–19 on the meaning of romanticism.
28Rosenberg, “The Therapeutic Revolution,” 492.
29Karl Marx and Frederick Engels, The Communist Manifesto, trans. Samuael Moore (N.Y.: International Publishers, 1948), 44.
30John William Ward, Andrew Jackson, Symbol for an Age (N.Y.: Oxford University Press, 1965).
31[No author], “Obituary. Pliny Earle,” 480.
32See Samuel May, Jr., “Reminiscences of the Earle Family,” in Sanborn, Memoirs, 387. Reverend Samuel May, Jr., long associated with Leicester, was its Unitarian minister from 1835 to 1846 and a prominent radical abolitionist. See Bruce Laurie, Beyond Garrison: Antislavery and Reform (Cambridge: Cambridge University Press, 2005).
33Sanborn, Memoirs, 196.
34Ibid., 77, 82, 198.
35Pliny Earle to Eliza Earle, March 24, 1833, Earle Papers, American Antiquarian Society (AAS), Worcester, Mass.
36Sanborn, Memoirs, 16.
37See Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum Keeping (N.Y.: Cambridge University Press, 1984).
38Sanborn, Memoirs, 52.
40Catherine Todd to Samuel C. Crafts, Oct. 14, 1829, Eli Todd Papers, Archives, Hartford Hospital. In spite of her brother's ministrations, Todd's sister Eunice killed herself by slitting her throat after suffering a decades' long cycle of debilitating depression.
41Sanborn, Memoirs, 313.
42Samuel May, Jr., to Franklin Sanborn, May 26, 1897, Earle Papers, AAS.
43Rebecca Spring to Franklin Sanborn, July 17, 1897, Earle Papers, AAS.
44McGovern, “The Early Career of Pliny Earle,” 30. And his sister Lucy at age 80 was admitted with cause “unknown” to the Northampton State Hospital in 1885 of which Earle was superintendent. Ibid., 31.
45Sanborn, Memoirs, 80–1.
46Pliny Earle, “On the Causes of Insanity,” Am. J. Insanity, 1948, 4, 185–211.
47Pliny Earle, “Research in Reference to the Causes, Duration, Termination, and Moral Treatment of Insanity,” Am. J. Med. Sci., 1838, 44, 339.
53Pliny Earle, A Visit to Thirteen Asylums for the Insane in Europe to which Are Added a Brief Notice of Similar Institutions in Transatlantic Countries and in the United States, and an Essay on the Causes, Duration, Termination and Moral Treatment of Insanity, with Copious Statistics (Philadelphia: Dobson, 1841), preface. See Pliny Earle, “A Visit to Thirteen Asylums for the Insane in Europe, with Statistics,” Am. J. Med. Sci., 1839, 25, 99–134.
54Pliny Earle, “Curability,” Am. J. Med. Sci., 1843, 10, 334.
60Quoted in Grob, The Mad among Us, 100.
61Pliny Earle, “An Analysis of the Cases of Delirium Tremens, admitted into the Bloomingdale Asylum for the Insane, from June 16, 1821, to Dec. 31st, 1844,” Am. J. Med. Sci., 1948, 15, 79.
62Pliny Earle, History, Description and Statistics of the Bloomingdale Asylum for the Insane (N.Y.: Egbert, Hovey & King, 1848), 54, 124.
63Amariah Brigham speculated that intense study, religious enthusiasm, entrepreneurial ambitions and mental agitation in general unhinged students, evangelicals, businessmen and women, among others, amidst the tumultuous antebellum period. See Amariah Brigham, Remarks on the Influence of Mental Cultivation on Health (Hartford: Huntington, 1832). Samuel Gridley Howe, physician and social activist, ridiculed Earle's data based conclusion that it is “a dangerous thing to call ones brain frequently and energetically into action.” See Howe, “The Insane and Their Treatment Past and Present,” Nat. Quart. Rev., 1863, 7, 229.
64Edward Jarvis, “On the Supposed Increase in Insanity,” Am. J. Insanity, 1854, 8, 344. Earle lauded his colleague for exposing “those gross and truth perverting statements” in “the numericals of the insane of the national census of 1840.” Pliny Earle, “Bibliographic Notes … Report on Insanity,” Am. J. Med. Sci., 1856, 62, 429. Earle continued that state and national data on the insane were inaccurate, often widely so. See 429–36 passim.
65Isaac Ray, “Statistics of Insanity in Massachusetts,” North Am. Rev., 1856, 82, 80. Ray added, “What we object to is the attempt to give a statistical form to things more or less doubtful and subjective,” which would later prompt Earle's expose.
68Ibid., 91. Earle identified Samuel Woodward and Dorothea Dix as instrumental “in creating public opinion which has founded hospitals for the insane in nearly every state of the Union. The Psychopathic Hospital of the Future (Utica: Roberts, 1867), 5.
69Isaac Ray, “Doubtful Recoveries,” Am. J. Insanity, 1863, 22, 44. Ray stated that “these unreliable improvements [in treatment] are not confined to the first month nor are peculiar to any particular form of disease, though most common in acute mania” (35). Samuel Gridley Howe in the same year was more hopeful but guarded: “results obtained thus far are not all that have been expected,” but there have been “great improvement in the treatment of the insane.” Howe, “The Insane and Their Treatment,” 207.
70Earle quoted in Sanborn, Memoirs, 151.
71Pliny Earle, “Remarks on the Climate, Population, Diseases, etc., of Malta, with an Account of the Asiatic Cholera As It occurred on That Island and Gozo, in the Summer of 1837,” Am. J. Med. Sci., 1840, 25, 309–16; Earle, “Observations on the Rapidity of the Pulse of the Insane,” Am. J. Med. Sci., 1842, 5, 84–90; Earle, “On the Pulse of the Insane,” Am. J. Med. Sci., 1844, 14, 306–17; Earle, “Observations on the Pulse of the Insane, Made in the U.S.: Collected, Arranged and Analyzed: Observations and the Pulse of fifty-eight Insane Persons,” Am. J. Med. Sci., 1845, 9, 56–85; and Sanborn, Memoirs, 155.
72Sanborn, Memoirs, 150; and Eric T. Carlson, “The Influence of Phrenology on Early American Psychiatric Thought,” Am. J. Psychiat., 1958, 115, 535–38.
73Pliny Earle, An Examination of the Practice of Blood-letting in Mental Disorders (N.Y.: Samuel S. and William Ward, 1854), 101.
75Pliny Earle, “On the Inability to Distinguish Colours,” Am. J. Med. Sci., 1845, 18, 346–53.
76Grob, The Mad among Us, 103. Compare Atul Gawande's similar comment on overcrowding in hospitals at the mid-twentieth century: “But hospitals couldn't solve the debilities of chronic illness and advancing age and they began to fill up with people who had nowhere to go.” Being Mortal: Medicine and What Matters in the End (N.Y.: Metropolitan, 2014), 71.
77Pliny Earle, The Curability of Insanity: A Series of Studies (N.Y.: Arno Press, 1972; originally 1886) , 77.
78Earle, Curability , 74.
79Earle, Curability , 58. See Jerome Kagan, Psychology's Ghosts: The Crisis in the Profession and the Way Back (New Haven: Yale University Press, 2012), 249, on the perspective that the urban-industrial revolution weakened traditional social supports and facilitated some mental disorders.
80Earle, Curability , 191. See Carla Yanni, The Architecture of Madness (Minneapolis: University of Minnesota Press, 2007).
81Earle, Curability , 85. Earle argued the data demonstrated that the “increase of expenditures does not enlarge the proportion of cures.”
82Earle, “Research in Reference,” 355.
83For a philosophical underpinning of the “cunning of the dialectic,” see G.W.F. Hegel, “The Actualization of Rational Self-Consciousness through Its Own Activity,” in Phenomenology of the Spirit, tr. A.V. Miller (N.Y.: Oxford University Press, 1977), 211–35.
84Earle, “Curability of Insanity,” 1876–77, 490.
90Earle, Curability , 142.
91Earle, Curability , 21.
93Earle, “Curability of Insanity,” 1876–77, 498.
94Bell quoted in Earle, Curability , 102.
95Earle, Curability , 182.
96Earle, Curability , 89–92.
97Earle, Curability , 67–9.
98Earle, Curability , 150.
99Henry P. Stearns, Essays on Insanity (Hartford: s.n., 1882), 9.
100Earle, “Curability of Insanity,” 1876–77, 512.
101Earle, Curability , 42–3.
102Earle, “Curability of Insanity,” 1876–77, 527.
103Earle, Curability , 83.
104Tuke quoted in Earle, Curability , 168.
105Ray quoted in Earle, “Curability of Insanity,” 1876–77, 505.
106Bates quoted in Earle, ibid., 506.
107McFarland quoted in Earle, Curability , 34.
108John Thurnam, Observations and Essay on the Statistics of Insanity (London: Simpkin, Marshall, 1845), 123.
109Earle, “Curability of Insanity,” 1876–77, 532.
111William A. F. Browne, The Curability of Insanity: Psychological Shadows, (London: s.n, n.d.), cited in Pliny Earle, The Curability of Insanity: A Series of Studies (Philadelphia: J.B. Lippincott, 1887), 150; and Andrew Scull, ed., The Asylum as Utopia: W.A.F. Brown and the Mid-Nineteenth Century Consolidation of Psychiatry (London: Routledge, 1991), xlvi.
112Sanborn, Memoirs, 267, 313. See also Franklin B. Sanborn, “The Present Status of Insanity in Massachusetts,” Am. J. Insanity, 1896, 52, 551–5.
113Sanborn, Memoirs, 313.
114Daniel Hack Tuke, “On the Best Mode of Tabulating Recoveries from Insanity in Asylum Reports,” Brit. J. Psychiat., 1980, 26, 375–83.
115Daniel Hack Tuke, The Insane in the United States and Canada (London: H.K. Lewis, 1885), 61.
116E.N.B. [initials only], “Recent Works on the Treatment of Insanity,” Am. J. Med. Sci., 1887, 94, 191.
117Isaac Ray, “Recoveries from Mental Disease,” Alienist Neurol., 1880, 1, 141–2. Ray originally presented the article at a professional meeting in July 1879. For a summary, see Isaac Ray, “Recoveries from Mental Illness,” Med. Surg. Rep., 1879, 4, 72–4. And for the response, see Pliny Earle, “The Curability of Insanity vs. Recoveries from Mental Diseases,” Alienist Neurol., 1880, 1, 82–97. On page 135, Earle concurs with Ray: “I have intended constantly to present, as a dominant idea, that public opinion has been greatly misled by the method of reporting recoveries at hospitals.”
118Ray, “Recoveries from Mental Disease,” Alienist Neurol., 1880, 1, 134.
119Henry P. Stearns, Sixty-First Annual Report of the Hartford Retreat for the Insane (1885), 15.
120Bockoven, Moral Treatment , 21.
121Bockoven, Moral Treatment , 191.
122Bockoven, Moral Treatment , 53.
123Bockoven, Moral Treatment , 65.
124Bockoven, Moral Treatment , 297.
125Bockoven, Moral Treatment , 297–8.
126Grob, The Mad among Us, 101.
128Grob, The Mad among Us, 101. See Grob, The State and the Mentally Ill, 246–56, for a sophisticated argument for the “cup half-full perception.”
129Quoted in Earle, Curability , 39.
130Earle, Curability , 31, for the phrase, “the glamour of Arabic numbers,” also used in the title.
131Deutsch, The Mentally Ill in America, 133.
132For a broad overview, see Ernest Lee Tuveson, Redeemer Nation: The Idea of America's Millennial Role (Chicago: University of Chicago Press, 1968); and Seymour Martin Lipset, American Exceptionalism: A Double-Edged Sword (N.Y.: Norton, 1996).
133See George M. Fredrickson, The Inner Civil War: Northern Intellectuals and the Crisis of the Union (N.Y.: Harper and Row, 1968); Drew Gilpin Faust, The Republic Suffering: Death and the American Civil War (N.Y.: Vintage, 2008); J. David Hacker, “Recounting the Dead,” N.Y. Times, September 20, 2001, http://opinionator.blogs.nytimes.com/2011/09/20/recounting-the-dead/?_r=0 (accessed March 27, 2015); and Matthew Josephson, The Robber Barons: The Great American Capitalists, 1861–1901 (N.Y.: Harcourt, Brace and World, 1962).
134Important works on the relationship between poverty and mental illness include: Arthur B. Holligshead and Frederick C. Redlich, Class and Mental Illness (N.Y.: John Wiley and Sons, 1958); Bruce P. Dohrenwend and Barbara Dohrewend, Social Status and Psychological Disorder: A Casual Inquiry (N.Y.: John Wiley, 1969); Allan V. Horowitz, Creating Mental Illness (Chicago: University of Chicago Press, 2002); Sebastian J. Lipina and Jorge A. Colombo, Poverty and Brain Development during Childhood (Washington, D.C.: American Psychological Association, 2009).
135Henry P. Stearns, Sixty-Seventh Annual Report of the Hartford Retreat for the Insane (1891), 12–3; and Lawrence B. Goodheart, “From Cure to Custodianship of the Insane Poor in Nineteenth-Century Connecticut,” J. Hist. Med. Allied Sci., 2009, 65, 106–30.
136Stearns, Essays on Insanity, 2–6.
137Norman Dain, Concepts of Insanity in the United States, 1789–1865 (New Brunswick, N.J.: Rutgers University Press, 1964), 140. See Lynn Gamwell and Nancy Tomes, Madness in America: Cultural and Medical Perception of Mental Illness Before 1914 (Ithaca: Cornell University Press, 1995).
138Samuel Woodward quoted in Grob, The State and the Mentally Ill, 76.
139Samuel Woodward quoted in Grob, Mad among Us, 100.
140Earle, Curability , 106–8, 120.
141Earle, Curability , 146. See Pliny Earle, “Subsequent History of Twenty-Five Persons Reported Recovered from Insanity in 1843: The Twenty-Five Recent Cases Recovered,” Alienist Neurol., 1880, 1, 65–77.
142Pliny Earle, “The Curability of Insanity: A Statistical Study,” Am. J. Insanity, 1885, 41, 208–9.
143Alexis de Tocqueville, Democracy in America, vol. II, trans. Henry Reeve (N.Y.: Schocken, 1972), 38.
144Pliny Earle quoted in Sanborn, Memoirs, 281.
145For the famous indictment of asylum doctors as antiquated, isolated, and disseminators of faulty data, see Silas Weir Mitchell, “Address before the Fiftieth Annual Meeting of the American Medico-Psychological Association,” Proc. Am. Medico-Psychol. Assoc., 1894, I, 101–21.
146See Dorman B. Eaton, “Despotism in Lunatic Asylums,” North Am. Rev., 1881, 132, 263–75.
147“Proceedings of the Association of Medical Superintendents of American Institutions for the Insane,” 1885, 42, 60–7; and “The American Medico-Psychological Association,” Am. J. Insanity, 1892, 49, 128–9.
148Pliny Earle, The Psychopathic Hospital of the Future (Utica: Roberts, 1867), 15.
149Earle, The Psychopathic Hospital, 12.
150Pliny Earle to Lucy Earle, September 30, 1840, Pliny Earle Papers, AAS.
151Pliny Earle, “Experiments to Determine the Physiological Effects of Conium Maculatum,” Am. J. Med. Sci. 1845, 10, 64.
152Sanborn, Memoirs, 299.
153Sanborn, Memoirs, 159.
154“Hospital Notes: Retirement of Dr Earle,” Alienist Neurol., 1886, 7, 149.
155“In Memoriam,” Alienist Neurol. 1892, 13, 574.
156“Selections. Psychiatry,” Alienist Neurol., 1886, 7, 503.
157Pliny Earle, “The Curability of Insanity: New Observations,” Alienist Neurol., 1883, 4, 61.
158Sanborn, Memoirs, 302.
159For a small sample of recent discussion, see: Jerome Kagan, Psychology's Ghosts: The Crisis in the Profession and the Way Back (New Haven: Yale University Press, 2012); Brandon A. Gaudiano, “Psychotherapy's Image Problem,” N.Y. Times, September 30, 2013, A23; [Letters to the Editor], “Can There Be Good Mental Asylums?” N.Y. Times, February 26, 2015, A24; and Marcia Angell, “Health: The Right Diagnosis and the Wrong Treatment,” NY Rev. Books, April 23, 2015, 43, 44–7.