The Great Pretender

by Susannah Cahalan

  When Bly stepped off the boat and onto the shore, the whiskey-soaked attendant welcomed her to the women’s asylum: “An insane place, where you’ll never get out of.”

  The word asylum comes from an ancient Greek word meaning “safe from being seized” (by, say, a Homeric warrior). Among the Romans, the word evolved to its current meaning—“a place of refuge” or “a place safe from violence.” The first asylums built specifically to house the mentally ill emerged in the Byzantine Empire around AD 500, and by the turn of the new millennium many towns in Europe, the Middle East, and the Mediterranean had one. As forward thinking as that seems, hospitals as we know them today are a modern concept. In the early days, there weren’t many differences among jails, poorhouses, and hospitals, and these “asylums” were known for their brutal treatment of their charges.

  The vast majority of the mentally ill lived with their families, but this, too, sounds more idyllic than the reality. In eighteenth-century Ireland, mentally ill family members were held in holes five feet beneath their cottage floors, a space not big enough for most to stand up, with a barrier over the hole to deter escape. (“There he generally dies.”) The rest of Europe around that time was no more progressive. In Germany, a teenager suffering from some unnamed psychological affliction was chained up in a pigpen for so long that he lost the use of his legs; in England, the mentally ill were staked to the ground in workhouses; in one Swiss city, a fifth of the mentally ill were under constant restraint at home.

  Europe’s oldest psychiatric hospital, Bethlem Royal Hospital (nicknamed “Bedlam”), started as a priory in London in 1247 and was a hospital in the medieval sense: a charitable institution for the needy. Bethlem began catering exclusively to the insane about a century later; their idea of a cure was to chain people in place and whip and starve them to punish the disease out of their systems. One person, confined to Bethlem for fourteen years, was held by a “stout iron ring” around his neck with a heavy chain that was attached to the wall, allowing him to move only a foot. The belief then was that the insane were no better than animals and should be treated even worse because, unlike livestock, they were useless.

  In the mid-1800s, American activist Dorothea Dix deployed her sizable inheritance to devote herself to these issues with a fierceness of purpose that hasn’t been matched since. She traveled more than thirty thousand miles across America in three years to reveal the brutalities wrought upon the mentally ill, describing “the saddest picture of human suffering and degradation,” a woman tearing off her own skin, a man forced to live in an animal stall, a woman confined to a belowground cage with no access to light, and people chained in place for years. Clearly, the American system hadn’t improved much on Europe’s old “familial” treatments. Dix, a tireless advocate, called upon the Massachusetts legislature to take on the “sacred cause” of caring for the mentally unwell during a time when women were unwelcome in politics. Her efforts helped found thirty-two new therapeutic asylums on the philosophy of moral treatment. Dorothea Dix died in 1887, the same year that our brave Nellie Bly went undercover on Blackwell Island, in essence continuing Dix’s legacy by exposing how little had truly changed.

  Blackwell Island was supposed to have been different. Built as a “beacon for all the world,” it was located on 147 acres in the middle of the East River and was meant to embody the theory of moral treatment that Dix had championed. Its central tenets came from French physician Philippe Pinel, who is credited with breaking his charges free of their chains (literally) and instating a more humanistic approach to treating madness—though his legacy, historians suggest, comes more from myth than reality. “The mentally sick, far from being guilty people deserving of punishment, are sick people whose miserable state deserves all the consideration that is due to suffering humanity,” Pinel said.

  Connecticut physician Eli Todd introduced moral treatment Stateside and outlined the new necessities: peace and quiet, healthy diet, and daily routines. These new “retreats” replaced the old “madhouses” or “lunatickhouses” and moved to soothing surroundings away from the stresses of the city. In some cases, asylums expanded into mini-cities, where hospital superintendents, doctors, and nurses lived alongside patients. They tended farms together, cooked in the kitchen together, even made their own furniture and ran their own railroads. The idea was that orderly routines and daily toil created purpose and purpose created meaning, which led to recovery. The doctor-patient relationship was key. People were treated as people, and the sick could be cured.

  That was the intention, anyway. Blackwell Island may have been founded on these ideals in 1839, but by Nellie’s era it had thoroughly earned its notoriety as one of the deadliest asylums in the country. After Charles Dickens visited in 1842, he immediately wanted off the island and its “lounging, listless, madhouse air.” (Dickens later tried to commit his wife, Catherine, to an asylum so that he could pursue an affair with a younger actress—a downright monstrous act considering what he knew of these places.) Blackwell’s asylum housed numbers that far exceeded its capacity. In one instance, six women were confined to a room meant for one. Reports detailed “the onward flow of misery,” including a woman made to give birth in a solitary cell alone in a straitjacket, and another woman who died after mistaking rat poison for pudding.

  The inhabitants Bly encountered on Blackwell Island looked lost and hopeless; some walked in circles, talking to themselves; others repeatedly insisted that they were sane but no one listened. Bly, meanwhile, dropped all pretense of insanity once she made it inside the hospital: “I talked and acted just as I do in ordinary life. Yet strange to say, the more sanely I talked and acted, the crazier I was thought to be,” she wrote. Any worry—which would soon turn to hope—that she might be exposed as a fake evaporated the minute the nurses plunged her into an ice bath and scrubbed her until her goosefleshed skin turned blue, pouring three buckets of water over her in succession. She was so caught by surprise that she felt she was drowning (a similar sensation, I imagine, to waterboarding). “For once I did look insane,” she said. “Unable to control myself at the absurd picture I presented, I burst into roars of laughter.”

  The first day, she quickly learned what it was like to be discarded by humanity. Whatever ladylike manner had caught the judge’s eye was meaningless here, where she was just another in a series of worthless paupers. Patients—even those with open syphilitic sores—were made to wash in the same filthy bathtub until it became thick and dirty enough with human waste and dead vermin that the nurses finally changed it. The food was so rotten that even butter turned rancid. The meat, when offered, was so tough the women chomped down on one end and pulled at the other with both hands to rip it into digestible pieces. Bly had too much decorum to discuss this in her article, but even using the toilets was a traumatic experience. They were long troughs filled with water that were supposed to be drained at regular intervals—but, like everything else on this godforsaken island, what was supposed to happen rarely did.

  Bly listened to the stories from her sisters on Hall 6. Louise Schanz, a German immigrant, had landed in this hell simply because she couldn’t speak English. “Compare this with a criminal, who is given every chance to prove his innocence. Who would not rather be a murderer and take the chance for life than be declared insane, without hope of escape?” Bly wrote.

  Another patient told Bly about a young girl who had been beaten so badly by the nurses for refusing a bath that she died the next morning. One of the “treatments” used on the island was “the crib,” a terrifying contraption in which a woman was forced to lie down in a cage so confining that it prevented any movement—like a tomb.

  Within a few days, Bly had gathered more than enough evidence for her exposé, but now she began to worry that she would never be free. “A human rat trap,” she called it. “It is easy to get in, but once there it is impossible to get out.” This was not much of an exaggeration. According to an 1874 report, people spent on average ten to thirty years on Blac
kwell Island.

  By this point, Bly was proclaiming her sanity to anyone who would listen, but the “more I endeavored to assure them of my sanity the more they doubted it.”

  “What are you doctors here for?” she asked one.

  “To take care of the patients and test their sanity,” the doctor replied.

  “Try every test on me,” she said, “and tell me am I sane or insane?”

  But no matter how much she begged to be reevaluated, the answer remained the same: “They would not heed me, for they thought I raved.”

  Thankfully, after ten days with no word from Bly, her editor sent a lawyer to spring her from the rat trap. Safely back in Manhattan, Bly filed a two-part illustrated exposé—the first called “Behind Asylum Bars,” and the second “Inside a Madhouse”—published in the New York World in 1887. The article was syndicated across the country, horrifying the public and forcing politicians to do something about it. The Manhattan DA convened a grand jury to investigate and Bly testified, leading jurors on a tour of the island, which had been rapidly scrubbed into shape. But there was only so much Blackwell Island could cover up. In the end, thanks to this young reporter’s courage, the Department of Public Charities and Corrections agreed to a nearly 60 percent increase in the annual budget for care of the inmates.

  If Bly’s publisher hadn’t intervened, how long would she have been confined on the island? And what of the other women still trapped inside? The line between sanity and insanity was far less scientific, less quantifiable than anyone wanted to admit. An op-ed in the New York World wrote that Bly’s exposé showed that “these experts cannot really tell who is and who is not insane,” which raised the question of “whether the scientific attainments in mental diagnosis possessed by the doctors who saw her amount to anything or not.”

  The truth is, at this point in the nineteenth century, alienists still didn’t know what to do with the hordes of people filling their asylums. Unsurprisingly, the rest of medicine had no use for these “insanity experts,” who seemed to have no expertise in anything. A few years before Bly went undercover, Louis Pasteur had successfully demonstrated the germ theory of disease, leading to the discovery of vaccines against cholera and rabies, which revolutionized medicine by introducing the concept of prevention. In the span of a few decades, medical science had largely dropped the harmful practice of bloodletting and had (decades before Bly’s hospitalization) identified leukemia as a blood disorder, helping to launch the new field of pathology. The invisible had at once become visible as medicine bounded into the next century. Yet the alienists, still blind, had only their asylums, cruel “crib” contraptions, and no solid theory about how to explain any of it.

  Other than some money being thrown at the problem, nothing changed after Bly’s exposé. (As we will see, that would take a much larger mortar shell landing in the heart of psychiatry, nearly a century later.)

  One of the most sophisticated and moneyed cities in the world, now aware of such cruelty visited upon its citizens, simply shrugged.

  As we still do.

  3

  THE SEAT OF MADNESS

  Today Blackwell Island no longer exists. In 1973, the island was renamed after Franklin D. Roosevelt, and the site where Bly spent her ten harrowing days is now home to a luxury condo development. But the kind of anguish she witnessed there doesn’t just disappear. The questions she was trying to answer—questions about what it means to be sane, or insane, what it means to care for a suffering human being who often scares us—remain.

  Madness has been dogging humanity for as long as humans have been able to record their own history. But the answer to what causes it—where it can be located, in a manner of speaking—has eluded us just as long. The explanation has ping-ponged throughout history among three players: mind/soul, brain, and environment. First, it was believed to be supernatural, a direct effect of meddling by the gods or devils. Thanks to unearthed skulls dated to around 5000 BC, we know that one of the earliest solutions was to bore holes in the head to release the demons that had presumably taken up residency there, a procedure called trephining. Another way to rid oneself of inner demons was to sacrifice a child or an animal so that the evil spirit could trade one soul for another. Early Hindus believed that seizures were the work of Grahi, a god whose name translates quite literally to “she who seizes.” The ancient Greeks believed that madness descended on them when their gods were angry or vengeful—a belief that continued on with the teachings of Judaism and Christianity. Lose faith or become too prideful and “the Lord shall smite thee with madness,” the Old Testament warned. In the book of Daniel, God punishes Nebuchadnezzar (“those who walk in pride he is able to abase”) by deploying a form of madness that transforms him into a raving beast, stripping away his human capacity for rational thought. Exorcisms, ritualistic torture, and even burnings at the stake were some of the approaches employed to release the devil in unquiet minds. Those who survived suicide attempts—seen as an act spurred on by the devil himself—were dragged through the streets and hanged.

  Enlightenment thinkers reshaped madness into irrationality and began to think of it as a by-product of the breakdown of reason rather than an outcome of demonic possession. René Descartes argued that the mind/soul was immaterial, inherently rational, and entirely distinct from our material bodies. Though religion clearly still played a role in this thinking, this dichotomy allowed madness to become “unambiguously a legitimate object of philosophical and medical inquiry,” wrote Roy Porter in Madness: A Brief History.

  This area of medical inquiry got a name in 1808: psychiatrie, coined by German physician Johann Christian Reil. The new medical specialty (which should attract only the most forward-thinking practitioners, Reil wrote) would treat mind and brain, soul and body—what is today called the holistic approach. “We will never find pure mental, pure chemical, or mechanical diseases. In all of them one can see the whole,” Reil wrote. The principles he laid out then are as relevant today: Mental illnesses are universal; we should treat people humanely; and those who practice should be medical doctors, not philosophers or theologians.

  Reil’s version of psychiatry didn’t deter the many doctors who chased promises of finding the “seat of madness.” What causes it? they wondered. Is there one area or hosts of them? Can we be driven to it by circumstance and environment, or is it rooted solely in the organs within our skulls? Alienists began to target the body, expecting that madness could be isolated and targeted—creating some truly horrific treatments along the way, from spinning chairs (developed by Charles Darwin’s grandfather Erasmus Darwin) that induced vertigo and extreme vomiting that was believed to lull the patient into a stupor; to “baths of surprise,” where floors fell away, dropping people into cold water below to shock the crazy out. As brutal as these treatments were, they were considered a step forward: At least we weren’t attributing cause to devils and demons anymore.

  An early practitioner named Benjamin Rush, a signer of the Declaration of Independence, believed that the cause of madness was seated in the brain’s blood vessels. This prompted him to dream up some deranged treatments, including the “tranquilizing chair” (a case of the worst false advertising ever), a terrifying sensory-deprivation apparatus in which patients were strapped down to a chair with a wooden box placed over their heads to block stimulation, restrict movement, and reduce blood to the brain. Patients were stuck in this chair for so long that the seat was modified to include a large hole that could serve as a toilet. The insane weren’t just neglected and ignored; they were abused and tortured—the “otherness” of mental illness making them fair game for acts of outright sadism.

  The invention of the microscope led to descriptions of the contours of the brain and nervous system on the cellular level. In 1874, German physician Carl Wernicke pinpointed an area of the brain that, when damaged, created an inability to grasp the meaning of spoken words, a condition called Wernicke’s aphasia. In 1901, Frankfurt-based Dr. Alois Alzheimer treated a
fifty-one-year-old woman with profound symptoms of psychosis and dementia. When she died in 1906, Alzheimer opened up her skull and found the cause: plaque deposits that looked like tangled-up sections of fibrous string cheese. So: Was her mental illness caused by nothing more than an unfortunate buildup?

  The greatest triumph came from the study of syphilis, a disease all but forgotten today (though seeing a resurgence1) that surfaced around 1400. The famous people suspected to have had syphilis could crowd a Western civilization Hall of Fame: Vincent van Gogh, Oscar Wilde, Friedrich Nietzsche, Henry VIII, Leo Tolstoy, Scott Joplin, Abraham Lincoln, Ludwig van Beethoven, and Al Capone.

  Stories of “the most destructive of all diseases” have abounded since the late Middle Ages. Doctors later called it the “general paralysis of the insane”—a group of doomed patients that made up an estimated 20 percent of all male asylum admissions in the early twentieth century. These patients staggered into hospitals manic and physically off-balance. Some under grand delusions of wealth spent all their money on ridiculous items like fancy hats. Their speech sounded spastic and halting. Over the course of months or years, they would waste away, lose their personalities, memories, and ability to walk and talk, spending their final days sectioned off to the back wards of some local asylum until death. Patient histories, when available, revealed a pattern: Many of these men and women had developed syphilis sores earlier in their lives. Could this sexually transmitted disease be a latent cause of madness?

  The answer came when two researchers identified spiral-shaped bacteria called Spirochaeta pallida in the postmortem brains of those of the insane with general paralysis. Apparently, the disease could lie dormant for years, later invading the brain and causing the constellation of symptoms that we now know of as tertiary syphilis. (Syphilis would come to be called the great pox, the infinite malady, the lady’s disease, the great imitator, and the great masquerader—one more example of the great pretender diseases, because it could look like a host of other conditions, including insanity.) This was, as contemporary psychologist Chris Frith described, a “kind of peeling of the diagnostic onion.” We had parsed out something we thought generally of as “insanity” as having a physical cause. And the best part was that we could eventually cure it if we caught it early enough, too.