When the US government started tracking the incidence of mental illness, it broke it down into two broad categories of “idiocy” and “insanity.” By 1880, the census had expanded to include seven categories of mental disease (mania, melancholia, monomania, paresis, dementia, epilepsy, and dipsomania), but in the first half of the 19th century most doctors believed that craziness was one-size-fits-all, something called unitary psychosis. If you acted crazy, you were crazy.

Almost anything could make you a ward of the state. “Compulsive epilepsy, metabolic disorders, syphilis, personality due to epidemic encephalitis, moral adverse conditions such as: loss of friends, business troubles, mental strain, religious excitement, sunstroke, and overheat,” read one intake log from California’s Patton State Hospital archive. One reason for commitment at Patton State in the 19th century was excessive masturbation. Another was for being “kicked in the head by a mule.” Other hospital records show that some poor souls were committed for “habitual consumption of peppermint candy” or “excessive use of tobacco.” Unmoored after a child died? You could be institutionalized. Use a foul word or two? In a cell you go. Miss a menstrual cycle and you could be committed. These kinds of convenient diagnoses, the sort given to citizens who don’t conform, have littered the annals of psychiatry. Hysteria was lobbed at women who dared defy social mores. In England, militant suffragettes, in particular, were diagnosed with “insurgent hysteria.” A 19th-century Louisiana physician outlined two “conditions” unique to the slaves he studied: dysaesthesia aethiopica, or pathological laziness; and drapetomania, the (evidently inexplicable) desire to escape bondage. Treatments for both included whippings. These were not, in any medical or scientific sense, real illnesses or disorders—they were pseudoscience, purely societal strictures posing as medicine.

Throw a rock into a crowd in the late 1800s, and there’s a good chance you’d hit someone who had spent some time in an asylum.

And, for those who did end up committed, odds weren’t great that they would make it out intact. Once declared insane, you could permanently lose custody of your children, property, and rights to inheritance. Many would remain locked away for a long time, if not the rest of their lives. Those who pushed back often were beaten or “treated” with bleeding, leeching, enemas, and induced bouts of intense vomiting (which were key parts of general medicine’s arsenal of care at the time). A substantial portion of people admitted to psychiatric hospitals in this period died within months, even weeks, of being admitted—though there is no definitive proof whether this is because they really suffered from misdiagnosed life-threatening medical conditions or whether the hospitals’ conditions themselves led to an early end, or if it was a combination of the two.

The malleability of the era’s definitions of insanity meant that any man of a certain means and pedigree could just pay off a doctor or two and dispatch whomever he wanted gone, a disobedient wife, for example, or an inconvenient relative. This understandably bred a widespread anxiety over false diagnoses. Newspapers stoked this fear by publishing a litany of articles about people sidelined into mental hospitals who weren’t truly sick.

the whiskey-soaked attendant welcomed her to the women’s asylum: “An insane place, where you’ll never get out of.”

There was Lady Rosina, an outspoken British writer whose feminist views estranged her from her famous husband, writer Sir Edward Bulwer-Lytton (creator of the most clichéd opening line of all time: “It was a dark and stormy night”). Sir Bulwer-Lytton didn’t have time for such a mouthy wife, especially with his seat in Parliament in jeopardy, so he tried to lock her up to shut her up. Thanks to her own celebrity and the pressure that the press put on her husband, she emerged three weeks later and wrote about her experience in 1880’s A Blighted Life. “Never was a more criminal or despotic Law passed than that which now enables a Husband to lock up his Wife in a Madhouse on the certificate of two medical men, who often in haste, frequently for a bribe, certify to madness where none exists.”

Elizabeth Packard continued Lady Rosina’s fight in America. Packard butted heads with her Presbyterian minister husband, Theophilus, about her interest in spiritualism. Her religious interests made Packard a direct threat to her husband’s stature in the community, so to save his own reputation he recruited a doctor to denounce her as “slightly insane” and commit her to Jacksonville Insane Asylum, where she lived for three years. When Packard was released into her husband’s care, she managed to escape the room he had locked her in by dropping a note out of the window. This note reached her friend, who arranged for a group of men to request a writ of habeas corpus on her behalf, giving Packard the opportunity to defend her sanity in court. A jury deliberated for only seven minutes before concluding that, despite what her husband and doctors said, Packard was sane.

She published the book The Prisoners’ Hidden Life, which also featured the experiences of other women unloaded into hospitals by their loved ones. Thanks to her work, the state of Illinois passed a “Bill for the Protection of Personal Liberty,” which guaranteed that all who were accused of insanity would be able to defend themselves in front of a jury—since doctors, it was recognized, could be bought and sold. (There were negatives to Packard’s reforms, as jurors could be grossly ignorant about matters related to mental illness.) After Bly successfully made enough of a scene at the boardinghouse for the police to be summoned, she was escorted to Manhattan’s Essex Market Police Court, where she faced the judge who would decide whether or not she should be locked up. Lucky for her, or rather for the New York World, the judge accepted the events of the morning at face value.

“Poor child,” mused Judge Duffy, “she is well dressed, and a lady . . . I would stake everything on her being a good girl.” Though she’d worn her most ragged clothes and acted as insane as she could, her genteel looks and manners made it hard for him to take the next step. The judge understood that Blackwell Island was far from a place of refuge, and he hesitated to send someone he felt was too well bred to suffer the indignities there. “I don’t know what to do with the poor child,” the judge said. “She must be taken care of.”

“Send her to the Island,” suggested one of the officers.

The judge called in an “insanity expert,” a colloquial term from the era to describe the doctors who chose to work with the insane. These specialists, also called alienists and medical psychologists, or mocked as “bughouse doctors,” “quacks,” or “mad doctors,” mainly spent their careers confined, like their charges, to asylums. (Psychiatrist would become the preferred term in the early 20th century.)

The insanity expert asked Bly to say “ah” so he could see her tongue. He shined a light into her eyes, felt her pulse, and listened to the beating of her heart. Bly held her breath. “I had not the least idea of how the heart of an insane person beat,” she later wrote. Apparently her vital signs spoke for her: On whatever quantitative grounds he found to set her apart from the sane, the expert took her to the insane ward at Bellevue. There she was examined by a second doctor who deemed her “positively demented” and shipped her off to Blackwell Island.

The vast majority of the mentally ill lived with their families, but this, too, sounds more idyllic than the reality.

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 18th-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 14 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 30,000 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 below- ground 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 32 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.

“Who would not rather be a murderer and take the chance for life than be declared insane, without hope of escape?” Bly wrote.

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 Blackwell 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.

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Excerpted from The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness. Copyright © 2019 by Susannah Cahalan, LLC. Reprinted with permission of Grand Central Publishing. All rights reserved.