As the nineteenth century progressed, physicians responded to mental illness in increasingly systematic ways. At first, physicians at Friends’ Asylum classified patients by the duration of their insanity, as experts held that the longer a person was deprived of the use of their reason, the less likely they were to recover.
In 1836, Friends’ Asylum began to also classify patients based on the type of insanity they were thought to have, as deduced from their symptoms. Mania was thought to be the most curable and dementia the least (Esquirol 128). Physicians also began recording the causes of mental illness for each patient if they were known. The classification schemes employed by Friends' Asylum doctors illustrate the variety of factors thought to cause mental illness, as well as the ways that physicians attempted to make sense of the wide range of symptoms that patients exhibited. Although Friends' Asylum did not base patients’ ward assignments on these diagnoses like at other institutions, instead choosing to separate patients by the disruptiveness of their behavior, these classifications still informed patients' treatments. Starting in the 1830s, medical and moral treatment were actively employed in tandem. Physicians used medical treatment to address physical ailments, while moral treatment was used to restore patients to reason.
The following are different ways of visualizing data pertaining to the types and causes of mental illness. The data were originally listed in the Admissions Day Book for the years 1836 to 1877 and contain entries for over 1,000 patients. The data have been compiled in the patient data page, and can be downloaded in multiple formats.
Explanation of Terms
Dementia was originally coined as ‘demence’ in the early nineteenth century by French physician Philippe Pinel. He defined dementia as a "rapid succession or uninterrupted alternation of insulated ideas, and evanescent and unconnected emotions; continually repeated acts of extravagance complete forgetfulness of every previous state; diminished sensibility to external impressions; abolition of the faculty of judgment" (Pinel 6-7). Jean-Étienne Dominique Esquirol distinguished dementia from imbecility and idiocy: the former involved a regression in understanding and sensibility, whereas in the latter it never properly developed (Esquirol 177).
Also referred to as ‘raving madness,’ mania was the most commonly ascribed type of insanity at Friends’ Asylum. In 1837, the English physician James Prichard described mania as full derangement of the understanding (as opposed to other types of mental illness involving only partial derangement), with the mind in perpetual confusion (Prichard 4).
Until the 1830s, melancholia referred to all types of partial intellectual derangement (as opposed to mania, the term used for full derangement of the mental faculties). After that, melancholia became most commonly used to describe illnesses marked by a gloomy and sullen demeanor. In the 1870s English physicians John C. Bucknill and Daniel H. Tuke explain that while the symptoms include being “cheerless, moody, and taciturn,” melancholia was usually not accompanied by delusions or mental inactivity (Bucknill and Tuke 220).
Monomania was a type of partial insanity in which a person showed deluded judgement only on certain subjects and otherwise remained rational. In 1845, French physician Jean-Étienne Dominique Esquirol explained that monomania could be accompanied by a variety of factors including delirium, reasoning, or homicidal tendencies (Esquirol 319-376).
Idiocy and Imbecility
Jean-Étienne Dominique Esquirol distinguished dementia from imbecility and idiocy: the former involved a regression in understanding and sensibility, whereas in the latter it never properly developed (Esquirol 177).
Information about Idiocy/Imbecility is not included in the data visualizations.
This data visualization shows the top causes of insanity divided amongst the four main types of mental illness. The colors represent the different types of mental illness, and the size of each circle shows the number of patients diagnosed with each combination of both type and cause of illness. For example, there were 90 patients with mania whose cause of illness was disease or ill health. On the other hand, there was only one patient with dementia caused by religion.
In this graphic, it is easy to see all the different causes attributed to each type of mental illness. Mania has both the largest circles, since it was the most common diagnosis at Friends’ Asylum, and the most circles, since each cause of insanity was linked to at least one insance of mania. The other three types of mental illness each have between 10 and 15 circles, meaning they have between 10 and 15 connected causes. This shows that there was a wide variety of causes for the same type of mental illness, but certain causes did only lead to certain diagnoses. For example, old age and excessive study are only found to cause mania and dementia. But many causes, such as domestic trouble, intemperance, and sexual, were listed under all four types of mental illness. Overall, this graphic shows that mania was the most generalized type of mental illness, and the other three were more particular and defined, in terms of their causes.
The alluvial diagram below illustrates in further detail the correlations between the most commonly listed types and causes of mental illness. The first column lists the simplified cause used in the visualizations, and the second column lists the specific cause that was listed in the original manuscript materials, along with any relevant background information about the cause. This visualization makes it possible to see which causes were most attributed to which types. While there are some classifications and causes that are strongly correlated, as seen in the thicker bands (such as from dementia to masturbation, melancholia to anxiety, and mania to most of the causes), this visualization proves that the relationships between causes and types of mental illness were incredibly variable. Every cause is connected to at least two types of mental illness. In other words, the classification schemes were not straightforward; physicians could not tell just by a patient’s cause of insanity what they should be diagnosed with, nor could they deduce from their diagnosis a definitive cause.
This bar graph shows the total number of male and female patients who were listed under each of the different causes of mental illness at Friends’ Asylum between 1836 and 1877. Female patients are represented by the red bars, and male patients by the blue bars.
In the nineteenth century, intemperance, usually used to refer to the excessive indulgence of alcohol, was seen as a dangerous vice. Men especially were the target of reform movements meant to reduce the amount of alcohol consumed in the United States, presumably since they were believed to indulge in alcohol more than women. In addition, intemperance was thought to be a cause of mental illness. At the end of the eighteenth century, American physician Benjamin Rush listed madness one of the diseases caused by alcohol, and did not give much detail since madness was “well known in every township where spirituous liquors are used” (Rush 4). Therefore, the fact that intemperance was such a common cause at Friends’ Asylum and was attributed almost exclusively to men is not surprising.
Significantly more women were listed under anxiety, disease or ill health, domestic trouble, and religion. Conversely, more men were listed under business or money, masturbation, and sexual. These differences are in line with the strict conceptions of gender roles in the nineteenth century. Physicians likely held preconceived notions about the range of causes they would expect to find for each gender. Therefore, it is important to interrogate these gender-based distinctions, with the context of nineteenth century society in mind.
The data recorded in the admissions books provide valuable insight into the way that Friends’ Asylum classified mental illness in the nineteenth century.
First, mania was both the most common and most generalized type of mental illness. While it did have certain characteristics, it also appears to have been a sort of catch-all category to use when a patient did not exhibit symptoms indicative of a more particular and specialized category of mental illness.
Additionally, the data illustrates that the causes and types of mental illness did not correspond in a linear way. Physicians tried their best to make sense of the causes and types, and did so by constructing elaborate connections between the two elements which were complicated and constantly in flux.
Finally, the way that gender was viewed during the nineteenth century had a tremendous impact on the way that causes were attributed to patients based on their gender. Preconceived notions and generalizations certainly influenced the causes that were assigned to patients, and these outside factors must be kept in mind when analyzing causal data from the nineteenth century.
Overall, using data to visualize the causes and types of mental illness at Friends’ Asylum provides an additional way of studying the workings of the institution. As more data becomes accessible, more opportunities for additional statistical analyses and visualizations will become available, and ultimately give us more insight into Friends’ Asylum.
Religious excitement – also known as also known as religious madness, religious melancholy, religious fervor, religious frenzy, and religious insanity – was a psychological diagnosis given to patients whose religious thought “involved the prolonged arousal of powerful emotions, especially fear or elation, accompanied by overly imaginative and obsessive chains of thought.” The height of religious insanity peaked in the nineteenth century, potentially spurred in parallel by both evangelical revivalism and increasing spiritualism in the United States. However, its roots lay beyond that time, as Alexandra Prince states: “as early as 1621, Robert Burton described religion as a kind, cause and symptom of madness in his famous work “The Anatomy of Melancholy.” Anglican critics of Puritans dismissed them with the mad label religious melancholy. In eighteenth century England, Methodists and Quakers were labeled insane for their emotional worship style.”
William Sims Brainbridge describes the causes of religious madness to include unresolved guilt, and intense religious experiences, stating “religion was a response rather than the cause of the problem.”  He believed the idea that as these causes were moral and not physical, those afflicted were curable, and therefore deserved humane treatment. This aligns deeply with Friends Asylum, whose treatment for the majority of the nineteenth century was drawn from moral treatment, which sought to treat each patient humanely, not only with medicine, but community connection, religious involvement, and different kinds of occupational therapies. Bainbridge illuminates the possible conundrum of religious insanity, elucidating that many elements of nineteenth century mental illness are due to a lack of coping strategies. At the same time, “religion provides plans and interpretations for dealing with the most terrifying challenges of life.” Therefore, treating the patient as a whole being, and not just treating their symptoms, would be the only way to fully resolve their illnesses.
With this also came the idea that mental illness was not seen as a moral or personal failure, but rather, in particular for religious insanity, part of being dedicated to one’s religion. Alice Mauger points out that it was in the late nineteenth century when asylum doctors were distinguishing between moral and physical causes of insanity – differentiating the moral or psychological causes “such as grief, bereavement, business or money anxieties, religion and ‘domestic trouble’ versus physical ailments.”
At Friends Hospital, patients were admitted for a plethora of reasons. The alluvial graph on the “Types of Mental Illness” page shows several examples of admission for religious insanity, such as religion, excitement, and excessive study. According to the main early admission book, from 1836-1875, 25 people were admitted to Friends Hospital with religious excitement or religious anxiety. Of those, at discharge 23 were listed as restored or improved, with one person stationary, and unfortunately one who died only seven days after admission to the Hospital. This is likely only a portion of patients with religious insanity; others were admitted with other main diagnoses[HS1] , or their religious mania did not always present at admission.
While there was some concern that religious books might cause or exacerbate religious fervor, in their library for patients, Friends Hospital maintained a selection of Quaker books, hoping these would provide comfort to their patients., Interestingly, Quaker patients were allowed to attend the local Frankford Friends Meeting for weekly worship. Ruth Scott, admitted in 1822 as incoherent and delusional, often had religious delusions. She regularly attended Frankford Meeting, though Superintendent Isaac Bonsall writes that she was not “in a suitable state of mind to go.” At one point, charismatic Elias Hicks called a meeting at Frankford Friends Meeting. Bonsall refused to let Scott attend. Scott escaped from the Asylum and was halfway to the meetinghouse before she was caught. Scott stayed at Friends Asylum for 18 months, at which point she was released, described as “much improved.”
In his 1841 “Observations on the religious delusions of insane persons […]” Nathaniel Bingham describes the differences between the diagnoses of religiously insane and insanely religious: for those who are religiously insane, religion is the cause of insanity, whereas for those who are insanely religious, they are “so far religious they are insane.” He continues on to state that those in the latter category are able to be “cured” when relieved of their religious fervor. From the data presented on Friends Hospital patients, it can be surmised that the majority of these individuals with religious excitement fall into the latter category, being restored before they are released from the Hospital.
 Broc, L. A. (2013). Religion and insanity in america from colonial times to 1900 (Order No. 3600355). Available from ProQuest Dissertations & Theses Global: The Humanities and Social Sciences Collection. (1465052060). Retrieved from https://ezproxy.haverford.edu/login?url=https://www.proquest.com/dissertations-theses/religion-insanity-america-colonial-times-1900/docview/1465052060/se-2 p5
 Prince, A. (2020). Religion and madness: Contests over faith and insanity in the american cultural imaginary, 1840-1920 Retrieved from https://www.proquest.com/dissertations-theses/religion-madness-contests-over-faith-insanity/docview/2423781187/se-2 page xiii
 Bainbridge, William Sims. “Religious Insanity in America: The Official Nineteenth-Century Theory.” Sociological Analysis, vol. 45, no. 3, 1984, pp. 223–39. JSTOR, https://doi.org/10.2307/3711479. page 236.
 Brainbridge, 234.
 Brainbridge, 236.
 Mauger, Alice. The Cost of Insanity in Nineteenth-Century Ireland : Public, Voluntary and Private Asylum Care. Cham, Switzerland: Palgrave Macmillan, 2018. page 152.
 View the data from this book here: https://github.com/HCDigitalScholarship/qmh-v2/blob/f01c0ed210fb6b211b583a5053185a647293c99a/admission_book_v_1_1817-1885_2021.xlsx
 Levin, Len. “Bibliotherapy: Tracing the Roots of a Moral Therapy Movement in the United States from the Early Nineteenth Century to the Present.” Journal of the Medical Library Association 101, no. 2 (2013): 89-91.
 Bonsall, Isaac, Superintendent’s daybook, Friends Hospital collection (MC.1261), Haverford College Quaker and Special Collections, Twelfth Month, 25th, 1822. Digitized book available: https://digitalcollections.tricolib.brynmawr.edu/object/hc34704
 Corcoran, Abigail. “A Mild and Appropriate System of Treatment”1: Moral Treatment and the Curability of Mental Illness at Friends Asylum. 2016.
 Bingham, N. (1841). Observations on the religious delusions of insane persons, and on the practicability, safety, and expediency of imparting to them Christian instruction;: with which are combined a copious practical description and illustration of all the principal varieties of mental disease, and of its appropriate medical and moral treatment.. London: J. Hatchard and Son ....