Diagnosis: Freedom PDF - The Civil War, Emancipation, and Medical Research

Okay, here is the transcription of the provided text, formatted in Markdown. ### CHAPTER 6 ## DIAGNOSIS: FREEDOM ### The Civil War, Emancipation, and Fin de Siècle Medical Research >The regular, simple life, the hygienic conditions, the freedom from dissipation and excitement, steady and healthful...

Okay, here is the transcription of the provided text, formatted in Markdown. ### CHAPTER 6 ## DIAGNOSIS: FREEDOM ### The Civil War, Emancipation, and Fin de Siècle Medical Research >The regular, simple life, the hygienic conditions, the freedom from dissipation and excitement, steady and healthful employment, enforced self-restraint, the freedom from care and responsibility, the plain, wholesome, nourishing food, comfortable clothing, the open-air life upon the plantation, the care and treatment when sick, in those days, all acted as preventive measures against mental breakdown in the negro. >-DR. WILLIAM P. DREWRY, SUPERINTENDENT, VIRGINIA STATE HOSPITAL FOR THE INSANE, 1908 >A witty statesman said, you might prove anything by figures. >-THOMAS CARLYLE, CHARTISM, 1840 His medical screeds indicate that Dr. Peter Bryce, superintendent of the Alabama Insane Hospital, thought of himself as progressive. He had run the Tuscaloosa institution since its 1860 opening and prided himself on his currency with scientific advances in mental health. Unlike other institutions for lunacy, his was no human warehouse where diagnostic labels were applied intuitively and treatment was homey and futile. Bryce was scientific: He compiled carefully annotated case histories and observed patients closely before hazarding a diagnosis informed by the very latest in medical research, even research on blacks. For unlike most southern asylums, Bryce's admitted a few black patients. In 1867, he had admitted a former slave of his, and now the very next year a hypervigilant forty-five-year-old ex-slave named John Patterson had been brought for treatment. Patterson was clearly manic, possessed of an unfocused energetic furor that Bryce had encountered often. The doctor believed that, as with other blacks with this condition, the psychological pressure of caring for himself when Patterson possessed neither the intelligence nor the judgment to do had proved too great, and Patterson had sunk into madness. Hence Patterson's mania could have only one cause. "Diagnosis: Freedom," wrote Bryce. However, Patterson's medical history belied this diagnosis, because Bryce meticulously documented the course of Patterson's mental illness over the previous dozen years, and Patterson had been free for only five. The pressures of freedom could not have caused his illness. But even had Bryce recognized the glaring illogic of his diagnosis, he might not have been swayed: After all, he had the weight of medical research behind him. As the Civil War approached, social changes laid heavy siege to the institution of slavery. There were still far more enslaved blacks than free, yet the specter of Negro freedom haunted southern culture. In 1800, Washington, D.C., one of the most important slave markets in the country, was already thronged with 6,152 free blacks; by 1840, its 8,361 free blacks dwarfed its population of 4,694 slaves. By 1860, free blacks there outnumbered black slaves by more than three to one. There were other intimations that American slavery was doomed, such as the panic generated by the escalating slave rebellions. The deaths of fifty-seven whites in Virginia's 1831 Nat Turner revolt radiated shock waves and engendered desperately repressive legislation throughout the slaveholding South. Some states, such as Tennessee, even forced free blacks to leave. Perhaps the unkindest political blow of all was delivered by Thomas Jefferson's grandson in 1831, when he introduced a bill in the Virginia legislature to abolish slavery. It was defeated by only seven votes. By 1840, the South's grip on slavery was loosening, but its nondiversified agrarian economy, political power, and medical advances remained utterly dependent upon an unpaid labor force. However, even more was at stake, because the burgeoning ranks of free blacks upped the ante in an all-or-nothing game of social Darwinism. Without the restraining effects of white control, the pro-slavery camp argued, Negroes and mulattoes would outbreed whites in short order. Indeed, the official count of mulattoes had leaped at least 50 percent in just thirty years, and this number represented only the acknowledged progeny of black-white matings. Southern whites feared that a proliferation of free, pale-skinned mulattoes would soon efface the all-important social boundary between white and black, rendering "whiteness" meaningless. Years earlier, they had frequented "white negro" exhibits in circuses to experience a frisson of delicious revulsion at a distance-a Coney Island of the southern mind. Now, the threat of the "white negro" was too common and too immediate to entertain. Scientific racists rode to the rescue by explaining that mulattoes were too weak and infertile to infiltrate and replace whites. Dr. Josiah Nott was the most oft-cited articulator of this "frail mulatto" theory. In his paper "The Mulatto a Hybrid-Probable Extermination of the Two Races if the Whites and Blacks Are Allowed to Intermarry," Nott explained that mulattoes were an infertile, weak species, who died at a younger age than did whites and whose progeny were born feeble. Thus, a mulatto's family line would die out long before the visible evidence of a black forebear became undetectable. Of course, slavery advocates came from disciplines other than science or medicine. Legal minds scaled the mountain of constitutional support for slavery; philosophers expounded upon the "natural law" that made blacks inherently subservient to whites; and spiritual leaders cited reams of biblical and moral sanctions for enslavement. But scientific medicine was beginning to trump other philosophies. Scientific theories of racial inferiority had strongly informed the entire nation's medical perception of African Americans as befitted for slavery, if only because few scientists outside the South troubled themselves to investigate. However, by the 1840s, the larger American social climate was inimical to slavery. The North's industrialized economy no longer depended upon cheap southern labor, and the rest of the nation had grown jealous of the political power that the "three-fifths clause" imparted to the South: Its slave population allowed southerners to control Congress. International opposition to slavery had made it an institution truly peculiar to the United States. The nation had become a lonely Western trafficker in human chattel. The medical rationale for slavery-that inferior and feeble blacks were simply unable to govern and care for themselves-was derided as insular and self-serving, and counted few active sympathizers outside the South. In this contentious climate, the sixth U.S. census (of 1840) began enumerating whites and free and enslaved blacks. For the first time, the census also undertook to count the "insane and idiots"-nineteenth-century argot for the mentally ill and intellectually challenged. ### Racism by Numbers When the census was completed, no one was prepared for its revelations. It enumerated seventeen million Americans, of whom three million were black. But far more important, it revealed that free blacks suffered far worse health, especially far worse mental health, than did enslaved blacks, who enjoyed low rates of disease and suffered almost no mental illness. These data bolstered pro-slavery arguments by providing copious statistical "proof" that slavery was essential to preserve the health of blacks. Printed in 1841 under the aegis of the U.S. Department of State, the document seemed the very model of objectivity, offering dense orderly rows and columns of numbers collected by census takers without salient bias. Census data consistently documented how free blacks died sooner and suffered dramatically higher rates from every known disease, including tuberculosis, malaria, pellagra, and the final stages of syphilis. The census also revealed high rates of miscarriage and infant mortality among free blacks that in turn were ascribed to blacks' higher rate of sexual immorality and sexually transmitted disease. The census data posited madness as the most dramatic indicator of black helplessness. The North and South held equivalent rates of "insane and idiot" whites but not of mentally defective blacks. One out of every 1,558 blacks in the South was an "idiot or insane"; but 1 out of every 144 northern blacks had similar mental problems. Thus, mental defects were eleven times more common among free blacks in the North than among slaves. Even the northern state with the lowest percentage of insane blacks, New Jersey, had twice the black insanity rate of Delaware, the southern state with the highest rate. This powerful scientific argument for slavery was fed by research conducted by the presumably disinterested federal government, not by southern slavery apologists. Slavery's defenders quickly roused themselves to explain to naïve northerners the dangers of freedom for the "sickly freedmen" of the North, who sank into debilitating insanity when faced with having to provide for themselves or indeed to undergo any of the pressures of daily life that whites managed as a matter of course. They claimed that blacks lacked the mature judgment of whites and were unable to resist the allure of liquor, indiscriminate sex, constant dancing, and frequent fighting. Medical case histories described how blacks almost starved after spending their money on wine and tobacco or fell ill with tuberculosis after buying flashy clothes that were completely unsuitable for cold northern weather. Moreover, blacks' probable doom was not ascribed simply to lower intelligence, because their profoundly defective bodies were prey to a host of diseases that never plagued whites: The conditions Cachexia Africana ("dirt eating," or pica), hebetude, pellagra, and Dysthesia Aethiopica, which have been discussed earlier, were just a few examples, and new "black" diseases still were being discovered. Blacks' fertility had also fallen, allegedly because they were murderously indifferent mothers and absent fathers in the best of circumstances: Without white intervention, black children had even less of a chance at life than their parents. Slavery was also thought necessary to protect whites, because freely roaming sick blacks were perceived as vectors of infectious disease. The supposed concern for the health of blacks and alarm for the safety of whites provided a welcome dual rationale for enslavement and it justified draconian public-health methods such as racial segregation to contain the contagion of freed blacks. >"So little trouble do men take in search for the truth," Thucydides once observed, "so readily do they accept whatever comes first to hand." The behavior of the U.S. intellectual elite validated his centuries-old lament. Powerful statistical Arguments for slavery were widely accepted in the corridors of power, and census data spiced many a fiery political speech delivered by powerful politicians. The message found an especially vociferous champion in Secretary of State John C. Calhoun, a former medical student and an inveterate southern advocate of slavery. Calhoun used the data to rebuff criticisms of slavery at home and abroad-on a U.S. government letterhead. The shocked political opponents of slavery, intimidated by the statistical weight of the numbers and by the impeccable prestige of the U.S. census, never mounted a coordinated refutation of the census. Although it probably could not have prevented emancipation, the census research did contribute to a revitalization of slavery until the early 1860s. However, the celebrated census data were deeply flawed, as was revealed when serendipity, in the form of a broken leg, drew one of the finest statistical minds of the era into the fray. Dr. Edward Jarvis, a Concord, Massachusetts, physician, was specially trained both in mental illness and in statistics and helped found the American Statistical Association in 1839. But the next year, the peripatetic physician was ordered to bed with a fractured leg, and, bored, he began to peruse the census report. He was instantly galvanized by what he saw, because he was familiar with northern health statistics and realized at a glance that the census was riddled with serious numerical errors. Jarvis investigated and found that the census was a "fallacious and self-condemning document," a mixture of accidental and intentional falsehoods. Jarvis, who was white, sagely refused to be drawn into debates about the merits or logic of scientific racism. Instead, he spent months analyzing the enumeration of black and white inhabitants and their health status. Jarvis compared these to independently verified data describing northern towns, their inhabitants, and the mental health profiles. He emerged with a catalog of misinformed calculations and the deliberate insertions of hosts of fictitious numbers. Some northern towns that had no black residents at all were credited by the census with "insane negroes." For example Scarboro, Massachusetts, which "had a lily-white population" was mysteriously endowed by the census with six insane Negroes; Dresden, Maine, which had three black inhabitants, was also invested with six insane Negroes. The 1840 census indicated that the town of Worcester, Massachusetts, was the home of "133 colored lunatics and idiots," but this was actually the number of white patients in Worcester's State Hospital for the Insane. The mysterious appearance of these imaginary black insane was only the beginning of the census duplicity. When Jarvis compared the numbers in the federal census, which was still being refined, with the accurate, verified state censuses, the numbers for blacks and whites were erroneous. Even the numbers in the four printings of the 1840 census differed, without explanation. His damning indictment of the census criticized only the northern data. But even before Jarvis had completed his attack of the northern data, Dr. James McCune Smith of Harvard had deftly analyzed both the northern and southern numbers. Smith, an African American physician, scientist, and social theorist, had earned an M.D. from Scotland's University of Glasgow in 1837 after American schools barred his entry on racial grounds. Like Jarvis, Smith was a statistical expert and member of the American Statistical Association. His clear analysis addressed the flaws in the southern data revealing that the census's methodology was so deeply flawed that it was tantamount to libel regarding the health and mental status of African Americans. Smith understood that black mental illness was destined to be underenumerated in the South, where there was almost no accommodation far the diagnosis and mental health treatment. Blacks were typically barred from mental hospitals, and those too deranged to work were dumped into almshouses or jails, into which census marshals did not venture. Enumerators took an owner's word that his slaves were healthy, by which owners meant not emotionally healthy but simply fit to work. Making the all-important racial assessments was a quixotic task. Census marshals had been told to go from house to house and to make note of every occupant to determine his or her race (either "white" or "colored") and health status. Such a simplistic assessment of people who were varying mixtures of Native American, African, and European was a herculean task in itself and determining race was made futile by such laws as the "one-eighth rule" or the "one-drop rule," which tended to assign a "colored" label to anyone with discernible or known African heritage. Although race was hard to gauge visually, census takers accepted a neighbor's assessment or simply glanced at a member of a family to determine its race, with predictable results. Take Jack Coon of Alabama. A federal census marshal had listed him as white in 1850, but that year's state census recorded him as a mulatto freeman. In the 1860 U.S. census, Coon was listed as "Indian." It was similarly difficult to determine health status. Diseases such as syphilis, cholera, and pellagra were largely racialized, and whites who suffered from them were loath to admit it. Meanwhile, diseases such as syphilis were ascribed to blacks en masse. An owner's complaint that all his slaves were sexually immoderate and syphilitic was taken literally. Even legal status could deceive: Some planters misrepresented their slaves as free persons to avoid taxes. Census takers were duped by the ruse, or were complicit. On May 3, 1844, Smith submitted to the United States Senate a "memorial," a shrewd analysis of the census document, denuding its many fallacies and reducing it to an absurdity. His paper "Comparative Anatomy and Physiology of the Races," delivered before New York City's intellectual elite, also painstakingly refuted the science that sought to explain the excess insanity among free blacks, including the popular theory that the Negro's arrested cranial development resulted in a smaller brain and lessened intelligence. That year, Jarvis published a similar refutation with this editorial comment: >Here is proof to force upon us the lamentable conclusion that the sixth census has contributed nothing in the statistical nosology of the free blacks,... such a document as we have described heavy with its errors and misstatements..... So far from being an aid to medical science, it had thrown a stumbling block in its ways, which will require years to remove. His last sentence proved prescient. Congressman and former President John Quincy Adams propelled a resolution through the House of Representatives to compel Secretary of State Calhoun to reexamine the census for "gross errors". But Calhoun appointed his friend William A. Weaver, the originator of the deeply flawed census, to examine it for intentional errors. Weaver pronounced the census flawless. Calhoun reported this to the House of Representatives, permitting himself a bit of triumphant sermonizing on the dangers of black freedom> "... so far from bettering the condition of the Negro or African race, by changing the relationship with the European in the slaveholding states, it would render it far worse. It would indeed, to him, be a curse rather than a blessing." This manipulation of public-health data specifically in furtherance of a racial agenda illustrates that public health and medical research are not mutually exclusive. Worse, the erroneous figures and conclusions persisted in medical journals. In 1851, the august American Journal of Insanity reprinted without comment an article asserting the following:"It is obvious taken from the following schedule [taken from the 1840 census] that there is an awful prevalence of idiocy and insanity among the free blacks over the whites, and especially over the slaves. Who would have believed without the fact in black and white before his own eyes, that [e]very fourteenth colored person in the state of Main [e] is an idiot or lunatic?" But finally war achieved what science would not: It doomed slavery. ### Without Sanctuary Military medicine proved inadequate in the face of the legendary carnage wrought by the War Between the States. Eighty-eight of every 1,000 white volunteer soldiers in the Union army died, but proportionally one and half times more black Union soldiers-148 per 1,000-succumbed." One Northern officer declared, "You can't replace these white boys, but if a nigger dies, all you have to do is send out and get another one." Still, it was much safer and healthier to be a black soldier than a black civilian. Most slaves fled the plantations when the war began and most free blacks fled the South. This internal nation of homeless roamed northward, hungry, tattered, sick, and penniless, seeking safe harbor. As the Union army drove back the boundaries of the Confederacy, it initially took control of 750,000 black people. The government assigned responsibility for their care to the reluctant Union army, which argued that it had neither, the resources, nor the expertise to give the refugee blacks the care they needed. Nevertheless, during its peak year, 1866, the army's Freedmen's Bureau health system comprised forty-six field hospitals, fifty-two colonies, asylums, and dispensaries (smaller clinics), 118 physicians, and 406 hospital attendants. Waves of sick blacks were herded into camps without adequate nutrition, sanitation, or medical care. Only 138 physicians ever cared for the 1.1 million freemen who eventually lived in the camps, and many of these doctors expressed disdain for the black "animals," as at least one doctor called the contraband in front of relief workers. Some flatly refused to care for them. The results were predictable: One out of every four freemen died in the camps. Many died of rampant infectious disease, especially tuberculosis. Infant mortality, which had always run high among enslaved blacks, swelled exponentially. The African American refugees themselves staffed and ran the camps, but always under the Argus eyes of paid white administrators. The high disease and death rate, primitive medical conditions, and callous attitudes of some camp physicians further fed African American distrust of medicine. When the war ended, Martin L. Delany, M.D., who had distinguished himself as an officer and surgeon during the war, headed the Freedmen's Bureau, but its medical services were sabotaged by a lack of financial support. When the freemen's camps dissolved, no public-health support replaced them. Poverty and desperation trapped southern blacks into an insidiously indirect new form of slavery-sharecropping. The exploitative, abusive medical care of slave owners was replaced by no medical care at all for most poor blacks, and disease and death ran rampant through black populations. However, nineteenth-century scientific medicine, bolstered by census data, perpetuated the belief that blacks' inherent inferiorities, not exposure, starvation, and neglect catalyzed by wartime privation, caused their public-health disaster. The censuses of the postbellum decades not only perpetuated but also expanded upon the racial libels of the 1840 documents. However, their principal foci were physical illnesses, not mental. By the time of the eighth census, that of 1860, superintendent Joseph C. G. Kennedy was predicting the certain demise of black Americans. By the census of 1890, the black birth rate had fallen in relation to that of whites. Life-insurance companies considered blacks uninsurable and black extinction was actually predicted for the year 2000. These predictions dwelled upon the inherent and immutable physical inferiority that doomed the Negro and offered frequent predictions of his extinction. Census analyses ignored many environmental and external causes of illness among blacks, and blacks were held to be inherently susceptible to venereal diseases and to such "black diseases" as pellagra and imaginary diseases, such as hebetude, drapetomania, and Struma Africana. The theories promulgated by the census takers were essentially updates of the old polygenist view that held such diseases to be immutable elements of blacks' evolutionary lot and maintained that races could not survive outside their climates of origin. For example, the British anthropologist James Hunt claimed in 1863 that blacks could not live north of the fortieth longitude and that death would ensue "at such a rapid rate that they would perish like monkeys and lions in a zoo." Therefore, the census apologists saw preventive and corrective measures such as better housing, health care, and nutrition as futile. This tendency to see environmentally and socially triggered illnesses as inherent defects of blacks is a troublingly persistent trend in American medical research. One of the delicious paradoxes of quantum physics is the Heisenberg uncertainty principle, which warns that the very act of measurement changes the entity being measured, destroying the accuracy of the data. Similarly, the census's methodological clumsiness, accidental and intentional, horribly distorted the image of the African American for decades. Yet the chief distortions of the census were intentional falsehoods, and these constitute yet another powerful example of how scientific fraud and abuse have often been traveling partners when it comes to research into African American health. A successive assortment of mental health and intelligence theories were adopted, "proved," and then discarded through the end of the century. These theories shared two constants: They were all detailed numerical assessments that indicated the lower intelligence of blacks and they all measured a fixed attribute that could never be improved. Phrenology, for example, involved determining personality (including a propensity to violence) by interpreting the shape of the head. Intelligence was gauged by measuring the size of the brain, either directly or by measuring the cranial capacity of a skull. Scientists compared the values for various races and each "found" the lowest intelligence in blacks. Furthermore, each detailed numeric was determined to be static and immutable. The same arguments for black mental inferiority that had kept slavery on life support were now applied to support claims of innate black physical inferiority. Blacks were also seen as a danger to whites and a vector of infectious disease because more blacks were now living in cities. In 1890, 12 percent of the 7.5 million African Americans lived in cities, although only 4 percent had been urban in 1860. Many spent most of their time in white households as domestic servants. Thus, the advent of the twentieth century saw a complete reversal of a basic mantra of scientific racism. Medicine had once justified slavery on the basis that blacks were hardier than whites and so were ideally suited to survive and to work in harsh climates that would have meant death to more delicate whites. Now, it was African Americans who were adjudged too delicate to survive. A familiar theme of medical journals and popular magazine articles alike became "Would blacks survive the new century?" ### Burgeoning Black Diseases Turn-of-the-century research into the once rampant disorder pellagra illustrates the tenacity of the identification of disease with inherent black frailty. Pellagra is marked by a constellation of symptoms, as deep skin eruptions are followed by diarrhea, dementia, and, in 40 percent of cases, death. Many survivors were relegated to mental institutions. It was long considered a black infectious disease caused by poor hygiene and was called the "sharecropper's scourge." Pellagra was actually neither a black disease nor infectious, but a deficiency disease caused by poor blacks' sparse and monotonous diet of white corn and inferior fatty pork, which was severely deficient in niacin, an essential amino acid. But after 1906, economic downturns and changes in processing corn that removed remaining traces of niacin fueled a more widespread nutritional deficiency among white southerners, as well, and pellagra was now recognized as a public-health emergency. In 1914, the United States Marine Hospital Service (USMHS), forerunner of the U.S. Public Health Service, assigned Joseph Goldberger, M.D., to investigate. Goldberger, the industrious son of Jewish immigrants and an 1895 honors graduate of Bellevue Hospital Medical School, doubted that pellagra was a black disease; in addition, he did not believe it was infectious, because he had noted that the patients but not the staff of institutions tended to contract it, and infections tend to be more democratic. He decided that the ultimate proof of the disease's noninfectious, nonracial nature would lie in inducing pellagra in healthy white people. He did this by limiting a group of white jail inmates to a strict diet, one similar to that on which poor blacks had subsisted for centuries. Because they developed the disease, Goldberger was able to demonstrate that pellagra was not infectious, but a deficiency disease that affected blacks and whites alike. Goldberger had divorced pellagra from race, but unfortunately, this revelation was resented and ignored. The nutritional, nonracial nature of pellagra became forbidden knowledge, just as