Last Days of Patient 33

In the afternoon of September 26, 1818, a family from Gloucester County, New Jersey arrived at Friends’ Asylum in Frankford, outside Philadelphia. They had brought their relative, a 26-year-old woman, fifteen miles from Woodbury to the asylum because she was suffering “in a violent state of insanity.” They hoped the asylum would be able to restore her health.

Staff recorded Patient 33 in the Asylum Register on September 26, 1818. Ten days later, according to the register, she died. The Asylum Register offers an accounting of patients admitted to the asylum, including basic information such as name, date, age, discharge date. Other copies of the register include more information, including sex. For reasons we can’t know, many of the most revealing columns remain empty.

Patient 33’s insanity had come on suddenly and without warning. According to the records she had been insane for only six days when they arrived at the asylum.[1] Before she could be admitted, however, the proper forms had to be completed. First, there was certificate of insanity, that had to be filled out by a physician. The superintendent called the resident physician who examined her and signed the necessary certificate. Second, the superintendent required the family to sign a contract agreeing to pay for room and board and any damages, and place a deposit. In this case, the superintendent required a deposit for 13 weeks, which could have cost the family as much $39.[2] The next morning the family returned home, leaving Patient 33 in the care of the asylum. Ten days later, they returned to the asylum to attend her funeral.

The Superintendent’s Daybook

The first superintendent, Isaac Bonsall, had no medical training. He had been hired to manage the staff and patients in the asylum. His concerns focused on maintaining order, ensuring that patients and staff were attending to their duties, and keeping the peace. Far from just a way to control patients, this approach was central to the asylum’s treatment of the insane, the “moral treatment” the asylum espoused. For Bonsall, then, Patient 33 was a challenge to be managed. Proper management and regulation of daily behavior would, in his view, restore her sanity. This approach shaped his understanding of Patient 33 and informed his responses to her condition.

In her first days at the asylum, Patient 33 behaved so violently that the staff felt compelled to restrain her. But she escaped her straps, either by slipping out of them or simply breaking them. Unattended, she risked harming not only herself but also the other patients and disrupting the calm, salubrious environment. Consequently, she was often confined to her room or to her bed except for meals. On September 28 Bonsall noted:

our new Patient very similar to Wm. B. [a particularly disruptive male patient] for getting out of her Straps & breaking them, eat [sic] her Meals tolerably well but had to be kept confined.

The superintendent, Isaac Bonsall, recorded in his day book the basic economy of the asylum, which patients were disruptive and which behaved, which ones worked and how much, etc. On September 28, 1818, he noted that the Patient 33, the “our new Patient” was disruptive but generally ate well.

As the head of the asylum symbolic patriarch of the family there, Bonsall was particularly concerned when patients damaged the building, especially the windows. His daybook is filled with reports of how many window panes disruptive patients broke. Soon he and his successor started hand writing on the admissions contracts a note that families were responsible for the cost of replacing broken window panes. Unsurprisingly, then, he noticed when Patient 33 seemed too interested in the window, though what exactly concerned him is unclear. He remarked:

…found it necessary to Shut the window of our new Patients [sic] Room She looked with so much earnestness out that we feared it would injure her.

Within a few days Patient 33 seemed to have recovered her sanity but now suffered from some physical ailment that required attention, Patient 33’s

…mind mostly rational today but great bodily debility — Doctor Lukens [the resident physician] being of the opinion it would be best to send for Doctor James to see her Samuel Raleigh [a worker at the asylum] went for him and he accordingly came and found her quite ill — much attention was given her.

Bonsall noted that Patient 33 seemed to have recovered her sanity but had grown so weak that they sent for a special physician to see her.

Over the next couple days Bonsall records all the attention he, his wife, and other members of the asylum paid to Patient 33—they took turns sitting with her all night and the next day; the women stayed home from meeting so they could take care of her. Although her physical health declined, she was increasingly lucid. Bonsall’s wife asked her one evening “if she did not feel her mind more comfortable than she had done her reply was ‘yes much more so’.” The following morning Bonsall noted that Patient 33 “appeared to possess a quiet mind” but was weaker than before. Later that morning Patient 33 passed away.

Bonsall recorded the various preparations for her funeral—sending the family a letter, assembling a coffin, planning the burial, arranging for other patients to attend the funeral. Even in her death, Patient 33 required proper management.

The Physician’s Casebook

In contrast to Bonsall’s managerial account, Dr. Lukens’s version of Patient 33 tends toward impersonal and clinical. Patient 33 is a series of symptoms that require different prescriptions and treatments. Lukens carefully recorded the initial conditions, daily symptoms—e.g., any discharge, her appetite and pulse, physical strength and vigor—and his treatments and their effects.

The first few days Lukens prescribed various purgatives, e.g., Calomel and Jalap, to expel harmful fluids and calm the violence:

28 — Bowels costive Rx. Calomel gr. x Jalap gr. xij it did not operate in the evening—but she could not be prevailed to take any thing now—apetite [sic] very poor—
29 — Rx Calomel gr. x Jalap 2j—it operated well—she is some better.
30 — Bowels lax—apetite [sic] very poor—a slight dawning of reason appears

In Dr. Lukens’s casebook Patient 33 is reduced to a series of symptoms and treatments. His spare prose, however, suggests the various ways he understood the relationship between somatic symptoms and mental conditions.

Perhaps hoping to apply a more targeted treatment, Lukens first applied cups to Patient 33’s temples to draw out harmful fluids but soon stopped. Instead, he chose to apply a blister to her head and neck. He left the blister on for two days, dressing it on the second. Later he applied blisters to her ankles, though he seemed to think they weren’t especially effective because they produced inflammation but very little discharge. The next day he applied a blister to her breast. Clearly Lukens had a complicated understanding of how the blister functioned when applied to different parts of the body. Although blisters had been used for years treat insanity, at this time their efficacy was being questioned, e.g., J. G. Spurzheim Observations on the deranged manifestations of the mind, or, Insanity (London, 1817). Nevertheless, there was a strong local tradition of using blisters, and Dr. Lukens remained committed to them.

As Patient 33 grew weaker, Lukens increasingly prescribed nourishment along with his other treatments. And like Bonsall, he noted when she became more rational. As she became increasingly rational, he noted her manic violence caused by an insanity was slowly replaced by an uncontrollable restlessness caused by some physical debility.

In the end Patient 33 died. On October 7, 1818 her family returned to witness her burial. Bonsall and Lukens understood their efforts to have helped restore her sanity, even if they couldn’t restore her physical health. There is probably nothing anybody could have done to save her. Rather than condemn Bonsall and Lukens for what we consider barbaric treatment, perhaps we should see them in a more generous light. We should see two people struggling to save and comfort a young woman. Bonsall deployed all the care-giving resources of asylum, with people attending to Patient 33’s needs. Lukens exercised his medical expertise to treat first a mental illness and then a somatic illness.

  1. When modern physicians hear that she had been insane for six days, they have a number of plausible diagnoses. Those diagnoses do not interest me. While we can safely conclude that she was not “insane,” and equally safely we can conclude that she suffered from some acute medical illness, we cannot determine her illness.  ↩

  2. It is unclear how the superintendent determined either weekly room and board charges or how much of a deposit to require. The records for Patient 33 don’t survive, but typically the weekly rate was around $2.50-$3.00.  ↩

Astrolabes and S•Town

On Thursday, February 16, at 5:36 PM I was standing in a faculty meeting when my phone vibrated. I fished it out of my pocket and looked at the screen. I had just received a voicemail and a text from the same number, a number I didn’t recognize. The text asked, simply: “Is this the phone of Darin Hayton?”

I stepped outside and listened to the voicemail. The person identified himself as a researcher for This American Life, asked if he had reached Darin Hayton, and wanted to ask about astrolabes. His message sounded urgent. I was intrigued. Why would anybody feel a pressing need to learn about astrolabes, at 5:30 on a Thursday evening? And why would that person not just turn to Wikipedia or some other on-line resource?[1] So I decided to respond.

As I was still, at least physically, in a meeting, I texted rather than phoned and offered to call later that evening or the next morning. He asked that I call him as soon as I was free.

Texting with the guy who turned out to be a researcher for This American Life.
When I phoned he immediately started asking about astrolabes. He had clearly done some research on them but wanted to confirm what he had learned—e.g., Hipparchus had developed the mathematics but not an instrument; early instruments dated from the late 9th century; you could use it to tell time. He was particularly interested in developments introduced by 10th-century Islamic scholars. He asked about different innovations we might attribute to them and wanted to know how they improved the astrolabe. Most of the innovations he mentioned cannot easily or definitively be traced back to early Islamic instrument makers. We chatted for 10–15 minutes. As our conversation wound down, I tried to find out why he was so interested in astrolabes. He offered few details, saying only that he was doing research for an up-coming This American Life show on a man from Alabama who had studied astrolabes and had even built his own. He wouldn’t tell me the man’s name, but did mention that he had recently died.[2]

After we hung up I tweeted about my brush with fame. I am clearly a nerd since I think having This American Life phone me constitutes fame.

I tweeted about my brush with fame—clearly I’m a nerd because I think talking to This American Life constitutes fame.
Fifteen minutes or so later as I stood in my bathroom brushing my teeth, my phone rang again. Same guy confirming a couple points and asking if his formulation was correct. Something to the effect: the Greek astronomer Hipparchus developed the mathematics behind the astrolabe and 10th-century Islamic scholars refined it to time their daily prayers. Yes, I said, that’s fine.

Because I am always late to the party, I didn’t hear about S•Town until late April, a month or so after it was released and became an instant hit.[3] Finally, when a friend suggested I listen to it because they “talk about astrolabes,” I downloaded it and listened while I repaired my washing machine. Sure enough, about 15 minutes in John B. McLemore (the main character) mentions astrolabes:

Because kids are talking about getting girls, or deer hunting, or football. Whereas I was interested in the astrolabe, sundials, projective geometry, new age music, climate change, and how to solve Rubik’s cube.

But he doesn’t say much more. Then, 30 minutes later, the astrolabe suddenly returns in the context of telling time.[4] Brian Reed, the host, reflects on various methods for tracking time, then describes the astrolabe:

BRIAN REED: The astrolabe looks kind of like a clock crossed with a compass. It’s a flat dial with a map of the night sky laid over it, and a pointer, or I guess a sight, attached on top of that. You pick a star in the sky, and aim the sight at it, twist the sky map until it aligns with the sight in a certain way. And then the dial shows you your direction, as well as the month, day, and time.

It’s a beautiful, complex device. And as a kid, John longed to figure it out, to put himself inside the brains of the people who puzzled through the earliest versions—the Greek astronomer Hipparchus, who devised the mathematics behind it, or the 10th century Islamic scholars, who refined the invention to help them time their daily prayers.

John wanted to go through what they had to go through to create an astrolabe. Which is why he made his own, designed specifically for the coordinates of this house. It hangs on the wall of his mother’s bedroom. That’s what he’s showing me, his astrolabe, when Skyler Goodson happens to walk in the front door.

When I heard this, I immediately recalled the man who had phoned six weeks earlier asking about astrolabes. There, in Brian Reed’s brief description, was the final version of what the man on the phone had crafted. It turns out that the man on the phone had been doing research for S•Town.

Thanks to S•Town and John B. McLemore, astrolabes are enjoying their 15 minutes of fame. Reddit pages on S•Town have astrolabe discussions. Websites promise to show you “How to Build an Astrolabe Like John B. McLemore From ‘S- Town’.” S•Town fans are turning up in museums asking to see astrolabes.

Visitors to Harvard’s museum are S•Town fans and want to see astrolabes.
Hey This American Life, perhaps you would like to do a whole show on astrolabes. While not as eccentric as John B. McLemore, I have built my own astrolabe, I know its history better than most, and I’m available. Your researcher/fact checker has my number. Have him give me a call.

  1. In talking to him, it seems he started with on-line resources, including my An Introduction to the Astrolabe.  ↩
  2. He probably used a euphemism, but somehow I think John B. McLemore would have preferred “died,” and I prefer it.  ↩
  3. And because I can’t just be late to the party, I find out late that I am late to the party, I learned about S•Town while listening to an old podcast of Wait Wait…Don’t Tell Me featuring Sarah Koenig[3a] that I had downloaded and then didn’t listen to for nearly a month. And even then I was in no hurry to listen to S•Town.  ↩

    3a. I should probably point out that the name Sarah Koenig meant nothing to me because I am one of perhaps only a handful of people, including John B. McLemore, who has never listened to Serial and only vaguely knows what it is.  ↩

  4. To be exact, Brian Reed’s description of the astrolabe comes at 44:05 into chapter 1. Astrolabes are mentioned in two other places: the first time is about 16 minutes into chapter 1; the last time is 2:35 into chapter 7. I don’t think I would say, as my friend did, that they “talk about astrolabes” in S•Town, but any popular culture reference is better than none.  ↩

Facts Are Never Enough

Scientists hope to dispel antiscience prejudices by better science education, and pundits hope to sway public opinion on issues like Obamacare or global warming by presenting the public with accurate facts and expert reports. Such hopes are grounded in a misunderstanding of how humans actually think. Most of our views are shaped by communal groupthink rather than individual rationality, and we cling to these views because of group loyalty. Bombarding people with facts and exposing their individual ignorance is likely to backfire. Most people don’t like too many facts, and they certainly don’t like to feel stupid.

Y. Harari “People Have Limited Knowledge” in NY Times—A review of S. Sloman & P. Fernbach’s The Knowledge Illusion.