Tag: Insane Asylums

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.  ↩

Patient #1

On May 20, 1817, five days after the Friends’ Asylum opened, a woman in her late 40s, who had been suffering from melancholy for 11 years was admitted to the asylum as Patient #1.[1] Neither the superintendent nor the attending physician noted who brought her. The superintendent noted, briefly:

[Patient #1] was brought this Afternoon as a Patient by the Certificate accompanying it appears that She is about 48 Years of Age and has been 11 Years Insane—She appears to be of the Melancholy cast.

The attending physician offered more detail:

[Patient #1] admitted into the Asylum “for the relief of persons deprived of the use of their reason.” 5th Mo. 20th 1817. She is a native of Wilmington Del. aged 49 years. Her disease is of eleven years continuance. She has been in the Pennsylvania Hospital some years (number not known) and was discharged from there incurable. The last three years she was confined in the Poor House near Wilmington. No cause has been assigned for her derangement. She never has shown any disposition to injure herself or any other person except her Father. Doct. Monroe says in his certificate that no medical means have been used for her recovery.

The years leading up to Patient #1’s arrival were difficult. She had been confined to Pennsylvania Hospital in Philadelphia. When she had been discharged, she returned to a poor house near Wilmington, her hometown. Whoever—probably her father— brought her to the asylum must have been intent on finding her better care, for they were willing to travel nearly 40 miles and pay $3.50 per week for her to stay at the asylum. Yet they didn’t offer the physician much information about her condition or its cause.

The physician’s Medical Register records symptoms and treatments for patients in the asylum. This is the first page of Patient #1’s treatment.

Three days after she was admitted, the physician prescribed medicine “Sulp. soda,” probably the cathartic sulphate of soda, which produced the expected results. Although she engaged the physician in rational conversation when she had to, he found her reluctance to converse or exercise as evidence that she continued to suffer from her melancholy. Two days later, he reported that “She appear[ed] more cheerful … [and] express[ed] great desire to go home to her father, and much fear that some person will kill her.” Two weeks later the physician prescribed another cathartic medicine, this time “Sulp magnes.,” probably sulphate of magnesia (or Epsom salt), along with a warm bath. The superintendent noted in his daybook that the warm bath and “salts” quickly became a common treatment. Patient #1 continued to express a desire to go home to her father. Only threats of restraint quieted her. Some days she engaged in productive labor, other days she hoped to die. All the while the superintendent and the physician administered different treatments, medicines, and threats of constraint to bring her behavior within the bounds of acceptable.

Patient #1 spent the next 39 months in the asylum, oscillating between these poles of cheerful and productive, at one end, and profoundly melancholic, at the other. Finally, on August 1, 1820 she was discharged “much improved.” The superintendent remarked:

This morning [Patient #1] left us. Her father mentioned his gratitude for our kindness and his high opinion of the value of the Institution. [She] parted with us on friendly terms and engaged to come back without difficulty if her father and Brother required it.

Through the superintendent’s records and the physician’s register we can piece together bits of her life during the three years she was in the asylum. Her experience in the asylum, the types of medicines and other medical treatments as well as the division of responsibilities for administering those treatments between the superintendent who had no medical training and the physician, the role of the superintendent’s wife, the importance of employment, her reported behavior, etc., give us a glimpse of what it meant to be deemed insane in early 19th-century America.

  1. The documents differ, the Daybook says “about 48;” the Medical Register indicates she was 49. Unfortunately, the admissions letters have been lost, so we can’t know more about her  ↩

Admissions Documents for Patient #144

Admissions documents for Patient #144, admitted to the Friends’ Asylum on June 1, 1824.

On June 1, 1824, Patient #144 was admitted to the Friends’ Asylum for the Relief of Persons Deprived of the Use of Their Reason. She was 53, married, and had been suffering for a number of years. Her admission documents—the physician’s certificate that guaranteed she was insane and her application for admission—survive along with thousands of other patients’ documents.

According to the physician’s report, she had been suffering for about two years, though she had also suffered a similar affliction many years earlier. She was under no regular medical care. Although she had not attempted to harm herself, her family was “uneasy on the subject in consequence of some expressions from her.” His report was dated April 5, 1824—almost two full months before she was admitted. The same physician noted on May 31 that his initial assessment was still accurate. We don’t know why her husband waited nearly two months before admitting her to the asylum. Once he made up his mind, however, he moved quickly. On June 1 he signed the application for admission, agreeing to pay $3.00/week for her board and to pay for any damage she caused to the “glass, bedding or furniture” and “in the event of her death whilst there [in the asylum] to pay the expense of her burial.” Six months later, following a request from her husband, she was discharged “much improved.”[1] Her story and thousands others like it wait their historians in the Friends’ Asylum archive in Special Collections at Haverford College.

  1. The Patient Register suggests a different story. It indicates that she was admitted on May 9, 1824 and was discharged nearly a year later completely “restored.” What we can’t tell from these documents is why the discrepancy between them.  ↩

Friends’ Asylum Demographics, 1817-1837

Over the first two decades the Friends’ Asylum admitted 540 patients. Fortunately, very good records survive—in the form of an Admissions Book, other admissions and discharge documents, Superintendent’s Daybook, and Medical Casebooks—that allow us to reconstruct what types of patients were at the Asylum, what forms of insanity staff at the Asylum recognized, where patients came from, how much they paid to stay there, and what sorts of treatment they received. Unfortunately, all that information is not (yet) in a form that is very handy. But even this overview of patient demographics drawn from the Admissions Book raises interesting questions.

Pages from the “Admission Book, Friends’ Asylum for the Insane” showing entries for patients nos. 369-414, admitted from October 23, 1833 to January 15, 1834.
Pages from the “Admission Book, Friends’ Asylum for the Insane” showing entries for patients nos. 369-414, admitted from October 23, 1833 to January 15, 1834.
Summary of Patients Admitted to Friends’ Asylum, 1817–1837
Total Single Married Widowed
Men 287 (53%) 154 (54%) 115 (40%) 15 (5%)
Women 253 (47%) 131 (52%) 82 (32%) 35 (14%)
Total 540 (100%) 285 (53%) 197 (37%) 50 (9%)

In the first twenty years, the Asylum readmitted 74 patients more than once. One male patient was readmitted 10 times, another two were readmitted 6 times, approximately 60 were readmitted at least twice. Extreme readmission rates seem to have declined slightly in the 1830s, i.e., the numbers of patients readmitted more than twice.[1]

Almost half the patients were discharged as “Restored,” but again that number disguises the fact that of the 24 patients admitted three times or more, they were discharged 27 times as “Restored.” In the case of the male patient admitted 10 times, he was discharged 8 times “Restored.”

Patients Condition on Discharge from the Asylum
Total Admissions Restored Much Improved Improved Stationary Died
Men 286 130 (45%) 34 (12%) 30 (10%) 39 (14%) 53 (19%)
Women 253 104 (41%) 33 (13%) 34 (13%) 34 (13%) 48 (19%)
Total 539 235 (44%) 67 (12%) 64 (12%) 73 (14%) 101 (19%)

Before being admitted to the Asylum patients had suffered from their affliction anywhere from 2 days to 48 years. The average length of time admitted patients had been insane was about 3 years and 4 months. Patients stayed in the Asylum as few at a couple days (many of these very short stays ended in the patient’s death) to nearly 47 years (many of these very long stays also ended in death, though probably for different reasons). 70 patients (42 males; 28 females) admitted during these first two decades spent less than a month in the Asylum. 30 patients (18 males; 12 females)admitted during the same period spent more than 10 years in the Asylum.

While the vast majority of patients were local—198 from Philadelphia, 189 from Pennsylvania, and 88 from New Jersey—as the Asylum’s reputation grew in the 1830s patients started turning up from more distant places, e.g., Virginia, North and South Carolinas, Ohio, and Indiana.

The early patient entries are incomplete, many of the columns in the Register were left blank.[2] In the mid–1830s staff began recording both the forms and supposed causes of a patient’s insanity. “Mania” and “Dementia” are the two most commonly recorded forms of insanity. While both are so common as to seem generic labels rather than specific diagnoses, staff did distinguish between different causes of these generic afflictions.

Common forms of insanity & their causes
Form Supposed causes
mania abuse of opium, amenorrhea, blow to the head, bodily injury, congestion of the brain, defective education, disappointed affection, domestic trouble, intemperance, masturbation, paralysis, pecuniary difficulty, puerperal, religious excitement
dementia domestic trouble, epilepsy, fever, pecuniary difficulty
monomania religious excitement

That the same causes give rise to different forms of insanity suggests staff were observing different symptoms. The range and types of supposed causes raise questions. How is “defective education” (suffered by a 17yo male; restored after a month) and “amenorrhea” (suffered by a 20yo female; restored after 3 months) related? At first glance, the first seems entirely social, while the second seems more like a biological cause.

This information suggests many different topics to pursue and, as I mentioned previously, this summary hides fascinating individual stories (yes, Patient #33’s story is still pending). As I work through the other sources and analyze the information I compile, I will continue to post my conclusions. Stay tuned.

  1. The outliers, the patient readmitted 10, raises all sorts of questions. The number of patients readmitted twice seems to have been fairly constant, but is right now an approximate value because the Patient Registers are not complete.  ↩

  2. Some of this information can be gleaned from other sources. As I work through these other sources, I will fill in what details I can.  ↩

Patients at the Friends’ Asylum, 1817-1833

On May 15, 1817 the Friends’ Asylum for the Relief of Persons Deprived of the Use of their Reason opened its doors to patients. Over the previous three and a half years the board of local, influential Philadelphia Quakers had raised money to purchase land, had overseen the design and fabrication of every aspect of the project, and had contracted with local craftsmen to build the Asylum.

View of the Asylum from annual report for 1820, State of the Asylum for the Relief of Persons Deprived of the Use of Their Reason (1820)
View of the Asylum from annual report for 1820, State of the Asylum for the Relief of Persons Deprived of the Use of Their Reason (1820)

In early 1817 the first superintendent, Isaac Bonsall, and his family moved into the Asylum buildings and completed the final preparations for its opening. When the Asylum opened its doors for patients, Bonsall with some disappointment noted in his daybook that no patients turned up:

Isaac Bonsall noted in his daybook that the “House is considered open“ yet no patients came. See “Superintendent’s Daybook, vol 1”
Isaac Bonsall noted in his daybook that the “House is considered open“ yet no patients came. See “Superintendent’s Daybook, vol 1

Fifth 15
This day the House is considered as open for reception of Persons deprived of the use of their reason but none came. 17 other persons were here—

Bonsall had little reason for concern. Five days later the first patient arrived, a 48 year-old woman who had “been 11 Years insane—She appears to be of the Melancholy cast.” People continued to bring patients to the Asylum, entrusting family members to the care of Bonsall and the Asylum’s staff. Over the first 15 years the Asylum would admit more 350 patients. Here is an initial overview of those patients, compiled largely from the Patient Register.

Over the first 15 years more men than women were admitted to Friends’ Asylum. Most (just over half) of the people admitted were single, a third were married, and about ten percent were widowed (the numbers don’t add up to the total (363) because the Patient Register doesn’t record marital status for every patient).

General Summary of Patients
(admitted through 1833)
Total Number Total Percentage Single Married Widowed
Men 194 53% 106 79 7
Women 169 47% 84 52 28
Total 363 (100%) 190 131 35

These rough numbers obscure the 51 patients who were admitted more than once, one as many as 10 times. Removing these, 280 unique patients were admitted to the Asylum.

Of the total number of patients admitted, almost half were considered “Restored” when they left the asylum.

Patient Condition on Leaving the Asylum
Total Admissions Restored Much Improved Improved Stationary Died
Men 194 82 (42%) 30 (15%) 18 (9%) 26 (13%) 38 (20%)
Women 169 70 (41%) 26 (15%) 21 (12%) 16 (9%) 36 (21%)
Total 363 152 (42%) 56 (15%) 39 (11%) 42 (12%) 74 (20%)

What exactly “Restored” meant, however, is unclear. The patient who was admitted 10 times was released the first 8 times “Restored,” the ninth “Much improved.” When he was admitted the last time, he spent more than two years there before finally dying in the Asylum “of Inflammation of the Stomach” (in total he spent three and a half years in the Asylum).

Patients stayed in the Asylum anywhere from 2 days to more than 40 years (14724 days). The average length of stay is 27 months. Patients who were there only a couple days as well as those who were there for years tended to die in the Asylum (probably from different causes—the former probably suffered from some acute illness, the latter from some chronic condition or simply old age). The median length of stay was 155 days.

Although the founders of the Asylum might have had a preference for “recent, curable patients,”[1] in fact it seems that many of the patients admitted over the first 15 or so years had been insane for more than two years. One patient was listed as having been insane for 44 years (another twenty or so had been insane for more than 20 years). At the other extreme, about 30 patients were listed as having been insane for fewer than 10 days.

Average duration of insanity before admission. For some reason 1817 and 1830 have particularly long average durations.
Average duration of insanity before admission. For some reason 1817 and 1830 have particularly long average durations.

Patients ranged in age from 16 years to 93 years. The average age for both men and women was 40.

Most patients were local. 122 were from Philadelphia and another 136 from Pennsylvania. 68 came from New Jersey. After that numbers dropped off quickly: e.g., 11 from Delaware; 7 from New York. A few came from as far away as Virginia and Rhode Island. In one case, a patient had previously been a patient in the York Retreat in England.[2]

This aggregate survey of the patients at the Friends’ Asylum, drawn largely from the Patient Register, raises all sorts of interesting questions, e.g., Why were some patients readmitted so many times? What did they mean by “Restored” or “Much Improved?” What symptoms were considered evidence of insanity, especially in the cases where a patient had been insane for 2 or 3 or 4 days? Because it effaces the individual patients, this survey of the Patient Register also raises questions about the stories of those individual patients, such as the young woman, patient #33, whose family brought her to the Asylum late one Saturday. She had been insane for six days….

Her story will be the subject of a future post.

  1. On the Asylum’s possible preference for “recent, curable patients,” see the excellent Quakers & Mental Health, especially the “Foundations of Friends’ Asylum” page.  ↩

  2. Friends’ Asylum was modeled on the York Retreat. See, “The York Retreat” and “Foundations of Friends’ Asylum.”  ↩