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. 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.
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.
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 ↩
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.” Her story and thousands others like it wait their historians in the Friends’ Asylum archive in Special Collections at Haverford College.
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. ↩
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.
Summary of Patients Admitted to Friends’ Asylum, 1817–1837
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.
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
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. 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
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
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.
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. ↩
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. ↩
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.
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:
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)
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
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,” 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.
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.
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….
A paradox lurks at the center of any archive. One the one hand, archives strive to keep the past alive, or at least on life support long enough for somebody to revive a sliver of that past, which sliver has lain comatose on a shelf locked away in a vault. Yet, on the other hand, the past is dead. Any inquiry into history is “first and foremost an encounter with death.” Sometimes that encounter with death is inescapable.
Shelved in Haverford’s Quaker and Special Collections is an archive from the Friends’ Asylum. Volumes of records, daily accounts, physicians’ reports, admissions documents all created for the asylum and its administrators, not for modern historians. The disjunct between the asylum’s needs and intentions and ours is most pronounced, or at least most poignant, in cases of a patient’s death.
You would be forgiven for not noticing anything special about the patient at the bottom of the first page of the Asylum Register of Admissions and Discharges. The entry doesn’t attract your attention. The patient was just one of thousands admitted to the Friends’ Asylum in the nineteenth century, cataloged on the Asylum Register’s hundreds of columned pages that transform patients into manageable, comparable, analyzable data.
These tables offer a glimpse into the ways Friends’ Asylum was trying to understand and treat insanity. After the basic identifying information, name, date, patient number, we see a handful of more interesting categories—some seem familiar, others seem strange, and some categories are striking by their absence:
Age on Admission
Age at First Attack
No. of Admission
Place of Residence
Place of Birth
Date of Discharge
The early pages of the Asylum Register lack many details that are noted for later patients. In these thousands of records you lose sight of the individual patient, each on a single row, and see instead columns of numbers. The aggregate becomes the meaningful scale. Even the “Result” column with its list of “Restored,” “M.I.” [Much Improved], “Imp” [Improved], “Status” [Status quo], and “D” [Died] is less the fate of any individual and more institutional bookkeeping that has reduced messy experience to digestible categories, the bookkeeping required to run any institution and to assess its effectiveness.
Any given patient disappears into this mass of information. Only with some effort do you notice things about the patient at the bottom of page one. You infer from her name, Jane, that she was a woman. She was admitted on September 26, 1818. Other columns reveal a bit more about her: she was the 33rd patient admitted to the asylum, was 26 years old, single, and from New Jersey. Like five other patients listed on this page, she died before she recovered. If you look a little more closely, two things seem to noteworthy: the duration of her attack had been only 6 days. If you do the math, you realize that she was the first patient to die in the asylum, just 10 days after being admitted.
The Superintendent’s Version
To learn more about Jane you have to turn to the Superintendent’s Daybook. Whereas the Asylum Register transforms patients into analyzable information, the daybook embeds those same patients into the quotidian management of the asylum. The superintendent was charged with recording significant events in the daily running of the institution so that his successors would have a record of how he had managed the asylum. But what counted as significant was open to his interpretation and relative to his immediate concerns, and without any knowledge of what would be considered significant by future readers of the daybook. You read about plowing the fields or hauling in crops or trips to the city alongside comments about patient behavior and his conversations with physicians or visitors. In 1818 when Jane was admitted, the superintendent was Isaac Bonsall.
September 26, 1818, was much like any other day at the asylum. Bonsall noted that one employee had left to see his father-in-law in New Jersey. Another employee plowed his own fields. Pumpkins were sorted “and other things attended to.” Then,
in the afternoon Jane of Woodbury Monthly Meeting Gloucester County New Jersey aged 26 years Insane 6 Days was brought here and appeared in a violent state of Insanity—they produced no Documents—a physician was sent for who after examining signed the necessary certificate—as it was evening and dark it was concluded we must lodge & entertain the friends who brought her five Persons and 4 Horses—I obtained a Check for 13 Weeks board and a Bond signed by Edward and Edmond for future pay &c.—the Order for admission is to be obtained and furnished.
There was little in Jane’s case to worry Bonsall, who dutifully recorded her admission, had the proper forms completed, and collected money for her stay. Over the next few days Bonsall noted Jane’s condition along with other happenings at the asylum. At first Bonsall saw some improvement. On the 27th, he noted: “found considerable difficulty in getting the new patient to each in the morning but at dinner She did much better.” Jane had been so disruptive (violent ?) that Bonsall felt she should be restrained. The following day he noted:
our new Patient very similar to Wm [another patient] for getting out of her Straps & breaking them eat [sic] her Meals tolerably well but had to be kept confined—Prince S. brought Doctor Williamson a respectable coloured [sic] Man from the Island of St. Domingo to see the Asylum
Bonsall folded Jane’s behavior into the daily management of the institution. It was no more or less remarkable than the foreign visitor who came to see the asylum. Over the next couple days Bonsall recorded Jane’s decline within the framework of overseeing the asylum, the comings and goings of managers, physicians, employees, his trip to the city, the sowing of wheat and rye, and the hauling of manure.
Reading Bonsall’s daybook you begin to see Jane as one part of a larger asylum economy. As superintendent Bonsall had manage the running of the institution, entertain visitors, attend to financial issues, oversee labor, and monitor all the patients. His attention and time were finite. He had to allocate both as he judged necessary and within his domains of expertise. He was a manager, not physician.
On October 1st Bonsall was worried because an employee had to go into the city just when Bonsall needed him to help “sow several acres of our grain.” While most of the patients were well behaved, Jane was not doing well, so her “head was Shaved and a Blister applied.” The next day Bonsall was occupied with sowing, clearing fields, collecting manure, and hauling crops. He also had to spend time with the visiting managers. Jane did not merit a mention.
By October 4th, however, Bonsall was becoming increasingly concerned about Jane. Although he reported “her mind has become clear” and was “mostly rational,” he worried because she suffered “great bodily debility.” When the resident physician suggested that Bonsall send for a second, he did so at once. Jane was “quite ill—much attention was given to her.”
Whatever else happened at the asylum on October 5th and 6th, Jane was the main focus of Bonsall’s attention and all he recorded in his daybook.
10th Mo: 5 second —
My Wife remained with Jane until near 2 O Clock A.M. when Ruth took her place and continued with Jane until day light after which different members of the family administered to her wants the Doctor being particularly attentive—in the course of the day She [Jane] told my Wife & Ruth She had two Mothers attending upon her and She told Ruth that She did more for her than many sisters would do for a sister—when I came towards her Bedside She said “this is a good friend I always loved good friends” She took hold of my hand and held it a considerable time toward evening my Wife enquired of her if She did not feel her mind more comfortable than She had done her reply was “Yes much more so” notwithstanding every means in our power to help her was rendered She continued to sink—my Wife and Ruth concluded to spend the ensuing Night as they had the preceding one in carefully watching her and supplying her wants—
The next morning Jane’s physical condition had worsened, though Bonsall remarked that her mental state seemed to remain improved, she “appeared to possess a quiet mind.” Then, “about half past 11 O Clock A.M. She very quietly departed this life.” Bonsall immediately sent a letter to her friends so that they could come to see her before the funeral the next day. Her brother and aunt came in time to pay their respects before the funeral, which took place in the afternoon of the 7th. “Jane’s brother and aunt appeared quite satisfied with our Conduct &c. relative to the deceased both before and after death.” With that final comment, Bonsall turned his attention back to the other aspects of running the asylum.
You finish reading Bonsall‘s daybook and now know more about Jane, at least more about her arrival, decline, and finally death from Bonsall’s perspective. You see him struggling to manage a growing institution filled with patients each of whom required particular attention. He had to oversee employees and ensure that the institution’s farm ran smoothly. He also had to manage the visiting managers. Bonsall’s understanding of Jane’s case was informed by the demands of his position. Reading his daybooks you sense his profound sadness at having lost a patient, but you also sense his confidence at having done what he could as well as his feeling of accomplishment at having restored her sanity before she died.
The Physician’s Version
Finally, you turn your attention to the physician’s medical register, looking for more information about Jane. Just as the superintendent was charged with keeping a daybook, during the early years the attending physician was charged with keeping a medical register in which he recorded his observations and treatments for each patient. During Jane’s time at the asylum, Dr. Lukens was the attending physician. You leaf through the volume looking for Jane’s entry and find it on pages 204 and 205. Jane’s final 10 days rendered as a series of medical observations, physical symptoms, and prescriptions.
9 Mo 26 — …[Jane] Has been extremely violent was very much bruised &c. by the violence used to restrain her—she had made attempts to injure herself—she is now very violent and has to be confined to the bed—Pulse frequent and debilitated.
Lukens recast Jane once again. This time she became the object of his medical expertise and, therefore, a concatenation of symptoms and treatments. The next day she remained extremely violent. So Lukens prescribed medicines to calm her, but noted that they did not produce the desired result. He looked for related symptoms and found them:
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
When his prescriptions failed to work, he augmented them with other treatments, particularly ones intended to draw out harmful fluids:
10 Mo 1 — She sat up some has three cups on her temples—but was faint and weak—and the operation was ceased. Her head shaved and a blistering plaster applied over it—
Lukens carefully recorded Jane’s reactions to his treatment as well as her general condition, and adjusted his treatment as her condition changed. When she continued to have no appetite, he gave up the Calomel and prescribed camphor and a mixture of “wine-whey as much as she will take.” He tracked her pulse, which remained weak, and monitored her bowel movements, which remained infrequent. He noted that she was throwing up with some regularity and prescribed “Carbon: amonia” along with the wine-whey and a beef tea. He also applied a blister to each ankle. In the evening he noted that her pulse was stronger and that she appeared better.
The next morning he worried that the blisters had “produced a good deal of inflammation but not much discharge.” He changed her prescription again, adding “vol-alkali” along with the wine-whey mixture. He decided to apply another blister this time to her breast. Nothing seemed to help much.
6 — Much restlessness through the night, though she seemed to sleep some…towards morning she swallowed with very great difficulty, after seven oclock she could not swallow anything—and died about eleven.
For the physician, Jane was a series of medical puzzles to be solved. His clues were her symptoms. His guesses were his prescriptions and treatments. The physician’s perspective is the hardest to understand. You try to see Jane as Dr. Lukens did, but your modern ideas about insanity and health stand in the way. His treatments seem barbaric, horrific, even harmful. You have to resist the urge to blame him, the urge to shout: “You killed her.”
But your task isn’t to judge Dr. Lukens. Instead, when you entered the archive, you agreed to try to understand the past, to understand Dr. Lukens’ efforts for what they were, the best he could offer. There is a more generous and humane approach. Try to appreciate his constant monitoring, evaluating, and revising his treatment in light of Jane’s developing symptoms and their refusal to respond to treatments.
Archives are nested experiences. Sort of Matryoshka dolls, each nested account giving you another version of the story, each resembling the others but not identical. Unlike the Matryoshka doll, however, the center of the archive rarely contains some solid core, a single account that can be judged right or wrong. Instead, you end up with multiple versions from which you piece together a history, which unlike the past is not dead but rather vibrant and meaningful. And even the shortest histories are often humbling. Lukens’ frenetic search for medical solutions to help Jane, Bonsall’s sorrow at her death, the asylum’s careful recording of her case all point to an institution struggling to understand mental and physical illnesses. Our shock and horror at Jane’s 10 days in the Friends’ Asylum, her last 10 days, should remind us that future historians and physicians are likely to consider our current efforts equally barbaric. But it’s the best we can do.
The French historian Arlette Farge used this expression to describe her experiences in the judicial archives in Paris. See A. Farge, The Lure of the Archives (Yale Univ. Press, 2013), 8. ↩
Although I present this post as as if we are exploring in real time, like all histories, I have reconstructed this story, having pruned out my fumbling through the archives, having omitted the dead ends and repetitions, and having imposed a coherent story meaning on otherwise recalcitrant, meaningless detritus from the past. ↩
There are two copies of the Asylum Register, one seems to have been made from the other. Neither copy includes much information for the early patients. ↩
Except for this last category, “Died,” to understand these various categories requires looking beyond the Asylum Register. What behavior indicated “M.I.” or “Restored” is far from obvious. The diligent historian could probably recover those behaviors poses significant challenges, given ↩
I want to be clear: I am not accusing the Friends’ Asylum of anything. At one level, institutions have to look beyond the individual, particularly if they are interested in tracking and improving the effectiveness of their treatment. ↩
Whenever I’ve mentioned this case to physician acquaintances, they immediately offer a range of acute ailments to explain this short duration of insanity. Unfortunately, we will never know what ailment caused Jane’s insanity. And my point is not to say what really happened. ↩
This last information is not obvious, is not recorded in the tables, but requires you to compare Jane’s entry with others. ↩
The superintendent was, in this way, creating an archive, a sort of bureaucratic archive for his successors. ↩
The people bringing a patient were supposed to submit a form completed by a physician that attested to the patient’s condition, and to complete an admissions form, guaranteeing to pay for board and damages. Unfortunately, Jane’s forms are missing. ↩
The medical register is the physician’s archive, the medical analog to the superintendent’s daybook. ↩