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.
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. 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. 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.
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.
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
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.
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. ↩
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. ↩
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. ↩