Tag: Moral Treatment

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.  ↩