Trenton State Hospital, 1961
Reposing in the midst of the most beautiful scenery in the valley of the Delaware, combining all the influences which human art and skill can command to bless, soothe, and restore the wandering intellects that are gathered in its bosom. — First annual report of the New Jersey State Lunatic Asylum, 1848
I’m as if left to rot in a “Tower of Silence,” with anti-Promethean vultures gnawing away at my vitals. — JOHN NASH, 1967
AT THE END OF JANUARY, ten months after Nash’s return from Paris, a much-aged Virginia Nash and her daughter Martha boarded a train in Roanoke and traveled north all day, arriving in Princeton in the late afternoon.1 The last time they had made this trip together was a decade earlier, to attend Johnny’s graduation, and the contrast between that trip and the present one was much on their minds. As they disembarked, tearful and weary, John Milnor, now a full professor in the Princeton mathematics department, was waiting for them. It was nearly dark and already snowing lightly. After a few awkward exchanges, Milnor showed them his car, turned over the keys, and gave them directions to West Trenton.
Martha took the wheel and the two women drove in silence down Route 1, the car slipping and sliding on the thin layer of slick ice that now covered the road. They were almost thankful for the distraction. They dreaded what lay ahead. Johnny was already at the Trenton State Hospital. He had been picked up earlier in the day by the police, taken first to Princeton Hospital, a small general hospital, and then transported by ambulance to Trenton State. Now they were going down to talk to the doctors, sign the necessary forms, and, if possible, see Johnny. They would see Alicia, at whose apartment they were staying, afterward.
Full of doubt and self-reproach, they felt they had little choice but to accede to another commitment. Whatever hope they had that Johnny’s settling in Princeton, in familiar surroundings and among old mathematical acquaintances, would bring about some improvement in his condition had been shattered weeks before. Alicia’s telephone calls had become increasingly frantic. The psychiatrist whom Alicia had been in touch with had tried, without success, to convince Johnny to go into the hospital on his own. Johnny had been dead set against the idea. Finally, the three women had agreed among themselves that there was no other way. He would have to go.
And this time it wouldn’t be to a private hospital. As Martha recalled in 1995: “At first, we had thought that thirty days at McLean would straighten him out. By then we knew there were no short-term answers. We were concerned that John’s illness would eat into Mother’s capital and that she couldn’t afford a private hospital.”2
• • •
In the moonlight and freshly fallen snow, the gray stone building, with its white marble dome and tall columns, set atop a gentle wooded slope, looked reassuringly solid and respectable. Institutions like the Trenton State Hospital owed their existence to the same mid-nineteenth-century reform movements that opposed slavery and advanced women’s suffrage.3 Many, in fact, owed their existence to the efforts of Dorothea Dix, a fiery, single-minded Unitarian who made the appalling plight of the insane — condemned to almshouses, prisons, and the streets — her life’s crusade.4 When she was old, ill, and penniless, Dix lived on the ground floor of Trenton’s administration building in an apartment set aside for her by the trustees of Trenton State until her death in 1887.
Like all such institutions, Trenton hardly evolved as its founder anticipated. In particular, it was soon overwhelmed by the sheer numbers of people who sought — or whose families sought on their behalf—shelter there. During World War II, Trenton State, long since expanded from a single large building into a large complex, had an average of four thousand patients.5 The census dropped sharply after the war, but was rising rapidly in the late 1950s. By 1961, there were nearly twenty-five hundred patients, ten times as many as at a private hospital like McLean. Staffing was minimal, and consisted mostly of young foreign residents. The six hundred patients in the so-called West hospital, for example, were cared for by six psychiatrists; the five hundred chronic patients in the annex — predominantly senile or epileptic—were cared for by just one doctor. The presence of a large number of chronic patients obscured the fact that most patients who came to Trenton stayed a relatively short time, perhaps three months.
“You really were not close to patients,” said Dr. Peter Baumecker, who worked at both the hospital’s insulin unit and the rehabilitation ward during Nash’s stay. The poorest and sickest patients wound up at Trenton. “I remember very few patients specifically,” Baumecker said. “There was one patient who gouged out the eye of another. There was another patient who’d lost his eye when the police beat him up after he’d killed his father. But that was very exceptional.”6
“There were good wards and bad wards. Trenton was not as plush as other places. As a matter of fact, Trenton was pretty crummy,” recalled Baumecker in 1995. “But I remember a lot of warmth, a lot of caring. We helped an awful lot of people.”7
• • •
Later Nash would recall, with great bitterness, the fact that he was assigned a serial number at Trenton, as if he were an inmate of a prison.8 To occupy a room shared by thirty or forty others, to be forced to wear clothes that are not your own, to have no place, not even a locker, for your things, even your own soap or shaving cream, is an experience that few people can imagine. Yet this is how Nash — a man who craved, because of his nature and the nature of his illness, solitude and mobility — lived for the next six months, surrounded by strangers. If he had dreaded military duty, what must this have been like for him?
Nash would have been brought to Payton One, the men’s admitting ward, on the ground floor of Payton, off to the right of the main administration building. Baumecker was in charge of admissions then and conducted the initial interview. “Nash was my patient,” said Baumecker. “He didn’t like me because my name started with a ‘B.’ He had something against the letter B.”9
The admission interview took place in a small admitting room that had a cot, a couple of chairs, a desk, and a small window. Baumecker asked Nash the usual questions, such as “Do you hear voices?” He tried to find out whether Nash had delusions and whether they were elaborate. He watched his expressions to see whether the emotions he showed were appropriate to what he was saying. The hijacking of a Portuguese ocean liner, the Santa Maria, off Caracas that week — and the subsequent efforts of the hijackers, who turned out to be anti-Salazar rebels, to obtain asylum in Brazil — was, it seemed, very much on Nash’s mind; he had his own private theory about it.10
The following morning, Nash’s “case” was presented to the staff, and he was interviewed in the dormitory before a group of residents. That was when the preliminary diagnosis was reached, treatment was decided upon, and he was assigned a psychiatrist.
• • •
One wound up in Trenton if one had no money or insurance, or was too sick for a private institution to handle. The decision to commit Nash to an overcrowded, underfunded, and understaffed state institution seems puzzling in retrospect. Alicia had at least some insurance coverage through her position at RCA, and Virginia, although by now worried that her son’s treatment would eat into her capital, was surely able to pay for some private care. Martha and Virginia certainly had their misgivings: “We went down to talk to them, to beg them to put a red flag on the case and pay special attention to John. It was the only state hospital that John ever stayed in.”11
John Danskin recalled:
I had heard he was in Trenton. I called his family and said, for God’s sake, do something. I drove down to Trenton State. I wanted to find out what the hell happened. I was shocked. It wasn’t brutal but he was being treated rather roughly. The attendant kept calling him Johnny.
I told the people there: “This is the legendary John Nash.” He was all right too. He gave me no sign at all of being out of his mind. I kept thinking, my God, these shrinks! Who’s going to figure out what’s wrong with a genius? I resented them.12
News that Nash had been committed to a state hospital spread quickly around Princeton. One person deeply disturbed by the notion that a genius like Nash was incarcerated at a state hospital, notorious for its overcrowding and aggressive medical treatments — including drugs, electroshock, and insulin coma therapy — was Robert Winters.13 Winters, a Harvard-trained economist who happened to be the business manager of the physics department at the time, was friendly with both Al Tucker and Don Spencer. Winters contacted Joseph Tobin, the Institute for Advanced Study’s psychiatric consultant and director of the Neuro-Psychiatric Institute in Hopewell, which is a few miles from Princeton, calling him in late January to say, “It is in the national interest that everything possible be done to bring Professor Nash back to his original productive self.”14 Tobin suggested that Winters contact Harold Magee, Trenton’s medical director at the time. Winters did so and won an assurance from Magee, as he later wrote to Tobin, that “there would be a thorough study of Dr. Nash’s condition before any treatment was started at the state hospital.”15
• • •
In truth, this was too much to expect. As Seymour Krim, a beat writer in New York, wrote in 1959 in his essay “The Insanity Bit” about his own experiences in mental hospitals, that work “in a flip factory is determined by mathematics; you must find the common denominator of categorization and treatment in order to handle the battalions of miscellaneous humanity that are marched past your desk with high trumpets blowing in their minds.”16
Very soon after that assurance was given, or perhaps even before, Nash was transferred from Payton to Dix One, the insulin unit.17 Ehrlich, the psychiatrist at Princeton Hospital who had recommended Trenton, was convinced that Nash would benefit from the treatments available at Trenton.18 Whether Alicia, Virginia, or Martha gave explicit consent for insulin coma therapy is not clear. “I don’t remember whether the family had to give further permissions beyond the commitment,” Baumecker recalled. “In those days you could do just about anything without asking anybody.”19 Martha recalled that she was consulted: “That was a drastic decision. We were extra wary of anything that might affect his mental abilities. We discussed this with doctors.”20
The insulin unit was the most elite unit within Trenton State Hospital.21 The unit had two separate wards — one with twenty-two male beds, the other with twenty-two female beds.22 Danskin later described it as looking like “the inside of the Lincoln Tunnel.”23 Its chief had the eye and ear of the hospital’s directors. It had the most doctors, the best nurses, the nicest furnishings. Only patients who were young and in good health were sent there. Patients on the insulin unit had special diets, special treatment, special recreation. “All the best of what the hospital had to offer was showered on them,” said Robert Garber, who was a staff psychiatrist at Trenton in the early 1940s and later president of the American Psychiatric Association. He said, “The insulin patients got a hell of a lot of TLC. In the family’s eyes, insulin had great appeal. Patients’ relatives were overwhelmed.”24
For the next six weeks, five days a week, Nash endured the insulin treatments.25 Very early in the morning, a nurse would wake him and give him an insulin injection. By the time Baumecker got to the ward at eight-thirty, Nash’s blood sugar would already have dropped precipitously. He would have been drowsy, hardly aware of his surroundings, perhaps half-delirious and talking to himself. One woman used to yell, “Jump in the lake. Jump in the lake,” all the time. By nine-thirty or ten, Nash would be comatose, sinking deeper and deeper into unconsciousness until, at one stage, his body would become as rigid as if it were frozen solid and his fingers would be curled. At that point, a nurse would put a rubber hose through his nose and esophagus and a glucose solution would be administered. Sometimes, if necessary, this would be done intravenously. Then he would wake up, slowly and agonizingly, with nurses hovering over him. By eleven in the morning, Nash would be conscious again. And by the late afternoon, when the whole group would walk over to occupational therapy, he would be among them, the nurses bringing along orange juice in case anyone felt faint.
Very often, during the comatose stage, patients whose blood-sugar levels dropped too far would have spontaneous seizures — thrashing around, biting their tongues. Broken bones were not uncommon. Sometimes patients remained in the coma. “We lost one young man,” recalled Baumecker. “We’d all become very alarmed. We’d call in experts and do all kinds of things. Sometimes patients would get very hot and we’d pack them in ice.”26
Good, firsthand accounts of the experience are difficult to find, in part because the treatment destroys large blocs of recent memory. Nash would later describe insulin therapy as “torture,” and he resented it for many years afterward, sometimes giving as a return address on a letter “Insulin Institute.”27 A hint of how unpleasant it was can be gleaned from the account of another patient:
Breaking through the first sodden layers of consciousness . . . the smell of fresh wool . . . they make me come back every day, day after day, back from the nothingness. The sickness, the taste of blood in my mouth, my tongue is raw. The gag must have slipped today. The foggy pain in my head . . . this was my unbroken routine for three months . . . very little of it is clear in retrospect save the agony of emerging from shock every day.28
It’s true, as Garber said, that insulin patients were coddled compared to others at Trenton. Insulin patients got richer and more varied food. They got special desserts. They had ice cream every night at bedtime. Most had ground privileges and permission to go out on weekend visits. All the patients gained weight. That was considered a good sign. The doctors on the ward were proud that their patients were in good physical health. “People would put on a lot of weight because of the insulin,” recalled Baumecker. “The low blood sugar would make it necessary to give them a lot of sugar and the sugar had a lot of calories. For some of these spindly, skinny schizophrenics it wasn’t such a bad thing.”29 But patients often hated it. Nash’s subsequent obsession with his diet and weight may well have stemmed from this experience of being “force-fed.”
• • •
Treating schizophrenic patients with insulin coma was the idea of Manfred Sackel, a Viennese physician who thought of it during the 1920s and used it on psychotic patients, especially ones with schizophrenia, in the mid-1950s.30 His notion was that if the brain were deprived of sugar, which is what keeps it going, the cells that were functioning marginally would die. It would be like radiation treatments for cancer. Some practitioners who used it in the 1950s, when the first effective antipsychotic drugs became available, took the view that insulin shock was more effective than antipsychotics, especially with regard to delusional thinking.31 No one understood the mechanism, but two large-scale studies in the late 1930s found that insulin-treated patients had better and more lasting outcomes than untreated individuals, but evidence for insulin’s efficacy was hardly overwhelming.32
It was in any case riskier and far more involved than electroshock, and by 1960, insulin shock therapy had been phased out by most hospitals as too dangerous and expensive when compared with electroshock. The conclusion was that insulin wasn’t worth the investment of time and money or the risks.
The treatments produced at least temporary improvement in many patients, according to Garber:
They’d see everybody hovering over them, very concerned about them, a feeling of loving camaraderie. I always thought that was very therapeutic. For the first time, somebody cared. Patients became more outgoing, more active. They got to go out on weekend visits. They got ground privileges. I think it helped. Patients were brighter, more alert, more conversational.33
While Nash later blamed the treatments for large gaps in his memory,34 he also told his cousin Richard Nash, whom he visited in San Francisco in 1967, that “I didn’t get better until the money ran out and I went to a public hospital.”35
• • •
As dangerous and agonizing as it was, insulin was one of the few treatments available for serious illnesses like schizophrenia which, until the middle of the century, often meant lifelong incarceration. And, like other state hospitals, Trenton was a laboratory for every “cure” that came along. Before the war, Garber recounted:
[We] treated all patients with the tools that were available. Colonic irrigation was still used. So was fever therapy. We had a strain of malaria that we would inoculate patients with. Later on we used a typhoid strain. We’d inject a typhoid vaccine and within hours patients would experience nausea, vomiting, diarrhea and fevers of 104 to 105. We’d do that for eight or ten weeks, two or three days a week. We did it to take the starch out of disturbed patients.
At Trenton the first order of the day, when I arrived at the hospital supervisor’s office at 8 A.M. was to see who could be moved out of seclusion to make room for another eight to fifteen patients who needed to be secluded. [The rooms] were ten by twelve, lined with glazed tiles, with terrazzo floors. There was a toilet and a sink and a drain in the middle of the floor so that if a patient, say, smeared feces around the room, we could hose it down.
You would do anything to give yourself a handle to bring the patient under control.36
After six weeks, Nash, whose insulin treatments were judged to be effective, was transferred to Ward Six, the so-called rehab or parole ward.37 There was group therapy every day, some recreation, and occupational therapy. “This was the cream of the patient crop,” Baumecker recalled. “There were only about fifteen beds. Other wards had thirty patients per room. Patients got individual attention, went on trips, and were allowed to go home on visits.”38
Nash actually began to work on a paper on fluid dynamics while he was on Ward Six. Baumecker recalled, “The patients made fun of him because he was always so up in the clouds. ‘Professor,’ one of them said on one occasion, ‘let me show you how one uses a broom.’ ”39 Alicia visited Nash every week. Once he was allowed out on passes, she took him to her folk-dancing group and out to Swift’s Colonial Diner.40 It was the highlight of Nash’s week.
He seemed to be in remission, clearly no longer a threat to himself or others. Baumecker recommended him for discharge, pointing out that, contrary to the popular belief, “We had to discharge people as fast as we could to get the census down.”41 He was discharged on July 15, a month after his thirty-third birthday.42 A few months after Nash got out, Baumecker called the Institute for Advanced Study and asked to speak to Oppenheimer about whether Nash was now sane. Oppenheimer replied, “That’s something no one on earth can tell you, doctor.”43