Providentia

The Medical Menstrual Menace (Part One of Two)

For all that the prevailing view of 19th century men was that women were "the weaker sex", not every woman was willing to agree.   Despite the formidable barriers placed in their path, women managed to force their way into the most unexpected places.  And that included any kind of medical training for women.   Given that such training would involve exposing women students to material deemed inappropriate for their gender, most medical schools automatically rejected any women applicants.  

By the mid-1850s however, things began to change.   Along with the example of Florence Nightingale and her fellow nurses tending wounded soldiers during the Crimean war, Elizabeth Blackwell made medical history by being the first woman to graduate from a medical school in 1849 and the first to be placed on the United Kingdom Medical Register in 1859.  Along with her sister Emily, Blackwell helped mentor a new generation of women medical students, as well as promoting the cause of medical education for women in general.

Not surprisingly, there was still considerable opposition.    One of the most outspoken of the doctors opposing medical education for women was Edward H. Clarke of Harvard University.  And, of course, being a doctor, his arguments focused on the medical reasons for why they shouldn't become doctors.  In his 1873 book, Sex and Education, Clarke emphasized that women had the right to do anything of which they were physically capable.   But it was the phrase "physically capable" that was the sticking point for him.

As Clarke pointed out, the development of the female reproductive system placed strains on the body which prevented them from the kind of intellectual development seen in boys going through puberty.   Since the nervous system couldn't do "two things well at the same time,"  females needed to concentrate primarily on their physical development to ensure their health.  Though Clarke was careful in how he worded his views, the implication seems clear enough:  Women who receive the kind of higher education that men do risk developing various health problems including "neuralgia, uterine disease, hysteria, and other derangements of the nervous system" because their overactive brains were using up the physical resources needed for proper development of their reproductive systems.

Even more importantly from Clarke's perspective, women who devoted too much time to intellectual pursuits also experienced mental changes.   This included losing their maternal instincts and "an an appearance of Amazonian coarseness and force."  He added that such women "are analogous to the sexless class of termites. Naturalists tell us that these insects are divided into males and females, and a third class called workers and soldiers, who have no reproductive apparatus, and who, in their structure and instincts, are unlike the fertile individuals." 

That wasn't to say that Clarke objected to all higher education for women.  He stressed that men and women needed to be educated separately and that different educational methods be used to avoid the medical problems associated with overstraining the female reproductive system.   Female-only classes would also include periodic rest times keyed to their menstrual periods to avoid conflict.   They would also need shorter study hours due to their inability to handle the kind of academic pressure that men could.   As he pointed out:

A girl cannot spend more than four, or, in occasional instances, five hours of force daily upon her studies, and leave sufficient margin for the general physical growth that she must make.... If she puts as much force into her brain education as a boy, the brain or the special apparatus [i.e., the reproductive system] will suffer.

Given his own status as a Harvard professor, he concluded that women be prevented from attending Harvard Medical School or any other academic institution where they might be forced to compete with men intellectually given that such pressure would endanger their potential status as wives and mothers.   For that matter, forcing men to compete with women in this way would diminish both genders since, as he phrased it, "To make boys half-girls, and girls half-boys, can never be the legitimate function of any college."

Not that Clarke was the only medical pundit to argue that women were too unstable and frail to be educated alongside men.  In his 1900 address to the American Gynecological Society, George Julius Englemann urged that schools for girls needed to  deal with the "instability and susceptibility of the girl during the functional [menstrual] waves which permeate her entire being" by providing rest during the menstrual periods.  

Given fears that menstruation made all women unstable, even educational institutions that had begun admitting women raised concerns about damaging the health of their women students. An 1877 statement by the Board of Regents at the University of Wisconsin suggested that "it is better that the future matrons of the state should be without a University training than that it should be produced at the fearful expense of ruined health; better that the future mothers of the state should be robust, hearty, healthy women, than that, by over study, they entail upon their descendants the germs of disease."   In other words, women students risked damaging their own health and the health of the future children by too much study.  

Well, into the 20th century, the co-education of men and women remained a controversial topic and most schools pushed for a sexually segregated curriculum that taught "appropriate" subjects for boys and girls.  This included courses such as Home Economics which were meant to direct women towards their future roles as wives and mothers.   Separate colleges for men and women were also founded including Radcliffe College in Massachusetts and Vassar College in New York and quickly developed reputations for academic excellence.  Still, their graduates often found themselves at a disadvantage in male-dominated industries such as medicine.

Not surprisingly, some of the early sexologists such as Mary Putnam Jacobi (a pupil of Elizabeth Blackwell) often found themselves challenging the prevailing opinions about menstrual instability in women.   It was Jacobi who had pioneered research into "the menstrual wave", and many male doctors cited her work while dismissing her conclusions that women were fully capable of handling the educational burden placed on their male counterparts.   This battle over women's education would continue for decades afterward.

Continue to Part Two

 

 

 

 

 

 

Can Hallucinogenics Treat Addictions?

Addictive disorders are very common and have devastating individual and social consequences. Currently available treatment is moderately effective at best. After many years of neglect, there is renewed interest in potential clinical uses for classic hallucinogens in the treatment of addictions and other behavioral health conditions. A new paper published in the journal  Progress in Neuro-Psychopharmacology & Biological Psychiatry provides a comprehensive review of both historical and recent clinical research on the use of classic hallucinogens in the treatment of addiction, selectively review other relevant research concerning hallucinogens, and suggest directions for future research. Clinical trial data are very limited except for the use of LSD in the treatment of alcoholism, where a meta-analysis of controlled trials has demonstrated a consistent and clinically significant beneficial effect of high-dose LSD. Recent pilot studies of psilocybin-assisted treatment of nicotine and alcohol dependence had strikingly positive outcomes, but controlled trials will be necessary to evaluate the efficacy of these treatments. Although plausible biological mechanisms have been proposed, currently the strongest evidence is for the role of mystical or other meaningful experiences as mediators of therapeutic effects. Classic hallucinogens have an excellent record of safety in the context of clinical research. Given our limited understanding of the clinically relevant effects of classic hallucinogens, there is a wealth of opportunities for research that could contribute important new knowledge and potentially lead to valuable new treatments for addiction.

For the abstract

Does Breastfeeding Boost Intelligence in Children?

Of all the health benefits linked to breastfeeding, its presumed impact on a child's later intelligence is likely the most controversial.  Though a 1929 study by Carolyn Hoefer and Mattie Crumpton Hardy first made the connection,  numerous studies since then have challenged these findings.   Since mothers who breastfeed tend to have higher intelligence than non-breastfeeding mothers, researchers have argued that maternal IQ is more important than breastfeeding in how their children develop intellectually.   When maternal IQ is controlled for, the presumed relationship between breastfeeding and intelligence tends to disappear.

But is there really no intellectual difference between breastfed and non-breastfed children?   There certainly seems little question breastfeeding helps ensure that infants are healthy and well-nourished.   According to a policy statement by the American Academy of Pediatrics,  Work Group on Breastfeeding,  "“Epidemiologic research shows that human milk and breastfeeding of
infants provide advantages with regard to general health, growth, and  development, while significantly decreasing risk for a large number of acute and chronic diseases”  

Since good nutrition is essential in various indexes of brain development, including intelligence, more recent researchers have questioned a number of the studies seeking to disprove the breastfeeding-intelligence link.  Since most of these studies were based on single IQ tests rather than more in-depth measures of cognitive functioning, more comprehensive research is needed.

To read more, check out my new Psychology Today blog post.

Quebec Expecting Federal Approval for Supervised Injection Sites

While Stephen Harper's Conservatives adamantly opposed allowing the opening of supervision injection sites in cities across Canada, Quebec health care workers are hoping that the new Liberal government will permit Montreal to become the second Canadian city to run the controversial harm-reduction program.  So far, Vancouver remains the only city in North American offering supervised injection under medical supervision , the Insite clinic in downtown Vancouver.   Despite numerous court challenges by the Federal government, the clinic continues to service thousands of chronic drug users every year and remains a model for harm reduction advocates from around the world.

Shortly before leaving office however, the Conservatives passed tough new legislation creating significant  legal hurdles for applicants seeking to opening similar centres in other cities.  One application  by Cactus Montreal seeks to open three fixed safe-injection sites in the city along with a mobile unit.    Since launching North America's first needle exchange program in 1989, Cactus Montreal has been at the forefront of health care for drug users and sex workers endangered by blood-borne diseases.  

While attempting to open a safe injection site since 2010, efforts have been stonewalled by the Federal Conservatives.  Now seeking approval for their application by the new Liberal government, Louis Letellier de St-Just, a founding member of Cactus Montreal is hoping to have their new sites up and running by next fall if approval comes quickly enough.  "The project will certainly get the go-ahead from the (new) federal health minister so we are thrilled," he said in an interview with CBC News.

But Montreal mayor Dennis Coderre may not be willing to wait that long.   In a joint news conference with then-Liberal leader Justin Trudeau last September, Coderre said that he will give the Federal government until the end of the summer of 2016 to approve the new clinics.  If approval fails to come, he vowed to open the clinics anyway.  "It's about public safety," he said. "It is about public health. And all we are asking is to be consistent with what the Supreme Court has said."   As for Justin Trudeau, he had nothing but praise for Coderre's determination and stated publicly that he looked forward to supporting him if the Liberals formed the new government. 

Still, despite the apparently unanimous support for the new sites, Health Canada refused to comment publicly on Montreal's application or how the new sites would be funded (Vancouver's Insite program is funded by the province).    

In September 2011, the Supreme Court of Canada ruled that Insite should remain open since it saved lives and improved health without leading to higher crime or drug use in the surrounding areas.  As for future safe injection sites, the government was authorized to grant an exemption to federal drug laws if evidence indicates that new sites would cut the risk of death and disease with little impact on public safety.  

Along with Montreal, the new Liberal government will eventually be expected to approve similar sites across Canada.

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Dr. Fliess' Patient

By 1895, Sigmund Freud's theories of psychoanalysis and the unconscious were still in the formative stage but his revolutionary "talking cure" for treating neurosis had already made him well-known. It seemed only natural that 27-year old Emma Eckstein should seek him out for treatment. She became one of Freud's first analytic patients and he viewed her as a special challenge with her complaints of menstruation-related depression, hysterical anxiety, and frequent nosebleeds. While he believed that Emma's symptoms were psychogenic in nature, he was cautious enough to call in a specialist to rule out possible physical causes.

Enter Wilhelm Fliess. A prominent otolaryngologist who practiced in Berlin, Fliess had already formed a long friendship with Freud since they met at a conference in 1885. In addition to a shared interest in neurosis, Fliess had come up with several, unique, theories of his own which had gained him some fame. Along with his work on biorhythms, Fliess had also developed what he referred to as the nasal reflex neurosis. Essentially, Fliess regarded the human nose as being an important link to sexuality and that sexual problems could be cured by treatment to the nose. Fliess claimed that he could give patients temporary relief by anesthetizing their noses with cocaine but he also advocated a more radical solution with nasal surgery. This operation involved removing several key bones in the nose.

In Emma Eckstein's case, Fliess viewed her as suffering from nasal reflex neurosis brought on by masturbation. Whatever misgivings she might have had about the diagnosis or the radical nasal surgery that Fliess proposed were quickly overcome by Freud's recommendation that she have the surgery. It probably helped that Fliess had also operated on Freud's nose to resolve some cardiac symptoms that he was experiencing. Despite the fact that Fliess had performed few operations of this type in the past and that he would be doing the operation in Vienna where he would not have the chance to follow up on his patient, the surgery went on as planned. He removed the turbinate bone in Emma's nose and instructed Freud to follow up on her after he returned to Berlin.

Emma experienced post-surgery complications from the very beginning. Not only was there considerable pain and hemorrhaging, but pus also began coming from her nose indicating infection (this was in a pre-antibiotic age). Freud called in a specialist who inserted a drainage tube but the bleeding continued along with a "fetid odour". Another surgeon, Ignaz Rosanes, cleaned the infected area and then, as Freud later described in a letter, "suddenly pulled out a thread, and kept on pulling. Before either of us had time to think, at least half a meter of gauze had been removed from the cavity. The next moment came a flood of blood. The patient turned white, her eyes bulged, and she had no pulse." Rosanes was able to pack the cavity and stop the bleeding after a minute but Emma was left "unrecognizable". Seeing what had happened, Freud fled to another room to strengthen himself with a glass of cognac. After returning, "a little tottery" to the room, Emma dryly commented, "So this is the strong sex".

She would need that sense of humour in the months that followed.  Recovery from the near-fatal surgery was extremely slow and left her permanently disfigured. Freud found himself in an extremely awkward position. Not only had Emma been his patient, but he had referred her to Fliess and recommended the surgery that had nearly killed her. Freud was worried about his patient but he also wanted to protect his friend Fliess from accusations of medical malpractice.  In a letter that he wrote to Fliess afterward, Freud reassured his friend that "You did it as well as one could do it...Of course, no one is blaming you nor would I know why they should".

Freud's determination to protect Fliess took him to remarkable lengths. He wrote to Fliess some time later and concluded in his letter that Emma's bleeding episodes had been hysterical in nature and resulted from "longing, and probably occurred at the sexually relevant times. The woman, out of resistance, has not yet supplied me with the dates." The fact that much of the bleeding was due to the unnecessary surgery that Freud talked her into having seemed irrelevant. Amazingly, Emma Eckstein continued on as Freud's patient and she was the likely inspiration for some his later self-analyses (including his "Irma" dream).  It is a testament to Freud's reputation as a healer that Emma Eckstein viewed her treatment with him as being highly successful despite the disastrous surgery.

Although Emma recovered to some extent, she eventually relapsed and became a bedridden recluse. After seeing another surgeon and having a hysterectomy following treatment for a myeloma, Freud was furious at her belief that her condition was organic and that she had sought treatment from another doctor. In his opinion, this "ruined her for analysis", and he dropped her as a patient. Freud continued to be a significant influence in her life though and she would later recommend her nephew, Albert Hirst, to Freud for treatment in 1910. She also became a psychoanalyst in her own right and wrote a small volume on child sexuality.

While Freud's relationship with Fliess had long since soured, he continued to defend his decision to send Emma to Fliess and described her case as being one of his success stories. When Emma Eckstein died in 1924 at the age of 59, Freud blamed her later relapse and poor health on her hysterectomy. After Fliess' death in 1928, his widow contacted Freud and asked for the letters that Fliess had written to him. Freud tersely told her that he had destroyed them and tried to have his own letters to Fliess destroyed as well.  She sold the letters instead. Orthodox psychoanalysts have restricted access to these letters for decades until Jeffrey Masson succeeded in publishing the complete Freud/Fliess correspondence (he was later fired as Director of the Freud Archives as a result of his controversial works on Freud).

Since the Emma Eckstein case represents one of the few actual examples that Freud ever provided to prove the success of psychoanalysis, the fact that this success story was not such a success seemed an odd omission from Freud's later writings. The disastrous surgery that nearly killed her and the extent to which Freud concealed his own role in damaging her health was largely hidden for decades. The case of Emma Eckstein also represents a warning to health professionals about potentially harmful "fad" treatments that ultimately prove to be more harmful than the conditions they were meant to treat.

Sexism and Social Media

Sexism and sexual harassment are not uncommon in online environments such as social networking sites, forums, and video games. A recent article in the journal Computers in Human Behavior describes a study investigating whether users’ anonymity and level of interactivity with sexist content on social media influenced sexist attitudes and offline behavior. Participants (N =172) used a Twitter account that was anonymous or had personally identifying details. They were asked to share (i.e., retweet) or write posts incorporating a sexist hashtag. After exposure, participants completed two purportedly unrelated tasks, a survey and a job hiring simulation in which they evaluated male and female candidates’ resumés. Anonymous participants reported greater hostile sexism after tweeting than non-anonymous participants. Participants who composed sexist tweets reported greater hostile sexism and ranked female job candidates as less competent than those who retweeted, although this did not significantly affect their likelihood to hire.

For the abstract

Predicting Suicides In Veterans

Combat veterans are at risk for several adverse outcomes such as posttraumatic stress disorder (PTSD), depression, hazardous alcohol use, and most critically, suicidal behaviors. The high rate of suicide in veterans has been understood as a correlate of PTSD and depression, but it is possible that certain specific types of combat experiences may lead to suicidal behaviors. Acts committed by veterans in the context of war such as killing may evoke a “moral injury,” which leads to thoughts of ending one’s life.  A research project published recently in the journal Psychological Trauma examined relationships between combat experiences and suicidal ideation (SI) and PTSD in a sample of 68 Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans (91% male, mean age = 32.31 years) who had screened positive for alcohol misuse. The researchers examined firing a weapon/killing in combat (Firing/Killing) and killing in combat (Killing) alone as predictors of SI and PTSD severity in both the full sample and men only. Results showed that firing/killing were associated with SI for the full sample and men only, and Killing showed a trend toward significance in predicting SI. Hierarchical regression analyses suggested that Firing/Killing did not predict PTSD for the full sample or men only, but Killing was predictive of PTSD for both samples.  These results indicate that there may be differences in Firing/Killing and Killing alone in OEF/OIF veterans who screened positive for alcohol misuse. Thorough screening of combat experiences and addressing moral injury in returning combat veterans may help reduce high rates of suicide and PTSD.

For the abstract

A Shock to the System

While transcranial direct-current stimulation (tDCS for short) has become more widely used to treat various neurological and psychiatric conditions, its use in improving brain functioning such as memory and attention is a bit more controversial.   Still, a recent study by researchers suggests that it can be an effective way to make human operators stay vigilant in monotonous tasks such as drone operation and cyber defense.    

Using scalp electrodes to stimulate key areas of the brain has been carried out by researchers for more than a century though it still hasn't been formally approved for clinical use by agencies such as the Food and Drug Administration.   When safety protocols are carefully followed, tDCS can usually be maintained for relatively brief periods with no negative effects (aside from occasional problems with skin irritation and nausea).   Studies have shown good results in treating depression and more mixed results for treating other conditions such as dementia, Parkinson's disease, and schizophrenia.  Tests on healthy subjects suggest that low-current stimulation to the brain can boost attention span, problem-solving, and memory though, again, these results tend to be controversial.

But what about something like vigilance?   While there are numerous tasks that we can do for relatively brief periods of time, performance often suffers if we are expected to do the same task for hours at a time without breaks.  Whether it involves operating heavy machinery or driving a car across the country, our minds have a tendency to "wander"after a while and the potential for making a mistake rise sharply with time.   Considering that some mistakes can be literally fatal, especially for military personnel, helping workers stay focused is essential.

To read more, check out my new Psychology Today blog post.

Japanese Cafe Provides Comfort for Tsunami Victims

The disastrous tsunami and earthquake in March 2011, quickly followed by a nuclear disaster that led to thousands of residents being uprooted,  has created a traumatic legacy that still lingers today.   According to Taio Kaneta, a Buddhist monk helping tend tsunami victims, many survivors have been emotionally numbed by what has happened to them.  "People lost their ability to feel," Kaneta said in a media interview.  "They became emotionless. It’s like their hearts froze to the point where they couldn't even cry.”

As volunteers were quickly overwhelmed by the sheer scope of the disaster, Buddhist monks like Kaneta needed to become innovative in finding new ways to assist people in need.   While the monks have traditionally handled funerals and helped survivors with grief,  Kaneta found that many of the people needing help belonged to different religions and different traditions.  Also, in the largely secular Japanese society, seeking comfort from religion is not as popular as it once was.

Since Kaneta is also a musician, he came up with a more eclectic solution for comforting survivors.   As he stated, "You’ve got to improvise, like in jazz. The base of what we do doesn't change. But you’ve got to groove with it.”    With that in mind, Kaneta created a rotating, pop-up cafe, that he called "Cafe de Monk."    The name is a play on words since Kaneta is a monk and the Japanese word, "monku" means "to complain."   Joined by other monks, Kaneta sets up operation at different spots in the temporary housing facilities in Yokoyama set up after the disaster. 

Once the cafe is operating, certain ground rules come into play.  First of all, though Buddhist monks provide services to visitors, often aided by practitioners from other faiths, they aren't there to preach and no religious arguments are permitted.  Instead, visitors simply eat cake, enjoy coffee, and listen to the music of Thelonious Monk.   Art therapy and massages are also available or visitors can work on beadwork.  As far as Kaneta and his fellow monks are concerned, the purpose of the cafe is to listen.  "We draw out their suffering, sadness, happiness. Really listen," he said. 

For most of the cafe's patrons, life in the Yokoyama temporary shelter is extremely difficult.   Most come from the town of Minami-Sanriku which has been largely destroyed by the tsunami.   The units where they live now are very different from the homes they once had and were never really meant for long-term living.   The worst part is the uncertainty surrounding their existence since nobody has any idea when they will be able to rebuild   After the cafe closes at the end of the day, Kaneta often visits many of his patrons at their makeshift homes, especially the ones mourning the loss of a loved one.  For them, Kaneta provides more traditional Buddhist comfort though only as patrons request. 

Part of the appeal of the Cafe de Monk is that it can cross religious boundaries and offer services in a way that government and aid agencies cannot.    Kaneta and his fellow monks admit to often feeling depleted by the burden placed on them but are still able to unwind as needed.   Taio Kaneta often plays jazz or songs by the Beatles on his guitar to deal with the stress of his responsibilities. 

But the patrons of his cafe appreciate his efforts.   As one patron said in an interview with Public Radio International, "When they do Café de Monk, a lot of people come. And we’re able to open our hearts to each other. And the monks, they’re really good at listening.”

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Poor Ivanushka (Part Two of Two)

Continued from Part One

Whatever Peter III's original intentions towards poor Ivan, the question of what to do with him remained a hot issue politically.   Not only did everyone know about his imprisonment despite Elizabeth's best efforts, but he had become a figurehead for various conservative factions across Russia.   One of the first things Peter did on becoming Emperor was to ride to Schlusselberg prison to see Ivan himself.   What he saw likely disturbed the new Emperor deeply.  

While none of the guards who wrote about Ivan's condition knew anything about psychiatry, and they were likely encouraged to exaggerate his mental state to play up the perception that Ivan was insane, decades of solitary confinement can break anyone.   Especially when you consider that he spent most of that imprisonment in a narrow cell without windows and with only candlelight that made him unable to tell day from night.  What it did to a boy who had known nothing else since he was four years old seems ghastly to consider.   One guard wrote that "In June [1759] his fits became more violent: the patient shouted at the guards, quarreled with them, attempted to fight, twisted his mouth, and threatened to hit the officers.”   Still, the treatment he received was inhumane as well and some guards teased him without mercy.  

Not only was Ivan kept in solitude but the entire prison was closed to outsiders to keep out anyone who might try to free the young Emperor.  In 1762, an unexpected coup led to the overthrow of Peter III by his German wife Sophie Friederike Auguste von Anhalt-Zerbst-Dornburg, a.k.a. Catherine the Great.   After succeeding as Empress (and discreetly disposing of her husband), Catherine inherited the problem of what to do about poor Ivan who was still in captivity in Schlusselberg.   One of the first thing Catherine did on taking the throne was to visit Ivan and issue new orders to his guards.  Far more ruthless than her husband, Catherine made it quite clear that Ivan could never be allowed to leave the prison alive and that he should be killed if anyone tried to free him.   She was likely the last woman Ivan ever saw.

Finally, what Catherine and all her predecessors had feared took place in 1764.   A twenty-three-year-old lieutenant named Vasilii Mirovich learned about Ivan when he was assigned to be part of his outer guard.   Disgruntled over his lack of promotion, Mirovich came up with a scheme to free Ivan and take him to St Petersburg to overthrow Catherine.   While there was no possibility that the long-imprisoned Ivan could ever rule Russia considering his mental state, Mirovich and his supporters likely saw him as a useful figurehead.  

On July 4, Mirovich deployed the soldiers under his command and arrested the commandant of the prison.  He then positioned his troops to storm the barracks where "Grigorii" was being held.   And it might have succeeded if not for Catherine's standing order of what to do with Ivan if anyone tried to release him.  Ivan's jailers, terrified for their lives (and what Catherine would do to them if he left the prison alive) promptly rushed into their prisoner's cell.   Ivan had already been awakened by the sound of gunfire but he suddenly began fighting for his life when he realized that the guards were there to kill him.   Despite his resistance, the guards quickly stabbed Ivan to death with their swords and Mirovich burst into the cell just seconds later.   Ivan's death put an end to Mirovich's ambitious schemes.  He promptly surrendered to the prison commandant knowing that he would pay with his life. 

The real question though was what to do with the guards who had killed Ivan.   Considering they had been following Catherine's orders, she had no problem clearing them of any blame.  If anything, they were heroes for ending Mirovich's plot by sacrificing the life of one man who, as Catherine's own manifesto would state, was "unfortunately born."   After several days, Ivan's body was buried in an unmarked grave somewhere in the prison courtyard. 

As for the rest of poor Ivan's family, they fared little better.    By the time of Ivan's death, his father, Anton Ulrich, had been imprisoned for twenty-two years along with his other four children.  While the house where they were kept was slightly less bleak than Schlusselberg,  everyone was still confined to two rooms (the men in one room and the women in another).   Prince Anton eventually went blind in captivity and died in 1776, having outlived his eldest son by thirteen years.   His body was taken out and buried in secret, much as Ivan had.   

After another four years of imprisonment, Catherine eventually relented and allowed all of Ivan's siblings to live with their aunt in Denmark.  By this time, they were all in poor health and had mainly learned to read and write on their own (Elizabeth had not permitted them any formal education).   The oldest daughter, Catherine, was completely deaf while the others suffered from a range of other maladies.  The prospect of being around other people terrified them but they were eventually led out of the prison for the first time in their lives and placed on a freighter for the last part of their journey.

It wasn't a particularly happy existence for them though.  Their aunt, who happened to be Denmark's queen, only took care of them out of duty and never bothered to visit.  Since they only knew Russian, they had trouble communicating with the servants who often took advantage of them.  Still completely isolated from Danish society, they slowly died out, one after another.  Ironically, the eldest, Catherine, was the last to die, deaf and alone in a strange land.  In 1803, she wrote a plaintive letter to the then-Emperor Alexander asking to be allowed to return to Russia.   Despite her poor writing skills (she had been largely self-taught), Catherine managed to convey her horror at living in Denmark surrounded by servants who openly mocked and stole from her.   After years of being ignored, Catherine finally died, forgotten and alone, in 1807.

Catherine's death is a sad footnote to the tragic life of the man who might have been Emperor Ivan VI of Russia and his siblings.  Would history have been changed if Ivan had remained on the throne?  Undoubtedly.   Still, the story of Ivan and his family is a tragic example of the kind of cruelty that can result from sheer political necessity.   While Schlusselberg prison s now a tourist attraction for its historical value, the exact location of Ivan's grave is completely unknown.  Countless tourists have likely walked right over his grave site without any idea of where they were stepping.

A sad fate for an Emperor.