AMERICA’S FIRST PSYCHIATRIC
SERVICE
It is well known that, in colonial times, society treated people suffering from mental illness with a disdain unimaginable today. Some victims wandered the streets, but more often they were confined in jails or basements, poorly fed and cared for, and frequently enchained. Philadelphia, before the Revolutionary War, saw a rapid growth in population, including many suffering from physical and mental diseases and impoverishment. Dr. Thomas Bond, who had studied medicine in London and Paris and was impressed with the hospitals he visited, joined forces with Benjamin Franklin to petition the Philadelphia Assembly for a public hospital. The first in the colonies, it opened in 1751 "to care for the sick poor of the Province and for the reception and care of lunaticks."
Pennsylvania Hospital, 1755 (Wikipedia)
Benjamin Rush, a prominent physician, European educated, active in politics, a signer of the Declaration of Independence, and a director of hospitals during the Revolution, joined the attending staff of the Pennsylvania Hospital in 1783. Rush found the mentally ill housed in cells in the hospital basement, often chained to the wall, lying on dirty straw and fed a meager diet. There was no heating in winter, and they received no particular therapy. Before long, on the retirement of John Morgan, Rush took over the professorship of
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| Benjamin Rush by Charles Wilson Peale (Wikipedia) |
Clinical Medicine. He initiated visits to the basement cells in his rounds with students - a first - and was soon in charge of all mentally ill patients. He installed stoves in the basement cells, countering the belief that the insane were insensible to cold and, with the help of an important board member and an indignant letter to the newspapers, persuaded the hospital to build a new above-ground wing for psychiatric patients.
Developments in the approach to mental illness were brewing elsewhere. In France, Phillippe Pinel had just assumed directorship of the Hospice de Bicetre, a hospice that housed, in degrading conditions, some 200 mentally ill patients. With
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| Phillipe Pinel, by Anna Mérimé |
the belief that many were curable or at least improvable, Pinel instituted “moral treatment,” consisting of a psychological approach to therapy that he outlined in a 1794 paper. Release from severe confinement, better food, attempts to understand the illness, and elementary occupational therapy were mainstays of “moral treatment.” Bleeding, purgatives, and water baths were still used but more sparingly. Pinel’s first book was in 1801, by which time Rush and Pinel probably knew of each other.
In England, in the 1790s, William Tuke, a Quaker merchant in York, outraged at the death of a woman in a local asylum, organized the York Retreat, recognized for its psychological approach to treatment. Another Englishman, Dr. Francis Willis, with whom Rush corresponded, ran a sanitarium for wealthy patients and treated King George III for madness (conjectured now to have been porphyria) in 1788. Willis took a more psychologic approach than Rush who, thinking that illness in body as well as mind were at fault, tended more to bleeding, purgatives, and so forth.
The York Retreat, 1792 (Wikipedia)
Rush published his own book on mental illness, entitled Medical Inquiries and Observations upon the Diseases of the Mind, released in 1812. He classified mental illnesses based on symptoms. Disease classifications at the time were varied and based on beliefs now obsolete. Fever, for instance, constituted a separate entity,
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| Title page, Rush's text (Wikipedia) |
divided into various categories such as intermittent, remittent, bilious, and so forth. He was completely ignorant of the causes. A similar situation existed for mental illness. Rush stated boldly (without much evidence) that “…the cause of madness is seated primarily in the blood vessels of the brain, and that it depends on the same kind of morbid and irregular actions that constitute other arterial diseases.” These actions are “a part of the unity of disease, particularly of fever, of which madness is a chronic form, affecting that part of the brain which is the seat of the mind.” The mind was in the brain but a separate entity.
Rush could know nothing of the ideas of modern neurophysiology. Humoral theories, though waning, still influenced medical thought, as did the idea of “the unity of disease.” Therapies of the day consisted mainly of bleeding, cupping, purges, and emetics, intended to move corrupting substances to the outside and relieve vascular congestion. Focused on the blood vessels, Rush employed bleeding liberally, claiming success in many cases (though he was later criticized for excess bleeding). He did away with straightjackets, primarily because they prevented access to the arms for bleeding and for taking the pulse. As a substitute he created a special "tranquilizer" chair (see illustration) that immobilized the patient but allowed access to the arms. The seat had a hole
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| Tranquilizer chair (National Library of Medicine) |
through which the results of purgatives could pass to a container below and, in some cases, a padded box could be placed over the head to diminish visual stimulation. He also used a chair that would spin around, the idea being to alter the circulation, the seat of the trouble, in the brain. Kindness, attention to the patient’s history, dream analysis, and occupational therapy, were other innovative treatments.
Few patients demonstrated the need for therapy more than Rush’s own son, John. After a promising medical education, he later made several suicide attempts, and eventually became incurably psychotic. Treatments did not help in his case. In correspondence, Rush commiserated with his close friend, John Adams, who had lost a son to alcoholism.
Though Rush’s life was filled with other projects, in the realm of psychiatry he made an important advance by considering mental illness (“lunacy”) a medical condition, amenable to therapy, and, despite bloodletting, he encouraged a humane and integrated approach to healing. He was America’s first psychiatrist and he created the nation’s first psychiatric ward.
SOURCES:
Fried, Stephen, Rush: Revolution, Madness, and the Visionary Doctor Who Became a Founding Father. 2018; Crown, N.Y.
Binger, Carl, Revolutionary Doctor: Benjamin Rush (1746-1813). 1966; W.W.Norton, N.Y.
Meyer, A, “Revaluation of Benjamin Rush.” Amer J Psych 101 (4): 433-442.
Shryock, R, “The Psychiatry of Benjamin Rush.” Amer J Psych 101 (4): 429-32.
