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

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

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,

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

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.

                                    Muscles’ Monikers Through Time

by Roy A. Meals, MD

While interest in and knowledge of anatomy increased steadily during the Renaissance, differentiating and naming the newly observed muscles proceeded with fits and starts. True, more than a millennium before, Galen had described muscles by their location and function, but he did not actually name them. For instance, “Two of the muscles on the inner side of the forearm…flex the fingers,” and “The next largest…flex the whole wrist,” are examples, obviously confusing to a student embarking on his first anatomical studies.

Vesalius (1514-1564) tended to number all anatomical structures and cross-referenced them in the text and drawings of his seminal Fabrica (1543). In addition to naming two jaw muscles and the six-pack, Vesalius also named an arm muscle the anterior cubitum

Andreas Vesalius by Jan van Calcar, the artist who
made woodcut prints for Vesalius (Wikipedia) 

flectentium musculus—though it seems, in this case, a nice succinct number would have been more user-friendly. Had all the muscles retained numbers, however, it could get cumbersome. For instance, somebody might ask you to flex your number 489 and you couldn’t remember which one it was, out of the roughly 650 that humans have.

One of Vesalius’s teachers, Sylvius (1478-1555), in Hippocrates et Galeni physiologicae partem anatomicam isagoge (Anatomical Introduction) (1555), named many anatomical structures, especially vessels and muscles “for the sake of brevity and the perspicuity of thing.” Possibly because Sylvius did not illustrate his work, his terminology did not catch on. Fifty years later, Bauhin (1560-1624) rekindled interest in descriptive terminology by referring readers of his unillustrated Theatrum anatomicum (1605) to Vesalius’s depictions in Fabrica. After that, naming proceeded in full force over the next 300 years.

Many anatomists pitched in and gave the muscles descriptive names and fortunately renamed the anterior cubitum flectentium musculus the biceps. Some of the original names were outright poetic. Consider, for instance, the contributions of Jan Jesenius (1566–1621), a Bohemian physician, politician, and philosopher. He was professor of anatomy in Wittenberg and later at Charles

Jan Jesenius (Wikipedia)

 University in Prague, where he also performed the city’s first public autopsy, an event said to have attracted 1000 onlookers. He named the muscles controlling the eyeball’s movement amatorius (muscle of lovers), superbus (proud muscle), bibitorius (muscle of drinkers - contraction of the medial rectus muscles would make one cross-eyed), indignatorius (muscle of anger), and humilis (muscle of lowliness). Twenty years later, early in the ThirtyYears War, Jesenius was executed for his Protestant views rather than his muscle naming. It is too bad that in 1895 anatomists standardized the nomenclature and dully renamed the eye muscles according to their location (superior, inferior, medial, lateral) and alignment (rectus [straight] and oblique). 

            In the eighteenth and nineteenth centuries the language in anatomical tomes began to move away from Latin to modern languages, confusing the terminology in a different way. In addition, new “systems” were proposed, such as that of Monro in Scotland and Francois Chausser in France, who both proposed a new terminology for muscles based on their sites of origin and termination. A few muscles’ names do identify their origins and insertions. For instance, the sternocleidomastoid is the strappy muscle on the side of the neck that turns your head to the side. One end attaches to the breastbone (sterno) and collar bone (clavicle, cleido) and the other end fastens to the mastoid process of the skull, which is palpable just behind the earlobe. By the nineteenth century, anatomists had identified and named nearly everything, but often with multiple synonyms first in Latin and later in more modern languages. In a non-muscular example, one author in 1917 listed 16 names for the pineal body, including “parietal eye” and “penis cerebri.” Anatomists and clinicians came to recognize that this towering Babel of terminology should be simplified to have clear meaning, logical consistency, and compact form.

            The German Anatomical Society began the reform process in 1887. The prominent Swiss anatomist Wilhelm His, Sr. (his son, W.

Wilhelm His, Sr. (Wikipedia)

 His, Jr., described the bundle of His) spearheaded the effort, forming a committee of prominent anatomists that in turn consulted  anatomists from several countries. In 1895 their efforts coalesced into the Basle Nomina Anatomica (BNA), the first compilation of standardized anatomical names, written in Latin. Several revisions have ensued.

            Some muscles received names of objects they resemble. Piriformis, a hip muscle, is pear-shaped. The deep calf muscle, the soleus, is sandal-shaped. Overlying it is the bulgy gastrocnemius, literally the belly of the leg. In each palm and sole are four worm-shaped muscles, lumbricales manus and lumbricales pedis, respectively. The Latin name for earthworm is Lumbricus.

Illustration from the Basle Nomina Anatomica, 1895 (Internet Archive)

         Other muscles received names according to their location, such as the subclavius (under the clavicle) and the intercostales externi (external layer, between the ribs). The number of parts determines a few labels: Bi- means two, and the biceps has two origins, one from the shoulder blade, one from the upper arm bone. The triceps has three origins, and the quadriceps has . . . well, guess. Length is another determinant. Thumb in Latin is pollux, and it has two muscles that fold (flex) the thumb across the palm—the flexor pollicis longus and flexor pollicis brevis. And a muscle’s action may determine the name; the cremaster, which lifts the testicle, derives from the Greek for “I hang.” 

(Courtesy of Roy Meals, Wikipedia, and British Library)

         Revisions of the nomenclature continued. In 1950 the newer International Anatomical Nomenclature Committee (IANC) took over the job. It was succeeded by the International Federation of Associations of Anatomists (IFAA) that issued, in 1998, its Terminologia Anatomica, containing both Latin and English versions of nomenclature.

         In today’s world where schools, buildings, and military bases are receiving new names after second thoughts on their historical origins, one wonders what monikers future committees will bestow on muscles and other anatomical structures.

 

References

Buklijas, Tatjana: “The science and politics of naming: reforming anatomical nomenclature, ca. 1886-1955.” Journal History Medicine Allied Sciences. 2017;72(2):193-218

Eychleshymer, Albert C.: “Anatomic Nomenclature.” JAMA 1915;64(19):1569-1570.

 

Harrison, R. J., and E. J. Field. Anatomical Terms: Their Origins and Derivation. Cambridge: W. Heffer and Son, 1947.  

Musil, Vladimir et al: “The history of Latin terminology of human skeletal muscles (from Vesalius to the present).” Surg Radiol Anat. 2015;37(1):33-41.

Sakai, Tatsuo: “Historical evolution of anatomical terminology from ancient to modern.” Anatomical Science International, 2007;82:65-81.

 THE FAMOUS MEDICAL CONGRESS

OF 1881

 

Leaders in the medical world of the nineteenth century convened international medical conferences every few years, partly to exchange and discuss new developments in medicine and partly, so it seems, to showcase the country hosting the congress. Born out of the French Medical Congresses, the first International Congress convened in Paris in 1867 during the Paris Exposition. The largest of the medical extravaganzas was the Seventh International Medical Congress, held in London in 1881. Over 3,000 names from numerous countries filled the registration book. The names included luminaries such as James Paget (president of the Congress), William Jenner (currently president of the Royal Society of Medicine), Joseph Lister, Thomas Huxley, Rudolf Virchow, Louis Pasteur,

James Paget in 1881 (Wikipedia)

Robert Koch, Jean Marie Charcot, Bernard von Langenbeck and, from America, John Shaw Billings, Samuel Gross, Austin Flint, and William Osler.   

Queen Victoria served as patron of the Congress and the Prince of Wales opened the proceedings on August 2 with his cousin the crown prince of Prussia at his side. The principal organizer was Sir William MacCormac, a prominent surgeon who had, with the American surgeon, J. Marion Sims, led the Anglo-American Ambulance Service during the Franco-Prussian War, caring for the wounded from both sides. Sadly, female physicians were absent from the Congress in spite of an appeal from 43 women licensed to practice medicine in their respective countries and the presence in London of the Medical School for Women.

         The germ theory of disease, despite doubters, was reasonably established and many papers dealt with the role of bacteria in disease. Robert Koch startled the participants with his demonstration of the use of solid culture media to isolate individual bacteria, prompting Pasteur to famously remark, “C’est un grand progress, Monsieur.” Pasteur himself gave papers on vaccines against chicken cholera and anthrax, major milestones in disease prevention. In the surgical section, Lister’s antiseptic techniques were discussed in depth. By this time many surgeons, especially in Germany, had adopted the carbolic acid solutions and sprays, acknowledging the importance of bacteria in wound infections. Primary closure of wounds without drainage, especially in abdominal surgery, was controversial, with some surgeons reporting infections and even carbolic acid poisoning after surgery. Lister held to his principles but commented that perhaps the spray could be dispensed with, an unexpected statement.

         Sir Henry Thompson, England’s first urologist (see essay of January 2023), and Henry Bigelow from Boston discussed lithotrity, the non-invasive technique for dealing with bladder stones, disagreeing mainly over the size of the instruments used. On public health, known then as “state medicine,” John Shaw Billings spoke about yellow fever, claiming that it could be transmitted from person to person and through contaminated clothing and similar articles.  Then a doctor working in West Africa opined that the disease arose from local causes and was not directly transmissible. The debate was not resolved until the Walter Reed project in 1900. Austin Flint spoke on the need to standardize the terminology used for physical diagnosis. Thomas Huxley spoke eloquently on the need for medical students to learn the workings of the human body through the study of basic sciences such as physiology and chemistry in order to understand treatment of diseases. John Shaw Billings (founder of what became the National Library of Medicine) held the podium again with a talk on the development of medical literature. William Osler presented cases of “exudative endocarditis” in which he noted the constant presence of bacteria but was doubtful of their significance.

John Shaw Billings, portrait in
the National Library of Medicine
(Wikipedia)

         A major problem discussed at the Congress was vivisection. England had recently passed the Cruelty to Animals Act (1876), a rather comprehensive law restricting vivisection. The medical profession viewed this as an impediment to progress and the Congress passed a resolution favoring vivisection, stating that experiments on animals have been of great service to medicine and “are indispensable for its further progress.” Cautioning on the need to avoid inflicting unnecessary pain, the resolution continued, “it is not desirable to restrict competent persons in the performance of such experiments.” 

         Several museums allowed physicians to examine preserved specimens, illustrations, and even a few patients. Illustrations by Sir Charles Bell of wounds encountered during the battle of Waterloo were a main attraction.

Charles Bell's drawing of war wound
(Wellcome Library)

         The only sour note at the Congress was news of President Garfield who had been shot on July 2, one month before the opening. The London medical press carried weekly bulletins on his depressing medical status.

         Entertainment was not neglected at the Congress. The Lord Mayor of London gave a banquet for 300 guests one evening and a later one for 3500 guests in the Guildhall, the latter lit by electric lights – a novelty at the time. Numerous dignitaries organized their own parties, one in Kew Gardens. The Royal College of Surgeons threw a large reception in their spacious museum, again illuminated with electric lights, that “had a somewhat ghastly effect” (Lancet report). One reception resulted in a notable artwork: that of the Baroness Burdette-Coutts, a wealthy heiress. She invited 100 selected guests and memorialized the occasion in a painting (below) that now hangs in the Wellcome Library. 

Garden Party (Wellcome Library)

     

Key to many of the figures in the painting

         

      On the final evening the guests dined at the opulent Crystal Palace, after which a magnificent display of fireworks that included fiery portraits of Paget, Charcot, and von Langenbeck, lit up the sky.

Crystal Palace in 1851, a huge structure (Wikipedia)

      It was a memorable Congress (described as a “week’s carnival of medical science” in The Lancet), attended by a Who’s Who of the medical world, enriched by the latest in bacteriology and surgery, and, not least, by extravagant entertainment.

 

SOURCES:

 

Sakula, A, “Baroness Burdette-Coutts’ Garden Party: The International Medical Congress, London, 1881,” Medical History 1982; 26: 183-190.

 

The Lancet, August 13-27, 1881.

 

Hunt, E M, “The Sanitary Significance of the International Medical Congress of 1881.” Public Health Papers and Reports 1881; 7: 353-67.

         

         

 

OBSTETRICS COMES TO THE COLONIES

 

         Obstetrics in American colonial times was practiced almost exclusively by midwives, whose medical knowledge and skills were generally low. Though the rare physician performed deliveries, the first American doctor to have formal training in obstetrics was William Shippen, Jr. He was also the first American professor of anatomy, a position he held at the newly opened College of Medicine of the University of Pennsylvania.

         After graduating from the College of New Jersey (later

William Shippen, Jr.  (Wikipedia)

Princeton University), young Schippen apprenticed for four years with his physician father in Philadelphia. For further study, he embarked, in 1758, to London. Possibly through family connections, he secured a position as student at St. Thomas’ Hospital, across the street from Guy’s Hospital and near London Bridge. There he made rounds with the surgical and medical staff, read widely, and often traveled to St. Bartholomew’s Hospital to watch Percival Pott operate. He seems to have decided early on a career in obstetrics and anatomy. He took midwifery instruction from a Dr. Colin Mackenzie, a former student of William Smellie, one of the first in England to practice obstetrics (or man-midwifery, as it was called). Mackenzie, less well known today, was highly regarded and a friend of William and John Hunter. Shippen's training with Mackenzie included valuable hands-on experience in his extensive practice.

For anatomy studies, Shippen enrolled in William Hunter’s

William Hunter  (Wikipedia)

 

 

private anatomy classes, considered the best in London. He moved into Hunter’s house in Covent Garden where the lectures and dissection took place. The students not only dissected, they practiced surgical operations on cadavers and injected waxy or oily solutions into vessels to demonstrate vascular patterns, a technique borrowed from the Dutch. It was these injections, done mainly by John Hunter, that first

John Hunter  (Wikipedia

demonstrated the separation of the maternal and fetal circulations of the pregnant mother. William Hunter also taught midwifery to Shippen, though his private practice and duties as Physician Extraordinary to Queen Charlotte limited his time. Shippen also benefitted from long conversations into the night with John Hunter, who found the young American an apt pupil.

 

Anatomy lecture at William Hunter's Anatomy School (Wellcome Library)

Shippen did not neglect pleasure in London. He frequented theatrical performances, from David Garrick’s Shakespearian dramas to low comedy, at the Drury Lane and Covent Garden theaters adjacent to the anatomy school. He attended the coronation of King George III. His easy personality helped him win invitations to dinners or weekend stays. He dined with Thomas Penn, proprietor of the colony, and Benjamin Franklin took him to the Royal Society and presented him at court. Shippen easily fell in with Franklin’s friend, Dr. John Fothergill, one of London’s most respected physicians.

John Fothergill (Wikipedia)

Fothergill, a Quaker, had an interest in Americans and in promoting medicine in America. He encouraged William to open a medical school in Pennsylvania.

William skipped study on the continent (the Seven Years War curtailed travel) and traveled to Edinburgh for a year, absorbing the lectures of William Cullen and the Monros. After receiving an MD degree in 1761, he married a woman from Virginia and sailed with her back to Philadelphia. He carried a letter from Dr. Fothergill recommending that the Pennsylvania Hospital start a medical school with Shippen as professor of anatomy. Fothergill had sent over copious anatomical drawings and skeletal parts as an inducement. The hospital demurred on the medical school but allowed Shippen to begin a private course in anatomy. It was well attended by the local doctors.

In 1765, Shippen began a course in midwifery, the first of its kind, open to men and women. He had initiated a small lying-in facility for poor people and used this for practical instruction in addition to giving lectures enhanced by models of female anatomy.

Shippen's lectures, taken by a student (Nat. Libr. Med)

Lectures also covered the circulation and nutrition of the fetus, labor, use of instruments (he was conservative), and diseases of women and children near birth. To maintain dignity in the profession, he urged a “grave deportment” during accouchements and warned against alcohol use.

That same year, another Pennsylvanian, John Morgan, returned from medical studies in Edinburgh, London, and the continent. He presented a second proposal to the Pennsylvania Hospital to open a

John Morgan (Wikipedia)

medical school. This time the trustees, now possessing a letter from Thomas Penn recommending the school, agreed and the first medical school in America opened later in the year. The Professorship of the Theory and Practice of Physick went to Morgan and Shippen was soon appointed Professor of Anatomy and Surgery. The first steps toward formal medical education in America had begun. Shippen continued with his midwifery school. The Pennsylvania Hospital did not acquire lying-in facilities and a separate department until 1803.

The American Revolution interrupted work at the school. Unfortunately, considerable hostility developed between Shippen and Morgan during the war. Both were appointed, at different times, to head the Army medical services, both were accused of incompetence or graft, and Shippen underwent a court-marshal, though he was exonerated. After the war, both remained on the faculty and Shippen continued his extensive obstetrical practice, imparting skills to the next generation of doctors and midwives. His open personality attracted such dignitaries as Washington, Hamilton, and John Adams, who all stayed at “Shippen House” in Philadelphia. He continued to teach, to dispel many myths about childbirth, and to promote the profession of man-midwifery. He did not write papers or books or carry out research, however, as many pioneers in their fields do. Only lecture notes and reminiscences remain to testify to his stature as the first professional obstetrician in America.

 

Note: No essay in May. I will be traveling. See you in June.

 

SOURCES:

Corner, Betsy C, William Shippen, Jr.: Pioneer inn American Medical Education. 1951; American Philosophical Society.

Thoms, H, “The Beginnings of Obstetrics in America.” Yale J Biol Med, 1932; 4: 665-75.

Scheffey, L C, “The Earlier History and the Transition Period of Obstetrics and Gynecology in Philadelphia.” Ann Med History, 1940; 2(3): 215-224.