SIDEBAR

Restored to Reason


Benjamin Rush had many ideas for easing the suffering caused by mental disorders. But did any of them work? We decided to ask some current Penn therapists to weigh in on the subject. Here are a few of the recommendations Rush offers in his seminal 1812 volume, Medical Inquiries and Observations Upon Diseases of the Mind, followed by their comments.



For general intellectual derangement

Confinement by means of a strait waistcoat, or of a chair, which I have called a tranquilizer. He submits to them both with less difficulty than to human force. The tranquilizer has several advantages over the strait waistcoat or mad shirt. It opposes the impetus of the blood towards the brain, it lessens muscular action every where, it reduces the force and frequency of the pulse, it enables the physician to feel the pulse and to bleed without any trouble, or altering the erect position of the patient’s body; and, lastly, it relieves him, by means of a close stool, half filled with water, over which he constantly sits, from the foeter and filth of his alvine evacuations.”

Robert DeRubeis: I don’t think anyone goes along with Rush’s theories about blood to brain impetus. But the straitjacket does have two actions: … Obviously, it protects those taking care of a person. It’s also believed to allow the person to use their own internal resources to calm down if they’re in the midst of manic fit or a peak of schizophrenia. Most people in modern times don’t think about it anymore as something that’s much done for mental illness, but in some hospitals there is felt the need to have such devices around for such a purpose.

Michael Thase (professor of psychiatry): The [Tranquilizer] chair he came up with didn’t survive the test of time.


Bloodletting: “From 20 to 40 ounces of blood may be taken at once, unless fainting be induced before that quantity be drawn. It will do most service if the patient be bled in a standing position. The effects of this early and copious bleeding are wonderful in calming mad people. It often prevents the necessity of using any other remedy, and sometimes it cures in a few hours.”

DeRubeis: Bloodletting has gone away, thank goodness, although what was its main effect perhaps was its weakening or tranquilizing effect. They didn’t have access to the range of pharmacopeia we have.

Thase: It’s not life threatening [in this amount], but it would be enough to provoke lightheadedness. It just kind of rolled out of your arm into a bowl, so I would think that not only the physiologic shock of losing that much blood, but also the sight of it … had a kind of startling effect on some people.


Low diet, consisting wholly of vegetables, and those of the least nutritious nature …”

Dianne Chambless: Copious bloodletting would calm people down because they would be in a stupor and a really poor diet would starve a person into relative tranquility. That all sounds pretty awful.


Solitude and darkness. “The passions become weak by the abstraction of company, and by refraining from conversation. For this reason, visitors should be excluded from the cells and apartments of highly deranged people … Darkness … invites silence, and it induces a reduction of the pulse, by the abstraction of the stimulus of light, and by the influence of fear, which is naturally connected with darkness.”

Paul Grant: There’s a lot of evidence that this makes psychosis worse, [increasing] delusions and hallucinations and disorganization.


Cold. “The hair should be cut off, and shaved from every part of the head … we not only expose the head to a greater degree of cold, but we favour by it, at the same time, depletion from the brain, by means of insensible perspiration.

“Cold water should be applied … to the head … by means of cloths, or a bladder, to which ice, when it can be obtained, should be added … The coldness should be continued for several days and nights. The signal for removing them should be when they produce chilliness, and sobbing or weeping, in the patient.

“In order to derive benefit from the application of cold water to the whole body, it should be immersed in it for several hours.”

Thase: There is some calming effect through the process of bathing [and being] immersed in cold water. Interestingly, various kinds of states of excitement are associated with increased blood flow and increased energy utilization in regions of the brain, so it’s not farfetched to think a cooling intervention might have a calming effect. A former colleague of mine at the University of Pittsburgh is looking at a forehead-cooling device to deal with chronic insomnia.


Diversion. “Divert the ruling passion or subject which occupies the mind, if it be one, and fix it upon some other… In order to do this, it will be necessary to find out the favourite studies and amusements of our patients … The distracted mind of the poet Cowper was composed while he was employed in the single business of translating Homer; and I have heard of a woman who was cured of madness, by keeping her constantly employed for several days in playing cards.”

Grant: This is really rock solid stuff. It is fundamental to the type of treatment we are doing with [schizophrenic patients] … A huge part of rehabilitating them is to reconnect them with things they used to enjoy. It makes them feel less like patients and more like regular persons … You can spend all day being paranoid or grandiose, depending on which [form of schizophrenia] you have, but if you do something you enjoy—playing a game, going to a movie, whatever—you have less time to be psychotic. [I have one] patient who’s completely withdrawn and sleeps all the time. One of the things we’re doing is getting her back into interaction with other people by playing cards.


Terror acts powerfully upon the body through the medium of the mind. I once advised gentle exercise upon horseback, in the case of a lady in Virginia who was deranged. In one of her excursions from home, her horse ran away with her. He was stopped after a while by a gate. The lady dismounted, and when her attendants came up to her they found her, to their great surprise and joy, perfectly restored to her reason.”

Chambless: Stress is not good for people with schizophrenia.

Grant: This seems to be almost a Hegelian approach to treatment: These symptoms are so strong and intense, you have to have something equally strong and intense to abate them. They used to give patients camphor to induce convulsions to calm psychosis. But camphor can also kill you. Many of the people who have psychoses also have symptoms of trauma. They’ve [already] been terrorized by other people.



For Hypochondriasis

Activity. “Man was made to be active …Hypochondriac derangement has always kept pace with the inactivity of the body and mind which follows wealth and independence in all countries … Building, commerce, a public employment, an executorship to a will; above all, agriculture, have often cured this disease.”

Grant: This is one of the main interventions we’ve been using with people who have negative symptoms. They’re not motivated to do very much. This is what keeps them out of the mainstream of life … This is true for depression, too. There’s a sense in which these people say, “I’ll start doing stuff when I feel better.” It turns out that as you do stuff, that’s how you start to feel better. We find a way to help them become more active, to volunteer … helping other people.


Amusements. “The chase, shooting, playing as quoits, are all useful for this purpose. … The theatre has often been resorted to, to remove fits of low spirits … Certain animals suspend the anguish of the mind of this disease by their innocence, ingenuity, or sports. Mr. Cowper sometimes found relief in playing with three tame hares, and in observing a number of leeches to rise and fall in a glass with the changes in the weather.”

DeRubeis: We don’t do that much anymore … [we] increasingly see these kinds of activities … as being avoidant. [For example, with] panic disorder, [people] used to think it was good to do this diversion thing, because … it basically puts a governor on the panic … People came along and said no, that simply reinforces the idea that one can’t tolerate the panic experience and one must get away from it, as opposed to one must ride it out and understand it’s not a big deal.


Music has often afforded great relief in this disease ... I attended a citizen of Philadelphia, occasionally in the paroxysm of this disease, who informed me that he was cured of one of them by hearing the old hundred psalm tune sung in a country church …

Grant: Music is like a fundamental thing that doesn’t seem to go away. I’m working in a hospital with 24 chronic [schizophrenia] patients [who] don’t express a lot of emotion. Often they don’t feel like doing anything. Once a week there’s a music group. They all want to do it. They sing along, play drums. You would think, all of a sudden, that none of these people seem [mentally ill].



For manalgia (characterized by “taciturnity, downcast looks, a total neglect of dress and person, long nails and beard, disheveled or matted hair, indifference to all surrounding objects, insensibility to heat or cold.”)

Exercise (and the Gyrator). “This should consist of swinging, seesaw, and an exercise discovered by Dr. Cox, which promises more than either of them, and this is, subjecting the patient to a rotary motion, so as to give a centrifugal direction of the blood towards the brain … I have contrived a machine for this purpose in our hospital, which produces the same effects upon the body ... These are vertigo and nausea, and a general perspiration. I have called it Gyrator. … It produces great changes in the pulse. In one experiment made with it, it increased the pulse from 84 to 88 strokes in one minute, and to 120 in two minutes …”

Labor. “It has been remarked that the maniacs of the male sex in all hospitals, who assist in cutting wood, making fires, and digging in a garden, and the females who are employed in washing, ironing, and scrubbing floors, often recover, while persons, whose rank exempts them from performing such services, languish away their lives within the walls of the hospital.”

DeRubeis: It’s been shown that exercise, period, is a treatment for depression.

Chambless: He’s onto something that exercise and labor are important for people who are depressed. To be occupied is to not be left to constantly dwell on their misfortune and how horrible they are. I don’t know that subjecting [patients] to centrifugal force is something we would suggest, but exercising does have an effect on depression.



For derangement of the passions (grief)

Opium.It should be given in liberal doses in its first paroxysm, and it should be repeated afterwards, in order to obviate wakefulness.”

Silent company. “In their first visit to persons recently bereaved of their relations, they should imitate the conduct of Job’s friends, who … the sacred historian tells us, ‘sat down with him upon the ground, seven days and seven nights, and none spake a word to him, for they saw his grief was very great.’ … in this way, grief most rapidly passes from the bosom of the sufferer into that of his friend.”

Removal. “The persons afflicted with grief should be carried from the room in which their relations have died, nor should they ever see their bodies afterwards. They should by no means be permitted to follow them to the grave … After the expiration of the weeks of mourning, care should be taken never to mention the names of the deceased persons to any of their friends.”

Chambless: None of these things I would recommend. We don’t want people to dwell 24 hours a day on their loss, but you do want them to acknowledge it and feel their sorrow and get through it. I had contact very early in my career with a woman who had a stillborn child. They kept her doped up in the hospital and disposed of the body before she woke up … Nobody in her family ever talked to her about this child. She stayed at home mostly because she couldn’t bear seeing people out with baby carriages. She never dealt with this grief.



For derangement of the passions (fear)

Darkness. “The fear which is excited by darkness may easily be overcome by a proper mode of education in early life. It consists in compelling children to go to bed without a candle, or without permitting company with them until they fall asleep.”

Teaching. “The fear of ghosts should be prevented or subdued in early life by teaching children the absurdity and falsehood of all the stories that are fabricated by nurses upon that subject.”

Foa: This child is going to scream and scream and scream, and finally will fall asleep, but it can take hours. We don’t do it like this now. In the beginning we let the child sleep with a dim light and then, in several days, maybe we can put a light in the corridor ... And maybe if it’s a small child, we will give him his favorite toy or stuffed animal to sleep with ... So we take it gradually instead to avoid misery.

I think he had a good notion that to get over an [unreasonable] fear, you have to be exposed [to it]. You cannot just tell a person not to fear the darkness and they’re OK. They have to experience that what they’re afraid of doesn’t happen.

Simply teaching [children] the absurdity of [ghost] stories … may not help. Maybe what we need to do with little children is to kind of do magic: “OK, we will just tell the ghosts to go away. Those ghosts listen to Mommy.” We use methods that would be commensurate with the developmental age of the child.S.F.


 

 


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