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Rush’s Remedies Two centuries after its publication, Founding Father and early Penn faculty member ’s pioneering work on mental illness prompts alarm and admiration—as well as reminders

about ongoing challenges in the mental-health field. BY SUSAN FRITH

Blessed science! Which thus extends its driasis.” In the depths of their despair, Sciences. Diseases of the Mind includes friendly empire, not only over the evils of some patients go on to hurt or kill them- treatments that therapists “would the bodies, but over those of the minds selves. “I should lay down my pen and never do today” because they’re inhu- of the children of men. —BENJAMIN RUSH bedew my paper with my tears, did I not mane, ineffective, or theoretically un- know that the science of medicine has sound. “They range from alarming to 44-year-old Virginia man could furnished a remedy for it.” eyebrow-raising to bemusing when you The not sleep over the din of his own In the following pages, Rush listed no read about them,” DeRubeis says. “But heartbeat. In fact, he reported, his mind fewer than 20 remedies for the syndrome. then there are another set of treat- was so distressed that “the least noise” His book includes dozens more treatments ments he describes that are perfectly felt “like a shock of thunder, so that for for patients in the throes of all kinds men- sensible—some of which are in quite seven years I have been in the constant tal distress, including the manic, the grief widespread use today and some of habit of stopping both ears with wax.” stricken, and those suffering from a “mor- which should be in more widespread In a letter to Dr. Benjamin Rush, the bid state of the sexual appetite.” use.” (For a look at how effective some patient explained that his problems Just how much comfort the afflicted of Rush’s remedies probably were, see began when he was suddenly attacked by drew from Rush’s care likely depended “Restored to Reason” on page 51.) “impious and profane ideas” while read- on which treatments they endured. Despite its many flaws, Rush’s book ing religious material. Now he couldn’t Depending on their diagnoses, patients “was so complete and so unique a study even turn to the Good Book for comfort. might have been prescribed exercise of mental diseases that it remained the Rush reflected the anguish of such pa- on horseback, strapped onto a spin- only comprehensive American study on tients when he sat down 200 years ago to ning table, or bled until their ravings the subject for seventy years, and was write his pioneering tract on mental ill- stopped (and their pulses plummeted). the foundation upon which superseding ness, Medical Inquiries and Observations “It really is a mix of things,” says studies incorporating scientific advanc- Upon Diseases of the Mind. Robert DeRubeis, chair of Penn’s psy- es were based,” writes Alyn Brodsky in Unfortunately, warned Rush, those are chology department and the Samuel H. his 2004 biography, Benjamin Rush: Patriot not the worst symptoms of “hypochon- Preston Term Professor in the Social and Physician. “We can attribute to Rush’s

46 JULY | AUGUST 2012 THE ILLUSTRATION BY MELINDA BECK THE PENNSYLVANIA GAZETTE JULY | AUGUST 2012 47 efforts more innovation in the - Morgan and William Shippen, Jr. at the izing and treatment—above all, the un- newly founded department of medi- Lean on Me— derstanding—of the mentally afflicted cine in the College of ,” In a Healthy Way than to any other physician of his time.” one of the University’s predecessor in- Medical Inquiries and Observations Though the mental-health field has stitutions. Penn’s first-in-the-nation IN Upon Diseases of the Mind, Benjamin seen numerous advances since 1812, medical school was founded in 1765.) Rush states there are only two reasonable Rush’s struggle to make sense of the Rush’s mentor Redman subscribed to fears: death and surgery. Dianne Chambless, mysteries of the mind and relieve pa- the theories of 17th-century English Merriam Term Professor of Psychology, tients’ suffering resonates with Penn physician Thomas Sydenham, who ar- wouldn’t go that far, though she can under- practitioners facing 21st-century chal- gued that “disease resulted from an ac- stand the tight focus of Rush’s statement. lenges. One professor, DeRubeis, even cumulation of ‘morbific matter’ in the “If you’ve ever been in the old operating room draws parallels between Rush’s well-in- body that could be drained only by bleed- of Pennsylvania Hospital and seen the hammer tentioned overreaching and the over- ing, purging, or sweating.” Much to his they used to conk people on the head with [before prescription of antidepressants today. disadvantage, Brodsky writes, “Rush there was] anesthesia, you’d think it’s pretty rea- sonable to be afraid of surgical intervention.” According to Steven Peitzman C’69, a never abandoned his belief in bleeding— What interests Chambless more is Rush’s nephrologist and Drexel University medi- which, as can be imagined often caused recommendation that fearful patients have cal professor who travels around the coun- the patient’s death quicker than the dis- someone keep them company the night before try lecturing about the history of American ease it was meant to ameliorate …” surgery. “We call that social support today,” medicine, Diseases of the Mind came out Rush continued his training abroad, she says. “We all need support from those at a pivotal time. Though a pious individu- earning a degree from the most presti- we’re most intimate with.” With that in mind, al, Rush was a product of the 18th century gious medical school of the day, the she is investigating how patients’ family rela- Enlightenment, which emphasized the University of Edinburgh, where he tionships affect anxiety-treatment outcomes. importance of rational thought and recog- came under the influence of William Family dynamics can impinge on treatment nized the natural causes of disease. Other Cullen. Cullen taught that all diseases in two ways, Chambless says. “One, if the influences were the humanitarian efforts stemmed from problems in the ner- family is meaning to be helpful but is actu- of the Philadelphia —and later, vous or vascular systems. ally overprotecting the person who is afraid the work of Quaker physicians in England, Systems thinking dominated medi- … they keep the patient from progressing in who “believed the spark of the divine to be cine at this time, according to Steven treatment.” Her second concern is when fam- in everybody,” including the mentally ill. Peitzman. Many physicians, including ily members engage in destructive and critical talk. “We think this arouses a lot of negative Rush, believed that one set of principles emotion that feeds into whatever psychopa- The man who would become the father could be used to explain most diseases. thology people have.” of American psychiatry, among other In 1783 Rush joined the medical staff To study these issues Chambless interviews achievements (Rush also signed the of the Pennsylvania Hospital, combining patients’ relatives. “I remember one husband Declaration of Independence, served in his duties there with a growing private who said [of his wife], ‘I don’t know what rock the Continental Congress, and champi- practice and faculty appointments at she crawled out from under. She’s a wacko.’ oned women’s education, penal reform, Penn’s medical school, where he was a That kind of contempt is a pretty bad sign. and the abolition of slavery) was born on a professor from 1769 until his death in We also bring patients and their relatives into farm 12 miles from Philadelphia in 1746. 1813. When Rush arrived at Pennsylvania the lab and ask them to talk about problems After the death of his father, a gunsmith, Hospital there were 24 “lunatics”—most in their relationships on camera, and we when he was five, Rush’s mother opened a of them shackled in dank basement cells. review those videotapes for the nature of their grocery to help support the family. When Rush was appalled by their treatment. interaction.” She’s found an average of one he was just 15, Rush graduated from the “Prior to Rush’s time, information on criticism in every 70 seconds of face-to-face College of New Jersey (later Princeton) psychiatry and the treatment of the in- interaction. Sometimes the problems can be with a bachelor’s degree and a gift for ora- sane was practically nonexistent, as was resolved by helping family members learn to tory. He planned to pursue law until an any book [on the subject] either written talk with one another. “People who live with people who have psy- uncle dissuaded him from a career “full of or published in America,” writes Brodksy. chological problems are under a great deal of temptations” and urged him to study med- “With few exceptions, there were no fa- strain,” she says. “It’s remarkable how well many icine instead, writes biographer Alyn cilities for the insane.” Those who weren’t people deal with that, without blaming them.” Brodsky. At the time there was no medical jailed with criminals or forced into alms- school in America, so Rush entered a six- houses were simply left to wander. year apprenticeship with Philadelphia When Pennsylvania Hospital was estab- God for [their conditions],” she says. physician John Redman, eventually sub- lished in 1751, its founders at least had the Guided by Enlightenment principles, stituting for the doctor when he took ill. intention of treating mentally ill patients, “they were going to … start to think about (During the latter part of this period, according to Stacey Peeples, the hospital’s how to cure people. The problem was according to a biographical note on curator and lead archivist. “We were step- they didn’t have any great ideas yet. Rush on the University Archives and ping away from a lot of superstitions and “One of the beliefs that was a carry- Records Center website, he also “at- a lot of beliefs around witchcraft, or that over [from earlier times] was that the tended the first lectures of John people were somehow being punished by mentally ill were impervious to hot or

48 JULY | AUGUST 2012 THE PENNSYLVANIA GAZETTE cold,” Peeples adds. The hospital man- pneumonias, tuberculosis. When some- Therapist or Coach? agers, “of course, were running a busi- body has a fever, their heart rate is in- patient that Dr. Paul Grant was inter- ness, and they figured, ‘Why should we creased,” he explains. “The notion of bleed- The viewing for a research project years bother to heat their rooms?’” When Rush ing was to tap off this excess energy.” ago had the typical disorganized speech of came along, he argued that patients’ According to DeRubeis, many of the a schizophrenic. Grant, now research assistant health would improve if steps were taken positive mental-health outcomes Rush professor of psychiatry at the Aaron T. Beck to enhance their basic living conditions. claimed from bleeding and other treat- Psychopathology Research Center in Penn’s “So the board of managers agrees to it, ments probably resulted from the place- Perelman School of Medicine, could hardly [and] of course there were much better bo effect. Either that, he says, or patients understand what the man was saying. outcomes than in prior years, because were so “derailed” that their weakened Then, all of sudden, the patient said, “I’m 52 they were not freezing.” At Rush’s urging, state was mistaken for a cure. years old. Where’s my wife? Where’s my kids? a separate hospital wing for the insane Rush also invented a contraption called Where’s my house?” was built in 1797. the Tranquilizer for restraining and calm- At the time, Grant recalls, he was surprised. Touting his own good deeds, he wrote: ing deranged patients. “I tell people to “There it is, in the middle of the cloud of psycho- “The clanking of chains, and the noise think of an electric chair, but with a box sis: basic human goals.” Since then Grant has of the whip, are no longer heard in their on your head,” Peeples says. Although no come to realize that this is actually the norm in schizophrenia. “Even very disorganized and cells. They now taste of the blessings of shocks were delivered, patients would be seemingly confused patients have goals.” air, and light, and motion, in pleasant strapped into an upright position, where Encouraging schizophrenia patients to set and and shaded walks in summer and in they might remain for several hours, in meet goals is one of the main tools Grant uses spacious entries, warmed by stoves, in order to reduce vascular pressure in the in cognitive therapy, along with helping them winter, in both of which the sexes are brain. Rush at least saw to it to provide a “overlearn” positive messages about themselves separated, and alike protected from the close-stool half-full of water underneath to block out the negative ones, engage in plea- eye of the visitors of the hospital.” the chair, where patients could deposit surable activities, and reflect on their own enjoy- Extending the ideas of Cullen, his old their “alvine evacuations.” ment. Such approaches have resulted in better mentor from Edinburgh, Rush proclaimed According to Brodsky, the Tranquilizer outcomes than antipsychotic medications and insanity to be a disease situated in the was soon discontinued because of the standard therapy alone in low-functioning schizo- blood vessels of the brain. He divided its injuries it caused. As a symbol of early phrenics, according to a study authored by Grant “remote or exciting” causes into those medical follies, the device is easy to last year in the Archives of General Psychiatry. that acted directly on the body (such as ep- mock. But other treatments Rush advo- Medication is no panacea for a disorder that ilepsy, a fall from a horse, or the “solitary cated have endured for two centuries. brings hallucinations, speech disturbance, apathy, vice” of onanism) and those that acted on He had the insight, for example, that pa- and social withdrawal, he points out, and it can it indirectly, through the mind (including tients who worked fared better than produce unpleasant side effects. Because schizophrenics are so often taken intense study, ridicule, and the “unexpect- those who were inactive. care of by other people, he tries to empower ed loss of money”). Rush’s cures were in- In one of the doctor’s anecdotes, a pa- his patients to do more for themselves. Even tended to work in both ways, as well— tient recovered from his afflictions after something as seemingly mundane as learning to through the body or the mind. helping out with his family’s hay harvest. operate a coffeemaker might be practiced many A document of its time, Diseases of the “He worked for some time and brought times until the patient (who typically struggles Mind is full of remedies that would make on thereby a profuse sweat, which soon with memory loss) masters the task. the 21st-century reader drop her smell- carried off his disease,” Rush writes. “We’re really like coaches, as opposed to ing salts (if she still carried them), in- By championing ideas such as the ben- therapists,” working with patients to break goals cluding the advice that physicians pour efits of work, Peeples notes, Rush acted into “manageable pieces,” Grant says. “Say a cold water up the sleeves of disobedient as a bridge between the old way of doing patient wants to finish a degree, but he or she patients or use terror as a treatment. things and a new, “” that can’t read. “The first step might literally be when Peeples asks, “Can you imagine anyone would flourish when Pennsylvania Hos- they come see you each week [to] read just a today in hospital administration saying pital opened a division of the insane in sentence or two to see that they can do it. Each [to a patient]: ‘You want to drown? Let me 1841 under the leadership of Thomas time you have them read a little more.” For the get some water for you.’” Kirkbride. (In addition to expanding oc- next step, the patient could sit in on a lecture. Rush insisted on bleeding early and of- cupational therapy Kirkbride took other A decade ago, Grant might have said that schizophrenics have to be on medication; how- ten—a position that had already scarred steps to enhance patients’ dignity, such ever, recent European studies show that some his reputation in the Yellow Fever as producing “magic lantern” shows on patients actually manage better without it. “What Epidemic of 1793, when critics said his various topics to entertain them and I don’t know is if there are some people for whom liberal use of the lancet contributed to stimulate their minds, and in his On the that is not possible,” he says. “The main point many of the victims’ deaths. Construction, Organization, and General is that medication is [only] part of the treatment The medical practice of bleeding actually Arrangements of for the In- package. Trying to keep it at a minimum is defi- goes back to the time of the ancient Greeks, sane, first published in 1854, Kirkbride nitely a good thing and [so is] trying to build in all Peitzman says. “Some people think it per- would provide the guidebook for mental these other things that can help a person have sisted in part because at one time febrile hospitals up through the beginning of mastery over their own situation and realize as diseases were so common—diarrheas, the 20th century.) much potential as they can.”

THE PENNSYLVANIA GAZETTE JULY | AUGUST 2012 49 and expert on post-traumatic stress In November 1812, just five months be- Facing Down Fears disorder and obsessive-compulsive dis- fore he died, Rush wrote a letter to an old order, criticizes many of Rush’s outdat- friend, the former President : dna Foa was once in a car accident, and ed approaches. She believes the doctor Ethough the Penn professor of clinical was on to something, however, when Herewith you will receive a copy of my psychology wasn’t badly hurt, her car was he discussed fears, making the distinc- Medical Inquiries and Observations totaled. As shaken as she was by the experience, tion between those that are reasonable upon the Diseases of the Mind. I shall she got back behind the wheel. “I learned you don’t (such as a fear of death) and those that wait with solicitude to receive your get into a car accident every day, so it’s OK.” are not (such as a fear of the dark). “I opinion of them. They are in general ac- By facing her fears, Foa kept from developing think he had a good notion that to get commodated to the “common science” post-traumatic stress disorder. Many people who over an unreasonable fear, you have to of gentlemen of all professions as well have been through traumatic experiences aren’t be exposed [to the source of fear],” she as medicine. The subjects of them have so lucky, including an estimated 200,000 to says. “This was a lot [of years] before hitherto been enveloped in mystery. I 400,000 veterans of Iraq and Afghanistan. Foa, who runs the Center for the Treatment Freud,” who divided fears into three have endeavored to bring them down to and Study of Anxiety in Penn’s Perelman School categories of anxiety—realistic, moral, the level of all the other diseases of the of Medicine, is a leader in the use of prolonged and neurotic. “There was no theory, to human body, and to show that the mind exposure (PE) therapy to treat PTSD sufferers and my knowledge, no systematic discus- and body are moved by the same causes people with obsessive-compulsive disorder. She sion of unreasonable and reasonable and subject to the same laws. For this was named one of Time magazine’s “100 Most fears” in Rush’s time. “I think what he’s attempt to simplify the “medicina men- Influential People in the World” in 2010 for her observing is quite astute.” tis” I expect no quarter from my efforts to disseminate this treatment to mental- For Dr. Martin Seligman Gr’67, the learned brethren. health professionals internationally and to those Zellerbach Family Professor of Psy- who work with military-combat veterans. chology and director of Penn’s Positive Rush must have felt both hope and “If you have a traumatic experience, it makes Psychology Center, what elevates Dis- frustration as he looked toward the fu- a lot of sense that you would try to avoid contact eases of the Mind above a “quaint his- ture of the field he was pioneering and with something that reminds you of it, because torical” document is the following pre- sensed its limitations (or perhaps his it’s painful,” she explains. “Those avoidances scription for hypochondriasis: own). His quest to relieve human mis- are actually perpetuating a perception that ... ery was a personal as well as a public the world is extremely dangerous.” For returning soldiers, that might mean avoiding highways, Destruction of the old association of ideas. one. Rush’s eldest son, John, had been because they were dangerous in Iraq, or pushing Every thing a hypochondriac patient sees or admitted to Pennsylvania Hospital in away bad memories of combat. hears, becomes tinctured with some sad 1810, after he killed a friend and fellow By gradually exposing themselves to anxiety- idea of his disease … Change therefore his naval officer in a duel. (His mental producing situations and revisiting traumatic dress, his room, his habitation, and his com- health would never improve enough for memories to create a more accurate, and forgiv- pany, as often as possible. him to leave the institution.) But per- ing, narrative of the past, patients manage to haps the seasoned doctor took some loosen PTSD’s grip over their lives. “Destruction of the old association of consolation in his own closing words: About 30 studies point to PE’s effectiveness, ideas” is quite directly what modern with an average of about 80 percent of patients Cognitive Therapy seeks to do,” Seligman But time I hope will do my opinions recovering from PTSD. Still, it’s hard to change writes in an email—for example, “by chal- justice. I believe them to be true and the habits of therapists used to treating the dis- lenging (destruction) the belief (old asso- calculated to lessen some of the greatest order in more traditional ways. ciation) ‘I am a loser’ with realistic evi- evils of human life. If they are not, Foa is now looking for ways to enhance expo- dence that you got ‘almost straight A’s,’ I shall console myself with having aimed sure therapy so patients get better results from Cognitive Therapists are direct, if uncon- well and erred honestly. fewer sessions, and to disseminate PE theory to scious, descendants” of this approach. more practitioners around the world. If Rush’s treatments seem all over the Few would doubt the doctor’s noble aims. place, one must appreciate that this was But for all the developments since Rush’s Paul Grant, a Penn research assis- a man trying to wrap his mind around a day, there remains much to be learned tant professor of psychiatry who works tremendously complex problem before about mental illness. with schizophrenic patients, says he there was such a thing as the DSM According to Grant, “The dream of uses some of the very same strategies (Diagnostic and Statistical Manual of psychiatry is that we will have illness- that Rush used, such as finding out pa- Mental Disorders). “He was covering the es such as schizophrenia cured within tients’ favorite pastimes to break waterfront,” says DeRubeis. “He was try- 50 years—understood genetically and through the haze of their illness, and ing to figure out how to get each [pa- neurobiologically, with treatments fol- encouraging them to become more tient] from point A to point B. The range lowing from this understanding. How- physically active and volunteer. “This of people he was thinking about is in- ever,” he notes, “the same dream exist- is the beginning of modern psychia- credible. From these little tests and an- ed 200 years ago.” try—this gentleman and his work.” ecdotes comes the evolution of psychol- DeRubeis links some of Rush’s over- Edna Foa, a professor of psychology ogy and psychiatry.” zealous remedies to a concern in men-

50 JULY | AUGUST 2012 THE PENNSYLVANIA GAZETTE PAUL GRANT: There’s a lot of evidence that this makes psychosis Restored to Reason worse, [increasing] delusions and hallucinations and disorganization. Benjamin Rush had many ideas for easing the suffering caused by mental ■ Cold. “The hair should be cut off, and shaved from every part disorders. But did any of them work? We decided to ask some current Penn of the head … we not only expose the head to a greater degree of therapists to weigh in on the subject. Here are a few of the recommendations cold, but we favour by it, at the same time, depletion from the Rush offers in his seminal 1812 volume, Medical Inquiries and Observations brain, by means of insensible perspiration. Upon Diseases of the Mind, followed by their comments. “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 … FOR GENERAL INTELLECTUAL DERANGEMENT The coldness should be continued for several days and nights. The ■ “Confinement by means of a strait waistcoat, or of a chair, signal for removing them should be when they produce chilliness, which I have called a tranquilizer. He submits to them both with and sobbing or weeping, in the patient. less difficulty than to human force. The tranquilizer has several “In order to derive benefit from the application of cold water to the advantages over the strait waistcoat or mad shirt. It opposes the whole body, it should be immersed in it for several hours.” impetus of the blood towards the brain, it lessens muscular THASE: There is some calming effect through the process of bathing action every where, it reduces the force and frequency of the [and being] immersed in cold water. Interestingly, various kinds of pulse, it enables the physician to feel the pulse and to bleed states of excitement are associated with increased blood flow and without any trouble, or altering the erect position of the increased energy utilization in regions of the brain, so it’s not far- patient’s body; and, lastly, it relieves him, by means of a close fetched to think a cooling intervention might have a calming effect. A stool, half filled with water, over which he constantly sits, from former colleague of mine at the University of Pittsburgh is looking at the foeter and filth of his alvine evacuations.” a forehead-cooling device to deal with chronic insomnia. ROBERT DERUBEIS: I don’t think anyone goes along with Rush’s ■ Diversion. “Divert the ruling passion or subject which occupies the theories about blood to brain impetus. But the straitjacket does mind, if it be one, and fix it upon some other… In order to do this, it will have two actions: … Obviously, it protects those taking care of a be necessary to find out the favourite studies and amusements of our person. It’s also believed to allow the person to use their own patients … The distracted mind of the poet Cowper was composed while internal resources to calm down if they’re in the midst of manic he was employed in the single business of translating Homer; and I fit or a peak of schizophrenia. Most people in modern times have heard of a woman who was cured of madness, by keeping her con- don’t think about it anymore as something that’s much done for stantly employed for several days in playing cards.” mental illness, but in some hospitals there is felt the need to GRANT: This is really rock solid stuff. It is fundamental to the type have such devices around for such a purpose. of treatment we are doing with [schizophrenic patients] … A huge MICHAEL THASE (professor of psychiatry): The [Tranquilizer] chair part of rehabilitating them is to reconnect them with things they he came up with didn’t survive the test of time. used to enjoy. It makes them feel less like patients and more like ■ Bloodletting: “From 20 to 40 ounces of blood may be taken at once, regular persons … You can spend all day being paranoid or grandi- unless fainting be induced before that quantity be drawn. It will do ose, depending on which [form of schizophrenia] you have, but if most service if the patient be bled in a standing position. The effects you do something you enjoy—playing a game, going to a movie, of this early and copious bleeding are wonderful in calming mad peo- whatever—you have less time to be psychotic. [I have one] patient ple. It often prevents the necessity of using any other remedy, and who’s completely withdrawn and sleeps all the time. One of the sometimes it cures in a few hours.” things we’re doing is getting her back into interaction with other DERUBEIS: Bloodletting has gone away, thank goodness, people by playing cards. although what was its main effect perhaps was its weakening or ■ “Terror acts powerfully upon the body through the medium of tranquilizing effect. They didn’t have access to the range of the mind. I once advised gentle exercise upon horseback, in the pharmacopeia we have. case of a lady in Virginia who was deranged. In one of her excur- THASE: It’s not life threatening [in this amount], but it would be sions from home, her horse ran away with her. He was stopped after enough to provoke lightheadedness. It just kind of rolled out of a while by a gate. The lady dismounted, and when her attendants your arm into a bowl, so I would think that not only the physiolog- came up to her they found her, to their great surprise and joy, per- ic shock of losing that much blood, but also the sight of it … had a fectly restored to her reason.” kind of startling effect on some people. CHAMBLESS: Stress is not good for people with schizophrenia. ■ “Low diet, consisting wholly of vegetables, and those of the GRANT: This seems to be almost a Hegelian approach to treat- least nutritious nature …” ment: These symptoms are so strong and intense, you have to DIANNE CHAMBLESS: Copious bloodletting would calm people down have something equally strong and intense to abate them. They because they would be in a stupor and a really poor diet would starve a used to give patients camphor to induce convulsions to calm person into relative tranquility. That all sounds pretty awful. psychosis. But camphor can also kill you. Many of the people ■ Solitude and darkness. “The passions become weak by the who have psychoses also have symptoms of trauma. They’ve abstraction of company, and by refraining from conversation. For this [already] been terrorized by other people. reason, visitors should be excluded from the cells and apartments of highly deranged people … Darkness … invites silence, and it induces a FOR HYPOCHONDRIASIS reduction of the pulse, by the abstraction of the stimulus of light, and ■ Activity. “Man was made to be active …Hypochondriac derange- by the influence of fear, which is naturally connected with darkness.” ment has always kept pace with the inactivity of the body and mind

THE PENNSYLVANIA GAZETTE JULY | AUGUST 2012 51 which follows wealth and independence in all countries … DERUBEIS: It’s been shown that exercise, period, is a treatment Building, commerce, a public employment, an executorship to a for depression. will; above all, agriculture, have often cured this disease.” CHAMBLESS: He’s onto something that exercise and labor are GRANT: This is one of the main interventions we’ve been using important for people who are depressed. To be occupied is to with people who have negative symptoms. They’re not motivat- not be left to constantly dwell on their misfortune and how ed to do very much. This is what keeps them out of the main- horrible they are. I don’t know that subjecting [patients] to cen- stream of life … This is true for depression, too. There’s a sense trifugal force is something we would suggest, but exercising in which these people say, “I’ll start doing stuff when I feel bet- does have an effect on depression. ter.” 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 volun- FOR DERANGEMENT OF THE PASSIONS (grief) teer … helping other people. ■ Opium. “It should be given in liberal doses in its first paroxysm, and ■ Amusements. “The chase, shooting, playing as quoits, are all it should be repeated afterwards, in order to obviate wakefulness.” useful for this purpose. … The theatre has often been resorted to, to ■ Silent company. “In their first visit to persons recently bereaved remove fits of low spirits … Certain animals suspend the anguish of of their relations, they should imitate the conduct of Job’s friends, the mind of this disease by their innocence, ingenuity, or sports. who … the sacred historian tells us, ‘sat down with him upon the Mr. Cowper sometimes found relief in playing with three tame ground, seven days and seven nights, and none spake a word to him, hares, and in observing a number of leeches to rise and fall in a for they saw his grief was very great.’ … in this way, grief most rapid- glass with the changes in the weather.” ly passes from the bosom of the sufferer into that of his friend.” DERUBEIS: We don’t do that much anymore … [we] increasing- ■ Removal. “The persons afflicted with grief should be carried ly see these kinds of activities … as being avoidant. [For exam- from the room in which their relations have died, nor should they ple, with] panic disorder, [people] used to think it was good to ever see their bodies afterwards. They should by no means be per- do this diversion thing, because … it basically puts a governor mitted to follow them to the grave … After the expiration of the on the panic … People came along and said no, that simply weeks of mourning, care should be taken never to mention the reinforces the idea that one can’t tolerate the panic experience names of the deceased persons to any of their friends.” and one must get away from it, as opposed to one must ride it CHAMBLESS: None of these things I would recommend. We don’t out and understand it’s not a big deal. want people to dwell 24 hours a day on their loss, but you do want ■ “Music has often afforded great relief in this disease ... I attend- them to acknowledge it and feel their sorrow and get through it. I had ed a citizen of Philadelphia, occasionally in the paroxysm of this contact very early in my career with a woman who had a stillborn disease, who informed me that he was cured of one of them by child. They kept her doped up in the hospital and disposed of the body hearing the old hundred psalm tune sung in a country church … before she woke up … Nobody in her family ever talked to her about GRANT: Music is like a fundamental thing that doesn’t seem to this child. She stayed at home mostly because she couldn’t bear see- go away. I’m working in a hospital with 24 chronic [schizophre- ing people out with baby carriages. She never dealt with this grief. nia] 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 FOR DERANGEMENT OF THE PASSIONS (fear) all want to do it. They sing along, play drums. You would think, all ■ Darkness. “The fear which is excited by darkness may easily be of a sudden, that none of these people seem [mentally ill]. overcome by a proper mode of education in early life. It consists in compelling children to go to bed without a candle, or without per- FOR MANALGIA (characterized by “taciturnity, downcast looks, mitting company with them until they fall asleep.” a total neglect of dress and person, long nails and beard, ■ Teaching. “The fear of ghosts should be prevented or subdued in disheveled or matted hair, indifference to all surrounding early life by teaching children the absurdity and falsehood of all the objects, insensibility to heat or cold.”) stories that are fabricated by nurses upon that subject.” ■ Exercise (and the Gyrator). “This should consist of swinging, FOA: This child is going to scream and scream and scream, and seesaw, and an exercise discovered by Dr. Cox, which promises finally will fall asleep, but it can take hours. We don’t do it like this more than either of them, and this is, subjecting the patient to a now. In the beginning we let the child sleep with a dim light and then, rotary motion, so as to give a centrifugal direction of the blood in several days, maybe we can put a light in the corridor ... And maybe towards the brain … I have contrived a machine for this purpose in if it’s a small child, we will give him his favorite toy or stuffed animal our hospital, which produces the same effects upon the body ... to sleep with ... So we take it gradually instead to avoid misery. These are vertigo and nausea, and a general perspiration. I have I think he had a good notion that to get over an [unreasonable] called it Gyrator. … It produces great changes in the pulse. In one fear, you have to be exposed [to it]. You cannot just tell a person experiment made with it, it increased the pulse from 84 to 88 not to fear the darkness and they’re OK. They have to experience strokes in one minute, and to 120 in two minutes …” that what they’re afraid of doesn’t happen. ■ Labor. “It has been remarked that the maniacs of the male sex in Simply teaching [children] the absurdity of [ghost] stories … may all hospitals, who assist in cutting wood, making fires, and digging not help. Maybe what we need to do with little children is to kind of in a garden, and the females who are employed in washing, ironing, do magic: “OK, we will just tell the ghosts to go away. Those ghosts and scrubbing floors, often recover, while persons, whose rank listen to Mommy.” We use methods that would be commensurate exempts them from performing such services, languish away their with the developmental age of the child.—S.F. lives within the walls of the hospital.”

52 JULY | AUGUST 2012 THE PENNSYLVANIA GAZETTE tal-health treatment today: “When a A Stimulating Concept person of sound mind, such as Benjamin Exercise before Rx for Depression Relief Rush, observes individuals who are middle-aged sales manager who functioning very poorly and are miser- Benjamin Rush’s day, the symptoms Thefound his way into a Penn research able as a result … it brings out an INof mental illness that might put a study complained of diarrhea and sexual side urgency to do something, to take some patient under his care were pretty severe. He effects from the antidepressants he’d been kind of action, because it’s just too described one clergyman who “lost his appe- tites and passions, so as to desire and relish taking. Eager to try something new, he traded hard to watch.” Today, he believes, that his meds for a seat, five mornings a week, in nothing, and to love and hate no one.” So far commonly takes the form of primary- gone was the man that “he lost all sense of something that looked like a dentist’s chair. But care doctors overprescribing antide- no drilling was involved. years, months, weeks, days, and nights.” pressants to their patients. “The doctor Today, says Robert DeRubeis, chair of Penn’s Instead, he remained there for about an hour who is sensitive and aware and con- each time, while a coil placed against his scalp psychology department and the Samuel H. cerned looks at someone and says, ‘My used low-level magnetic energy to set off changes Preston Term Professor in the Social Sciences, in his brain circuits. “By the end of the first week, goodness, this person is in pain, I’ve “when a person is not quite within the norm he seemed a little brighter and thinking a little got to do something’ … which is provide in terms of their mood or behavior or sense more clearly,” recalls Dr. Michael Thase, professor a prescription for pretty much any of self, we’ve brought those into the arena of of psychiatry and chief of the Division of Mood and complaint a patient has. It’s very hard things that must be addressed” with psycho- Anxiety Disorders Treatment & Research Program. not to do that.” therapy or medication. But both come with “By the second week he was definitely better—may- DeRubeis calls the overuse of antide- costs—either in dollars, side-effects, or time be his symptom-level had improved by 50 percent. pressants “a big puzzle, a big problem”— spent seeing a therapist each week. By the third week, he was profoundly better.” not one that requires “big solutions, DeRubeis has been studying how the health For patients who can’t tolerate or get little relief but more sensible solutions.” system can more sensibly help patients with from antidepressants, Transcranial Magnetic Edna Foa believes that researchers mild-to-moderate symptoms take charge of their depression. Stimulation (TMS) is a promising new option, says have made huge strides in some areas Thase. TMS is safe and doesn’t come with the com- The milder side effects of today’s antide- of mental health. “I think we know a pressants, combined with the decreasing plications of a procedure like electroconvulsive thera- lot about treating anxiety disorders. py, which works by inducing seizures in the brain and stigma of mental illness, has made patients That doesn’t mean every patient can less resistant to seeking treatment. While requires patients to be under general anesthesia. be treated, but that’s also true about The procedure is painless, though some increased awareness is a good thing, “it’s also high blood pressure,” she says. “We patients report feeling an odd tapping sensation led to expectations that we should never feel in their forehead or jaw. A bigger issue is keeping have had amazing success with PTSD, depressed or sad,” DeRubeis says. “I’m not for patients from falling asleep “just out of boredom,” with phobias … We have developed sad, but it can be a part of human life and it Thase says. “We try to keep people awake, just treatment protocols which can be needn’t be a big part of human life.” in case, because the relationship between the taught and disseminated to a large Assuming that a person’s depression is not regions of the brain is changed if you fall asleep.” number of people.” severe, exercise, proper diet, and a reengage- Researchers don’t know yet how this would affect Schizophrenia, on the other hand, has ment with work, recreation, and social activities the procedure. (It might even improve it.) not been “one of medicine’s success sto- should be tried first, DeRubeis says. Thase has also conducted research on another ries, Grant points out. “There does not Far from feeling a threat to their profession, neuromodulation therapy, called Direct Brain appear to be a few genes that are going he thinks, psychologists “could be very helpful in designing and overseeing and participating in Stimulation (DBS), which involves implanting tiny to account for most of the heritability. these systems that would bring the most effec- wire electrodes into different regions of the brain. (It looks like it could be hundreds, if not tive and efficient care in the places where peo- In a recent DBS study at Penn, more than half of more, with each conferring very little in patients improved significantly, but not as rapidly ple are getting their treatment, whether anybody terms of the likelihood of developing likes it or not—in the primary-care setting.” as hoped. It remains an experimental treatment. the disorder.)” In contrast, a few insurance plans are begin- On top of that, he notes, “the more ning to cover TMS, and Thase believes more research that returns on the medica- social structure, having friends, [and] will cover it over time—in carefully monitored situations and after medication has been tried. tions, the better we see that the placebo having meaningful work.” Researchers are still working to achieve a better effect is substantial, the drug beats Grant saw this in a patient for whom patient-treatment match. placebo only modesty, and that the vast the key to feeling better “was essentially Unfortunately, says Thase, the patient who majority of schizophrenia patients serving coffee and being a short-order fared so well during his course of TMS treatment either do not respond at all or show cook at her mental health center.” found his old symptoms returning after the treat- quite a substandard response.” Volunteering and helping other people ment ended. He had to return for follow-up ses- Interestingly, what does seem to offer “made it so she could ignore her voices sions on a less frequent schedule. promise for schizophrenia as well as and so she could get up in the morning. Thase and his colleagues are about to begin a other mental disorders is the “human “This must be something Rush ob- new study of TMS. One of the questions they’re side of treatment,” Grant says. “Rush served,” says Grant. “Human nature hoping to answer is whether the use of magnetic [already] knew some of what my team hasn’t changed since the 1800s.”◆ resonance imaging to better pinpoint the “sweet has learned [about the importance of] Susan Frith is a former Gazette staffer and a free- spot” to target in the brain’s prefrontal cortex having a meaningful place within the lance writer based in Orlando. produces better results. THE PENNSYLVANIA GAZETTE JULY | AUGUST 2012 53