Benjamin Rush - Myths Turned Into Propaganda

  

If you are a casual reader of this blog, you may not have noticed a large post in the past that was dedicated to countering common antipsychiatry propaganda that involved Benjamin Rush (1746-1863).  Rush was a physician who was a participant in the Continental Congress and a signer of the Declaration of Independence. He is considered both a Founding Father and the Father of American psychiatry.  In the latter case, I have expressed the opinion that he was not really a psychiatrist and that his methods as a physician were somewhat primitive – particularly the propensity for bloodletting that he encouraged his own physician to use. Of course, writing this in 2023 and calling his 18^th century methods primitive is an easy task and I am sure that if civilization lasts – 24^th century physicians may say the same thing about the current practice of medicine.  The reason why Rush’s connection to psychiatry has persisted is that he was an important historical figure and prolific writer, he made useful observations about alcoholism and the care of patients with mental illnesses in his time and provided asylum care.  He was considered one of the most prominent physicians of his time.  There is also overlap between Rush’s lifetime and the American Journal of Insanity (1844-1943) – the precursor to the American Journal of Psychiatry. 

His historical prominence  was probably the reason the American Psychiatric Association (APA) incorporated Rush and his image into various seals, certificates, and awards.  As an example, I have two medals and two certificates that contained his embossed image and name from the APA.  These same considerations are probably why the detractors of psychiatry have either made up stories about him or interpreted his work in the most negative possible light. Much of that rhetoric has been so successful that it now exists in the psychiatric literature.  In a 2015 rebranding the APA dropped Rush's image from its logo - but retained the image for ceremonial purposes. 

Rush has been a target of antipsychiatry criticism and rhetoric since the 1970s. Some of the most enduring but inaccurate tropes have been about him – most notably involving the invention of the condition negritude and being affiliated with Samuel Cartwright – a southern proslavery physician who promoted the concept of drapetomania or a disease that caused slaves to want to run away and the need to treat that condition with physical coercion.  Szasz successfully developed both conditions into antipsychiatry tropes in a 1971 paper.  Both are still actively used today as antipsychiatry critics seek to tie modern day psychiatrists with racism and social injustice as well as early physicians who were not really psychiatrists.  By my estimate the discipline has existed in the US for about 100 years.  These tropes have been so successful that they have found their way into professional literature including the flagship journal of the American Psychiatric Association – The American Journal of Psychiatry.

Here are a few examples of the inaccuracies:

“Of particular interest was Benjamin Rush (considered the father of American psychiatry), who believed that Black skin was a mild form of leprosy that he called “negritude,” which could be cured only by becoming White. An apprentice of his, Samuel Cartwright, coined the diagnosis “drapetomania,” a mental illness that caused Black slaves to flee captivity. After the Civil War, the frequency that severe mental illness was found in the diagnoses of patients admitted in the country’s first psychiatric hospital for Blacks patients—Central Lunatic Asylum in Petersburg, Va.—raises an important question about whether Black patients were overdiagnosed with severe mental illness, as they have been in modern times. In addition, numerous references can be found to the hypothesis that mental illness in the Black population increased substantially with the end of slavery.” (1)

“In 1851, Samuel Cartwright, a prominent Louisiana physician who had studied under Benjamin Rush but was not a psychiatrist, identified two mental disorders peculiar to slaves: Drapetomania, or the disease causing blacks to run away, and Dysaethesia Aethiopica, or the condition that accounted for laziness among slaves. Such diagnoses, of course, were racist pathologizing of reasonable behavior.” (2)

“Cartwright’s theories were embraced in the slave states and mocked in the free states, including in medical journals,” Geller said. “APA was silent, and that is our shame. They were silent then, and we have been silent for 176 years.”

In fact, Cartwright’s theory was not embraced in either group of states, it was not a diagnosis that was used.  The APA and psychiatry did not exist. (3)

“Over 60 years after the ratification of the U.S. Constitution, physician Samuel Cartwright played a prominent role in the rise of racism in the field of psychiatry. His descriptions and characterizations of mental health conditions in enslaved Africans, particularly drapetomania, which he described as the illness of enslaved people wanting to run away and escape captivity, and dysaesthesia aethiopica, a disease of “rascality” or laziness in enslaved Africans, were the beginning justifications of pathologizing normal behavioral responses to trauma and oppression. These “diseases” paved the way for long-standing rationalization of harsh, inhumane treatment of mental illnesses in communities of color; Cartwright’s prescribed treatment for both conditions was whipping (22). The historical origins of racism in psychiatry set the stage for instances of structural racism that impact the diagnosis, management, and treatment of mental illnesses and substance use disorders to this day.”

If you consider Cartwright to set the “historical origins of racism in psychiatry” then there is no structural racism in psychiatry. (4)

“In 1792 Benjamin Rush, considered the father of American psychiatry and the best known physician throughout America in his era, proclaimed that Black skin was actually a disease. Rush was a remarkable mix of contradictions. He was an ardent abolitionist who owned a slave. He spoke out on the position that Blacks were of equal intelligence and morality as whites. Nonetheless, he created a disease called negritude, a disease whose cure was turning a Black person white.” (5)

“I consider Cartwright's "Report," and especially the two diseases afflicting the Negro that he discovered, of special interest and importance to us today for the following reasons: first, because Cartwright invoked the authority and vocabulary of medical science to dehumanize the Negro and justify his enslavement by the white man; second, because the language and reasoning he used to justify the coercive control of the Negro are identical to those used today by mental health propagandists to justify the coercive control of the madman (that is, the so-called "psychotic," "addict," "sexual psychopath," and so forth); and third, because Cartwright's "Report" is the sort of medical document that has, for obvious reasons, been systematically ignored or suppressed in standard texts on medical and psychiatric history

One such omission, discussed in detail in The Manufacture of Madness, is Benjamin Rush's theory of Negritude, according to which the black skin and other physical "peculiarities" of the Negro are due to his suffering from congenital leprosy (1, pp. 153-159).”

Any serious historical look at the diagnosis of drapetomania would show that it was ignored – even by southern physicians interested in racial medicine.  Szasz's analogy of slavery and mental illness is purely rhetorical. (6)

The tropes about Rush and his relationship to Samuel Cartwright and racial medicine seem entrenched at all levels of discussion of psychiatry including writing by psychiatrists. From a rhetorical standpoint they are used to legitimize an argument that the profession is either racist, built on a racist foundation, or did not actively counter racism when the opportunity presented itself. They are also used to suggest that psychiatric diagnoses are invalid - even though these pseudo-diagnoses by a non-psychiatrist were never used by any physicians.  Those specific narratives are false at best and fabricated at the worst.  This historical record is now clearly available and should be consulted in the future when writing on this topic at the University of Pennsylvania Benjamin Rush Portal.  If you read all the segments what I have written in this post covers only a portion of the myths.  You will also note that some of the myths are described as villainizing Rush.  I think the same characterization could apply to Szaszian rhetoric that has been applied to the entire profession of psychiatry in modern times on a repetitive basis.

While it may be unrealistic to think that historically accuracy will have much of an impact in this era of for-fame-and-profit-misinformation, I am suggesting a higher standard.  That standard is that members of the psychiatric profession and the editors of that literature should be aware of it and make the necessary changes.  I am fully aware of the current concerns about structural racism and building diversity. That cannot be based on a false narrative.  In fairness to Rush, I think it is necessary to set the historical record straight as his biographer Stephen Fried has done. Like most of the historical figures I write about on this blog – I see him just as that - with no relevance to modern day psychiatry.  Anyone reading Fried’s detailed biography of Rush will see him as a progressive thinker that would probably easily maintain that description even in today’s polarized political climate.

    

George Dawson, MD, DFAPA

 

 

References:

1:  Dike CC.  Misuse of Psychiatry.  Psychiatric News. Published Online:23 Apr 2022 https://doi.org/10.1176/appi.pn.2022.05.5.30

2:  Jeffrey Geller, MD, MPH. The Rise and Demise of America’s Psychiatric Hospitals: a Tale of Dollars Trumping Decency.  Published Online:26 Feb 2019 https://doi.org/10.1176/appi.pn.2019.3a36

3:  D’Arrigo T. Black Psychiatrists Call on White Colleagues To Dismantle Racism in Profession, APA.  Psychiatric News Published Online:23 Jun 2020 https://doi.org/10.1176/appi.pn.2020.7a34

4:  Shim RS. Dismantling Structural Racism in Psychiatry: A Path to Mental Health Equity. Am J Psychiatry. 2021 Jul;178(7):592-598. https://doi: 10.1176/appi.ajp.2021.21060558

5:  Geller J.  Structural Racism in American Psychiatry and APA: Part 1.  Psychiatric News.  Published Online:23 Jun 2020 https://doi.org/10.1176/appi.pn.2020.7a18

6:  Szasz TS. The sane slave: An historical note on the use of medical diagnosis as justificatory rhetoric. American Journal of Psychotherapy. 1971 Apr;25(2):228-39.

 

 

Supplementary:

I decided to include a section on Rush’s theory of black skin color to avoid the typical gotcha arguments from antipsychiatrists.  These arguments are contained in the reference below and I have supplied a link where you can download the entire paper. Context is always important when considering the medical, social, or political opinions from over 200 years ago.  The important contexts would include prevalent racial bias that obviously persists today, and the lack of important medical advances including germ theory, general pathophysiology, and medical genetics. 

He opens by referencing An Essay On the Causes Of The Variety Of Complexion and Figure In The Human Species by Rev. Samuel Stanhope Smith, DD – a professor of moral philosophy.  The essay is a book the content of which was based on a previous lecture given on February 28, 1787.  Rush touches on the four main causes listed in this text – climate, state of society, diet, and diseases.  Citing a moral philosopher and clergyman is not an ideal start to an opinion piece on pathology or pathophysiology, but it forms the main outline of his essay.

He suggests that the color and figure “of that part of our fellow creatures who are known by the epithet of negroes, are derived from a modification of that disease, which is known by the name of Leprosy.”  He says the leprosy outbreaks in Europe in the 13^th and 14^th centuries were caused by “unwholesome diets.”  He observes that “in some instances” leprosy causes a black color of the skin and that some Africans have other symptoms. He notes Biblical and real world observations describing inconsistencies in skin color. He suggests that “insensibility” as a feature of leprosy (meaning sensory neuropathy) may explain why people with African origins have a lower pain sensitivity.  He also connects leprosy with “strong venereal desires” and suggests this is also true in people of African origin.  He comments that leprosy can produce characteristic skin changes in whites as well and notes that matted hair in people of Polish descent is a sign.  He notes the longevity of the illness and that it took 3 to 4 generations to clear in Iceland.  He gives other examples of physical signs that are locally transmitted among ethnic groups.

He anticipates the objection that leprosy is an infectious disorder but that does not appear to be the case in Africans by saying that it has “ceased to be infectious” but also that there are exceptions in the case of mixed-race couples where white women acquired the features and skin color of their black husbands. Since he expects that leprosy does not significantly affect longevity he expects these traits to continue.  The causative bacterium for leprosy (Mycobacterium leprae) was eventually discovered in 1873 by Hansen.  The genetics of skin coloration was not discovered until the 21st century.

These are clearly very weak and biased observations.  Rush’s conclusions based on these observations are interesting.  First, claims of superiority of whites based on skin color are “founded in ignorance and inhumanity.” He suggests that if a disease is causing this difference “it should entitle them to a double portion of our humanity, for disease all over the world has always been the signal for immediate and universal compassion”.  Second, the facts outlined should teach white people to not keep intergenerational prejudices. Third, science and humanity should unite to find a cure for the disease, but the science at the time was non-existent. He goes on to list several anecdotal approaches.

Rush ends his paper speculating about how curing this disease of leprosy producing blackness would add greatly to the happiness in the world and that of people with African ancestry.  He qualifies that by noting that black people seem to prefer their skin color to white. He wraps it up in a Biblical myth at the end to say:

“We shall render the belief of the whole human race being descended from one pair, easy, and universal, and thereby not only add weight to the Christian revelation, but remove a material obstacle to the exercise of that universal benevolence which is inculcated by it.”     

This was 60 years before Darwin's Origin of the Species. It is doubtful than anyone at the time had a theory of how isolated groups of humans might evolve with different characteristics.

Although Rush did not technically invent a disease or word called negritude or suggest that it was responsible for skin color in African Americans – he certainly proposed what I would characterize as an off-the-wall theory.  His writing further suggests that a solution of universal white skin would allow for a more harmonious existence – with less discrimination and that would be a solution to the problem of racism. It is an overly simplified and biased solution by today’s standards.  Since Rush was obviously not racist the logical explanation for this opinion is a significant knowledge deficit and speculating outside of his lane.     

 

Rush B: Observations intended to favour a supposition that the black color (as it is called) of the Negroes is derived from the leprosy. American Philosophical Society Transactions 4 (old series): 289-297, 1799.  Link directly loads PDF:  https://canvas.emory.edu/courses/86982/files/5134312/download?download_frd=1

Drapetomania - The Lack of Relevance To Psychiatry

 

I will address this issue one final time. I have written about it in the pages of this blog in past. Drapetomania was a pseudo diagnosis coined by Southern physician named Samuel A. Cartwright. He wrote the following in 1851:

“DRAPETOMANIA, OR THE DISEASE CAUSING NEGROES TO RUN AWAY.
It is unknown to our medical authorities, although its diagnostic symptom, the absconding from service, is well known to our planters and overseers...
In noticing a disease not heretofore classed among the long list of maladies that man is subject to, it was necessary to have a new term to express it. The cause in the most of cases, that induces the negro to run away from service, is as much a disease of the mind as any other species of mental alienation, and much more curable, as a general rule. With the advantages of proper medical advice, strictly followed, this troublesome practice that many negroes have of running away, can be almost entirely prevented, although the slaves be located on the borders of a free state, within a stone's throw of the abolitionists.” 

Characterizing running away from slavery as a disease and physical punishment as a treatment was certainly a radical concept even in the Southern states before the American Civil War. In subsequent paragraphs Cartwright invokes divine providence to explain why white masters are destined to remain in a superior role to slaves.  He was concerned about “two classes of person who were apt to lose their negroes – the overly permissive defined as “treating them as equals” and the cruel owners who denied slaves the ordinary necessities of life.  His solution was to treat them well enough, but not allow many freedoms, and physically punish them into a submissive state “for their own good.”  Since Cartwright wrote these paragraphs the common interpretation is that his disease characterization of a rational act is a prototypical misapplication of the disease concept.

Not much has been written about criticism at the time. Writing in the Buffalo Medical Journal Samuel Hunt provided a satirical editorial on the original paper (2):

“Our purpose in this formal introduction, is to give due importance to an article recently published in its pages by Dr. Samuel Cartwright, of New Orleans. Characterized by the same cautious induction and logical accuracy whichever attended the literary efforts of that gentleman, it deserves careful consideration of the medical philosopher, the anatomical statesman, and the benighted Saratoga convention.

Those of our readers who are in the habit of referring to Cullen’s Nosology for the definition of diseases, will find no mention there of Drapetomania. The ignorance of the ancients was surprising, and we need but refer to Drapetomania as an evidence of this progressive spirit of the age in which we live.

Dr. Cartwright has conferred this name, Drapetomania, upon a disease peculiar to the south, and which is, we believe entirely confined to that section, and only manifested at the north in certain analogous if not identical forms, which we shall have occasion to mention when we have given our readers time for the perusal the following extract from Dr. Cartwright’s able article:”

After additional sarcasm following the extract, the author goes on to close his editorial by describing a disease he calls Effugium discipulorum or a tendency of school boys to leave school and spend time in the fields and orchards of rural districts. He suggests that the same solution – whipping “have been sanctioned by ages of experience in Effugium discipulorum; thus confirming the allied nature of the 2 diseases and the correctness of Dr. C’s hypothesis.” Hunt’s satirical editorial of 1855 and additional sources describing how the paper was mocked in the northern states is an indication of how serious this “diagnosis” was taken by some physicians at the time.

Historian Christopher D. E. Willoughby (3) described a much more nuanced environment and the multiple roles that Cartwright played. He was apparently widely published on a number of medical topics and there was widespread interest in the medical community about racial differences in medicine. Cartwright portrayed himself as an expert in this area, but due to his reputation he generally received deferential treatment – even when other physicians disagreed with him.  The medical emphasis at the time was on anatomy and in terms of disease theory there was a doctrine of specificity outlining the few factors relevant to how a disease could be treated. One of those factors was race. A physician could be regarded as a quack if one of these factors was disregarded – reinforcing the role of racial medicine. Despite Cartwright’s medical and political role, Willoughby describes his drapetomania as being so far outside of the medical norms at the time that drapetomania was not adopted as a diagnosis by many physicians and it was never a psychiatric diagnosis for the obvious reason that psychiatry and its diagnostic systems did not exist.

.The sampling of how often the term was used over the intervening decades both independently and relative to actual psychiatric diagnoses is indicated in the following Google NGRAMS.  To read about the graphing procedure consult this source (4). (Click to enlarge)

It seems fairly obvious that there was a flurry of references around the time of Cartwright’s article and then a very long flat period until Szasz resuscitated it in the 1970s (5) and it was picked up by the anti-psychiatry crowd subsequent to that.  Given the Google NGRAMS approach, relative to standard psychiatric diagnoses the interest in this pseudo diagnosis was practically nil.

A critical question is how a theory largely ignored at the time, now has more references than in the past?  A lot of that may have to do with a reinterpretation of his image. The description of him as a respected surgeon who trained with Benjamin Rush at Pennsylvania Hospital was apparently due to mistakes in an early biographical history (3) and persist today in Wikipedia and many other places.  Further reading suggests that he was in medical school as a teenager, dropped out to fight in the War of 1812 where he sustained injuries and then went back to complete his medical training. Looking at that timeline does it seem plausible? (click to enlarge)

Cartwright was born in 1793. In the years 1808-1813 he would have been 15-20 years old. Benjamin Rush died in April of 1813 and had been ill since the previous November. His biographer Stephen Fried (6) described Rush writing and active doing hospital rounds during this time period but for the first time starting to miss those rounds. It seems unlikely that even in the 19th century that anyone in their late teens would have been a military veteran and in medical school between the ages of 15-19. Willoughby (3) confirmed that there was no evidence that Cartwright matriculated at Penn or that he apprenticed with Rush. There are a multitude of sites on the Internet and in papers that state otherwise. Contrary to these many references there was no connection between Cartwright or Rush and the University of Pennsylvania Medical School. He did graduate from Transylvania Medical School (Lexington, KY) in 1823.

What about the purported connection between psychiatry and Cartwright and his invented diagnosis? Per the timeline above psychiatry had not yet been invented. There was an organization of asylum superintendents at the time but they had no formal diagnostic system.  The Association of Medical Superintendents of American Institutions for the Insane (AMSAII) was founded in 1844 and it had a total of 13 members - none of them were described as psychiatrists or alienists.  Despite the fact that racism and proslavery attitudes were widespread,  none of them used the term drapetomania or admitted asylum patients on that basis. In fact, only one asylum accepted slaves with mental illnesses at that time.  

The American Medico-Psychological Association was established in 1892 and at that time the number of alienists versus psychiatrists was not known.  In fact, it wasn’t until a meeting of the Alienists and Neurologists of America in 1917 (7) that anyone suggested specific training was necessary to treat asylum patients.  In those proceedings there are three times as many references to alienists than there are to psychiatrists, despite Reil’s first use of the term in 1816.  No mention at all of drapetomania but an interesting section on the importance of social diagnosis and social work.  The main diagnostic focus was on alcoholism, catatonia, epilepsy, syphilis, dementia praecox, various forms of chronic illness, and intellectual disability described as “feeble mindedness”.  None of the alienists or neurologists seem remotely concerned about drapetomania.  This is the only reference to race in that 228-page document:

“Preservation of self and of the race are directly dependent upon gratification of the appetites and this fact necessitates reaction of man to his environment and appropriation of those things which serve to fulfill his desires.”

It was included in a section on “Criteria of Defective Mental Development”.

On the timeline, the initial forms of psychiatric diagnostic manuals appeared in 1918 and 1952. Neither contained any reference to drapetomania and most of the diagnoses proposed are recognized as being similar or precursors to current diagnoses. One of the often-used tactics in criticizing psychiatry today has to do with the diagnostic manual and what it means.  Contrary to the rhetoric, alienists and psychiatrists involved in asylum care were often criticized for the lack of science in those settings most notably by the neurologist Weir-Mitchell (8):

“I shall frankly have to reproach many of those who still bear the absurd label of ‘medical superintendents'. Where are your annual reports of scientific study of the psychology and pathology of your patients? We commonly get as your contributions to science, odd little statements, reports of a case or two, a few useless pages of isolated post mortem records and these are sandwiched among incomprehensible and farm balance sheets”.  He went on to state that neurologists believed asylum care was care of “last resort”.

From the start psychiatric diagnostic manuals had the dual role of diagnostic description and data collection in asylums, specialty hospitals, specific populations, and for research purposes. Contrary to modern antipsychiatry philosophy there was no goal to increase diagnoses or the number of people with a diagnosis and no goal of social control through diagnosis.

I have established that Cartwright had no connection to Benjamin Rush of the University of Pennsylvania medical school. I have also established that drapetomania was certainly not accepted as a diagnosis and was probably widely derided in some areas.  It was essentially a product of the racist south, inadequate diagnostic theory and medical racism, had medical and political implications, and was written by a physician who owned 14 slaves and had a personal interest maintaining that practice.  I have also established that it has nothing to do with the field of psychiatry or its intellectual roots. It is only through massive misinformation that these false ideas persist. That misinformation landscape if so large at this point that it is not likely to ever be corrected. I certainly doubt that this blog will have much of an effect against what is now decades of drapetomania misinformation.  Many of the people spreading that misinformation are doing it in bad faith and by definition are not interested in correcting it.  There are also many (presumably) good faith errors such as recent statements from within organized psychiatry and in texts. A psychology colleague posted that every undergraduate Abnormal Psychology text uses drapetomania as an example of coercive psychiatry. Hopefully the good faith errors will correct themselves.  

The modest goal of this post is to hope that I can keep all of this misinformation out of the psychiatric literature.  That will be no small task. Szasz is already published despite the fact that he has been widely discredited. Even last month I was reading the American Journal of Psychiatry (9) and came across this statement:

“Over 60 years after the ratification of the US Constitution, physician Samuel Cartwright played a prominent role in the rise of racism in psychiatry.  His descriptions and characterizations of mental health conditions in enslaved Africans, particularly drapetomania which he described as the illness of enslaved people wanting to run away and escape captivity, and dysaethesia aethopica, a disease of ‘rascality’, were the beginning justifications of pathologizing normal behavioral responses to trauma and oppression.”

Based on everything I have established this is an inaccurate statement. Cartwright was not a psychiatrist or even an alienist. He was not trained in researching or diagnosis any mental health conditions and essentially made these up. His isolated racist ideology has nothing to do with the subsequent development of psychiatry or the way psychiatry is practiced today. Cartwright and drapetomania have become a convenient meme with the imitators using it as an indictment of psychiatry or the psychiatric diagnostic system – even though it is unrelated to both.  The latest application has been the use of this meme by psychiatrists to acknowledge systematic racism within the field as a basis for future correction. I have no problem with acknowledging that racism in psychiatry and society exists – but let’s make that acknowledgment on a realistic basis not an unconnected anecdote.

I expect a fair amount of opposition to this post. I base that on a reaction I got in a psychiatry listserv when I suggested that professional organizations should suggest the Rosenhan paper be retracted. Although I got several very supportive replies and replies from people who were shocked about the facts, there was also a very vocal contingent proclaiming they want social justice. Social justice cannot be predicated on a misinformation, even if that misinformation seems consistent with your overall message.  And there is a much better way.  That better way was in this weeks New England Journal of Medicine (10) in an article highlighting the work of W.E.B. Dubois and his colleagues who accomplished what can only be described as landmark work in the area of structural racism. In it DuBois and colleagues concluded that the excess mortality from tuberculosis in the black community was a product of racial disparities secondary to social forces. The report was published in 1899.  DuBois also successfully countered the theory of an insurance company actuary who suggested that black people were “ill adapted to freedom but also doomed to imminent extinction because of their biological differences from white people.” (note the parallels with drapetomania). Dubois successfully refuted these claims and showed that heredity could explain only a small part of differential mortality between groups and that social inequity accounted for most differences. The work of these social scientists and theorists is a solid place to start.

The solid scientific ground that we are on today is that we know race is a non-specific factor and that biologically all of mankind comes from the same place.  We are much more biologically similar than different. Discrimination and the resulting outcome disparities based on racism are the real problems to be addressed and there has been a scientific basis for that since 1899.    

 

George Dawson, MD, DFAPA

 

References:

1:  Cartwright SA.  Diseases and Peculiarities of the Negro Race.  De Bow's Review. Southern and Western States. Volume XI, New Orleans, 1851  Link

2:  S. B. Hunt (1855). "Dr. Cartwright on "Drapetomania"". Buffalo Medical Journal. 10: 438–442. (full text). https://books.google.com/books?id=coBYAAAAMAAJ&pg=PA438#v=onepage&q&f=false

3:  Willoughby CDE.  Running Away from Drapetomania: Samuel A. Cartwright, Medicine, and Race in the Antebellum South. Journal of Southern History
The Southern Historical Association Volume 84, Number 3, August 2018 pp. 579-614; 10.1353/soh.2018.0164

4:  Younes N, Reips UD. Guideline for improving the reliability of Google Ngram studies: Evidence from religious terms. PLoS One. 2019 Mar 22;14(3):e0213554. doi: 10.1371/journal.pone.0213554. PMID: 30901329; PMCID: PMC6430395.

5: Szasz TS. The sane slave. An historical note on the use of medical diagnosis as justificatory rhetoric. Am J Psychother. 1971 Apr;25(2):228-39. doi: 10.1176/appi.psychotherapy.1971.25.2.228. PMID: 5553257.

6:  Fried S. Rush: Revolution, madness & the visionary doctor who became a founding father. Crown Publishing Group, a division of Random House LLC; New York, 2018.

7:  Alienists and Neurologists of America: Proceedings of Sixth Annual Meeting.  Chicago, IL  July 10-12, 1917.

8:  Shorter E.  A History of Psychiatry: from the era of the asylum to the age of Prozac.  John Wiley & Sons, Inc. New York, 1997: p.68

Weir-Mitchell’s criticism was delivered in 1894.

9: Shim RS. Dismantling Structural Racism in Psychiatry: A Path to Mental Health Equity. Am J Psychiatry. 2021 Jul;178(7):592-598. doi: 10.1176/appi.ajp.2021.21060558. PMID: 34270343

10:  White A, Thornton RLJ, Greene JA.  Remembering Past Lessons about Structural Racism — Recentering Black Theorists of Health and Society.  New England Journal of Medicine August 26, 2021 385(9):850. doi: 10.1056/NEJMms2035550

11:  Callender JH.  History and Work of the Association of Medical Superintendents of American Institutions For The Insane - President's Address.  Am J Insanity. July 1883: p. 1-32.

In this reference, the Association President reviews the first 40 years of progress and points out that 13 members started in 1844 but by 1880 there were 115 members representing 130 public and private institutions in the US or Canada and a total of 41,000 patients.  In this same document the President refers to the distinguished members of the organization as alienists rather than psychiatrists. Gonaver (see below) refers to the physicians of the AMSII as "asylum doctors" or "psychopathists" but also points out that many had no specialized training at all in the treatment of the mentally ill.

Supplementary 1:

This reference was posted to me on Twitter.  In it the author points out that the term drapetomania was not a diagnosis in the only asylum that treated slaves during the time when there was peak interest in the term:

"Readers may be therefore surprised by the conspicuous absence of these so-called conditions in the only insane asylum in which  slaves were patients."

Gonaver W. The Peculiar Institution and the Making of Modern Psychiatry, 1840–1880. University of North Carolina Press, 2019.

Supplementary 2:

The nosology text by Cullen referenced in the satirical critique of Cartwright's work is available online through the National Library of Medicine.  The only references to mental disorders were mania, melancholia, and bulimia.  

Cullen W (1710-1790).  Synopsis and nosology: being an arrangement and definition of diseases. Hartford : Printed by Nathaniel Patten, MDCCXCII [1792]: 80 pages.  Link to NLM

Supplementary 3:

 

I got this book in the mail today and read it.  It is a 1918 edition "prepared for the Committee on Statistics by the American Medico-Psychological Association" - see timeline. The text is 40 pages long, contains 21 diagnoses in the classification system and was designed to facilitate data collection for statistical analysis. There was a detailed section on race and ethnicity that would not be included in any modern analysis.  Drapetomania was not listed anywhere in this volume.

Supplementary 4:

Precursor organizations to the American Psychiatric Association published a journal - The American Journal of Insanity that encompassed the period of time when drapetomania was proposed. In order to see if there was any recognition of drapetomania in the line of journals that the APA considers related to psychiatry I went back and looked at one 1850s decade of the American Journal of Insanity and then did a search on the APA web site validated against terms like sitomania discovered in that decade of material.

On the APA web site, the time span of journals is indicated below:

American Journal of Insanity vol. 1 no 1 (July 1844) to vol. 99 no. 6 (May 1943)

American Journal of Psychiatry vol. 100 no. 1 (July 1943) to current time.

There were no references to drapetomania in the interval 1851-1859.

The search engine was validated to discover relevant diagnoses in the American Journal of Insanity.

The search of APA journals yielded 19 references dating back to 1971.  The first two references from that year were both written by Thomas Szasz.  The references in general have to do with racism in medicine including a recent number of references, some book reports including one about ADHD that for some reason contains the word drapetomania. 

The exercise in this supplemental information confirms that drapetomania was never considered a diagnosis in what are considered the early journals of psychiatry.  In my reading of the American Journal of Insanity I also found much to support Weir-Mitchell's 1894 criticism of the field (see above and reference 8).

Supplementary 5:

I received the following book in the mail today after a Twitter colleague referenced it.  The author Wendy Gonaver is a historian who had access to a significant volume of records from the only asylum that treated and accepted slaves and free black persons as patients and employed slaves as caregivers.  So far I have read the 18 page introduction and the writing and rationale are excellent.  She introduces a level of insight and objectivity that is rarely seen in the content that she is covering. On page 6 and 7 she debunks the importance of drapetomania that occurred right in the middle of the years she is covering for this book (1840-1880). In commenting on the complete absence of Cartwright's invented diagnoses:

"For good reason, Cartwright's work has become synonymous with all that was horribly wrong with both slavery and spurious science.... but Cartwright's posthumous notoriety does not appear to match his reputation during his lifetime.  His fabrications were, at least for Southern doctors who considered themselves serious practitioners, more rhetorical proslavery provocation than legitimate diagnoses." (p. 6-7).

She points out that Cartwright was not a "mental health specialist", never attended a meeting of The Association of Medical Superintendents of American Institutions for the Insane the only professional organization at the time, his work was never discussed at those meetings, and there were no records to suggest that slaves were admitted for running a way or that they were whipped.  There is also no mention of a connection to Benjamin Rush - another frequent error when Cartwright is discussed.

At the same time Gonaver points out that previous historical documents ignored race as a dimension for analysis and illustrates some of her insights in that area in the introduction.  I look forward to completing the book. 

A brief synopsis of the book follows:

After some consideration, I elected to post a synopsis of the book rather than each chapter due to the length of that document. The book is based on archives of the Eastern Lunatic Asylum (ELA) as reviewed by the author historian Wendy Gonaver. The descriptions of the state of the asylum, administration, staff including the enslaved staff, and the patient population role based on detailed notes by the asylum superintendent during the time interval of interest (1840-1880). Most of the material consisted of records written by John Galt, the superintendent. He was appointed age 22 and 1841 after studying at the University of Pennsylvania. He remained the superintendent until his death by suicide on May 18, 1862. Although the author refers to her book as a study of the “broader ideological underpinnings of early psychiatry” - the asylum doctors were clearly not psychiatrists. They are typically referred to as “asylum doctor” or “psychopathist”.  He was a member of the Association of Medical Superintendents of American Institutions for the Insane (AMAAII). This association was founded in 1844 and at that time it had 13 members. The only real connection to psychiatry is that the American Psychiatric Association uses this date to claim that psychiatry was the first medical specialty. That is a questionable claim on multiple levels.

The ELA itself was housed in an inadequate physical plant even in the pre-Civil War era. Sanitation was clearly a problem with inadequate drainage and sewerage systems. Potable water was also problem. There were a large number of fires on the campus for heating purposes until central heat could be installed. Nutrition was also a problem. Although the patients got about a pound of meat 5 days a week and fish 2 days a week several patients were diagnosed with scurvy. That led to an emphasis on expanded gardening of fruits and vegetables. Children of staff living on campus were not served regular meals but had to subsist on scraps.

One obvious conclusion is that there is much material in this book that could be used to blame psychiatry in much the same way that drapetomania has been used. But there are many qualifiers. Racism both overt and covert were clearly present in both the northern and southern states. Even though much of the events described in this book occurred 30 – 70 years after Benjamin Rush’s death there were no true abolitionists, not even reformer Dorthea Dix.  John Galt supported his enslaved staff in many cases humanistically but from a pragmatic rather than a moral perspective. He clearly believed that blacks were socially and intellectually inferior, but he realized that his institution could not run without enslaved blacks.  That led him to defend the quality of care provided by the enslaved staff at his institution. Racial stereotypes cut across the dimensions of religion, gender, and culture with African Americans receiving the harshest treatment and the greater work load. When John Galt died and the Civil War ended, the integrated ELA also ended and black patients were transferred to a segregated institution where their care was noticeably worse.  During a transition period, multiple military physicians with no training in asylum care were appointed to run the ELA.

Politics factored prominently in the workings of the ELA and whether Galt received any recognition for his work of ideas.  Shortly after his arrival, a conflict developed with the asylum board when they removed his hiring ability and blamed him for the resulting problems. He was also resented by AMAII colleagues over his advocacy for integrated asylums and eventually an outpatient community-based model. Despite praise for innovation at their meetings he was never credited for his ideas or his death mentioned in one of their meetings.

The author is a critical presence in this book. In places, she is clearly suggesting that stressors, abuse, domestic violence, war, and other forms of trauma may be the most important factors in why someone, but particularly white, black, and enslaved black women ended up in the ELA. She acknowledges that there may be a role for severe post-partum states. As I read though these case reports, I had questions about the degree of detail available as well as the primitive to non-existent diagnostic system. If all of the details of stressful events were there – could they really not be considered given the primitive state of medicine that was being used?  The only treatment being supplied was basically moral therapy and environmental containment to reduce the risk of aggression, suicide, and starvation.  There were no trauma or stress based therapies available in the mid-19^th century. If there were it would take a much larger professional staff to administer them.

All things considered, the logical conclusion is that the ELA, like most institutions was not able to rise above the prejudices of the population where it was located. The practices described in the book are common overt and implicit racist themes – even today. Covert segregation still exists even though school segregation ended in 1954. In keeping with the timeline of this book, the Civil Rights Act of 1875 was supposed to have ended racial discrimination but the Supreme Court overturned it in 1883 saying that individuals and private business could discriminate on the basis of race.  

The Peculiar Institution is a very scholarly work. It is well written and I encourage anyone with an interest in the history of this time or discrimination based on race or gender to read it.  My only other concern is with the extended title – The Making of Modern Psychiatry.  I would submit that it really contains very little to do with modern psychiatry – and like Cartwright’s drapetomania diagnosis is more the product of racism, politics, and an inadequate system of care. 

Supplementary 6:

The state of Virginia lists Eastern State Hospital as the first mental hospital in the United States dating back to October 12, 1773 and states that at one point it was called the Eastern Lunatic Asylum.  There is some history available on this Virginia State web site including commentary on Dr. Galt.

Supplementary 7:

The journal Alienist and Neurologist: a quarterly journal of scientific, clinical and forensic psychiatry and neurology was published between 1880 and 1920 when publication ceased.

Full text of this journal is available via the HathiTrust web site. 

Supplementary 8:

Drapetomania errors on the Internet - needless to say there are many.  I thought I would catalogue them but do not have the time. Unless the use is restricted to Cartwright and not applied to psychiatry it is probably safe to say it is being used rhetorically.