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 18th century methods primitive is an
easy task and I am sure that if civilization lasts – 24th 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 13th and 14th
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
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