Rush's rounds at Pennsylvania Hospital became a new cornerstone of his life. They were done at least twice a week and Rush quickly became known for starting his rounds at 11 a.m. with obsessive punctuality. Rounds began on the second floor ward—a broad room with high ceilings and large windows—where female patients were treated.
The process was quite formal. Every patient was in a bed or a chair, their dressings "all ready to be taken off and exposed to view the instant the Doctor came to them." Rush offered his observations "in every case worthy of notice," pointing out "its nature, the probable tendency, and the reason for the mode of treatment." Everyone then followed him down the staircase to the first floor, the all-male ward, where the process was repeated. He explained that a number of the cases were chronic patients, many with "swellings and ulcerations," which he said were the result of "their drinking spirituous liquors," as he never failed to remind them that "the greater proportion of his patients in the city . . . originated from the same cause."
The rounds finished in the lower, partially underground story, where Rush and his students "took a view of the Maniacs" in their locked ward, which had individual locked cells, "about ten feet square, made as strong as a prison." The ward was filled to its capacity of about thirty patients, men and women.
Some of them were extremely fierce and raving, nearly or quite naked; some singing and dancing; some in despair," the visitor noted. "Some were dumb and would not open their mouths; others incessantly talking."
Rush had been treating patients in his office and at their homes for more than a decade, and he had recently taken on a partner — his young cousin James Hall — to handle the more routine work. But the experience of interacting regularly with the city's most serious cases moved and upset him. The endless assault of illness deepened ideas he had developed while treating the wounds of war.
The single most devastating illness, Rush quickly figured out, also appeared to be the most preventable. In 1784, after less than a year on the hospital staff, he published a 10-page pamphlet called "An Enquiry Into the Effects of Spirituous Liquors Upon the Human Body, and Their Influence Upon the Happiness of Society," which offered one of the first modern descriptions of the effects of chronic alcohol use.
Spirituous liquors destroy more lives than the sword. War has its intervals of destruction — but spirits operate at all times and seasons upon human life. . . . [They] fill our church yards with premature graves . . . fill the Sheriff's docket with executions . . . [and] crowd our jails. . . . [They] produce debts — disgrace and bankruptcy. Among farmers they produce idleness with its usual consequences, such as houses without windows — barns without roofs [and] . . . half clad dirty children without principles, morals or manners. . . . A people corrupted by strong drink cannot long be a free people.
Next to alcoholism, what intrigued and horrified Rush most in his rounds were the patients locked in the basement cells. He felt immediately that the circumstances these patients lived under were absolutely unacceptable. But the "lunatics," who most people still viewed as damned rather than diseased, presented a unique and troubling situation. They weren't truly in the hospital to be treated, because nobody knew for sure what their treatment should be. They were in the basement primarily to keep them safe from society, and society safe from them.
One of the hospital's more appalling practices had been to allow members of the general public to pay four pence ($1.70) to come in and gape at the lunatics. But in August 1784, one of Rush's former students, Dr. John Foulke — now a member of the junior staff — campaigned to change the rules. Soon only two people could visit the basement at a time, and under no circumstances were they allowed to talk to the patients. … In the meantime, Rush and other younger doctors tried to figure out how to improve living conditions in the cells.
But Rush had something more ambitious in mind than just making these patients more comfortable. He sought a more radical kind of progress: to actually better understand what was wrong with those locked in the basement and even one day know how to treat them as patients, not as prisoners. Rush discussed some of these broader ideas about patient care with the doctors and trainees at Pennsylvania Hospital. As early as 1783 he began describing madness in new ways. Instead of viewing aberrant, antisocial, or self-destructive behaviors as the result of immorality or lack of self-control, he talked about them in the language of medicine. He told the medical staff and students that melancholia, or depression, was "a disease of the body as well as the mind," and that mania was a "disease of the brain." At a time when most viewed lunacy as demonic possession or lack of will or character, these were surprising ideas.
Rush and his colleagues were also coming to appreciate the importance of talking, and listening, to the occupants of the cells. One of the first psychiatric patients he encountered was a woman in her late 60s named Hannah Garrett Lewis, who was admitted around the same time Rush joined the hospital staff. She was well known on the streets of Philadelphia for her incessant public preaching, which she had done for decades, since the death of her husband in the 1740s. Her many erratic behaviors included eating broiled mice and cats, catching mosquitoes and flies, tearing off their heads or wings and keeping them in a jar "for the presumption of daring to bite the King's daughter." Rush diagnosed Hannah Lewis with a "mania" in her charts, which he also described in a case report as "grief induced madness . . . in middle life" triggered by "the loss of her husband." She was one of the first patients whom Rush and others on the staff really tried to talk to, to better understand her thought processes and what Rush viewed as "errors of thinking." Hannah Lewis' case presented physicians with a unique opportunity to try to treat the most publicly mad woman from the streets of Philadelphia as an actual patient with a psychiatric illness, taking her delusions and thought disorders seriously as symptoms and studying them in the hope of healing her.