Celebrating a Storied History: Moscow Preobrazhenskaya Mental Hospital Marks its 245th Anniversary

In 2022, Mental-health Clinic No. 4 named after P. B. Gannushkin, one of the oldest mental health institutions in Russia known as Preobrazhenskaya Hospital before the October Revolution of 1917, celebrated its 245^th anniversary. The history of the hospital reflects all stages of the evolution of the basic principles and aspects of mental health care in Russia. On many occasions, the institution served as a platform for eminent researchers and clinicians to achieve scientific breakthroughs and their application in practice. This article is a review of the major milestones in the history of the hospital. It highlights the great achievements of its psychiatrists and presents some previously unpublished archival documents that offer a new perspective on the history of Preobrazhenskaya Hospital.

Introduction

In 2022, Mental-health Clinic No. 4 named after P. B. Gannushkin, one of the oldest mental health institutions in Russia known as Preobrazhenskaya Hospital before the October Revolution, celebrated its 245^th anniversary. This represents the number of years since Catherine the Great signed a decree establishing the Moscow House of Invalids, where several dozen beds were set aside for the mentally ill. The document, issued in 1777 [1], laid the foundation not only for Moscow’s first specialized institution that could accommodate patients with mental disorders, but also, without exaggeration, for the entire field of Russian psychiatry.

The implementation of the Pinel reform in Russia, the introduction of the concept of “moral treatment”, the first scientific conferences and open clinical discussions, all these stages in the evolution of the basic principles and aspects of mental health care have found their reflection in the history of Preobrazhenskaya Hospital over the past 245 years. This is why Vasily Gilyarovsky poetically referred to the Hospital as “the cradle of Russian psychiatry” [2].

Each page in the history of Preobrazhenskaya Hospital is not only an impressive list of achievements and innovations, but also a unique gallery of distinguished names [3–7]. It served as a basis for the greatest medical luminaries of the time, such as V. F. Sabler, V. R. Butzke, V. A. Gilyarovsky, N. N. Bazhenov, A. V. Snezhnevsky, D. E. Melekhov, T. I. Yudin, S. G. Zhislin, and G. Y. Avrutsky, from which to make their scientific discoveries and validate them in practice; this was also the place where such luminaries of Russian psychiatry as S. S. Korsakov, A. U. Frese, E. K. Krasnushkin, P. E. Snesarev, A. S. Tiganov, and I. Y. Gurovich, and many others, began their medical careers.

It is a well-known and undisputed fact that Preobrazhenskaya Hospital was the first (and almost only one until the end of the 19^th century) psychiatric hospital to appear in Moscow. But historians and researchers in psychiatry have spent more than 100 years trying to dig up documents that could allow them to determine the exact year of its founding.

Starting in the second half of the 19^th century, the question has frustrated many eminent physicians of Preobrazhenskaya Hospital, including S. I. Steinberg [8], I. V. Konstantinovsky [9], N. N. Bazhenov [10], M. A. Dzhagarov [11], and A. B. Alexandrovsky [12]. Their work can now help us to form a fairly comprehensive view of how the State and society gradually, step by step, developed an awareness of what such an independent institution as a psychiatric hospital was all about. They painstakingly assembled scattered documents and facts to finally pinpoint with certainty the day it all began and the events that could be considered key milestones in the hospital’s history.

From First Mentions to 19th Century Reform

The first building that hosted Preobrazhenskaya Hospital, originally known as Moscow Dolgauz, opened its doors on June 15, 1808. In the 20^th century, it became routine to trace all anniversaries of the institution back to that date. But is that right? Could the mere fact that the hospital acquired its own building be considered the seminal event of the first inpatient psychiatric hospital in Moscow?

On July 13, 1777, Catherine the Great signed a decree mandating the opening of the House of Invalids in Moscow, with one of its “wards” dedicated to the care of the mentally ill. This is the date that, 100 years later, the doctors at Preobrazhenskaya Hospital referred to as the starting point in the history of their institution [8]. One of their main arguments was the fact that, on May 17, 1792, Catherine the Great issued a decree [1] establishing for the first time the position of Special Doctor at the mental health hospital. Hence, this decree confirms that this type of social institution for people with mental disorders already existed in 1792.

According to the decree signed by Catherine the Great, the primary role in the observation of patients was assigned to the warden, who was in charge not only of the guards (retired soldiers), but also of the doctor responsible for the professional supervision of patients. In reality, however, the staff physician had to juggle work at the mental health hospital with his duties in the nursing home, the hospice, and the almshouse. As a result, his attention was limited to those patients who had a chance of recovery [13].

When assessing the efforts of the first doctors at the mental health hospital, such as F. Raschke, then C. Pouliard, A. Blimmer, J. Karas (and all this happened long before the hospital had its own building), N. N. Bazhenov wrote in his book about Preobrazhenskaya Hospital: “It is important to note that even then there was a firm belief that the insane person was a patient, with all that such a conclusion entailed, including examination by a physician, admission to the mental health hospital for treatment (no matter how crude and primitive that treatment might have been), and finally discharge when the physician was satisfied that the goal of admission (a cure) had been achieved” [10].

Other doctors at Preobrazhenskaya Hospital also left their mark in the history of Russian psychiatry of the 19^th century. For example, Zinovy Ivanovich Kibalchich, Chief Doctor of the hospital in 1811–1828, left us a documented description of the prevailing realities in a mental hospital at the beginning of the 19^th century. In his 1821 article “Report on the House of the Insane in Moscow and the Methods of Treatment Used There” published in the Journal of the Imperial Philanthropic Society (issue No. 11, 1821), he not only described in detail Moscow Dolgauz and the methods of treatment used there, but he was also one of the first to point out the existence of mental disorders that are now referred to as “borderline conditions” [14].

Vasily Fedorovich Sabler, chief doctor of Preobrazhenskaya Hospital in 1828–1871, was a true “revolutionary” in the early history of psychiatric care in Russia (Figure 1).

Figure 1. Vasily Fedorovich Sabler (1797–1877) — chief doctor of Preobrazhenskaya Hospital in 1828–1871.

A brilliant clinician and talented scientist, V. F. Sabler provided evidence for the nosological independence of progressive paralysis, described its accompanying mental and neurological disorders, and developed humanistic principles of individual approach to patients. He was one of the first to hypothesize that some forms of illness can evolve into others, and that severe somatic illness accompanied by high body temperature (fever) can contribute to the cure of psychosis.

In the history of Preobrazhenskaya Hospital, V. F. Sabler played an equally prominent role as an outstanding manager. With a radical reform of the hospital’s management system, he ensured that the Chief Doctor would become the actual head of the institution. He supervised all areas of the hospital’s activities and prepared reports on the clinic that were published in the press (including in Europe).

This administrative reform marked a dramatic shift in attitudes toward the mentally ill. V. F. Sabler was greatly influenced by Philippe Pinel’s concept, which led him to completely overhaul the patient management system, finally replacing the chains used on violent patients with straitjackets and restraint chairs with straps.

It was the first instance when treatment was given priority over charity. This included the first patient histories (known as “case sheets”, see Figure S1 in the Supplementary) and prescription books. Depending on the course of their disease, patients were categorized as acute or chronic and treated using a different therapeutic approaches.

The new emphasis was not only on the medical observation of the patients, but also on their moral challenges and re-education. Patients were no longer seen as “dangerous madmen” but as “unreasonable children” who needed proper care and exercise. That is why occupational therapy was considered so important. According to the instruction “On the Exercises for the Sick People Placed at the Mental Health Hospital” published in 1834, each patient was assigned a strictly individual occupation. It was then that Preobrazhenskaya Hospital established a sewing shop, a tailor’s shop, a shoemaker’s shop, a dyer’s shop, a paint shop, a plasterer’s shop, and a vegetable garden. The women could also knit socks and embroider canvas.

V. F. Sabler initiated the effort to draft legislation on the mentally ill, which provided the impetus to address a long overdue problem in the patient examination process. For centuries, medical matters had been handled by officials with no expertise in diagnosing mental illness, and during the reign of Nicholas I, the authorities began committing patients to institutions “pending further orders” rather than “pending recovery”, as had always been the case. It was not until February 18, 1835, that a decree was issued establishing a procedure for forensic psychiatric examination that required convincing evidence of mental illness from credible medical experts.

In 1841, the so-called “special patient examination procedure” was introduced and implemented for the first time at Preobrazhenskaya Hospital. If in St. Petersburg the “lunatics” continued to be transported to the Provincial Board, in Moscow the “subjects” were now sent to Preobrazhenskaya Hospital for “expert examination” and placed in a ward specially purposed for such subjects in a section of St. Catherine’s Almshouse. Membership in the Patient Examination Committee was also established at that time and did not change until 1917. It included the hospital doctor, his/her assistant, the provincial marshal of the nobility, the chief of the district police or the head of the city. Patients were discharged only after a new examination, which could take place at the end of a two-year “observation” period, and this period could be shortened only by special decision of the Senate.

The hospital owes both its name, Preobrazhenskaya, and the confirmation of its new official status as a medical institution to V. F. Sabler. It was he who on May 31, 1838, petitioned Emperor Nicholas I to sign a decree renaming the Moscow Dolgauz as the Preobrazhenskaya Mental Hospital.

Assessing the changes that took place in the hospital during the first hundred years of its existence, historians of psychiatry are quite right to note that as early as the middle of the 19^th century Preobrazhenskaya Hospital had made the transition from a “charity house” to an in-patient psychiatric institution and had evolved into “the center of not only practical but also scientific psychiatry, which became the tradition of the Moscow psychiatric school, distinguishing it from the St. Petersburg psychiatric school” [7].

These changes, most of which were introduced during V. F. Sabler’s leadership, allowed Samuil Ivanovich Shteinberg (the hospital’s chief doctor in 1872–1877) to begin work on the institution’s first collection of scientific papers in the run-up to the centennial of Preobrazhenskaya Hospital in 1877. The preserved documents (“Preobrazhenskaya Hospital Office File on the Centennial Anniversary...”) show that the preparations for this anniversary had begun well in advance. As early as in February 1876, the chief physician, S. I. Shteinberg, wrote a letter to the trustees of Preobrazhenskaya Hospital with a detailed plan of the celebration. A circular letter was sent to the staff instructing S. S. Korsakov, N. I. Derzhavin, and V. R. Butzke to begin preparing articles identifying the major milestones in the history and development of the hospital (Figure S2 in the Supplementary).

In the 1870s and 1880s, the hospital attracted a cadre of brilliant and exceptionally gifted young physicians who introduced the most advanced methods of patient care into existing medical practice. First of all, this applies to Sergey Sergeyevich Korsakov, the founder of the nosological branch of psychiatry, the creator of the Moscow scientific school and the author of a classic course in psychiatry [4, 5]. His name is closely connected with the history of the “therapeutic revolution” at Preobrazhenskaya Hospital. The energy and reputation of S. S. Korsakov helped to complete and irretrievably establish “moral treatment” at the hospital and the “open door” policy (from 1889), followed by out-of-hospital care, which radically changed the entire approach to patients.

20th Century: Transformations and Achievements

Looking back, it is impossible to ignore one obvious fact: almost all the chief doctors of Preobrazhenskaya Hospital in the period before the Russian Revolution of 1917 acted as reformers of the entire Russian psychiatric care system. An honorable place in this gallery of illustrious figures is occupied by Nikolai Nikolaevich Bazhenov, chief doctor of the hospital in 1904–1917 (Figure 2).

Figure 2. Nikolai Nikolaevich Bazhenov (1857–1923) — chief doctor of the hospital in 1904–1917.

Preobrazhenskaya Hospital owes its vast expansion and the introduction of the then — revolutionary system of “advanced care” to this fascinating figure of Russian psychiatry, outstanding clinician, ingenious manager, and respected teacher.

In the new “advanced care” system, the uneducated wardens and nannies were replaced by young medical interns and sisters of mercy. The doors to the wards were unlocked, the bars on the windows were replaced with tempered glass, and the straitjackets were displayed as museum pieces [15–17]. To ensure that patients were under continuous and competent supervision, the interns were required to live in the hospital, rotate on round-the-clock duty, welcome new admissions, and complete patient histories and observation diaries. All direct patient care was assigned to mid-level medical staff. Thirty-two sisters of mercy washed and fed the patients, gave them baths, accompanied them on walks, etc. Each ward had a head nurse who distributed medications, served lunch and dinner, was in charge of laundry, and performed other household duties. Nannies and servants were assigned only janitorial duties. In the spirit of those times, the hospital widely applied a system of moral influence, a prototype of today’s psychosocial therapy that included respectful treatment and support of patients, their socialization, and involvement in various activities.

At the beginning of the 20^th century, with N. N. Bazhenov’s contribution, the hospital was transformed into a research and treatment institution, which became a center of advanced psychiatric knowledge. The scope of N. N. Bazhenov’s innovations is quite impressive: in just a few years the clinic, where at the turn of the century treatment of patients resembled more that in a prison than in a medical institution, was transformed into a modern hospital, on par with the best that Europe could offer [15–17].

Preobrazhenskaya Hospital was also the place where the Law on the Mentally Ill, a revolutionary act for its time, was proposed 80 years before the adoption of the Russian Federal Law on Psychiatric Care in 1992. The legal principles outlined by N. N. Bazhenov at the first congress of the Russian Union of Neuropathologists and Psychiatrists in 1911 are still relevant today:

“The following issues need to be brought to the forefront of mental health care and legislated:

a) The principle of extending state care to all mentally ill people in the country, and specifying the measures to implement this task and the central and local authorities responsible for these tasks.

b) Conditions for allowing treatment at home in the patient’s own family.

c) Sufficient safeguards must be in place to ensure that the principles of inviolability of the person and individual liberty can only be violated when the mental illness of the person in question makes this imperative” [18].

N. Bazhenov is also connected with the first commemoration of the foundation of the hospital celebrated in the 20^th century. In December 1909 the 100^th anniversary of the opening of the first building hosting Preobrazhenskaya Hospital on Matrosskaya Tishina Street was commemorated in gushing but solemn fashion, with the participation of the general public.

By that time the clinic had already received a plot of 11 dessiatins of land with the two and three-story buildings of the former Kotov factory (known as “Kotov’s Half”) (Figure 3).

Figure 3. Kotov factory. Photo of the beginning of the 20^th century.

The factory buildings were refurbished, and a dormitory for the staff was equipped with ventilation, plumbing, and even central heating, which allowed N. N. Bazhenov to write proudly that “now Preobrazhenskaya Hospital has such premises for the staff that few Russian or even Western European hospital institutions can boast of” [10].

However, the problem of overcrowding could be solved only by the construction of new buildings on Kotov’s Half, which required additional funds. So, N. N. Bazhenov decided to organize a gala evening for the city’s dignitaries on the former Kotov estate.

The day of the anniversary celebration was packed with events, including a solemn liturgy and breakfast for 300 guests; in the afternoon, there was a large concert by professional musicians from Moscow; a festive tea ceremony for patients, distribution of anniversary souvenirs, such as cups with the hospital insignia; and in the evening a banquet for 200 guests was held at the Kotov’s cottage located in a picturesque setting on the border of the Preobrazhenskaya and Sokolnicheskaya groves.

In addition to the concert, the highlight of the “cultural program” was the exhibition, for which N. N. Bazhenov selected not only everyday objects from psychiatric hospitals of different centuries (straitjacket, restraint chair, and “case sheets”), but also the creative works of patients (paintings and caricatures, wood and paper crafts, embroidery, and knitting). The models of Preobrazhenskaya Hospital and the Eiffel Tower were particularly popular with the public, because of their size and resemblance to the originals.

In addition to the gala dinner, the guests were treated to a theatrical performance, which included an act from the play “The Marriage of Krechinsky”, with a reference to Preobrazhenskaya Hospital, and, at the end of the evening, fireworks from an area near the buildings in Kotov’s Half — N. N. Bazhenov did not miss a single opportunity to draw the attention of the patrons and city authorities to the matter of financing the future construction. In 1910–1914, his work culminated in the successful completion of three new buildings and repairs to the old factory facilities on Kotov’s Half.

But let’s take a closer look at the year of this anniversary: Why was it celebrated in 1909? For a long time, 1809 was mistakenly considered the year in which the first specialized hospital for the mentally ill was opened. It was mentioned both in the Historical Essay on the Imperial St. Catherine’s Almshouse by V. Molnar [13] and in the Historical Essay on Preobrazhenskaya Hospital by I. V. Konstantinovsky [9]. For this reason, the anniversary was celebrated in 1909 and the following plaque was installed on the facade of the building: “1809–1909: To the centenary of the Preobrazhenskaya Mental Hospital, the first in Moscow designed specifically for psychiatric purposes”.

Only later, while working on the manuscript of his book “The Moscow Dolgauz” or “Essays on the History of Preobrazhenskaya Hospital” did N. N. Bazhenov study the documents in the hospital archives and found out that the new mental health hospital in Preobrazhenskoye was opened earlier, in June 1808, when 53 patients from the house of the former Secret Expedition were transferred to the building on Matrosskaya Tishina¹ [10].

By the beginning of the 20^th century, the records had cemented all three major milestones in the history of the establishment of Preobrazhenskaya Hospital: 1777, 1808, and 1838. One might think that this would have settled the question of the first dates for future celebrations once and for all.

However, the revolution of 1917 and the subsequent division of the hospitals sowed confusion into the “question of anniversaries”. In the spirit of Soviet traditions, Preobrazhenskaya Hospital was stripped of its former name in 1920 and became Moscow City Hospital No. 1. What’s more, in 1931, it was divided into two independent medical institutions with different goals and missions. The hospitals kept changing names, numbers, internal organizational structure, and overall scope of activities, and only relatively recently, in 2017, did the two hospitals return to their historical roots by merging under the name of P.B. Gannushkin Mental-health Clinic No. 4 (Figure 4).

Figure 4. The history of the renaming of the hospital in the 20^th century.

Over the next 100 years, Kotov’s half of Preobrazhenskaya Hospital acquired a different, but equally illustrious, name — Gannushkin Hospital. In the second half of the 20^th century, it maintained its position as an advanced center of research and practice, with many pioneering milestones in the history of Russian psychiatry:

– It developed the system of maintenance therapy, which is so important in preventing relapses.

– For the first time in the USSR, it began to use insulin shock therapy (under the direction of M. Y. Sereisky), as well as electroconvulsive therapy (with the contribution of G. A. Rotshtein).

– It also marked the beginning of the “psychopharmacological treatment era in psychiatry” with the trials of many medications that were subsequently integrated into mainstream clinical practice.

Recent Developments

Reflecting on the title of this article, “Celebrating a Storied History”, one may note that in 2022 the institution historically known as Preobrazhenskaya Hospital will celebrate its anniversary for the first time in more than a century since that memorable evening organized by N. N. Bazhenov at the former Kotov estate. How does Gannushkin Hospital, the illustrious heir to the great traditions established by Preobrazhenskaya Hospital, look at the new generation in the year of its 245^th anniversary?

More recently, just 3–4 years ago, it got a facelift after extensive repair and construction work to restore the buildings dating back to the early 20^th century. Most importantly, the reorganization allowed for more streamlined psychiatric care, created a common information space, rationalized territorial localization, and brought patient treatment and routing patterns into a consolidated format.

With four specialized clinics in operation since 2020, the hospital now has several new structural units, including a clinic for affective and suicidal disorders, a clinic for borderline conditions, a clinic for first psychotic episodes, a clinic for pharmacoresistant conditions, and a clinic for mental disorders that are compounded by substance abuse. The Mental Health Counseling Center, opened in 2021, provides outpatient care for individuals suffering from various mental disorders including somatoform, stress-related, and neurotic disorders.

Today Gannushkin Hospital boasts a center for complex diagnostics, a clinical and diagnostic department with specialized clinics (such as dentistry, ophthalmology, gynecology, ENT, ultrasound), an anesthesiology and intensive care unit, a clinical and diagnostic laboratory, a psychological and psychotherapeutic center, a social and legal assistance center, as well as a physiotherapy department (including a transcranial magnetic stimulation room and xenon therapy room), pharmacy, X-ray rooms, and a physiotherapy room.

At the moment, the hospital has 9 outpatient branches known as Psychoneurological Dispensaries (PNDs), some of which have a history spanning more than 100 years.² Three Memory Clinics were founded on the basis of PND. These medical and rehabilitation units are designed to help elderly patients with early signs of dementia and mild cognitive decline.

The staff of the oldest psychiatric hospital in Moscow has carefully passed down to younger generations traditions that combine the utmost sense of humanity and the highest level of professionalism in helping patients with mental disorders. These traditions are the cornerstone that enables the team at Mental-health Clinic No. 4 named after P. B. Gannushkin to live its mission every day by providing personalized and comprehensive mental health care based on the principles of partnership and trust, with the aim of restoring and maintaining a high quality of life for its patients.

¹ The house on Myasnitskaya Street, formerly owned by the Secret Expedition, was transferred to the Public Charity Office in the early 19^th century. This is where the patients of the House of Invalids and the Madhouse were accommodated in 1801.

² PND No. 8, for example, was founded in 1919 and made psychiatric history as the prototype of the emerging district-level psychiatric care in Soviet Russia.

Appendix (PDF)

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