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Destroying Angel: Benjamin Rush,
Yellow Fever and the Birth of Modern Medicine
by Bob Arnebeck
As he cured himself Rush was chagrined to see his cure publicly impugned again. In a letter to the newspapers on Thursday, September 12, Alexander Hamilton, who was on his way to recovery, suggested that the College of Physicians ask Dr. Stevens about his methods since they varied "essentially from that which has generally been practiced - and... where pursued, reduces [the fever] to one of little more than ordinary hazard."
To Stevens, not Rush, belongs the credit of making medical theory an issue during the epidemic. In his letter printed on the 16th, Stevens did not mention Rush by name but did ask "should not violent evacuations which evidently weaken and relax be avoided," given the "extreme debility in animal functions and great derangement of the nervous system" occasioned by the disease. The "utility" of his stimulating prescriptions were "confirmed by experience and coincides with our reason and the soundest theory."(1)
In framing the dispute between the doctors, historians have mistakenly cast Stevens' therapy as a better one. John Duffy blames Rush for "obscur(ing) the views of other, more observant and perceptive physicians." Kuhn, Stevens, Currie and Hutchinson "were all opposed to purging and bleeding and generally followed a mild supportive policy, the only course that could have been of any help at that time."(2)
While cooling a patient with a damp cloth is accepted modern practice, and Rush would soon urge that measure, standing a patient in a tub every two hours and wrapping him in blankets soaked in brandy is not.(3) Again as in the case of Kuhn, Stevens jars the modern sensibility as much as Rush by insisting that his treatment rendered such a dreadful disease a trifle. As for the suggestion that Rush somehow "obscured" Stevens' views, it was his inability to do just that that enraged Rush. Newspapers printed all opinions offered.(4) Rush ignored the contributions by laymen, but felt duty bound to controvert expert opinion. Even though both Kuhn and Stevens left the city by the 16th, Rush feared the continuing affects of their publications. Rush immediately complained to the college that Stevens' letter would "co-operate with Dr. Kuhn's plan... in adding to the mortality of the disorder."(5)
In that letter to his colleagues, Rush finally faced up to the theoretical implications of his treatment. His hope that its obvious benefits would sway his colleagues had been defeated. He made clear at the outset that he was not fully prepared to placate those who demanded theoretical soundness. If he survived the epidemic, Rush wrote, then he would prove Stevens wrong. For the moment he borrowed a line of argument that John Brown often used to suggest that a more sophisticated interpretation of symptoms was needed to get a true understanding of the underlying morbid action.(6) The debility Stevens treated was not a direct result of the disease but "arises wholly from an excess of the stimulus of contagion upon the system." It made no sense to further stimulate that which was so overstimulated that it mimicked the symptoms of collapse. All stimulus first had to be removed by purging and bleeding, which would reduce the disease "to a level with a common cold," provided patients could "be visited by physicians as often, and attended by nurses as carefully, as in other acute diseases." The letter was printed in the newspapers on the 17th.
Not until the epidemic of 1798 would Rush learn that disputes over treatment were counterproductive. At this juncture he did not heed complaints in the newspapers that the disputes were disgraceful to the medical profession and were demoralizing the community.(7) Today, having no respect for Rush's therapies, his role in that raging controversy continues to demoralize historians.
However, Rush's purging and copiously bleeding Sansom was certainly a defining moment in medicine. Rush's defense of it was verified in the short run as copious bleeding became the cornerstone of therapy for the next two generations. In the long run he defined an attitude, that remains with us still, which was soon called and still called heroic medicine.
Lacking the tools of modern medicine, Rush was able to realize the insidious power of viruses that continues to baffle medical researchers. Some of the latest research in yellow fever presents a situation similar to that in which Rush found himself. After testing the effects of human gamma interferon on yellow fever in monkeys, researchers at Yale concluded that the interferon "changed the course of yellow fever," which is exactly what Rush felt he was doing. The researchers concluded that "more aggressive treatment," including chemotherapy with interferon combined with other anti-viral agents "might improve on the results shown here."(8)
Rush felt the same imperative. Given the context of the times, he was unable to confine his work to the laboratory. He decided to make the public partners in his quest. From our view his crusade might seem unseemly, but it shouldn't be condemned as unscientific. As we shall see, younger doctors especially, who, lacking experience, sought guidance from what passed for science, soon rallied to Rush's cause.
However, given that Kuhn and Stevens left and Hutchinson died, Duffy's suggestion that Rush triumphed because alternatives became obscured by Rush's prestige and the arts of propaganda deserves examination. But it simply does not hold. Rush did not reign supreme. The city placed the care of indigent patients in the hands of a French physician who opposed Rush's remedies.
In his book J. H. Powell chronicles the genesis of the Mayor's committee to alleviate the suffering of the poor.(9) A crisis arose from the desertion or sickness of public officials. The mayor called for a public meeting on Thursday, September 12, to raise volunteers to help the poor. Rush did not attend but his public letter on bleeding, published that day, spoke to the crisis. The root of the civic terror was fear of contagion. Popular report blamed William Sansom's work as an overseer of the poor for his getting the fever.(10) One alarmist wrote that it was "impossible to say, how slight a communication with infected persons, or their attendants may convey it."(11)
Rush tried to calm the city. "The risk from visiting and attending the sick, in common cases, at present," he explained in his letter, "is not greater than from walking the streets." Friends and family should nurse the sick. He had advised flight. That was no longer necessary. "The disease is now under the power of medicine."(12)
It is tempting to credit the bravery of the men who rallied to mayor's call to Rush's recent assurances, but there's no evidence of that. The French-born merchant Stephen Girard merely wanted to exhibit the courage that seemed so lacking in his adopted city. He wrote to a friend blaming "the deplorable conditions" on fear and fright, as much as disease. He had a "slight attack of the fever" in late August, and blamed doctors for creating a panic by treating the disease as the plague. Their "pernicious treatment" had sent many "to another world." He came to the meeting because he was "not afraid of death," and saw no "risk in the epidemic."(13)
Girard's fearlessness led directly to the ascendancy of a French doctor at the city's fever hospital. After the debacle at Rickett's Circus the overseers of the poor began organizing a hospital at Bush Hill, a vacant estate two miles out of town. They staffed it with a dozen nurses who were supervised by the young doctors Cathrall and Physick who came to observe patients once a day. The nurses, a group of men and women, were soon accused of debaucheries and drunkenness, that the young doctors could not or chose not to check. The mayor's committee of 28 appointed a subcommittee of 10 to supervise the hospital,(14) but Girard and a cooper named Peter Helm took over supervision themselves after they went out and astounded the city by personally visiting each of the 40 or so patients there.(15) When the hospital committee met on Sunday, Girard and Helm not only provided a list of all that was needed, they offered to superintend the whole operation, spending as much of their time at the hospital as necessary to get it in good order.(16)
Girard soon consolidated his control of the hospital, replacing the young American physicians with Dr. Jean Deveze, a French doctor who had just come from St. Domingo. Like Girard and unlike the Americans, Deveze believed the disease non-contagious. It grew from seeds formed in the body by long exposure to the debilitating climate of America. The poor diet of Americans and the sickly atmosphere of Philadelphia the past several months brought the seeds to deadly fruition.(17) It bears noting that the ease with which Girard and Deveze took over reflected the suspicions doctors and patients had of hospitals. The American doctors made no fuss after being dismissed. Since hospitals were essentially warehouses for the sick poor, and since the debilitated poor were, according to accepted medical theory, very prone to die of infectious diseases, a doctor mindful of his reputation avoided Bush Hill.
Rush did not cooperate with the hospital. His public health measure in response to the crisis was to encourage his African American friends to purge and bleed the patients they were called to nurse.(18)
At first laymen feared Bush Hill. A passage in Brown's Arthur Mervyn captured the pervasive feeling. "My sickness being suspected, I should be dragged in a cart to the hospital," the hero worried, "where I should indeed die; but not with the consolations of loneliness and silence. Dying groans were the only music, and livid corpses were the only spectacle to which I should there be introduced."(19)
Slowly Deveze would correct that perception. Historians credit him with using the most creditable therapies during the epidemic.(20) They seemed more supportive and his frequent autopsies of victims make him, at cursory glance, seem more modern. However, he couched his work in the language of humoral medicine.(21) Despite their differing theoretical biases, Rush and Deveze seemed to view the struggle against the disease in the same way. They both sought to create an "artificial crisis." Rush used purges to collect poisons in the bowels from whence they could be expelled. Deveze used blisters to collect poisons near the surface of the skin.(22)
Actually Deveze's remedies were not that supportive. While he did use herbal teas, carbonated water, and cordials, he also used large doses of bark and vitriol. Like most practitioners during the epidemic, he thought medicines were necessary.(23) He also bled patients, frequently (but not copiously) when the symptoms indicated the need, up to three times a day in one case. He did realize the danger of bleeding when the fever became most malignant, a precaution Rush would not realize until he too worked in a yellow fever hospital.(24) Deveze was very critical of Rush's purges and blamed them for the deaths of many of his patients.(25)
Unlike Rush, Deveze did not publish advisories during the epidemic. But the public understood that his approach differed from Rush's, and that, with an array of strategies, he sought to manage the disease in a traditional fashion.(26)
Just as he tried to counteract Stevens by laying out the theoretical grounds of his approach, Rush tried to publicize his simple approach in a favorable light. On the 16th an anonymous paragraph echoed what he had written to his wife Sunday morning: "Some persons object to Dr. Rush's mode of treating the yellow fever because it is so simple - requiring only two remedies mercurial purges and bleeding. Such persons should recollect, that a stone and a sling in the hands of little David, brought Goliath to the ground."(27) In a signed article Rush also tried to show that his approach did show regard for the comfort of the patient. He reiterated that the sick must "by no means... take vomits, bark, wine, or laudanum," but did approve "napkins dipped in pump water... applied frequently to the forehead."(28)
The use of newspapers to defuse medical information was commonplace, but Rush used them in a new way. During the revolutionary and founding period, Americans perfected the art of using newspapers to shape public opinion on the political issues of the day. Otherwise the newspaper then was more like a bulletin board, a hodgepodge of homilies and public notices. Rush tried to shape public opinion on medical issues.
Energetic though he was, he did not manage it well. That he was so often wrong was not the real problem since everyone else was essentially as ignorant of the reality of yellow fever. His talent for exaggeration and simplification angered medical colleagues and did not inform them.
In 1797 William Currie penned an anonymous attack on Rush claiming he was insane during the 1793 epidemic. Currie described how Rush terrified many "into chilly fits, some into relapses, and some into convulsions by stopping them in the street and declaring they had the fever. 'You've got it! You've got it!' was his usual salutation upon seeing anyone with a pale countenance." In 1797 Currie himself purged and bled in yellow fever, so what stung him more in retrospect was the way Rush promoted the remedy not the remedy itself.(29)
As eagerly as Rush celebrated his cures, his opponents catalogued his failures. At the hospital Deveze's autopsies showing the ill affects of calomel became known enough to excite Rush's suspicions. Rush quizzed the young American doctors who joined Deveze in cutting open cadavers.(30) But Rush's opponents could never mount a conclusive case against him, not even after revealing purged stomachs pinching backbones.(31) The equivocal nature of Deveze's findings is demonstrated by the reaction of one of the young doctors. Physick, a student of Kuhn's, soon rallied to Rush's cause, convinced by the evident inflammation revealed by the autopsies that Rush's recourse to bleeding was proper.(32)
Physick's support of Rush is significant. In London he had been the principal laboratory assistant of John Hunter, then the leading expert on blood.(33) In his critique of Rush, Binger uses passages from Hunter's work on blood to show that given medical knowledge at the time, Rush should have known that copious bleeding was improper. In evaluating patients Rush relied not only on the pulse but also on the appearance of the blood. Binger contends that Hunter showed that some of those appearances were inherent in any blood exposed to air. Thus, when Rush bled he would always see a reason for more bleeding.(34) Clearly Physick was more conversant with Hunter's ideas than Binger, and his support of Rush indicates that Rush was well aware of the latest medical thinking on the nature of blood.
As in his work with calomel, the major lapse in Rush's evaluation of his bleeding therapy was his lack of case studies and statistical evidence. Again he may have been seduced by his continuing to win new supporters like Physick into thinking that the time spent on collecting rigorous data was still not warranted given the continuing crisis. And his opponents did not challenge him with case studies and statistics. They argued theory, and managed to ignore the death toll of over 50 a day. As late as September 17, Currie still argued that there were very few cases of yellow fever in the city.(35)
Evidence to force Rush to change his therapy (or as modern critics would say, come to his senses,) still had to come from his own observations. Rush kept letters from patients during the epidemic, and from them we can get an idea of the patient feedback that might have influenced him. Dr. John Mease did not stint in following Rush's prescriptions. He lost 4 1/2 pounds of blood in five days, and had 25 bowel movements.(36) After that Mease's father wrote to Rush wondering if it was time to begin stimulating the patient with "nourishing drinks." What alarmed him was the twitching and starting as his son drifted in and out of sleep.(37)
Alexander Cochran gave the best description of mercury poisoning. The purges were violent, working "pretty severely up and down." The side effects were daunting: "My lips and gums have been much swelled, and the skin excoriated these several days past. In consequence whereof I have spat blood these three nights past, but particularly last night from a half a pint upward." He asked for something to stop his bleeding mouth. If it was not "alarming," it was still "weakening and very disagreeable." Cochran did not submit to bleeding very well. After losing 6 ounces he "nearly swooned away."(38)
In the case of the ten year old son of the prominent merchant Mordecai Lewis, "liquids color'd with blood" continually "rose out of his mouth while sleeping." Rush had some inkling of the problem. After taking his purges he confessed it made his mouth sore.(39) When he began making his rounds again on Thursday, the Lewis boy was one of the first he saw. Rush's apprentice Fisher had bled him and the incision would not stop bleeding. When Rush saw the boy, he changed treatment, using medicines that were anathema in his published statements: laudanum and bark in glysters. To no avail. The glysters would not stay. The father tried to get the medicine down his son's throat but that seemed to strangle him. That night the boy "vomited up a large worm, 8 or 9 inches long and full thick as a quill," and died shortly afterward.(40)
There are many more examples of mercury poisoning since Rush, if he culled his letters at all, would have kept those that showed his medicines having affect. Reading them one can't help but accept the main point of Rush's modern critics, that Rush's remedies had to have been detrimental to patients. Their affects seem so violent that even the argument so often used in support of exotic therapeutic practices, that the patient was so prepared to expect them that not using them would have been traumatic, doesn't hold. These were, Rush himself proclaimed, old remedies used in a new way.
Yet we must be aware of our rather recent phobia against depletion. Rush began describing yellow fever as a hurricane and his remedies as a way to get the body to bring in its sails and ride out the storm.(41) In that respect Rush was anticipating acceptable modern practice. Through depleting remedies he was enforcing complete bed rest. Purging and bleeding seemed to put an end to the restlessness characteristic of the disease. But there is no point in trying to insinuate purging and bleeding back into the Merck Manual.
As the epidemic raged, Rush's opponents had a difficult time finding a case of a prominent patient certainly killed by Rush's treatment. Indeed they would not get a cause celebre until the epidemic of 1797. The power of the fever was such that few blamed Rush for deaths, and many lauded his remedies when they preserved a seemingly sick person from having the most fearful symptom, black vomit. Despite Sansom's prostration from Rush's remedies, when his friend Richard Wells got a fever, Rush was immediately sent for. Rush's quick, authoritative treatment of his uncle impressed Benjamin Smith. Wells seemed to have a "light" fever, yet "the doctor took every precaution, the first appearances not having always proved a sure presage of its progress - he has been repeatedly bled and has taken freely of the mercurial powders which seem to have operated kindly and... with good effect; his fever is much reduced tho' not quite removed & he spent last night as easy as could be expected when under the operation of his physic." (A week later, Smith found Wells "much reduced under Dr. Rush's mode of treating the disorder," but still alive.)(42)
As Rush continued a well orchestrated newspaper campaign to support his remedies, there was no evidence to warn him to be cautious. So confident was he that evidence alone would win the argument that when Physick offered to write a letter of support, Rush cautioned the young doctor not to offer theories for why bleeding worked. The "theory" behind the treatment, Rush explained, had best "be settled hereafter."(43)
After items in the newspaper celebrated the recoveries of Drs. Mease and Penington, and Rush himself, thanks to purging and bleeding,(44) An Observer wrote that while not grounded in theory, Rush's cure had "nothing to recommend it at present but its wonderful success." Doctors said his dose "would kill a horse." Observer knew "it has not killed a weakly infirm lady.... On the contrary it has restored her to health and may not the same be said of hundreds who have submitted to his prescriptions." As for the West Indian method, "we are tired with numbering those it has already laid in the dust."(45)
Even the death of Dr. Penington soon after his testimonial in favor of Rush's remedies did not cause a pause in the drumbeat of Rush's publicity campaign. He explained to the press that "in consequence of going out too soon after his recovery, [Penington] relapsed a few days ago and is since dead."(46) Then the drumbeat of glowing testimonials continued. On the 21st "T.P." noted the cures in his family and the deaths of neighbors "under other modes of treating the disease."(47) ("T.P." was Postmaster General Timothy Pickering. He had been away negotiating an Indian treaty and returned the first week in September to find a servant and one of his three sons sick with the fever. He called for Rush, and explained to those who asked why he didn't flee that he was loath to leave "the one physician on whom I could depend.")(48)
Two ministers visited Rush. Father Fleming found many in his congregation cured by following Rush's printed directions without the advice of a physician.(49) Whenever the father saw a doctor who didn't use calomel, he begged them to swallow their pride and save the people.(50) The Lutheran minister J. H. C. Helmuth also lauded Rush.(51) (Helmuth mentioned his visit in his journal: "Met Dr. Rush who is feeling well and confident. Felt bad myself. Lord, your will may be done!")(52)
A major reason for Rush's confidence was that in the middle of September there was a lull in the epidemic. Wednesday morning it was 44 degrees. Many observers rejoiced,(53) and the federal official left in charge of the government offices there, Comptroller of the Currency Oliver Wolcott, wrote to President Washington suggesting that the epidemic would soon end.(54) They were all wrong and one of the households to be stung by its renewed virulence was Rush's.
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1. Rush 1793 pp 215-23.
2. Duffy p 67.
3. Berkow p 58.
4. see Fed. Gaz. from Sept. 11 - 16, 1793.
5. Rush 1793 pp 223-5.
6. Coulter vol. 2 p 291.
7. Powell p 211.
8. Arroyo, p 650.
9. Powell pp 140-194.
10. B. Smith to D. Smith, Sept. 12, 1793, Haverford.
11. Barton to Coxe Sept. 9, 1793, HSP.
12. Rush 1793 p 228.
13. McMaster, pp 212ff.
14. Minutes pp 14-27.
15. B. Smith to D. Smith Sept. 17, 1793, Haverford.
16. Minutes pp 19-27.
17. Deveze (1) pp 36-40.
18. Allen p 5.
19. Mervyn p 147.
20. e.g. see Powell pp 163-164.
21. Deveze pp 38, 40, 64.
22. Deveze p 64
23. Deveze p 66.
24. Deveze p 54
25. Deveze p 76.
26. e.g. Logan letter in Fed. Gaz. Oct. 2, 1793.
27. Butterfield p 664; Fed. Gaz. Sept. 16, 1793.
28. Rush 1793 p 229.
29. Gaz of US. Oct 6, 1797.
30. Rush to Annan, undated, Rush Papers.
31. Deveze (1) p 76.
32. Pickering to Clark, Oct. 1, 1793, MHS.
33. Hunter p 94.
34. Binger p 229.
35. Rush 1793, pp 230-233.
36. Fed. Gaz. Sept. 30, 1793.
37. John Mease to Rush, Monday 11 o'clock, Rush Papers.
38. Cochran to Rush, Monday and Tuesday, Rush Papers.
39. Butterfield p 672.
40. Lewis to Rush, Sept. 16, 19(1) & 19(2), 1793.
41. Rush 1793 pp 273-4.
42. B. Smith to D. Smith, Sept. 21 & 23, 1793, Haverford.
43. Pickering to Clark, Oct. 1, 1793, MHS.
44. Fed. Gaz. Sept. 17, 18, 20, 21, 1793.
45. Fed. Gaz. Sept. 18, 1793.
46. Fed. Gaz. Sept. 20, 1793.
47. Fed. Gaz. Sept. 21, 1793.
48. Pickering to Clark Oct. 1, 1793, MHS.
49. Butterfield p 669.
50. Rush Notebook Sept. 21, 1793.
51. Butterfield p 669.
52. Helmuth diary, Sept. 18, 1793, Mt. Airy.
53. Fed. Gaz. Sept. 18, 1793.
54. Wolcott to Washington Sept. 20, 1793, CHS.