Destroying Angel: Benjamin Rush,

Yellow Fever and the Birth of Modern Medicine

by Bob Arnebeck

Chapter Eleven

Rush showed the way to a new role for American physicians, which remains in many respects their modern role. Rush demonstrated that it was their duty to observe diseases and advise their fellow citizens how to cope with them without regard for any city's reputation. This imperative arose from the very nature of fevers. Rush's principal of the unity of fevers girded physicians with a respect for the potential of any fever to ripen, if allowed to thrive in a mephitic environment, into a deadly epidemic. Critics might view Rush's theory as fanciful, glossing over critical distinctions a scientific observer should make, but his theory served science because it taught that no observation of symptoms and environment should escape a physician's notice. He should not defer to colleagues about identifying fevers; he should not leave it to a vote; he should err on the side of alarming his fellow citizens, not lulling them with assurances until it was too late to do anything to defeat contagion.

Distressed by Rush's simplifications, too many historians assume that they must have been made with cavalier disregard for the reality of disease. The medical historian Lester King blames Rush for being inflexible. "In the study of febrile disease he faced toward the past rather than toward the future." King lauded the achievements and style of Chisholm. His work "heralded the new spirit of the nineteenth century, the spirit of eager youthful inquiry, of flexibility, of a new empiricism, which, repeatedly proved wrong, nevertheless persevered undaunted.... There was, in short, the rise of a new perspective in which speculative and experimental tendencies could, after suitable discipline had been achieved, disregard the fetters of authority and tradition and seek truth for itself. Medical science, as the eighteenth century drew to its close, was thus experiencing a true renaissance."(1)

While King should be lauded for recognizing ferment where most historians see none, he misunderstands Rush and the effect he had on his colleagues. Lacking a framework of medical progress, because there was precious little objective evidence of it, Rush had to create one in order to excite the comprehensive quest for a new understanding of disease. Especially in an age that did not offer financial rewards for research per se, a vision of a better, simpler, a more sublime future animated scientists. Rush's theories fostered such visions. Chisholm's heralding the advent of a new fever which, like Rush, he fought with an old remedy, calomel, simply failed to inspire colleagues and medical students.

Rush's theories dismay so many historians because they don't understand that they were fashioned also as a motivational tool. One historian for example assumed that Rush, following his theory of one disease, completely did away with pathology.(2) Actually he shared with his students his appreciation of the pioneers in morbid anatomy whose work would not only prove him wrong but make his theories seem ridiculous.

One of his students, Samuel Jackson, who went on to become one of the founders of pathology in America, saw through and appreciated Rush's approach. He certainly didn't, as many commentators do, credit Rush for retarding the development of pathology. In a biographical essay written long after Rush's death, Jackson recalled that despite his urging the unity of disease, about which Jackson recalls students had grave doubts, Rush encouraged others to study morbid anatomy. He loved to garnish his lectures with fresh observations published by the European researchers who in the late 20th century would be credited for looking toward the future. While Jackson and his fellow students always thought of Rush as "most wonderfully entangled in the delicate web of his honest sophistry, that the great Rush, after having reduced all disease on earth into a unit, should have described every distinct disease most accurately and minutely in his lectures on practice, is one of the most inscrutable mysteries in the absurdities of learning."(3)

Rush's weakness was not his entanglement in medical systems, but his eagerness to embrace medicines that dramatically demonstrated his principles. He became obsessed with bleeding not out of any respect for its use in the past but because of its simple directness. He frequently remarked that one of the boons of bleeding was that it was completely in the physician's control, assuming of course one had a compliant patient. He could extract just the amount he wanted.(4) There was enthusiasm for purging too, but it never achieved the level inspired by bleeding. Once medicine entered the body there was some suspense and a great deal of mystery about what it was doing. How easy to feel the pulse and bleed, feel the pulse and bleed, feel the pulse, bleed....

"I drew 60 ounces of blood from a man in the maniacal state of fever in twelve hours and cured him in two days," Rush wrote to John Coxe on December 8, 1795. "But Dr. Physick has far exceeded me in this mode of reducing the system. He drew 75 ounces at one bleeding from Dr. Dewees in the apoplectic state of fever, and cured him thereby in a few hours." Rush and his colleagues also proved the efficacy of bleeding in intermittent fevers when the bark did not work.(5)

Physick, who was developing into the nation's foremost surgeon, used the procedure as an anesthetic. He bled a hospital patient with a dislocated shoulder to the point of fainting and then was able to fix the shoulder easily and painlessly. Dewees began perfecting the technique of bleeding during childbirth to reduce pain, Rush offered theoretical justification by classifying pregnancy and child birth as diseases, just more states of fever in which the arteries needed to be regulated.(6)

During September 1795 ten members of his household were sick with a "remitting fevers." Rush credited his use of the lancet for preventing them from developing into something serious. All told he took blood 24 times, twice from himself in one day, and even 6 week old Samuel Rush was likewise "bled twice, and thereby rescued from the grave."(7)

A student wrote to him that the use of the lancet in a dysentery epidemic in central Virginia, "procured me success beyond my own expectation; and astonishing those who a little before had shunned the instrument as the instrument of death."(8) "My beloved Master," began a letter from Chestertown, Maryland, that reported, "we have never had so much business, we have never bled so much, and we have never been so successful."(9)

A recent apprentice met resistance in North Carolina when he bled in bilious fevers. "The anti-bleeders I hope will succumb under the weight of authority," he wrote back to that authority, "and, unable to refute, will be forced by all lovers of truth and improvement, to be silent upon a subject of which they are ignorant. You are I hope to afford the world one example among a very few, where a physician has lived to trample error and his enemies under his feet." Active as he was in North Carolina, he regretted not being in Philadelphia with Rush's "impenetrable phalanx,... rendering my little service to promote under your banner the cause of humanity and truth."(10)

At the hospital in New York, Samuel Mitchill and Elihu Smith bled in as many cases as they could, not only fevers, but dropsies and mania. "When we have had any thing like a fair opportunity for doing any good, in fevers, we have always done it by bleeding," Smith wrote and reported that another physician lost only 2 fever patients out of 60 when he bled. "After all these testimonies in favor of this remedy," Smith concluded, "one would think that the cavillers should be silent."(11)

Depleting remedies only represented one side of the revolution in medicine. Rush's discussions of the etiology of yellow fever inspired research into the cause of fevers. At first pinpointing local origin fortified the non-alarmist approach to epidemics. In August 1795 the New York health committee sent Dr. Valentine Seaman to investigate the area near the east side wharves reportedly rife with fevers. The young doctor ignored the considerable anecdotal evidence of the family and friends of victims that blamed visits to noxious ships along the wharves. Instead Seaman reported to the health committee that he had found "the cause of the present complaint,... a fruitful matrix generating the seeds" of the fever. The city corporation had built up Water Street in that area with landfill without requiring lot holders along the street to fill their yards to a level with the street. "Hence, the refuse water and offal substances from the families occupying these places are left to stagnate and putrefy." Even a rain shower which contributed to the health of well drained areas, only made matters worse in that sunken plain where each building housed "several families."(12)

In August 1795 Dr. Samuel Mitchill, a 31 year old chemistry professor at Columbia College, put the finishing touches on an essay arguing that since nitrous gas, which Lavoisier had shown could kill a bird, was produced by putrefaction in cities and in stomachs, it was the likely cause of contagion. If the gas could be detected, it should be easy to identify and control. "Since we are become acquainted with its production and composition, it is very much in the power of individuals to guard themselves against it, and for magistrates to protect cities from its ravages."(13)

Dr. William Smith, the city's new port physician, was persuaded by Mitchill's ideas, and thought rotting cotton the principal culprit in making the deadly gases.(14) Store owners with suspect warehouses storing cotton protested that there was nothing rotten. When the health committee learned that 11 people had died of the fever on the 25th, it stopped bickering with store owners, and ordered the cotton removed and the stores cleaned because the public was "too alarmed."(15)

Rush appreciated New York's evident appreciation of his etiological ideas, but rightly chafed when the city's health committee insisted that the fever was not contagious and that the victims of it were mostly poor and of no account and thus themselves the principal cause of the fever. He argued that it was neither scientific nor moral to stigmatize victims.(16)

However, unlike the 1791 and 1794 epidemics in New York, the 1795 epidemic was too big to be minimized. Around 800 people died and many prominent people did get sick.(17) While not an alarmist by nature, Elihu Smith felt compelled by the example of Rush's memoir of the 1793 epidemic to survey the low lying areas where the fever prevailed. He understood that New York presented a laboratory for proving Rush's theories on the origin and nature of yellow fever. He soon enlisted an important ally, Noah Webster.(18)

Like Smith, Webster was a Yale graduate and transplant from Connecticut. His spelling book and grammar had been published a decade before. In 1794 he published a New York newspaper. In 1789, he had observed first hand the progress of the influenza epidemic that swept the nation. That gave him an abiding interest in epidemics.(19) During the 1795 epidemic he was frequently out of the city, but Smith talked with him at length about the epidemics in New York, Philadelphia, New Haven, Baltimore, and elsewhere. Webster grasped that they were harbingers of a threat to the whole nation. Webster decided to use the New York fever as the centerpiece for a national debate on the nature of the threat yellow fever posed to the new nation, and on the reforms that might save America.

Webster wrote an open letter to the physicians of Philadelphia, New York, Baltimore, Norfolk and New Haven, asking them to send him information which would help determine if yellow fever was of domestic origin, and if it was contagious. Answering those questions was "equally interesting to every part of the United States, and one that deeply affects the happiness of families and the general property of the country." He didn't limit his inquiries to the big ports. After alluding to the bad fevers experienced that year along the Hudson, in the Genesee country, and in swampy districts in central New England like Sheffield, Massachusetts, he called for physicians anywhere with information on malignant fevers to send papers to him for eventual publication. Once the threat was identified and understood measures could be taken to stop importation or neutralize local causes for the disease. It was perilous to let the disease become rooted in America. "Our latitudes are the same as those of many countries in Asia, where the plague rages; and perhaps our climate, which formerly resisted the progress of fatal epidemics, is assimilating itself annually to that of Smyrna and Constantinople."(20)

In his account of 1794 epidemic Rush would blush "for the shameful submission made by the science of medicine to the commercial spirit of the city."(21) Smith and Webster began to create a national scientific vision that could overwhelm parochial politics. As it turned out the results of Webster's solicitation were meager. Smith and Seamen wrote about the New York epidemic much as Rush would have, though they were more adamant about the fever not being contagious. Seamen compared those who believed it contagious to the ignorant and wicked men who believed Salem had witches in 1692. There were reports on two rural epidemics which of course supported local origin. Two New Haven doctors presented evidence that the disease there was imported.(22)

Disappointed, Webster looked to history as a guide and decided to write a history of epidemics beginning with Bible time to the present. Smith continued to pursue the vision of a national consensus on fevers, and in 1797 announced, with two colleagues, the creation of the Medical Repository, a quarterly devoted to medicine and science in general and dedicated especially to understanding American fevers and their epidemic potential.(23) The first issue of the Medical Repository came out in August 1797. Rush did not contribute because he had plans to start a medical journal in Philadelphia. But that didn't prevent Smith from lionizing the master in a review of Rush's latest volume. To Smith the only blessing of the deadly epidemics was that it had allowed Rush to revolutionize man's understanding of medicine: "Perceiving at an early period of the epidemic, that the moment of important observation was arrived, and that nature might then be subjected to a close inspection and decomposition of her morbid operations, he watched, and scrutinized, and penetrated with a degree of ardor, assiduity and success which do him great honor."(24)

Unfortunately, many physicians were skeptical of Smith's and Webster's bias. They understood that by equating the yellow fever of the Atlantic ports and the bilious remittents of places like Sheffield, Massachusetts, just as Rush had done, Webster skewed the debate in Rush's favor. William Currie never responded to Webster. A contagionist believing the 1795 fever was imported did rise to the occasion, though he didn't reveal his name.

"A.B." wrote a series of letters for the press that appeared in July 1796. He traced the initial fever cases to recently arrived ships. While anti-contagionists excoriated George Street for its filthy and sodden condition, and all but blamed the Irish who crowded the flimsy wooden houses there, A.B. cited the testimony of those very people who blamed the fevers on the ship Scipio which arrived in a sickly condition and docked nearby. A.B. did not excuse the conditions of the streets. Indeed he detailed the states of the pavements, walks and yards and the types of houses and the habits of the people living and working in them. Filthy local conditions and the heat and humidity thoroughly infected the neighborhoods but the contagious matter, A.B. insisted, came from the ships in the West Indian trade. He quoted a Dr. Grant to contradict Rush's theory that a common remittent could be excited into a yellow fever: "Each species of fever arises from a seminum, or cause peculiar to itself, and is always the same, and will breed its own likeness." These letters were bitterly denounced as not having "a shadow of ground" to stand on, and creating "a fatal evil" by excusing a lack of vigilance in cleaning up the city.(25)

Then the Rushites claimed a victory over A.B.. They warned in April that a new dock being built near the Battery was a health hazard. As land fill the builders used dead horses, horse manure and night soil. Then the crew of a ship from Copenhagen that docked nearby all sickened and had to be sent to Bellevue, the fever hospital, to recover. People in the neighborhood also became sick. The Rushite health officer refused to adopt the euphemism "dock fever" and publicly identified it as "yellow fever, if you please, that murderer of our own creating."(26)

What especially cheered Rush was that his disciples understood that because the fever appeared near the wharves it did not mean that sailor brought it. In his book on the 1794 epidemic Rush had written that it was "possible" that the New Haven epidemic was imported, as New Haven doctors claimed, but he warned that seemingly imported fevers often arose because "the proximity of the ships to filthy wharves and docks" allowed the seeds of the fever to have deadly affect on overworked, intemperate sailors.(27)

Then the mini-epidemic in New York ended quickly which was attributed to the same storms and cold front that Rush thought saved Philadelphia from an epidemic.(28) He wrote on August 16, 1796, that the city was healthy thanks "not to the vigilance of our government, or committee of health, but to the heavy rains which fell about the middle of July, and the cool weather that succeeded them."(29) Rush wrote to a European correspondent on September 22, 1796, that "the opinion" of the fever's "domestic origin has become almost universal in the United States."(30)

Rush and his disciples entered the sickly season of 1797 with a level of confidence unparalleled in the past, and anticipating the assurance common to the 20th century. Not only did they have an effective and easy to use remedy, even in the matter of etiology, which had always been more bitterly attacked than bleeding and purging, Rush thought he had triumphed over ignorance. He thought he had successfully explained why the fever appeared and disappeared, and had confirming evidence from disciples throughout the nation.

Which is not to say that they didn't face considerable opposition. The Rushite therapy and etiology went against common sense. Rush never announced the triumph of bleeding. He noted that "the lancet has at last become less unpopular in our city.... Griffitts and Physick are forced upon Kuhn in consultations only because they are believed to be acquainted with the most successful manner of using it."(31) It bears noting that Kuhn had never been opposed to bleeding per se.(32)

Conversely, it would be a mistake to assume that Rush bled indiscriminately. Timothy Pickering's son Charles had a "hectic fever," as the flush and fits of tuberculosis were then called. To stop the cough Rush recommended a punch of brandy and milk poured over loaf sugar; a little salt beef morning, noon and night to strengthen the boy; and a ride in a tree swing to quiet the fits. Pickering promptly went out to buy a suitable rope.(33)

Elizabeth Drinker's husband, Henry, had tried the newest cure-all for his rheumatism, Dr. Elisha Perkins' "metallic points," a sparking machine that was the talk of the city that winter. When he woke up a few weeks after that treatment in great pain, Drinker sent for his regular doctor, Rush. Bleeding was sometimes prescribed for rheumatism, but Drinker didn't care for it so Rush prescribed castor oil, which relieved Drinker by evening and the pain did not return for months.(34) Rush had to be sensitive to the feelings of patients and their families. Most of his research was done on charity patients at the hospital. Rush confessed that with his paying patients he was always relieved when a pain in the chest developed because bleeding in a pleurisy was traditional so there was less opposition to his bleeding to cure the fever.(35)

Rush never promoted bleeding the way Elisha Perkins promoted his metallic points with newspaper ads and public demonstrations.(36) Rush limited his promotion to passing along letters endorsing bleeding to Philadelphia newspapers. His defense of bloodletting which came out in the summer of 1796 was written for doctors not the general public. But since the name of the most famous doctor in the country became associated with the procedure, it achieved a cachet which in some circles may have helped bleeding become the pain killer and mood changer of choice in an era when opium was readily available. In his diary a young doctor in New York, who had treated yellow fever patients at Bellevue the city's fever hospital, explained that when he felt out of sorts, he took "a pound of blood" out of himself. That same day two friends, likewise out of sorts, asked him to "take a pound."(37)

We would like to find a physician then who opposed bleeding in the same way that our physicians do today. But there were virtually none because at that time there were few sedatives and painkillers, and opium and liquor had more dangerous side effects. Among some laymen however visceral squeamishness had developed into a cult of opposition. This group would soon form the converts for Homeopathy, but in the late 18th century opposition to bleeding in America organized on two levels: those for whom it symbolized the best reason for opposing all academically informed medicine, and those who thought it was foreign, a French practice.

In cheering Rush on, his North Carolina disciple spoke primarily of the English, who Rush had long dreamed of impressing, when he wrote, "Your book, [defense of bloodletting,] will afford a bone for the European physicians to gnaw. They appear so stupid that unless they are electrified from the New World, they must die in palsied, contented ignorance."(38) Elihu Smith reported a struggle with the family of one patient who "had all the prejudices of Englishmen" against bleeding. Then the patient bled from nose and gums. "How benevolent is Nature," Elihu Smith wrote to Rush, "thus to pour forth the offending fluid, herself, when she has not been wisely anticipated!"(39)

Rush couldn't believe opposition to bleeding per se animated his opponents. He became convinced that the attacks on his medical revolution arose from the virulent partisan politics of the day. He explained to friends that opposition to his remedies arose "chiefly [from] an unkind and resentful association of my political principles with my medical character." He had signed that ultimate anti-English document, the Declaration of Independence.(40)

Then in August 1797 yellow fever returned to Philadelphia to test the doctor who had claimed to have conquered it, and in a month he apparently had a nervous breakdown.

Go to Chapter 12

1. King, p 154.

2. Shryock (1) pp 213, 242.

3. Gross, pp 56, 60. 61.

4. e.g. Rush 1815 vol. 4, p 191.

5. Butterfield p 765.

6. Rush 1815 vol. 4, pp 220, 222.

7. Butterfield p 763.

8. Everett to Rush July 20, 1796, Rush Papers vol. 4.

9. Anderson to Rush Oct. 30, 1795, Rush Papers vol. 37.

10. Alexander to Rush Nov. 4, 1796, Rush Papers vol. 1.

11. Cronin pp 214-218, the actual letter in the Rush papers varies somewhat.

12. Seaman pp 32-4.

13. see Hall pp 31-62, & Mitchill, Remarks....

14. Phil. Gaz. Sept. 3, 1795.

15. NY Minutes Aug. 24, 25, 26, 1795.

16. Phil. Gaz. Sept. 19, & Oct. 7, 1795, Rush 1796 p 21.

17. Seaman & Bayley, op. cit.; Phil. Gaz. Oct 6, 1795.

18. Cronin pp 75, 81, 82, 91, 92.

19. Spector pp 1-6.

20. Ford, p 131, & Webster (1) introduction.

21. Rush 1796 p 20.

22. Webster (1), Seaman p 26.

23. Cronin p 204.

24. MR vol 1 #1 p 73.

25. Phil. Gaz. July 1, 2, 5, 8, 14, 17, 18, 30, 1796.

26. Bayley 1799, pp 5, 8.

27. Rush 1796 pp 68-9.

28. Bayley pp 13ff.

29. Rush to Webster Aug. 16, 1796, Webster Papers, NYPL.

30. Butterfield p 780.

31. Butterfield p 765.

32. Drinker diary Mar. 6, 1796.

33. Pickering papers

34. Drinker diary Mar. 23, 1796.

35. Rush 1815 vol. 4, p 190.

36. W. S. Miller, pp 41-57.

37. Anderson diary, Aug. 28, 1797, NYHS. In Rush lecture 1799 p 33, Rush notes similarity of effect between venesection and opium.

38. Alexander to Rush, Nov. 4, 1796, Rush Papers.

39. Cronin p 216.

40. Butterfield p 767.