Destroying Angel: Benjamin Rush,

Yellow Fever and the Birth of Modern Medicine

by Bob Arnebeck

Prologue

Sometime between 1794 and 1805 the Danish naturalist Johann Christian Fabricius distinguished the Aedes aegypti mosquito from the 14 other mosquitoes familiar to naturalists in Europe. Fabricius obtained two specimens from his friend the Danish civil servant Tonder Lund who in turn got them back in the 1780s from one of the customs house officers posted in the West Indian island of St. Croix, then a Danish colony. Fabricius was a student of the consummate classifier of nature Linnaeus, and had taken it upon himself to further systematize the insect kingdom. He had little trouble seeing how the Aedes aegypti differed from other mosquitoes. It was smaller and had black and silver stripes around its minuscule body. The Danish doctor did not suspect that, while he carefully fit what he called the Culex stegomyia into the new system which he published in 1805, billions of those mosquitoes had spread yellow fever with its attendant death and terror in the northern ports of the United States, as well as St. Croix and most of the West Indies.(1)

Not that there was any reason for Fabricius to suspect the mosquito. Benjamin Rush, his old classmate at the medical school in Edinburgh, Scotland,(2) was making quite a name for himself by explaining how putrefying vegetable matter caused the disease. He even boasted that he could cure the disease if called to a patient soon enough. We can't be certain that Fabricius did know of Rush's work with yellow fever. It is likely since Rush's performance in the 1793 epidemic in Philadelphia earned for himself great merit in the eyes of European doctors.(3) Which is not to say that Rush's explanation for the etiology or cause of yellow fever, and his treatment of it with purges and bleeding, startled Fabricius. Rush's new ideas were variations on old themes, dating from the time of Hippocrates over 2000 years before.

In a word Rush's reaction to the terrible epidemic, from the stand point of medical science then, seemed provincial. Which after all was to be expected. America, even its capital city, was very much provincial in 1793, and the few men of learning there could be expected to make great noise merely to connect the rude American experience with that of European civilization. The agency of the mosquito in spreading yellow fever would not be postulated until 1881 by the Cuban physician Carlos Finlay and not proven until 1900 by the American army doctor Walter Reed. Despite Rush's claim yellow fever remains incurable. A vaccine was developed in 1937.(4)

Even those who celebrate Rush today, his biographers, take short cuts to avoid an extended discussion of his work with yellow fever. After applauding his sacrifice in fighting the 1793 epidemic, they regret that he suborned his observations of the disease to suit his theories of medicine, sacrificing both his patients and his claim to be taken seriously by posterity. As early as 1844 Dr. Elisha Bartlett alluded to the "utter nonsense and unqualified absurdity" in Rush's writings and historians have been quoting him approvingly ever since.(5) Of course it did not help Rush's reputation that not only are his writings generally held to be prolix and pointless in relation to modern medicine, but the medical thinkers of Europe who he was trying to impress are themselves as irrelevant.

Given that Rush's heroism in 1793 has already been celebrated, someone essaying the subject of Rush and yellow fever, at book length, in the late 20th century had best explain himself. That much of the historical treatment of Rush's work with yellow fever is inaccurate does not justify a reexamination. The antics of ancient doctors, so pompous and so wrong, invite ridicule.(6) The art of historical writing is generally well served when incisive wit at times is unshackled from the bed rock of facts. And the facts in Rush's case are many and difficult to plumb. He wrote an account of every yellow fever epidemic he fought: 1793, 1794, 1797, 1798, 1799, and 1802. He revisited the epidemics in his medical school lectures, and because of his renown, students copied and widely shared their notes of his lectures. His correspondence during the epidemics is vivid and replete with detail and self-justification. He engaged in public controversies during the first three epidemics, defending himself and attacking rivals in signed and unsigned letters to newspapers. A celebrated law case initiated by Rush culminated in an invidious recounting of his medical practices during the epidemics. Thus Rush presents the historian with a torrent of information and rather than wade into it, with so little seemingly at stake, there is safety in merely stepping back and charting its general course.

The disease he fought is almost as unappealing as the doctor. "....(A)s much, perhaps, has been written, particularly within the last sixty years, as upon any other malady flesh is heir to," a doctor wrote of yellow fever, but that was in 1854.(7) Today, as epidemics go, yellow fever is not as sexy as venereal disease, not as sociologically revealing as cholera, and not so firmly a part of European and North American culture as tuberculosis. A social history of yellow fever in Philadelphia, New York and Boston from 1793 to 1805 condemns the reader to contemplate a tropical disease appearing in places it does not belong, inspiring "science" that was completely wrong, leading to the deaths of 15,000 to 20,000 people, none of them that notable.

Yet as the AIDS epidemic is tragically demonstrating, medical science today is not so right, not so powerful as we had thought. AIDS too may be a tropical disease out of place. It is forcing us to ask questions about disease that makes a return to the time when most died of infectious diseases seem a possibility. In the last dozen years ancient doctors have become contemporary once again. The hope is that their arts will provide clues to pharmacologically active plants that may indeed bolster our suddenly suspect arsenal of wonder drugs.(8)

This new interest has not yet extended to Rush and never will. His wonder drug, mercurous chloride, is a poison; his "scientific" approach to the application of the ancient art of bleeding remains unappealing. However, Rush deserves our attention, not because his treatments might be apropos, but because he created expectations that still inform our fears and hopes.

Rush's response to yellow fever glorified the heroic manner of addressing public health problems that typifies the modern medical culture. In place of resignation and flight, he taught action; in place of the Biblical mentality that this too will pass, he proclaimed his conviction that research unlocking the secrets of this killer would rapidly lead not only to its conquest but the conquest of other diseases as well. In the previous 2,000 years doctors had not consolidated their place in society by treating epidemic diseases.(9) To be sure throughout history doctors had boasted of getting the better of disease, even of making headway against epidemics, as indeed they had in controlling smallpox with inoculation, and some malarias with a bark containing quinine. But it's difficult to find any antecedent to Rush's heroism and audacity, not only in the particular moment when a city of almost 50,000 lost 10% of its population in less than three months, but also in Rush's tireless efforts in the remaining twenty years of his life to change medical practices and dogmas.

The snapshot of Rush presented to us by medical history, a macabre scene of bloodletting and purging to prove his pet dogma that all diseases would respond to variations of his one draconian cure, is false. Rush initiated and led a truly scientific quest to control, if not conquer, infectious diseases. It is to Rush that we can trace a change in man's attitude toward medicine. As invalid in our eyes as his scientific work is, he sowed the seeds of the modern frustration. Simply put, with Rush, medical science began to promise, as it still does, more than it can ever deliver in our lifetime. He even speculated on the possibility of putting patients into suspended animation until cures could be found for their mortal illnesses.(10)

My thesis is a novel one both in social and medical history. In the eyes of medical historians apart from some advances in morbid anatomy sporadically applied, principally in London and Paris, in a setting pre-figuring the modern clinic, the 18th century, even in comparison with the 17th century, contributed little to the development of modern medicine. The optimism generated by the confluence of the Enlightenment idea of progress and the religious idea of the millennium is duly noted by historians, but only as a fad, a charade of theory not based on true scientific observation. Since his bogus theories based on the symptoms of disease obviated any need for pathology at all, Rush is usually credited for retarding the development of modern medicine in the United States.(11) For all his hope-mongering historians cast him into the darkness before the dawn of modern medicine. What success he achieved in deluding his contemporaries is attributed to his personality, not his science.(12)

However Rush's performance is not a charade. He did not charm his contemporaries into doing themselves ill. He was a model scientist, not only sharing his research but demonstrating an acute awareness that scientific progress depended on candid cooperation. He valued the rapid analysis of experience to enable quick application of medicines to medical problems whose threat to society he tended to overdramatize. Few doctors have observed disease so faithfully. Far from being charmed by his audacity, at first many colleagues in Philadelphia were shocked and suspicious. They only accepted his therapies and theories after their own observations.

In some ways the historical mission to exclude Rush is protective, an effort to prove that bad medicine can never arise from good science. To say otherwise is demoralizing as long as we trust that medical science will conquer disease through improved techniques and increasingly superior knowledge of nature.(13) However, as an exploration of Rush's fight against yellow fever will help reveal, what defines medicine are not techniques and analytical systems but disease itself. Lost in our glorification of technological triumph is a correct idea of man's relationship to disease. Responding to an exotic disease, Rush defined a new attitude to disease in general. Through a study of his work with yellow fever, we can begin to see how the diseases of our day, or one disease, create the interplay of dread and hope that defines medicine and notions of personal and public health.

Rush's science should not be held up as an error for our scorn, but as a reaction to a phenomena as old as man. Rush bent himself with exemplary heroism to conquer a dreaded disease. For one generation he was the best witness to a killer, that in another guise, stalks us still.

Go To Chapter One

1. Zimsen, p 11.

2. Corner, p 44.

3. Chisholm, p 276.

4. Zuchau, p 490. This source credits Josiah Nott with suggesting mosquito transmission in 1848. However, while he suggested insect transmission, he did not specify the mosquito, see Humphreys, p 20.

5. Shryock(1), p 235.

6. for recent joking at Rush's expense see Elkins, p 823, "The most notorious Republican cure, that of Benjamin Rush, required drawing extraordinary amounts of blood, more than most patients possessed. (Somewhat reminiscent of the guillotine, the treatment was frequently lethal.".

7. R. LaRoche, as quoted in Winslow, p 193.

8. e.g. Washington Post Nov. 11, 1991, "West Puts Ancient Chinese Malaria Remedy to the Test," p A-3.

9. Cipolla, p 7; Creighton, p 243. Rush searched the literature on epidemics and found two instances in which doctors won honors for successfully treating epidemic diseases, Heinsius in Verona and Masdenal in Spain, Rush 1977, pp 227 & 228.

10. Rush 1977, p 162, in this he followed John Hunter.

11. Shryock (1), pp 205, 212, 249.

12. Shryock (2), p 123; Shryock (1), p 206, and Duffy (1), p 67. Duffy wrote: "Against his better qualities, Rush was a complex pesonality, rigid and self-righteous, and he pursued his medical thesis with a fanatical zeal. The tragedy is that his personality obscured the views of other, more observant and perceptive physicians.... Rush represents a transition between the eighteenth-century age of reason and the nineteenth-century age of science. He had a philosophic bent that made him seek fundamental causes, and his medical training encouraged this tendency. Although he was a keen clinical observer, Rush had little interest in pathology and laboratory research....(H)is status as a signer of the Declaration of Independence, and his brief services as an army medical officer all added to his public exposure and helped enhance his medical reputation."

13. see Rosenberg's critique of medical history in Rosenberg, p 2-3.