Return to Fever 1793
Benjamin Rush, Yellow Fever and the Birth of Modern Medicine
by Bob Arnebeck
Prologue: my introduction to the manuscript in which I outline my argument.
Chapter One: why Rush and his contemporaries did not anticipate the germ theory of disease nor suspect insects as a cause of fevers. Despite that Rush was still able to recognize the deaths along the Philadelphia waterfront as yellow fever and react with energy to combat its spread.
In 1802 an anonymous letter to the Philadelphia newspapers suggested insects as a cause for fever. I cite this document in chapter one and explain why Rush had other ideas. Click here to see the document .
Chapter Two: Rush found treating the fever difficult. He refused to indulge in fatalism or denial as other doctors did. His religious Millennialism and frustrations with the theories of fevers he learned at Edinburgh energized his efforts to understand the disease.
The Quaker merchant Benjamin Smith wrote almost daily letters to his father and others during the epidemic. This early letter discusses illnesses in his family. While it doesn't mention Rush, it shows the difficult situation Philadelphia doctors faced in late August 1793. Click here to see the letter.
Chapter Three: Rush led efforts to control the disease by attacking the complacency of his colleagues. He also investigated the medical literature to learn about the morbid anatomy of the disease. He decided the fever was "seated" in the liver, which led him to use calomel in large doses.
Rush wrote almost daily letters to his wife about the progress of the epidemic and his efforts to treat it. In a portion of one, he wrote about the difficult symptoms he had to treat. Click here to see the letter.
Chapter Four: Rush believed medical progress depended on candid communication with his colleagues and their candid testing of new ideas. At a meeting of the College of Physicians he explained his mercurial treatment. However, one dying colleague, James Hutchinson, refused to try his remedies. Another denied that Rush had any success with true yellow fever patients of whom there were very few. Many were fooled by a momentary lull in the number of deaths, but not Rush. He enlisted African Americans, thought immune to the disease, to nurse fever victims. (Here is a link to Richard Allen's Memoir of the 1793 Epidemic.)
Chapter Five: While many believed the claims Rush made for the success of his remedies and while many hailed Rush as a savior, his medical colleagues published letters in the newspapers recommending other remedies. Rush responded to the challenge by also publishing his remedies. Meanwhile he continued to adjust his prescriptions as he sensed the nature of the fever changing. Again his understanding of morbid anatomy prompted these changes. He began to recommend bleeding as well as purging.
Rush was most enraged at the letters written by Drs. Adam Kuhn and Edward Stevens. Click here to see their letters and Rush's "Directions" for treating the fever.
Chapter Six : In describing his successful treatment of Alexander Hamilton, Dr. Edward Stevens attacked the theory behind Rush's treatment. A French doctor, Jean Deveze, took control of the city's fever hospital and privately impugned Rush's therapies. Rush continued to win allies, even one of the doctors who helped Deveze autopsy victims. Rush orchestrated a publicity campaign lauding his simple therapies.
Chapter Seven: the increasing death toll, including three of Rush's apprentices and his sister challenged his assurances that he could control the fever. Other doctors continued to write from outside the city that his methods were wrong. Others in the city resolved the crisis in religious or class terms. Rush tenaciously maintained his scientific gains. His continued exposure to his patients continued to confirm his faith in his practices.
Chapter Eight : In the first week of October, Rush was incapacitated by the disease, not only physically. Fears that colleagues conspired to ruin his practice infuriated him. At epidemic's end, he feared that the world would not believe the lessons he had learned from it.
A letter from Rush to Dr. Caspar Wistar shows his bitterness at the slights of his colleagues.
Chapter Nine: In describing his personal experiences and scientific work during the epidemic, Rush tried to make the epidemic a challenge to the nation as a whole. His account of the epidemic was as much a guide to the coming "sickly season" as a history of the past. By blaming local pollution for the epidemic rather than imported contagion, Rush excited opposition from commercial interests and energized reformers.
Chapter Ten: Epidemics in Baltimore, New Haven and New York confirmed aspects of Rush's model of the etiology of a yellow fever epidemic. His therapies won support in those cities. His own work on a handful of yellow fever cases allowed him to better quantify the benefits of bleeding. He extended his yellow fever therapies to other diseases, and began to consolidate his medical ideas and experiences into a new system of medicine.
Because it was small and well documented, and completely forgotten by history, the New York epidemic of 1795 might be fruitfully studied. Here is the beginning of a cache of documents about it, including a list of its victims.
Chapter Eleven: Despite the carping of modern critics, Rush's theory of the unity of disease served the useful purpose of destroying the artificial nosologies of the 18th century, much to the delight of medical students. The benefits of Rush reviving interest in copious bleeding were more problematical. A "phalanx" of young doctors joined the cause. As an alternative to hard liquor and opium, bleeding had virtues as a pain killer and sedative.
Chapter Twelve: The epidemic of 1797 challenged Rush's etiology and therapies. His rival William Currie first recognized the epidemic and anticipated its spread. The editor William Cobbett led an attack on Rush for his "remorseless bleeding," prompting Rush to sue for libel. More attacks led another doctor to challenge Rush to a duel.
Chapter Thirteen: Despite the controversy Rush continued to respond creatively to the yellow fever crisis, solidifying, especially in the minds of younger doctors, his leadership role in American medicine. A new medical journal, the Medical Repository, and the work of Noah Webster on epidemics exemplified this.
Chapter Fourteen: The 1798 epidemics in Philadelphia, New York, Boston and elsewhere mocked the pretensions of Rush and his allies. They could not control the epidemic nor successfully treat the fever. Rather than retreat into the countryside, as his wife urged, Rush found a new point of observation, the city's fever hospital where he helped younger colleagues. While not encouraged by the results of his therapies, he remained convinced that they were better than others or no treatment. He did decide that the fever was not contagious.
A collection of documents on the Great Epidemic of 1798 1798.html
Chapter Fifteen: While Rush found treating the victims of the 1798 epidemic frustrating, other doctors claimed to have successfully used his remedies. The repeated epidemics and the power of yellow fever seemed to divide society into two camps: those who, largely thanks to Rush's work, still retained confidence in medicine, and those who refused all medicine.
Chapter Sixteen: In the wake of the epidemic civic leaders enforced clean up and purification of bedding and houses of the poor. An attempt was made to institute reforms to prevent another epidemic. While informed by scientific opinions on the epidemic, they tried to avoid the scientific controversy. They foundered because of a lack of money. Confronted with yet another epidemic in 1799 the city's elite fled, leaving the relief effort in the hands of a man who saw dispensing comfort to the dying as the only valid reaction to the epidemic. Rush served again at the hospital and tried again to educate the public.
Chapter Seventeen: In the defeat and confusion of the epidemics, Rush's inspirational role in the development of American medicine became apparent. His importance in creating the expectations that made modern medicine possible was best symbolized by his victory in Rush v. Cobbett. Medical research was given protection from the carping of uninformed critics.
Chapter Eighteen: A concluding chapter rejects the current model for the rise and fall of Rush's therapies. His work is best understood as a reaction to the onslaught of dangerous malignant fevers, especially yellow fever. The decline of his influence, as observers at the time noted, is best explained by the changes in the nature and prevalence of diseases, especially malaria and yellow fever.
Sources: A listing of books, periodicals, newspapers and manuscript collections consulted.
This book was published on the web in 1999
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