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TO BLEED OR NOT TO BLEED
Henry Brewer, M.D.
In searching about for a subject for my presentation to the Innominate Society, I became interested in a series of events centering in Philadelphia which occurred in the early days of our country. The beginning of this story is in late summer and early autumn of 1793. At this time the capitol of the young United States of America was in Philadelphia. Plans were underway for removal of the capitol to Washington. President George Washington made his home in Philadelphia. The city served as a very busy and important port. Philadelphia had experienced a very mild spring and a very hot and dry summer. Indeed, the dry summer had progressed into a severe drought. The citizens were made miserable by the heat and dust and their misery was further compounded by the influx of great hordes of refugees from the West Indies. Slaves on the French Island of Santo Domingo had revolted. Many of those Santo Domingos who were fortunate to escape found refuge in Philadelphia. For weeks during that summer the ships kept coming bringing more and more refugees. By the end of August, 2,000 refugees had been absorbed by this city of 55,000. The refugees brought stories of horrors about the revolution. They also described terrible fevers which were raging through the West Indies. Beginning in early August and lasting until early November, Philadelphia experienced one of the most severe epidemics which has devastated any city on this continent since the white man came. This was an epidemic of yellow fever. It seems probable that some of the friendly mosquitoes of the Philadelphia area bit some of the infected refugees from the West Indies who descended upon Philadelphia that summer and then proceeded to carry the virus to the native Philadelphians. This epidemic of yellow fever which began in early August and lasted until the cold weather and frost arrived, changed the city from a bustling, busy center of commerce and culture to a city in which most commercial, cultural and political activities were almost completely paralyzed. No accurate figures are available as regard to the number of deaths which occurred during the epidemic, but at least 4,000 and probably almost 5,000 people died during the three month period. This figure is made even more impressive by the fact that a large segment of the population fled the City to escape the dreaded yellow fever. I think it could be said with reasonable accuracy that about 1 out of every 10 people remaining in Philadelphia during this period died as a result of this epidemic. It is of considerable interest to observe how the doctors of Philadelphia viewed the yellow fever. They didn’t really know what it was or what caused it. It was more than a hundred years later when Walter Reed identified the virus and demonstrated that is was transmitted by the bite of the mosquito. Some thought the disease was transported from the West Indies with the Santo Domingos, others thought the disease sprang from the filth of the city with its open sewers and surrounding marshes and swamps. Philadelphia had known yellow fever epidemics before, but had been virtually free of the disease during the previous thirty years; the last epidemic had been in the 1760’s and was thought by some to be related to the fact that Pennsylvania troops had at that time returned from fighting in the West Indies. A very sage observation and bit of advice appeared in one of the Philadelphia papers during the early days of this epidemic. The contributor was identified only as “A.B.”. He wrote as follows: “As the late rains will produce a great increase of mosquitoes in the city distressing to the sick and troublesome to those who are well, I imagine it will be agreeable to the citizens to know that the increase of these poisonous insects may be diminished by a very simple and cheap method which accident discovered. Who ever will take the trouble to examine their rain water tubs will find millions of the mosquitoes fishing about the water with great agility in a state not quite prepared to emerge and fly off. Take up a wine glass full of the water and it will exhibit them very distinctly. Into this glass pour a teaspoonful or less of any common oil which will quickly diffuse over the surface and by excluding the air will destroy the whole brew.” It is unfortunate that the citizens of Philadelphia failed to recognize the sagacity of this advice. On the morning of Monday, August 19th, Dr. Benjamin Rush was called to see a Mrs. LeMaigre at her home. He found Catherine LeMaigre desperately ill with abdominal pain and with repeated vomiting of a black bile. She was dying in a horrible manner similar to that which he had seen in other patients during the past few days. Dr. Hodge remarked that the savage fever had caused the death of no less than five persons within sight of the LeMaigre’s door. Dr. Foulk spoke of some cases of his own and called attention to the stale, pungent smell in the air rising from a cargo of rotted coffee which had been dumped on a wharf nearby. Dr. Rush remembered his student days and the plague of thirty years before. He announced that the disease was the bilious remitting yellow fever. Within a week following this pronouncement the epidemic was well established in the city and people were fleeing from the City in order to escape the dreaded yellow fever. The death rate began to rise steadily and by Saturday, August 24th, there were seventeen deaths as compared to an average expected three to five deaths in Philadelphia during August at that time. In September, over 1400 deaths were recorded and during two weeks of that time burials amounted to more than seventy a day. On Friday, October 11th, there were 119 deaths. This being about the peak of the epidemic. After the middle of October, and with the appearance of cooler weather, the number of deaths began to diminish. By the end of October the fever had almost completely disappeared. A crisis soon arose as to where sick patients could be hospitalized. Both the Pennsylvania Hospital and the Alms House, a home for the indigent, were closed to victims of the yellow fever because of the fear of contagion. A large home on an estate along the city’s northern boundary called Bush Hill was uninhabited by its owner who lived in England. This property was taken over (in early September) and used as a hospital for the indigent. It proved to be a reasonably efficient hospital and its success was due in large part to the efforts of Steven Girard, a one-eyed prosperous French merchant and Peter Hamm, a German cooper. The creation of this hospital at Bush Hill significantly contributed to stopping some of the panic in the city regarding the care of the fever victims. The outstanding medical figure in Philadelphia during this epidemic was Dr. Benjamin Rush. He was 47 years old in 1893. Benjamin Rush’s ancestors had arrived in Pennsylvania in 1683. Benjamin was born on the 4th of January in 1746. His father was a gunsmith and had inherited a 500 acre farm along the bank of the Delaware River, twelve miles upstream from Philadelphia. His father died when he was five years old leaving an estate consisting of three houses in Philadelphia. He had moved to Philadelphia a few years before his death. Following his death, his widow found it necessary to open a grocery shop called the Blazing Star to supplement her income. She apparently was a very intelligent and energetic woman. At the age of 9, Benjamin was sent to the West Nottingham Academy in Maryland. At the age of 13, he entered the College of New Jersey, later to become Princeton University, from which he graduated with a B.A. degree when he was not quite 15 years old. He then planned to enter the law profession, but was persuaded to change his mind and study medicine. At the age of 15 he began studying medicine under Dr. John Redmond in Philadelphia. Rush was with Dr. Redmond until July of 1766, a period of five years. These were probably rather strenuous years for the young apprentice. At the age of 20 Benjamin Rush embarked for Edinboro where he stayed until September of 1768, a period of about two years. While there he was greatly influenced by Dr. William Cullen. From him, Rush got the notion that all life is an expression of nervous force and that disease is due to a failure of its regulatory powers leading to exaggeration of nervous function, or to weakness of them. Treatment consisted in building up nervous energy by restorative drugs and diet or by reducing nervous energy by bleeding, purging and semi-starvation. In June of 1768, Rush received the Degree of Doctor of Medicine. In September of 1768, Rush proceeded to London where he attended lectures and dissections by Dr. William Hunter. He seemed to have had ready entry into high society. In one of his letters he describes sitting at dinner between Dr. Samuel Johnson and Dr. Oliver Goldsmith. After four or five months in London he proceeded to Paris where again he seemed to have ready access to the society of the leading social and intellectual figures of the day. It seems probable that his friendship with Dr. Benjamin Franklin served him well in gaining introduction to these prominent people. Rush then returned to England and set sail for American arriving in New York on July 14, 1769, after a voyage of forty-nine days. From 1769 to 1774 Rush devoted his time to starting a practice in Philadelphia. For the first 7 years of his practice he was never sent a patient by one of his colleagues, possibly in large part because he followed the teachings of Dr. Cullens. He found that it was a bit difficult to establish himself in private practice. He was apparently not popular with the well to do people of Philadelphia, largely perhaps because of his known political affiliation and the revolutionary spirits of the day. Whereas rather than those of Boerhaave who’s teachings were than popular in Philadelphia. In order to establish a successful practice, Rush found it necessary to turn to the poor people which is precisely what he did. He did not have the patronage of a great man, influencial family connections or the backing of a religious sect to help him in starting his practice. He was greatly helped by the fact that during the first month after his return from Europe he was appointed as Professor of Chemistry at the College of Philadelphia. By the time he had been in practice for five or six years, he had been reasonably successful and was earning about 9,000 pounds a year. He was dogmatic and uncompromising in his convictions regarding medicine. This is illustrated by a quotation from one of his lectures. “I have formerly said that there was but one fever in the world. Be not startled gentlemen, follow me and I will say there is irregular, convulsive or wrong action in the system effected. This, gentlemen, is a concise view of my theory of disease. I call upon you gentlemen at this early period either to approve or disapprove of it now.” During this five year period, Rush apparently had very little social life. He was a hard worker. He made contributions to the public press on such subjects, as “Sermons to Gentlemen upon Temperance and Exercise”, “An Address to the Inhabitants of the British Settlements in America upon Slave Keeping”, “Experiments and Observation on the Mineral Waters of Philadelphia, Ebinton, and Bristol in the Province of Pennsylvania”, and “An Inquiry Into the Natural History of Medicine Among the Indians in North America”. In 1773, Rush became romantically involved with a lovely and spirited girl named Sarah Eve. Three weeks before the date of their planned wedding she died with tuberculosis. In January of 1776 he married Julia Stockton of Princeton, New Jersey, whose parents he had known while he was in college at Princeton. The two seemed to have been devoted to each other throughout their entire married life. I think they had eight children, two of whom died in infancy. At this time, Benjamin Rush became intensively involved with the struggle of the colonies to gain independence from England. He was appointed to the Continental Congress and was one of the signers of the Declaration of Independence. In 1777 he became Physician General of the Middle Department of the Continental Army. During the war he was very sharp critic of Dr. William Shipping, who was the Inspector General of the army. In his usual uncompromising fashion he attacked Dr. Shipping very vigorously. He also wrote a letter to Patrick Henry which was sharply critical of General Washington and which ultimately fell into General Washington’s hands. This conflict with General Washington and with Dr. Shipping, eventually resulted in his resignation from the army and in early February of 1778, he retired to a small farm in Princeton. Ultimately Dr. Shipping was brought to trial and forced to resign as Director General. Rush considered at this point taking up the study of law, but at this time the British evacuated Philadelphia and he returned to Philadelphia. During the 1780’s Rush practiced medicine in Philadelphia with considerable success. He had many other activities as well. He was highly instrumental in the founding of Dickinson College in Carlisle, Pennsylvania. Two of his greatest interests were his opposition to alcohol and slavery and he conducted a never ending campaign against these two evils. He apparently thought it was alright to drink light wines and beers, but was strongly opposed to liquors. In addition to his private practice, Rush served as a senior physician at the Pennsylvania Hospital from 1783 to the end of his life. He was also active in the College of Philadelphia and he was elected to the chair of Theory and Practice of Psychic. This brings us back to the yellow fever epidemic of 1793 in which Benjamin Rush played a very active role. In the early days of the epidemic, Dr. Rush was frustrated by his inability to successfully treat this dreadful disease. He pored over the books in his library in an effort to come upon some solution to his problem. He ran across a manuscript by John Mitchell describing an epidemic of the Yellow Fever in 1741. Mitchell observed that in yellow fever the abdominal viscera were filled with blood and must be cleaned out by immediate evaculation. Mitchell said that “An ill timed scrupulousness about the weakness of the body” on the part of the physician was fatal. Mitchell further asserted, “I have given a purge when the pulse has been so low that it could hardly be felt and the debility extreme, yet both one and the other have been restored by it.” Dr. Rush seized upon this idea with great enthusiasm. The strongly purge Rush had previously seen was the 10 and 10 used in the Revolutionary Army. This was 10 grains of Calimal and 10 grains of Jalap. Rush was resolved to try this dose and on August 29th he tried it on a man whom he thought would surely die. Amazingly the purge worked, and still more amazingly the man recovered. He became excited and enthusiastic about his success and resolved that he must also take off enough blood to remove all inflammatory stimulus. His new method seemed to work and from this point forward Dr. Rush was totally convinced that the treatment for yellow fever was severe purging and copious blood lets. He excitedly and enthusiastically informed the other physicians and his fellows of the College of Physicians. He strongly urged others to resort to this method of treatment. He said, “I now save 29 out of 30 to whom I am called on the first day and many to whom I am called after it.” He gave huge doses of purgatives and withdrew unbelievable amounts of blood. Toward the end of the epidemic he drew from 70 to 80 ounces from a patient in five days and some cases up to 114 ounces in five days. When you consider that 114 ounces is 3,420 cc. of blood, it becomes quite impressive. Rush was willing to take as much as a quart of blood at a time and to repeat this process several times in two or three days. When his great purge caused the bowels to bleed he felt this was merely an additional benefit supplementing his venous suction. He urged that bleeding be continued at intervals until four-fifths of the blood contained in the body are withdrawn. He believed that the total volume of blood in the average person amounted to twenty-five pounds, which is more than twice the actual amount. Imagine trying to remove twenty pounds of blood from patients who have only about twelve pounds to start with. As might be expected, many of the other physicians did not agree with Rush’s advice to bleed and purge. There were probably about eighty physicians in the City in 1793, but it is uncertain as to just how many of them stayed in Philadelphia and were practicing during the epidemic. A number of them who did stay died of the yellow fever. The French doctors caring for the patients at Bush Hill used much gentler supportive measures. Many of the doctors rejected the idea of blood letting. Strong criticisms of various methods of treatment frequently appeared in the newspapers. No statistics are available with regard to the effectiveness of the various methods of treatment used during the epidemic. It is rather astonishing that the method of Dr. Rush didn’t soon fall into disrepute even in his own eyes, but such is not the case. As a matter of fact there were many of the physicians who followed his advice and the amount of severe bleeding and purging that went on in Philadelphia at that time is truly unbelievable. By the time frost came and the epidemic quickly ended, there was still very harsh disagreement among different groups of doctors as to the treatment of choice for the fever. Benjamin Rush was attacked, criticized, and excoriated by his colleagues and he in turn with his followers was equally critical of his critics. After the epidemic of 1793, things didn’t go too well for Benjamin Rush. During the ensuing years his practice did not prosper. There were recurrent, but milder epidemics of the yellow fever in the autumn of these years of the 1790’s. He seemed to have the nack of making enemies with his dogmatic, unyielding stand on sometimes unpopular causes. By 1797 his practice had begun to steadily decline. He began to feel deserted and surrounded by enemies. Benjamin Rush had very clearly aligned himself politically with the Democratic-Republicans of Thomas Jefferson who placed their faith in the people who govern themselves and were opposed to the federalists of Alexander Hamilton who wanted to see the voting power limited to the higher ranking classes of citizens. At about this time there appeared on the scene in Philadelphia, a William Cobbett, who was to prove to be quite a thorn in the side of Benjamin Rush. Cobbett had been forced to flee from England a few years earlier, when his efforts to expose graft and corruption in the British Army had backfired on him and he had barely escaped in time to avoid being thrown in jail. For a year and a half he lived in Wilmington Delaware, teaching English to French immigrants from the West Indies. In 1794 he moved to Philadelphia. He soon discovered his talent in writing pamphlets which were scathingly critical of the Republican-Democrats and always in support of the Hamilton Federalists. He started his own daily newspaper called “Porcupine’s Gazette” and wrote under the name of Peter Porcupine. He spoke strongly in favor of England and was strongly opposed to the French Revolution. Benjamin Rush alienated William Cobbett, alias Peter Porcupine, in December of 1796 when in a speech delivered as a eulogy for a Dr. Rittenhaus, President of the American Philosophical Society, he digressed from his eulogy to belittle the monarchies of the world and to praise the Republic of America. Peter Porcupine in his paper responded with unfavorable criticism of Dr. Rush’s speech. In another paper, “Dr. Rush, in that emphatical style which is peculiar to himself, calls mercury the Samson of medicine. In his hands and those of his partisans it may indeed be justly compared to Samson. For I verily believe that they have slain more Americans with it then ever Samson slew of the Philistenes. The Israelite slew his thousands but the Rushites have slain their tens of thousands.” The effect of all this on Dr. Rush’s reputation was considerable. His practice, which had not really begun prospering up to this point, fell off very sharply. He decided to leave Philadelphia and take his Professor’s chair at Columbia in New York. It turned out however that his appointment to that chair was blocked by Alexander Hamilton who at that time was one of the Trustees of Columbia University. Benjamin Rush was despondent, but help came to him at this time from John Adams, President of the United States, who was his very close friend. Adams recognized the doctor’s difficulties and offered him the government job of Treasurer of the Mint carrying a salary of $1,200.00 a year. This was salvation for Benjamin Rush at this particular time. During the midst of William Cobbett’s venomous attacks against him, Benjamin Rush filed a suit claiming damages for liable against William Cobbett. In spite of this Cobbett continued his attacks again Rush in his Porcupine’s Gazette. Because of delays and postponements it was two years before the case came to trial. In the meantime, Cobbett’s position in Philadelphia deteriorated rather sharply when President John Adams stood strongly against the policy of Alexander Hamilton who wanted war with France. This was, of course, Cobbett’s policy too. Adams made overtures of peace toward France and nominated a new minister to Paris. Cobbett declared that the President was traitor to his cause and party. Adams in turn repudiated the Hamilton faction and considered deporting Cobbett under the alien and sedition acts. The Porcupine’s Gazette lost its popularity and in December of 1799, five days before the trial was to begin, William Cobbett left Philadelphia and went to New York. He was not present at the trial. After the completion of the trial the Judge more or less gave a directed verdict to the jury. The verdict of the jury was in favor of Dr. Benjamin Rush and the damages were $5,000.00, Cobbett was to pay the court costs which amounted to $3,000.00 or more. It is a little ironic that on the second day of the trial, George Washington died at Mount Vernon. His death was attributed to croup or inflammatory quinsy. It is interesting that Washington was bled copiously, nine pints in twenty-four hours. The news of Washington’s death did not reach Philadelphia until six days later. William Cobbett opened new attacks against Rush from New York and indeed he published a new periodical called “The Rushite” which he devoted entirely to abuse of Benjamin Rush. This publication achieved considerable popularity and helped recoup some of its editor’s fortunes. It became obvious very soon though to William Cobbett that the political currents in America were running against him and in June 1800 he sailed for England. It is said that he paid $4,000.00 of the $8,000.00 judgment against him and that Benjamin Rush gave the money to charity. He was 37 years old in 1800 when he left America. He died in 1885 at the age of 72 and at that time was a Member of Parliament. During the intervening years he became in England a champion for the liberties of the ordinary man and paroxically was really a champion of causes common to Thomas Payne and Thomas Jefferson, both of whom he criticized so strongly while he was in America. Because of his harsh criticism of corruption in the British Government, he was at one time imprisoned for two years on a charge of sedition. He became a very powerful spokesman against tirrany and his written word was very influencial in England during these early years of the Nineteenth Century. Benjamin Rush was 54 years old in 1800 when Cobbett returned to England. He died in 1813 at the age of 67. During these latter years of his life he became more successful in his profession than he had ever been before. His reputation and fame spread beyond the confines of Pennsylvania and even across the Atlantic. He received medals and awards from the King of Russia, The Zyar of Russia, the King of Spain, and the Queen of Etruria. His greatest medical contribution during these latter years of his life was his contributions in the field of psychiatry. In 1812 he published “Medical Inquiries and Observations on the Disease of the Mind”. Prior to this time mad men were generally regarded as brutes or wild beasts and treated accordingly. Benjamin Rush was a pioneer in introducing reforms in the care of the mentally ill. All of his ideas regarding the treatment of psychiatric patients would not be well received today, but he was in truth a pioneer in bettering the cruel treatment that these patients had previously received. It is interesting that Dr. Rush thought that purging and blood letting were helpful in the treatment of severe psychiatric illnesses. Apparently Dr. Rush became Dean of the Medical School of the University of Pennsylvania during the latter years of his life. He died on April 19, 1813, after an illness of five days which was probably pneumonia and possibly tuberculous pneumonia. During this illness he was bled of 10 ounces of blood on one occasion and 3 ounces on another. So ends the story of Benjamin Rush, Peter Porcupine, and the bleeding and purging of the yellow fever epidemics in Philadelphia in the 1790’s. The central figure in this story is of course, Dr. Benjamin Rush. I have come away from all of this with several distinct ideas about Dr. Rush. He was a very intense and religious person. It seems to me that he had very little humor in him, but that he was a man of action who stood firmly by his convictions regarding controversial matters and he did not retire into the background when the going got tough. He was a very liberal man in his day and believed strongly in the rights of the common man and in the ability of the common man to govern himself. He was strongly opposed to slavery, as he was to the use of strong drink and of tobacco. His role in the yellow fever epidemics is an impressive, if sad, one. It is impressive in that he was industrious and faithful to his duties and gave of himself unstintally in the care of his patients. He refused to leave the disease ridden city as many of his associates did to escape the fever. The sad part of Dr. Rush’s role in the epidemics was his deep conviction that bleeding and purging were the proper methods of treatment for this strange disease. He must have done a lot of harm with this treatment, but he was genuinely convinced to his dying day that he had done the right thing. He apparently was a very intelligent and articulate person. His writings are those of a credible person and apparently he was a gifted public speaker. I can’t help but admire the intensity with which Dr. Rush actively attacked the problems and impediments that he encountered in his life. I think maybe I would have liked him a little more if he hadn’t taken life quite so seriously and if he had seen a little more humor and fun in what was going on around him. He might have been a little more effective if he had been somewhat more tolerant of those who did not agree with him and somewhat less stubborn in always defending his own views. Through it all however he seems to have earned the inscription on his tombstone which reads, “Well Done Good and Faithful Servant. Enter thou into the joy of the Lord”.
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