The Paradoxical Doctor Benjamin Rush

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One of Benjamin Rush’s biographers has compared him to quicksilver, the brilliant and elusive element mercury that changes so unpredictably yet so curiously reflects the images around it. The metaphor is appropriate in another sense, too, for not only was Rush mercurial as a person, but as an eighteenth-century physician he freely resorted to the use of mercury in its various forms to purge patients of certain “morbific” or disease-making substances that were supposed to lurk in their bodily fluids. Dr. Rush, who practiced from 1769 to 1813, believed that illness could be expelled from the human frame in exactly the same way that evil could be driven out of human society. At the bedside, in the lecture room, and in the whole arena of politics and life Dr. Rush saw himself as a purifier.

Intriguing and challenging, Rush was a man of glittering contradictions. Take, for example, his medical record. A professor for much of his life, he trained as many as three thousand doctors, a great proportion of all those who practiced “physick” in the infant United States. He also composed a huge array of pamphlets full of firm advice on every aspect of the healing art. As a result he was probably the most influential figure in American medicine and remained so until long after his death.

But was he a trailblazer in medical progress? The answer can only be equivocal. Although for his day his training was unusually solid, he undertook almost no experimentation after he got his own medical degree. He was an acute observer and recorder of symptoms. But his scrutiny rarely led him to revise an opinion, and he persisted to his life’s end in a simplistic theory that blamed nearly all disease on a single cause. He was the first American doctor to propose intelligent and humane care of the mentally ill in place of the torture and confinement common in the early 1800’s. But he was also addicted to the virtues of bloodletting, and his busy lancet, according to James T. Flexner, shed more blood than any general in history—a hyperbolic statement, certainly, but not out of line with Dr. Rush’s sanguinary enthusiasm.

In politics, too, the record is spotted with inconsistencies. Rush was an early and ardent spokesman for American independence and a signer of the Declaration. He supported democratic reforms in the government of Pennsylvania and was far ahead of his time in battling for popular and practical education, recognition of women’s mental abilities, moderation in drinking, and emancipation of slaves. Yet these progressive views coexisted with rigid religious orthodoxy. Though Rush shifted from the Presbyterian to the Episcopalian fold in middle age, and later into a distrust of denominational machinery, his formative years were marked by faith in an absolute and heavily Calvinistic God.

Rush’s willingness to entertain social change did not come from flexibility in values but rather from ironclad notions of how life could be bettered. Always furiously energetic, he was never slowed by that most debilitating but humanizing of maladies, selfdoubt. Touched with genius but with an excess of zeal, too, he became a kind of second-line founding father. He had the diligence, curiosity, and political drive of a Franklin, an Adams, or a Jefferson, but without the needed leaven of sophistication and patience.

 

Only after it was clear that his character blocked him from political pre-eminence did Rush settle definitively into his medical career. It is there, in the framework of his success, that he can be effectively studied in full dimension, even though his nonmedical activities could independently fill a biography. Rush the physician is in many ways a model eighteenth-century American. He believed that Nature was majestic but could and should be mastered. He yearned to systematize knowledge, and to find the hidden harmonies and balances of the universe and reflect them in human conduct. He saw few potential limits to the betterment of mankind. And finally, he had a strong streak of practical inventiveness about him. If these habits of mind sometimes contradicted each other, that only made Rush a more typical son of his era.

Rush was born Christmas Eve of 1745 (according to the Old Style calendar), on a farm near Philadelphia. His ancestors were among the earliest settlers of Pennsylvania, and his father was both a farmer and a gunsmith. He died when Benjamin was not yet six years old. Susanna Rush, who then had seven children, proved to be a strong and competent widow. She opened a general store in Philadelphia which she ran with considerable success. Perhaps Rush had his mother in mind when he wrote years later that young women in the United States should be taught bookkeeping, for if a wife survived her husband, “she cannot fail of deriving immense advantages from it.” In any case, he was devoted to her and overtly resentful of her marriage to a distiller, Richard Morris, who was, in the boy’s jealous eyes, often abusive of her.

The occupations of his parents put Rush squarely in the colonial middle class. He was low enough on the social scale to need to make his own fortune and high enough to afford schooling that would help him do it. In 1754 he was sent off to a boarding school, Nottingham Academy, about fifty miles south of Philadelphia. It was run by the Reverend Samuel Finley, who became one of the first great influences on Rush’s life. Finley, a Presbyterian minister, was ordained during the Great Awakening, the wave of religious enthusiasm that swept the colonies in the 174o’s. He fell in step with a faction in the church known as the New Lights, who hoped to warm the chilly formality of Calvinist doctrine with a dose of emotional enthusiasm. The message of the Awakening, in contrast to the Calvinist belief in predestination, was that salvation was available to the willing and hardworking. God loved the world enough to redeem it. He needed men and women who would wrestle tirelessly with its imperfections to act as His agents.

 

Finley infused his handful of boys with this philosophy through a program of hard work and frequent prayer. Benjamin spent five years there, emerging with a fundamental grounding in arithmetic, geography, Greek, and Latin and with a determination to lead a purposeful life. In 1759, not yet fourteen years old but so well prepared that he graduated in a year, he went on to the College of New Jersey, later to be better known as Princeton. It was a new school, created in the aftermath of the Great Awakening to train young, pious colonials for the ministry and other professions. The first lesson it impressed on its fifty-odd students in 1759 was that they must be diligent. The schedule began with prayers at 5:30 A.M. and ran through almost continuous periods of study and instruction until a 9 P.M. bedtime. Samuel Davies, the president, was, like Finley, a New Light Presbyterian, deeply admired by Rush. Davies was convinced, however, that worldly learning need not conflict with the word of God, and he not only added books on mathematics and Newtonian physics to the twelve-hundredvolume library but emphasized scientific and literary studies in the curriculum. He also filled the boys with his patriotic antislavery ideals, and especially with his conception that the chief glory of religion was to kindle a spirit of public service. “Bravely live and die,” he told Rush’s graduating class in 1760, “serving your generation —your own generation.”

It was not any wonder that Rush, baccalaureate degree in hand and contemplating a career, gave first choice to the ministry. “Every pursuit of life must dwindle into nought when Divinity appears,” he wrote to a friend. But with an uncharacteristic humility he decided that he had an “incapacity” for what he called “the Sacred Desk.” For a time he likewise considered a legal career. Colonial lawyers were a busy and ambitious group, already becoming prominent in the legislative assemblies. But in a visit to his old master, Finley, his mind was changed. Finley warned of “temptations and dangers” that beset the path of an attorney and apparently commended medicine as a calling of greater usefulness. He urged Rush to take a day of fasting and prayer to think it over, but the young man was swayed without such meditation. He went back to Davies and asked for a letter of recommendation to Dr. John Redman, likewise an alumnus of Nottingham and “Nassau Hall,” as Princeton was sometimes known. Five months after his graduation Rush moved into Redman’s house to begin an apprenticeship that lasted five and a half years, with only eleven days of absence.

Redman was one of the few American physicians formally trained in his art. He had studied at Edinburgh and Leyden, both outstanding centers of medical education. But most colonial practitioners learned by working at the master’s elbow as he performed his tasks, a system that neatly suited the needs of a simple society. Benjamin (still a teen-ager) mixed prescriptions, held the basin or the lamp while Redman treated his patients, entered notes in the record books, and kept accounts. Apparently he was able to overcome what he called an “aversion” to the grislier sights of medical practice, and he was soon reconciled to his new career. “To spend and be spent for the Good of Mankind is what I chiefly aim at,” he told a former classmate, and medicine could fulfill that aim. He did not even mind the demands of his training, as he noted somewhat primly in the same letter, “for the town is a snare to betray unwary youths.”

When he was not actually at work in what was prosaically called Redman’s “shop,” Rush read through his master’s library and grounded himself in theory. What distinguished the doctor from the amateur healer in the lyßo’s was simply that the doctor attempted a formal explanation of what he was doing by reference to principles of biology and chemistry. The herb doctor, the unlicensed quack, or the do-it-yourself sea captain or plantation master simply prescribed “empiric” remedies, based on experience, hearsay, or almanacs, and hoped for the best. Skin infections got poultices of fat, honey, mustard, cobwebs, and animal dung. There were decoctions of vegetable and berry juices for stomach disorders. When all else failed, charms and amulets might be tried.

As it happened, the eighteenthcentury patient often was no worse off in the hands of such therapists than in those of formally trained physicians. But still the only hope of progress in curing illness lay with the scientifically educated. Quackery could not build on its hit-or-miss successes or learn from its failures. A serious concern for quality led Rush to decide, in 1766, to join the small company of academically schooled doctors. With his mother’s blessing and promise of support, and with recommendations from Redman, he sailed for Edinburgh. After a voyage made miserable by seasickness, he took up residence in the frowning but intellectually alive Scottish city and entered the universe of eighteenth-century scientific thought.

The courses into which he plunged were in anatomy (but the students did not perform dissections), botany, chemistry, and the theory and practice of “physic.” Almost no clinical or laboratory work was involved. The best-liked teachers were lecturers who summed up existing knowledge most attractively. Not until Rush did some 1768 postgraduate work in London hospital wards did he see many patients or handle instruments. Apparently he preferred it that way. He delighted in chemistry, which offered such “rational entertainment,” and he remarked condescendingly of London doctors: “Few of them indeed practice medicine upon philosophical principles, but notwithstanding this, they have enriched the science with a number of very useful facts.”

Rush’s most adored professor was William Cullen, in “institutes of medicine.” Like other eighteenth-century theorists Cullen had two objectives. One was to classify diseases in the orderly way in which the great botanist Linnaeus had arranged plants and animals. The purpose was to allow for a systematic approach to cures. Once a doctor knew to what “family” or “class” a symptom belonged, he could then use the remedies proved to work for that general category of sickness. The second goal of medical speculation was to find a single underlying explanation for disease, as majestically all-embracing as Newton’s laws of motion.

The search for such a unifying concept satisfied the era’s constant taste for order and regularity, so evident in eighteenth-century music, poetry, and architecture. It also made medical study a pleasure for anyone who, like Rush, was philosophically inclined. It did little, however, to encourage hard specific research. Pathological examination of organs, autopsies, chemical analyses of bodily fluids, microscopic study of tissues (even though microscopes were available), were all neglected, and basic discoveries like the germ theory had to await the following century.

When Rush studied at Edinburgh, one of the reigning medical “philosophies” was that of Hermann Boerhaave, a Dutch doctor who saw the body as a kind of hydraulically operated machine. Fluids coursed through its various pipes and gutters, and illness resulted from interference with their natural flow and pressure. But Cullen explained to Rush and other eager disciples that Boerhaave was wrong. Life was a form of energy, emanating from the brain and transmitted to the solid parts of the body through the nervous system. Diseases were caused either by an excess ofthat energy or a short supply of it. In the former case it was the doctor’s job to reduce “tension” by “depleting” the patient through bleeding and similar measures. If, on the other hand, the system was sluggish, stimulants and restoratives were called for.

Rush became and remained Cullen’s ardent defender for more than twenty years, after which he developed a theory of his own that bullion Cullen’s foundations. It clearly appealed to his appetite for “rational” thought. And it also involved a struggle to overcome nature, something like the Christian’s hand-to-hand combat with sin or the pioneer’s clash with the wilderness. For in battling to raise or lower the energy level of the diseased victim, the doctor piayed an active, even a “heroic,” role.

The real heroes of the day were the suffering patients. The doctors actually knew very little. Without anesthetics or aseptic techniques surgery was seldom a cure, more often killing through shock or infection. And known medicines were few. The resources of pharmacology could mildly alleviate pain or inflammation. In addition, there were drugs that could induce the sick person to vomit, perspire, and defecate copiously, and these were used with special vigor when doctors thought that “depletion” was called for.

The lucky patients were those whose physicians were “vitalists” and believed in letting natural healing processes work unaided. The patients of these doctors were left alone. Or if diagnosis indicated that building up was needed, they were fed such dainties as eggs, broth, and wine. By most other practitioners, however, patients were submitted to the puking, purging, and bleeding routine that only the hardiest could survive.

Such was Rush’s medical universe. In 1768 he cleared the last hurdle to his M.D. , a “dissertation,” through an exercise that says much about him and his time. He chose as his subject the process of digestion and posed the question of whether or not it was caused by an acid-fed “fermentation” in the stomach. His research method was Spartan. He ate three meals—one of beef, one of veal, and one of poultry. Several hours after each he took an emetic, vomited into a basin, and tested his stomach’s contents for acidity. When the results proved positive, he considered himself to have proven that the answer to his query was Yes. After writing up his results in the required Latin, Rush never delved into the problem again. Nor did his examiners for the degree, evidently, see fit to ask whether he had tested and ruled out other hypotheses. It would be years before the role of enzymes in the entire digestive process was unveiled.

There was no lack of interest on Rush’s part in medical inquiry, but experimentation was not his forte. And the world beyond the sickroom made major claims on his attention. As a handsome, widely read, voluble, and intelligent young colonial Rush found his way quickly and easily into the society of Edinburgh and London. His social success was also aided by introductions from Benjamin Franklin. As agent for Pennsylvania in London, Franklin enjoyed showing off bright American visitors as further high-quality products of his native land. Rush dined with such lions as Joshua Reynolds, Samuel Johnson, and Oliver Goldsmith and was pleased but not swept off his feet. (Johnson he found “offensive in his manners” and Goldsmith lacking in the “usual marks of great and original genius.”)

In fact, Rush’s three years in Scotland and England, topped off by a visit to Paris, confirmed him as a republican and a patriot. In Edinburgh he had listened with enthusiasm to radical young friends who talked against monarchy, and by the time he got to visit the House of Commons, he had decided that it was a “cursed haunt of venality” where “the infernal scheme for enslaving America was first broached.” Rush presumably had reference to the Stamp Act and the Townshend taxes, both of which were convulsing the colonies with resistance during his early twenties. Writing home to the Pennsylvania Journal , he urged his countrymen to continue their boycott of British manufactures.

The fascinations of politics had already bitten him when he returned to Philadelphia in 1769, and he launched himself into so many activities that it was hard to tell whether he hoped to make his lasting reputation as a physician or a pamphleteer. His activities on the eve of the Revolution show a strange mixture of self-promotion, self-destructive arrogance, idealism, and practicality, fuelled by immense energies. Rush was one of those extraordinary individuals whose tired bodies are renewed by a change in activity. He would rise early and spend a day seeing patients in his “shop” and then making house calls, but his evenings found him ready for study. “I seldom went to bed before 12 o’clock,” he recalled, “and many many times have I heard the watchmen cry 3 o’clock before I have put out my candle.” If he tired of reading, he would write for a while, and when writing palled, he went back to reading. He found, on the whole, that the “greater exertion” of composition chased away sleepiness, though it was also helpful to poke up the fire in winter or take a breath of fresh air on his balcony in summer. His writings (which fill fortyfive volumes in the Pennsylvania Historical Society’s library today) consisted of innumerable letters, drafts of lectures in medicine, and essays on various subjects, all intended to improve the manners and morals of his peers. In 1772 he published three Sermons to Gentlemen upon Temperance and Exercise —anonymously, since he sought “nothing from his countrymen but the pleasure of doing them good.” The next year saw him tackling a touchier subject than overeating, in An Address … upon Slave-keeping . Sixty years before William Lloyd Garrison unequivocally blasted Negro bondage in the United States, Rush—in a city whose leading citizens still included many slaveholders—supported abolition and warned: “Remember that national crimes require national punishments.” (Yet he himself, guiltily but undeniably, kept one slave until 1794.) Late in 1773, drawn ever deeper into anti-British agitation, he warned that the plan of the royal ministers to give the East India Company a monopoly of the tea trade with the colonies was part of “the machinations of the enemies of our country to enslave us.” By the time the First Continental Congress met in Philadelphia in 1774, Rush’s views were already well known, and he spoke out for independence from the moment actual fighting began. Early in 1775 he met and instantly liked a down-at-the-heels English newcomer to Philadelphia, Thomas Paine. Discovering that they shared many of the same beliefs, Rush encouraged Paine to write Common Sense . It was a happy culmination for Rush when he himself was elected to the Continental Congress in July of 1776, in time to sign the final, formally engrossed copy of the Declaration of Independence.

But while moving into the public spotlight Rush was laying the solid foundations of his medical practice in a way that revealed his basic traits. He did his best to make some practical moves. The first of them was getting support for an appointment as professor of chemistry at the College of Philadelphia, which gave him status and needed income. Another was the frequent publication of short medical papers. It might be added that a third was a happy and also advantageous marriage to Julia Stockton, daughter of a highly successful New Jersey lawyer-landowner. (By a historical coincidence Rush’s father-in-law was also a signer of the Declaration, as was John Witherspoon, the clergyman who married them.) Thirteen children came of the match, and Rush apparently had no difficulty in maintaining his studious habits even when his home was full of offspring.

 
 
 

Yet at the same time Rush could not refrain from quarrelling with his colleagues. He announced his loyalty to Cullen’s theories in terms that stung those doctors who followed Boerhaave. With deliberate or unconscious self-revelation he wrote in his autobiography many years later:

The system of Dr. Cullen was calumniated. … Perhaps my manner of recommending it provoked this opposition, for I know by experience as well as observation that an indiscreet zeal for truth … has cost more to the persons who have exercised it, than the total want of zeal for any thing good. … One of the physicians of the city I remember complained in severe terms of my having given at my table in the presence of a number of students of physic, the following toast, “Speedy interment of the System of Dr. Boerhaave, and may it never rise again.”

With that kind of tact it was not surprising that Rush did not at first get a large number of referrals from Philadelphia’s other doctors. He made up for it, in part, by cultivating a practice among the city’s poor. Day in and day out he made his way among ramshackle huts, treating patients who lay on vermin-infested mattresses, administering doses and “glysters” (enemas) with his own hands. Even though payment was irregular, Rush’s practice grew large enough in this way to give him a reasonable income. His work with the indigent also broadened his clinical experience.

But even more, it tended to confirm his democratic leanings, his sense of doing good in the world, and his sizable self-righteousness. Rush would insist in later writings that medical practice should be stripped of “imposture” and “mystery.” He urged frank discussion with patients, the writing of prescriptions in English, and a simplification of medical instruction so that “a young man will be able to qualify himself to practice physic at … much less expense of time and labour than formerly.” Simple ways might be best, and the American landscape itself might produce cures unknown to the Old World. “Who knows,” Rush declaimed after the Revolution, “but that, at the foot of the Allegheny Mountains there blooms a flower that is an infallible cure for the epilepsy? Perhaps on the Monongahela or the Potomac there may grow a root that shall supply by its tonic powers the invigorating effects of the savage or military life in the cure of consumptions.”

Circumstance and temperament made Rush a walker of solitary paths. Temperament, especially, ended his Revolutionary political career, after a medical battle in which he was right in principle but tactically outgeneralled. In April of 1777 he was appointed surgeon general of the “Middle Department” of the colonies, where the campaigning centered. Full of confidence, Rush prepared to tackle the job of keeping the American army healthy. He began with a manifesto to the officers on preserving the health of the troops. As Rush noted, “a greater proportion of men perish with sickness in all armies than fall by the sword.” His suggestions were full of hard good sense, though often presented on the basis of inaccurate theories and full of allusions to the practices of the Romans. Rush urged the adoption of a vegetarian diet and the elimination of liquor from the army, a pair of unlikely changes that probably would have induced mutiny had they ever been adopted. But he also insisted that “too much cannot be said in favor of CLEANLINESS .” He wanted the soldiers’ hair kept short, compulsory baths two or three times a week, frequent changes of linen, and careful cleansing of cooking utensils after each use. He urged that tents not be overcrowded and that camps be kept away from “marshes and millponds.” He also wanted the troops to air their blankets daily and to have the straw that filled their beds changed regularly.

Curiously enough, these wholesome ideas arose out of Rush’s conviction that disease was carried by the “effluvia,” or foul vapors that arose from decaying or putrid matter. The major point of his sanitation program was to prevent the “putrefaction” of the perspiration that accumulated in long hair and unwashed uniforms, and to keep large bodies of troops away from stagnant waters or garbage and dungheaps (which should be “buried or carefully removed every day”). Rush had no idea that the measures he proposed would work by reducing exposure to germs and the vermin that carried them. He was, characteristically, wrapping his own acute observations of the connection between dirt and disease in a mantle of a mistaken hypothesis that satisfied his mind and that he would never test.

Had Rush remained long enough in his job to enforce his regulations, the health of Washington’s hard-pressed army (which was driven from Philadelphia in September and stumbled on to encamp at Valley Forge that winter) would certainly have improved. But Rush, almost from the start, flung himself headlong into battle against the army’s medical system. He found the various hospitals in which he was supposed to care for his military patients to be in a chaotic state. They were overcrowded and undersupplied, and the unlucky troops brought into them died by the thousands, of infection and neglect. Rush demanded to know why clean bedding, wine, sugar, medicines, vegetables, and other necessities were lacking, and why ambulatory patients were allowed to wander in and out unguarded, ignoring doctors’ orders and bringing rum, improper foods, and outside infections into the wards. He wrote stormy letters to friends in Congress and to Washington, raging at the medical administration of the army as “a mass of corruption and tyranny.”

 

In his impatience Rush looked about for villains and found one in the director general of the army’s medical services, Dr. William Shippen. By December of 1777 Rush was accusing Shippen of willful neglect, incompetence, and the outright crime of appropriating army stores for himself and selling them. In Shippen he had chosen an almost invulnerable target, however. Shippen was a well-known and well-connected Philadelphia physician who could and did dismiss the attacks on him as a case of personal jealousy. He could also point out—with reason—that desperate shortages of supplies existed everywhere in the army. And Rush, by publicly campaigning for his replacement, gave Shippen the status of a victim and offended the necessary pattern of military discipline.

But Rush, always full of the “indiscreet zeal for truth,” persisted in frontal assault. He had no skill in manipulation, he overestimated the support he would get in Congress, and worst of all, when he sensed that Washington was unwilling or unable to take his advice immediately, he wrote an angry letter, which he cautiously left unsigned, to Patrick Henry, clearly indicating that a change in top command was necessary to save the Revolution. Henry, most indiscreetly, showed the letter to Washington, who recognized the handwriting, and Rush’s situation rapidly became hopeless. The man who was later called “Dr. Froth” by an anonymous correspondent had unsuccessfully tried to mix medicine and politics. The Rush-Shippen feud was turned over to a select investigating committee of Congress, which quietly informed Rush that it saw things Shippen’s way and that if the medical service was not big enough for the two men, it was Rush, the junior, who would have to go. On January 30, 1778, Rush resigned, having failed to learn the lesson contained in a letter from his friend John Adams, who had begged him to stay on and fight abuses from the inside: “Patience! Patience! Patience! The first, the last, and the middle virtues of a politician.”

Exiled to idleness in New Jersey while the British occupied Philadelphia, Rush went through a period of depression and, for one last time, thought of giving up medicine for the law. But the reopening of the city made it possible for him to resume his practice, and in the 1780’s he entered a new period of intellectual and political activity that would have exhausted several lesser men. Underlying Rush’s whirlwind of involvement in public affairs was a zestful nationalism that flowered throughout the young United States as the war ended in victory. As he wrote in 1786: “The American war is over; but this is far from being the case with the American revolution. On the contrary, nothing but the first act of the great drama is closed. It remains yet to establish and perfect our new forms of government, and to prepare the principles, morals, and manners of our citizens for these forms. …”

To assist in that cultivation of republican soil Rush undertook a diversified list of activities. He was one of the major founders of a new college in the “back country,” at Carlisle, Pennsylvania, named after John Dickinson, whose Letters from a Farmer in Pennsylvania to the Inhabitants of the British Colonies was one of the basic pamphlets that had helped promote the Revolution. He also assisted in the founding of a Germanlanguage academy, Franklin College (later Franklin and Marshall), in Lancaster, amid the Pennsylvania Dutch. He ardently supported the Constitution and served in the crucial Pennsylvania ratifying convention, which won a hard-fought victory for the nationalists. And he wrote essay after essay designed to combat “vulgar errors or popular prejudices.” He advocated a new penal code aimed at rehabilitation of the criminal; education for “females” that would expose them to geography, astronomy, philosophy, chemistry, history, and poetry; a statewide plan for public schools, capped by a national university. He blazed away anew at tobacco, slavery, and strong waters. And he dabbled in such sidelines as expunging from the American language such aristocratic misfits as Latinisms, borrowings from French, and many-syllabled English words based on an educational overdose of the classics.

But he was busy medically as well. He had gone from teaching chemistry to lecturing on the theory of medicine at the College of Philadelphia, and when that was merged into the modern University of Pennsylvania in 1789, he held the chair of “institutes” and clinical practice there until his death. Teaching was never merely routine for him. He usually delivered his lectures while seated, but occasionally rose to make a particular point. Opposite each page of his lecture he left a blank one on which he made notes and additions as questions and ideas came to him. Every four years or so he would work up a complete new set of lectures. He wrote voluminously to his many students, and he continued to publish medical observations on a wide range of subjects.

For in the end Rush wanted to make his major contribution to mankind’s perfection as a doctor. “While the world, from the progress of intellectual, moral and political truth, is becoming a more safe and agreeable abode for man,” he opined in 1789, “the votaries of medicine should not be idle.” The “convulsions” of the American Revolution had thrown open “the doors and windows of the temple of nature,” ran his mature medical credo. “… We have already drawn from them discoveries in morals, philosophy and government, all of which have human happiness for their object. Let us preserve the unity of truth and happiness, by drawing from the same source … a knowledge of antidotes to those diseases which are supposed to be incurable.” Instead of arguing, as some later “votaries” were to do, that politicians should adopt the detachment and objectivity of science, Rush urged the scientists to help in the search for the great principles at the root of good government.

His personal search led him, in 1789, to the formulation of his own overall theory of disease, and his defense of it for the remainder of his days illuminated all his strengths and shortcomings. He discarded his old master Cullen’s elaborate “tree” of over a thousand diseases arranged by type and substituted for it the idea that almost all illnesses were forms of fever. And fever was caused by overstimulation of the blood vessels. The body, through fatigue, chilling, or some other factor, fell into a state in which the arteries were easily shocked into hyperactivity. The resulting feverish states could be classified by their symptoms, duration, and end results.

By reducing hundreds of illnesses to a few fevers, all arising from a single cause, Rush hoped to demystify and democratize medical practice. A simpler “nosology,” or classification of diseases, would also allow for a shorter list of remedies to be mastered. Briskly seizing analogies from physics and religion, he defended his slashing simplification. “Fire is a unit,” he observed, “whether it be produced by friction, percussion, electricity.” The “multiplication” of diseases was “as repugnant to truth in medicine, as polytheism is to truth in religion.” The physician who thought that every inflammation of every part of the human system was a distinct affliction resembled “the Indian or African savage, who considers water, dew, ice, frost, and snow, as distinct essences.”

The lamentable flaw, clinically speaking, in Rush’s scheme was that it led him to a virtual war on the fever patient’s circulatory system. He believed that the blood maintained the irritation of the veins and arteries and that removing an “excess” of it was as useful in reducing fever “as the abstraction of a particle of sand is to cure an inflammation of the eye.” By depleting the overexcited body through venesection the doctor supposedly could promote its restoration to equilibrium by rest and nourishment. Bleeding would be as effective as sweats, purges, and other prescriptions to reduce pain and restlessness. And it could be undertaken on a heavy scale. So long as the pulse remained “tense” or “full,” ten to twenty ounces (equivalent to one or two large glassfuls) could be removed repeatedly, even “until four-fifths of the blood contained in the body” was drawn away.

Rush’s testy defense of his views provoked quarrels only with other doctors until 1793, when differences of medical opinion spilled into the public prints during a savage epidemic of yellow fever. The killing disease often hit the city in the summer season, spreading from the wharves, where ships recently in from the West Indies unloaded their cargoes of sugar, coffee, chocolate, and spices. It spread rapidly, bringing down victim after victim. Its symptoms were a dark flush to the skin of the face, jaundiceyellow eyes, a high fever, and acute pains. Eventually internal hemorrhaging led to the dreaded “black vomit” of mingled blood and bile, followed in an alarming proportion of cases by death.

 

By the end of August, 1793, the number of fever cases began to escalate alarmingly. Those who could do so fled the city. Those who remained began to die like flies. There were 1,443 deaths in the city in September out of a total population of 45,000. The toll for a single week in October was 720. Altogether, between August i and November 9, some 4,044 deaths took place in the city, most of them due to the plague. The corpses lay unburied; deserted shops and homes were looted; and Philadelphia, the seat of the United States government, was paralyzed.

Rush, like other doctors, stayed at his post and worked with grim intensity to care for the sick. Sleeping fitfully and irregularly, he was visiting as many as a hundred patients a day and was having to fight off the relatives of more, who crowded his waiting room and tearfully clamored for help. Three of his students and his sister died. And on September 14 Rush himself came down with the fever. He purged and bled himself and was able to resume his rounds within a few days, but he collapsed a second time on October 4 and was sick for several more weeks. There was no question of his heroic devotion to helping those who filled the hospitals and sickrooms of the doom-haunted city.

There was no question, either, that he resorted to his favorite remedy with so much zest that other doctors took issue with him in the newspapers. Rush ignored their criticisms, and he continued not only to open the veins of his patients often and long but also tripled and quadrupled their dosages of such purgatives as jalap and calomel. From some victims he took as many as eighty ounces of blood in five days. And all the while he stubbornly insisted that he was curing his patients. “At no period,” he wrote, “did I lose more than one in twenty of those whom I saw on the first day, and attended regularly.” Overall, he claimed, he had saved some six thousand fellow citizens by his drastic treatments.

It is hard to believe that Rush did not fatally weaken many of those whom he treated, and it is certain that he did not really undertake any careful correlation of mortality statistics with various kinds of treatments. His powers of observation were great, but his willingness to apply them critically to his own ideas was limited. When he was right, it was, as in the case of his military sanitation theories, for the wrong reasons. Believing that yellow fever was spread by the “effluvia” from rotting waste heaps and slimy rain barrels, he unsuccessfully urged a clean-up of the docks and streets. Had this been done, it would have helped to kill off the mosquitoes that actually carried the virus from victim to victim as they bit and sucked blood. But at the same time Rush refused to budge from his theory that the disease was entirely local in origin, which called down the wrath of civic boosters on his head—and was incorrect. It was in fact brought in from the Caribbean by visiting passengers and sailors.

Philadelphia had new epidemics of yellow fever in 1794 and 1797, and Rush doughtily clung to bleeding his patients. As a result he was attacked mercilessly by two newspapermen, John Fenno and a transient from England, William Cobbett. Fenno denounced Rush’s “lunatic system of medicine,” while Cobbett referred to the “remorseless Dr. Rush” who might bleed him “white as this paper” before he would admit an error of opinion. He also denounced the doctor’s followers, the “Rushites” who had “slain their tens of thousands.” Rush, no man to turn the other cheek, struck back at Cobbett with a libel suit and won a judgment of five thousand dollars in damages plus three thousand dollars in costs, a large sum for the day. Cobbett was only able to pay four thousand. Rush donated it to charity and had the satisfaction of seeing a dead-broke Cobbett leave Philadelphia. But the whole controversy had pained him so much that in the autumn of 1797 he courted and got an offer of a professorship on the medical faculty of New York’s Columbia University. The arrangement fell through when Alexander Hamilton, a Columbia trustee and a political enemy of Rush, blocked the appointment.

It is pleasant to end with a happier image of Rush than that of intractable knight of the lancet. From 1783, when he joined the staff of the Pennsylvania Hospital, until the end of his life, Rush took a particular interest in the care of the insane. He summed up more than a quarter of a century of experience in primitive psychiatry with his final medical volume, Medical Inquiries and Observations upon the Diseases of the Mind , in 1812.

Rush believed that mental disease, like every other kind, was due to overstimulated blood vessels in the brain. And he was willing, in some cases, to subject the unhappy “maniacs” to his purging and bleeding routines, to tame their savage fancies. But he likewise had a common-sense notion that the best treatment was to reduce excitement by calming and soothing the patients. Nor did he think of them as animals to be chained, flogged, and abused, as was the common custom. He noted that “degraded as they are by their disease, a sense … of joy, of gratitude, of neglect, and of injustice is seldom totally obliterated from their minds.” His prescription for “derangement” included pleasant surroundings, useful occupations, the conversation of others when feasible, and the sense of being still a part of the human community. Rush even suggested getting the “madmen” and “madwomen” under his care to unburden their distressed minds by writing out their fantasies for discussion, vaguely foreshadowing psychoanalysis.

Though he could and did occasionally suggest restraints and harshness, in general Rush saw a connection between mind and body and thus was disposed to handle insanity as an illness instead of a curse or a sin. He who was so willing to storm the citadel of an inflamed vascular system, knife in hand, conceded that something less than a frontal assault on the nervous system was needed to deal with the mentally ill. In that area of treatment he was inclined to cooperate rather than to wrestle with nature.

Rush died in 1813, after catching a cold; and, consistent to the last, he persuaded his attending doctors to bleed him. In his last years, with the old passions cooled, he contributed several studies of particular diseases—especially infantile cholera and infection of the teeth—to medical literature. They are studies that were respected long after Rush’s theory was discarded. For all of his optimism and faith in progress he belonged to a passing era in medicine. The future lay with experimentation and the steady refinement of diagnostic tools. An age of x rays, stethoscopes, and antiseptics dismantled the all-embracing certainties of eighteenth-century theorizing.

Yet Rush remains an important American figure, the quintessential reformer, passionate in his sense of his own virtue and convinced that simple remedies cure all problems in the moral and political, as well as the natural, worlds. His energy, warmth, good will toward men, and practicality saved him from the worst excesses of his type. And that was fortunate—for his ultimate reputation as well as for the patients whose ailments he battled.