An Account of the Bilious Remitting
Yellow Fever, as it Appeared in the City of Philadelphia, in the Year
Philadelphia: Printed by Thomas Dobson, at the Stone House,
no. 41, South Second-street, 1794.
Between August and November 1793 the 55,000 citizens
of Philadelphia, Pennsylvania suffered a calamitous epidemic of yellow
fever. Yellow Fever, we know today, is a vector borne virus carried
by mosquitos. This virus killed millions in tropical and semi-tropical
climates before its taming by U.S. Army doctors, led by Walter Reed,
during the building of the Panama Canal. More than a century before
this in this first city of the nation, home of both state and federal
governments, their was no such knowledge, and up to five thousand perished
in the most wretched conditions imaginable. People fled the city - President
Washington went to Mount Vernon - the government dispersed, and local
administration was close to a breakdown. The redoubtable mayor, Matthew
Grayson, formed a non-elected committee from among those brave enough
to remain so that essential services and emergency tasks such as the
burial of the dead could be undertaken. Philadelphia was also the center
of American medicine, and its College of Surgeons struggled to come
to grips with contagion, individual doctors risking their lives to administer
both traditional and innovative treatments to the stricken. As one would
imagine, with medicine in the stage of development it was, with no knowledge
at all of viruses, let alone their methods of spreading or impact on
the body, these same doctors argued as they worked over causes and cures.
The leading medical name of the day, Benjamin Rush, was at the forefront
both in his courage and his opinion. Rush claimed to have diagnosed
the outbreak, determined its cause, and set out to attack the disease
with a drastic "cure" drawn from his extensive reading and
his own experiments on the early patients of the outbreak. Throughout
the epidemic he worked tirelessly, encouraging the population and attending
at every bedside he could, from the wealthiest to the poorest, white
and black. He is often credited, along with Mayor Grayson, of holding
The problem with these undoubted heroics is that Rush - a man of certainties
once he had devised a course of action - was incorrect in his understanding
of the disease, and the treatment he prescribed was perhaps as deadly
as the illness itself. The "purging and bleeding" method that
Rush favored was not uncommon, but in his vigorous attack upon the disease
he was willing to take their use to a remarkable level. He ordered vigorous
purges of calomel (mercurious chloride) and jalap (a grinding of the
tuber of that plant) together with copious bleedings. Mercury, of course,
was a common tool of doctors in the eighteenth century, but its ingestion
was still poisonous. Rush was also prepared routinely to bleed a patient
of a quarter of his or her blood and to take four-fifths in emergency.
Compounding this error was the then current estimation that the human
body contained twenty-five pints of blood, while the actual figure is
approximately twelve. No doctor in Philadelphia, of course, was correct
in his treatment. The French trained doctors familiar with the disease
who worked tirelessly at the emergency hospital Grayson set up at Bush
Hill came the closest to modern methods with supportive rather than
aggressive treatment and an intuitive awareness from experience that
yellow fever was not directly contagious in humans. With the coming
of the frosts of November and disappearance of its vector, the four
month epidemic slowly came to an end. Soon after, Rush turned to the
extensive notes he had taken during the crisis and drew from his remarkable
skills of observation to write his Account of the Bilious remitting
Yellow Fever, as it Appeared in the City of Philadelphia, in the year
1793, which was published the following June.
In more than three hundred pages, Rush recounts his struggles both with
the disease and with those colleagues who were opposed to his opinions
and methods. The book is both a defense of his methods and a veiled
attack on those methods that had, unlike his, failed; he writes that
he wants these failures to be known in preparation for the next arrival
of the disease. The work is divided into several large sections. The
first is an account of how the disease arose and how it progressed.
Rush begins by laying out his theories of contagion, warning those who
have decided that the recent influx of several thousand French refugees
who had fled the Caribbean slave revolts had imported the outbreak.
He holds that this importation argument is partly a political one, spread
to protect Philadelphia's reputation, but it is wrong; Philadelphia's
environment of stagnant pools, rotting cargoes, and inadequate sanitation
is quite capable of generating the attack itself. He then expands on
his belief that disease is carried on the air itself with an argument
for the "original exhalation." This he draws from a detailed
account of the weather and atmosphere of the previous winter and spring
and the heat and dryness of summer that rotted abandoned cargoes on
the wharves. In particular, he famously blames a load of rotting coffee
on the dockside near where the first victims lived. He then goes on
to describe those who were more liable, in his experience, to have contracted
the disease. It struck men more than women, young more than old, and
those who worked in elevated heat, like bakers and blacksmiths. People
in conditions of fear and grief, exposed to cooler night air, and those
asleep were also susceptible.
Rush then goes on to describe the symptoms as they appeared. He notes
first, and correctly, that the disease had two stages and differed in
symptoms and degree in patients. Rush was particularly advanced for
his day in the understanding of the systems of the body, and he described
the way these various systems suffered under the attack of the contagion.
With this he repeats a central theory of his, that there is actually
only one disease that arrives in various forms. One type becomes dominant
at a time, and that form drives out all others. Although the yellow
fever "counterfeited" other types of disease, all people sick
in the city were suffering from that illness alone. This means, of course,
that all patients receive the same treatment.
He goes on to describe the facets of the epidemic that attracted his
curiosity. The refugees were virtually untouched, while serving maids
and those in wooden houses suffered particularly. Heavy drinkers, especially
those permanently drunk, tended to survive. Only three butchers died
out of a hundred in the city, and of the 40 men who cleared the garbage
from the streets on his recommendation, only one died. Blacks he had
originally declared as immune, recruiting them as nurses, but they proved
to be susceptible as well; three hundred died by the end of the epidemic.
In the midst of all his environmental observations He notes, ironically,
that mosquitoes that summer were "uncommonly numerous."
Rush charts the course of the epidemic, with tables comparing deaths
and weather for each day, till he writes, "On the fifteenth of
October it pleased God to alter the state of the air." In the second
half of the book, "Of the Method of Cure," he describes in
detail the treatment he prescribed. Purges and bleeding and their effects
are recorded scrupulously from his scribbled notes of the previous summer.
He ends this section, interestingly, with the hope that laypeople can
be taught to treat themselves in emergencies using his methods. The
final section of the book is a most interesting self-examination and
personal memoir of the epidemic, his responses both mental and physical,
and an account of his own attack of the fever and the way that his treatment
cured its innovator.
Rush's book is a valuable example of eighteenth century observation
and a detailed retelling of the story of the disaster that struck Philadelphia.
It remains, however, firmly slanted to Rush's own point of view and
serves as a combative defense of his methods and actions in 1793. Yellow
fever returned to visit Philadelphia, and other cities on the eastern
coast, for several decades after 1793, and the illness became the most
studied disease in America. With this book, Rush staked his place in
that study. His book demonstrates also the character of the supremely
self-confident man who attacked all criticism as he came to attack disease.
His work and writings outside of medicine, whether on slavery, education,
or politics, confirmed this same certainty and his unwillingness to
accept anything less than complete agreement with his ideas. With his
determination to attack disease directly rather than ameliorate its
effects, Rush influenced American medicine for decades, until the new
thinking of the French system made its way to Philadelphia in the 1840s.
But Rush must be credited with helping to hold the city together, largely
with that same remarkable self confidence that saw him greet his new
patients with a cry of "you have nothing but a yellow fever."
And Philadelphia did hold together; the state general election took
place in the city at the height of the epidemic, the decreased population
available to vote contributing to Governor Mifflin's second term.
The disease remains to this day, and at the end of the twentieth century
it is again on the rise in equatorial areas. Its modern appearance and
symptoms reflect many of Rush's observations, including its two phases
and its symptoms of high fever and low pulse. Though not contagious,
easily inoculated against, and with the incident of infection rather
low in places where it is endemic, yellow fever still has no cure beyond
intensive supportive care of the type practiced at Bush Hill. Mortality
rates among people who are infected today remain curiously at just about
the level of deaths the entire population of Philadelphia suffered in
1793. Rush's environmental theory and his idea of contagion "carried
on the air" were close to correct, but it would take the discovery
of viruses and of vectors to provide the missing link.