About the Book

Rush, Benjamin.

An Account of the Bilious Remitting Yellow Fever, as it Appeared in the City of Philadelphia, in the Year 1793.

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 Philadelphia together.

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.

Researched and authored by John Osborne, Ph. D.