By the end of the eighteenth century, the population of the British col- onies had grown to over 1.6 million. Occupying and expanding into an area much larger than Britain, the colonists were well aware of their suc- cesses in establishing an economic, social, religious, and even political life quite different from that of the mother country. Rising tensions culminated in the American Revolution, a war that began in 1775 in Lexington and Concord, Massachusetts, led to the signing of the Declaration of Independence on July 4, 1776, and ﬁnally ended seven years later in 1781 with the surrender of the British at Yorktown, Virginia.
The military activities and general disruption of ordinary life asso- ciated with the Revolutionary War obviously increased the demand for the services of physicians, surgeons, drugs, and hospitals. During the war supplies of imported drugs and surgical instruments were limited by the British blockade. The lack of experience and cooperation among the colonies, as well as the chronic shortage of funds and supplies, meant that little was accomplished in terms of organizing military medi- cine during the Revolution. Finding competent leaders for the revolu- tionary medical services proved exceptionally difﬁcult. Indeed, the ﬁrst three Directors General of medical services were quickly discharged for reasons ranging from alleged treason to fraud and speculation in medical supplies. The War of 1812 revealed that the chaotic situation during the Revolutionary War had taught the new nation almost noth- ing about the importance of organizing a military medical service.
Having been largely isolated from the formal medical practices, educational system, licensing restrictions, and professional institutions of Great Britain, the former colonies experienced little change in medi- cal and public health activities after the Revolution. Medical practi- tioners in the new republic could generally be divided into two groups: those referred to as regular, orthodox, or mainstream physicians and a diverse group of competitors, usually referred to as unorthodox or irregular practitioners. Orthodox practitioners claimed to represent the mainstream of learned, respectable medical theory and practice going back to Hippocrates.
Few American doctors had attended European univer- sities or participated in clinical or scientiﬁc research, but they did claim that orthodox medicine represented all the scientiﬁc advances of the Renaissance and Scientiﬁc Revolution. In practice, however, most medi- cal men followed some simpliﬁed version of one of the medical systems constructed by eminent theoreticians like Georg Stahl, Friedrich Hoffmann, Herman Boerhaave, William Cullen, and John Brown. Other than an intense opposition to orthodox practitioners, members of competing medical sects had little in common. Irregular practitioners often dismissed orthodox practitioners as members of a competing sect that they called allopathic medicine. During the post-Revolutionary period of growth and social trans- formation, new civic, cultural, educational, and scientiﬁc institutions were established. As part of this rush to create indigenous institutions, American physicians established local, county, and state medical socie- ties. Elite physicians, who had studied in Europe, believed that obser- vation and experiment would lead to new understanding of human physiology, but most practitioners emphasized the importance of common sense and experience.
Many medical societies adopted codes of professional ethics and standardized fee tables for speciﬁc medical services as a means of unifying the profession, limiting economic com- petition, establishing professional prerogatives, and excluding irregular practitioners. Physicians also organized scientiﬁc societies that spon- sored journals and lectures. If little that was original appeared in these journals, they did, at least, provide information about scientiﬁc and medical advances in Europe. Health and the circumstances that would promote public welfare were topics of great concern to eighteenth-century Americans. Several of the most eminent of the nation’s revered Founding Fathers—Benjamin Franklin, Thomas Jefferson, and Benjamin Rush—had serious scientiﬁc interests.
Five of the 56 signers of the Declaration of Independence (Josiah Bartlett, Matthew Thornton, Oliver Wolcott, Lyman Hall, and Benjamin Rush) were physicians who also shared a passionate interest in public affairs. Practical issues may have dominated discussions of American society, but Enlightenment concepts also inﬂuenced debates about the relationship between the political and social organization of the new republic and the health of the people. The writings and activities of Thomas Jefferson and Benjamin Rush (1745–1813), in particular, exemplify the ways in which leaders of the Revolution and framers of the new republic thought about these issues. Benjamin Rush, known to history as the ‘‘Revolutionary gadﬂy,’’ served as a member of the Continental Congress, a signatory of the Dec- laration of Independence, and Treasurer of the U.S. Mint. He was a passionate opponent of alcohol, tobacco, and slavery who described himself in the words of the prophet Jeremiah as ‘‘a man of strife and a man of contention.’’ Although his abrasive nature earned him many enemies, John Adams eulogized him as ‘‘a man of science, letters, taste, sense, philosophy, patriotism, religion, morality, merit, and usefulness’’ without equal in America. Revered by his admirers, Rush was called the foremost physician of the new republic and the father of American psychiatry. A learned man by any standard, Rush attended the College of New Jersey and served a ﬁve-year apprenticeship with Doctor John Redman (1722–1808), a disciple of Herman Boerhaave (1668–1738).
Rush earned a medical degree from Edinburgh in 1768 and spent an additional year in London and Paris studying chemistry and medicine. Returning to Philadelphia, Rush accepted a series of professorial appointments in chemistry, the theory and practice of physic, physiology, pathology, and clinical medicine. He also served as physician to the Pennsylvania Hospital. Both Jefferson and Rush believed that only an agricultural society provided an authentic foundation for health and prosperity. ‘‘Those who labor in the earth,’’ Jefferson proclaimed, ‘‘are the chosen people of God.’’ Urbanization and industrialization, in contrast, led to pov- erty, disease, political inequality, and social injustice. Industries that restricted men to indoor, sedentary work were unhealthy. Unless men enjoyed the beneﬁts of fresh air and exercise they were susceptible to rickets and other debilitating conditions. Women and children, how- ever, were suited to sedentary, indoor work. Urban epidemics, though tragic in many ways, offered conﬁrmation and consolation to these Founding Fathers, because, as Jefferson said in a letter to Rush, such epidemics would ‘‘discourage the growth of great cities as pestilential to the morals, the health and the liberties of man.’’ Rush agreed with Jefferson that cities were like ‘‘abscesses on the human body,’’ but he lived and worked among the approximately 40,000 residents of Philadelphia. Because political liberty was associated with individual and social health, Rush asserted that patriots enjoyed good health, cheerful dispo- sitions, and fruitful marriages.
Enemies of the Revolution, in contrast, were subject to both mental and physical decay. Good political princi- ples encouraged good health, but, Rush warned, an excess of liberty, leading to social instability and anarchy, could cause illness and insanity. Even though liberty, freedom, and good government promoted the physical, moral, and political well-being of the American people, they could not completely eradicate all forms of disease and disability. Physicians, therefore, had to develop therapies for physical and mental disorders that were appropriate to the American environment. Rush’s Medical Inquiries and Observations upon the Diseases of the Mind (1812), the ﬁrst general treatise on psychiatry written in America, served as a guide for the management of America’s early institutions for the care of the insane. In addition to advice about immobilizing patients with mental illness when necessary, Rush generally prescribed the usual therapeutic approach, that is, bleeding and purging. According to Rush, all diseases were due to the accumulation of putrid materials that caused a nervous constriction of the blood vessels.
Symptoms seemingly associated with different diseases were actually modiﬁcations of the same primary disorder, which could be explained as an ‘‘irregular convulsive or wrong action’’ in the affected system, or a ‘‘morbid excitement’’ of the vascular system. Effective therapeutic measures should, therefore, rid the body of morbid materials and bring about relaxation of nervous excitement. In practice, this invariably meant depleting the body of harmful materials by bleeding, cupping, vomiting, purging, sweating, and salivation. Nevertheless, Rush insisted that treatment had to be modiﬁed according to local conditions and the speciﬁc characteristics of the patient. In an age where diseases were ubiquitous, unpredictable, and often fatal, doctors generally assumed that in the absence of active intervention the natural result of illness was death. Since few diseases were recognized as speciﬁc entities, and the early stages of many illnesses are quite similar, doctors could easily convince themselves and their patients that medical treatment of what might have been a minor illness had warded off death.
Although all diseases were attributed to the same primary disorder within the body, Rush was very interested in the environmental con- ditions associated with epidemic diseases. His ﬁrst contribution to epi- demiology was an essay published in 1787, ‘‘An Enquiry into the Causes of the Increase of Bilious and Remitting Fevers in Pennsylvania with Hints for Preventing Them.’’ But the city remained notoriously unsuccessful in preventing epidemic fevers, as indicated in Rush’s account of ‘‘The Bilious Remitting Yellow Fever as it appeared in the City of Philadelphia in the Year 1793.’’ The origin of yellow fever is almost as mysterious as that of syphi- lis and concerns the same problem of Old versus New World dis- tribution of disease in pre-Columbian times. Claims that Mayan civilization was destroyed by yellow fever or that epidemics of this disease occurred in Vera Cruz and San Domingo between 1493 and 1496 remain doubtful. By the eighteenth century, yellow fever was one of the most feared diseases in the Americas. An attack of yellow fever begins with fever, chills, headache, severe pains in the back and limbs, sore throat, nausea and vomiting. Experienced physicians might detect diagnostic clues during the early stages of the disease, but mild cases are easily misdiagnosed as inﬂuenza, malaria, or other fevers. Characteristic symptoms in severe cases include jaundice, fever, delirium, and the terrifying ‘‘black vomit’’ (caused by hemorrhaging into the stomach). Damage to the heart, kidneys, and liver can lead to death. Although outbreaks of the disease occurred in many American cities, the situation in Philadelphia was particularly striking. Eighteenth- century Philadelphia was America’s cultural, social, and political center and an active trading partner with the West Indies.
The 1798 yellow fever outbreaks in Philadelphia, New York, Boston, and other Ameri- can cities proved that very little had been learned during the 1793 epidemic in terms of prevention and treatment. For his conduct during the 1793 yellow fever epidemic in Philadelphia, Benjamin Rush is often cited as the very model of the American practitioner of ‘‘heroic medi- cine.’’ Certainly, he was very enthusiastic about the value of therapeutic bloodletting and vigorous purgation, and he aggressively attacked the arguments of his opponents and their therapeutic timidity. He did not, however, claim that he had invented a new therapeutic system, nor did he call his methods ‘‘heroic.’’ Instead, he spoke about the value of ‘‘copious depletion’’ achieved by means of large doses of jalap and calo- mel, bloodletting, cold drinks, low diet, and the applications of cold water to the body.
After the epidemic of 1793, Rush extended his yellow fever therapies to other diseases, and began to consolidate his medical ideas and experiences into a new system of medicine. In general, the term heroic medicine refers to the treatment of disease by means of copious bloodletting and the aggressive use of harsh drugs or techniques that cause purging, vomiting, and sweating. Some historians have questioned the use of the term, but Oliver Wendell Holmes (1809–1894), physician and poet, had no problem using it when reﬂecting on the history of American therapeutics. In his most rhetorical manner, Holmes asked how it could have been possible for the people of the Revolution to adopt any system of medicine other than ‘‘heroic’’ practice.
That brave generation, he explained, was accustomed to consuming ‘‘ninety grains of sulfate of quinine’’ and ‘‘three drachms of calomel.’’ In any case, the term heroic medicine had already been popularized in the 1830s by doctors, both orthodox and sectarian, who were adopting more moderate approaches than the aggressive bleeding, purging, and puking of their predecessors. Given prevailing concepts of the vital functions of the body in health and disease, extreme measures of depletion were considered rational and necessary.
Physicians and patients generally thought about health and disease in terms of humoral balance and the movement of the blood. If blood could not move freely it could become thick, weak, and putrid. Just as a healthy society demanded the free movement of people and goods, a healthy body required the free movement of blood through the vessels and the therapeutic or prophylactic removal of putrid blood. In theory, toxins and impurities could also be removed from the body through other ﬂuids, such as sweat, urine, stools, pus, and vomit. The term ‘‘heroic’’ seems especially appropriate for Rush’s actions during the 1793 epidemic in Philadelphia. With hardly time to rest, sleep, or eat, Rush visited hundreds of patients throughout the city and responded to dozens of others who came to his house. Critics of the good doctor might say that those who were unable to obtain his services were actually better off than those subjected to his routine of bleeding and purging. In a direct assault on raging fevers, Rush wrapped his patients in cold, wet sheets and dosed them with buckets of cold water and cold enemas. Daily bleeding and purging continued until the patient either recovered or died. Rush knew that his critics thought his purges were too drastic and his bloodletting was ‘‘unnecessarily copious,’’ but he believed that disease yielded to such treatment and insisted that the only danger in treatment was excessive timidity.
Physicians in Europe might have prescribed different treatments for yellow fever, but their recommendations were not necessarily milder. In an autopsy report on a soldier who died of yellow fever, P. C. A. Louis (1787–1872), the great French clinician, provided details of the treatment prescribed by a French army doctor. On the ﬁrst day the patient was given a large dose of castor oil, an enema, and several doses of calomel, while leeches were applied to his temples. On the second day, in addition to a large dose of calomel, the patient was bled by leech and lancet. On the third day, the patient was given several enemas and 25 drops of laudanum before he died. William Cobbett (1763–1835), a British journalist and social reformer, made Rush the special target of the wit and sarcasm that enliv- ened his polemical writings. While living in Philadelphia, Cobbett (also known as Peter Porcupine) established a newspaper called Porcupine’s Gazette. Like Rush and Jefferson, Cobbett gloriﬁed traditional rural life and deplored the impoverishment and deterioration brought about by the Industrial Revolution. But where medical practice was concerned, Cobbett and Rush were implacable enemies. Based on studies of the Philadelphia yellow fever epidemic, Cobbett asserted that Rush had an unnatural passion for taking human blood and that many of his patients actually died of exsanguination. According to Cobbett, Rush’s method was ‘‘one of those great discoveries which have contributed to the depopulation of the earth.’’ In response, Rush sued Cobbett for libel. Not surprisingly, the American jury favored the Revolutionary hero and granted Rush a $5,000 judgment against Cobbett. Losing the libel suit did not silence Cobbett, who proclaimed that the death of George Washington (1732–1799) on the very same day that Rush enjoyed his legal victory was the perfect example of death by exsanguination ‘‘in precise conformity to the practice of Rush.’’ After the trial Cobbett launched a new periodical for the express purpose of attacking Rush’s methods, but he later returned to England to publish a journal dedicated to social and parliamentary reform.
Prevailing methods of education also attracted Cobbett’s blistering contempt. Many of the best years of a young man’s life, he complained, were ‘‘devoted to the learning of what can never be of any real use to any human being.’’ Although it is impossible to diagnose George Washington’s ﬁnal illness with certainty, it probably involved inﬂammation of the throat caused by infection with streptococci, staphylococci, or pneumococci. In order to show that everything medically possible had been done, Washington’s physicians published an account of his death in the news- papers. Doctors James Craik and Elisha C. Dick blamed Washington’s illness on exposure to rain while riding about Mount Vernon on horse- back. Suffering from a violent ague, sore throat, and fever caused by what the doctors called cynanche trachealis, Washington realized that bloodletting was necessary. A local bleeder took 12 or 14 ounces of blood from his arm. The next day the attending physician, worried by the ‘‘fatal tendency of the disease,’’ performed two ‘‘copious bleedings,’’ blistered the throat, dosed the patient with calomel, and administered an enema before the arrival of two consulting physicians. Seeing no improvement, the physicians carried out another bleeding of about 32 ounces of blood, and dosed the patient with more calomel, emetic tar- tar, and fumes of vinegar and water. Despite further treatments, includ- ing blisters applied to the extremities and a cataplasm of bran and vinegar for the throat, the patient ‘‘expired without a struggle.’’ During the summer of 1793, Philadelphia was plagued by great swarms of mosquitoes, as well as unusually large accumulations of ﬁlth and putrefaction in the streets, alleys, and wharves. Doctors anticipated an increase in the usual ‘‘autumnal fevers.’’ Observing the great num- bers of ‘‘moschetoes’’ in the city, Rush noted this as another sign of unhealthy atmospheric conditions. [The role of mosquitoes in the dis- semination of yellow fever was not demonstrated until the early twenti- eth century by Walter Reed (1851–1902) and his colleagues on the U.S. Army Yellow Fever Commission.] As soon as a few suspicious cases appeared, Rush warned the authorities that yellow fever had returned to Philadelphia for the ﬁrst time since 1762. As the number of deaths climbed, thousands of residents ﬂed from the city. Within months, more than 10 percent of Philadelphia’s 40,000 inhabitants had died of yellow fever.
Mayor Matthew Clarkson convened a committee of citizen volun- teers to establish a hospital and orphanage, supervise the collection and burial of abandoned corpses, organize efforts to clean the streets, dis- tribute supplies to the poor, and ﬁght the panic that gripped the city. Blaming the epidemic on the morbid vapors emanating from coffee putrefying on the wharf, Rush warned that the exhalations of other rot- ting materials would eventually produce fevers miles away from the original outbreak. Other physicians ridiculed this theory and argued that the disease had been imported by ships coming from the West Indies. Despite the controversy among the physicians, the mayor did order the removal of rotten materials along the wharf. Fear of epidemic disease generally inspired sanitary reforms in cities that otherwise toler- ated offensive odors and mountains of garbage. For example, in 1797, when landﬁlls along the waterfront on Manhattan became unbearably putrid, public health authorities blamed these ‘‘ﬁlthy nuisances’’ for an outbreak of yellow fever. To ﬁght ﬁlth, stench, and disease, the mayor had the area covered with ‘‘wholesome earth and gravel.’’ South Street was built on top of the ﬁll. Such sanitary campaigns might not affect yellow fever directly, but they did improve the atmosphere in a general way. Debates about the proper response to yellow fever became entangled in the political conﬂicts that wracked Philadelphia in the 1790s. Generally following partisan divisions, some Philadelphians blamed the epidemic on the inﬂux of foreigners coming by ship from Haiti, while others insisted that the epidemic was caused by unsanitary local conditions. For the most part, Republican (Jeffersonian) doctors and politicians said the fever was caused by local conditions.
Republi- cans opposed contagionist theories, quarantine regulations, and re- strictions on trade with the West Indies. The strength of anticontagion sentiment was demonstrated by physicians who attempted to prove that the fever was not contagious by inoculating themselves with the vomit, blood, or saliva of yellow fever patients. Even a strict anticontagionist needed great dedication and bravery to care for the sick, because most doctors believed that even if an epidemic were generated ﬁrst by noxious vapors, the exhalations of the sick might also generate a dangerous miasmatic condition. Conta- gionists, of course, greatly feared the sick and demanded their isolation, which often meant that the sick died of neglect. Arguing that his method was democratic and egalitarian because it could be used by virtually anyone, Rush claimed that attacks on his therapeutics were politically motivated and dangerous. Perhaps his decision to publish directions for treatment in the newspapers so that any reader could treat the dis- ease alienated many doctors.
Physicians of the eighteenth century had good and cogent reasons for rejecting the idea that yellow fever was transmitted by a contagion, which was deﬁned as ‘‘a force operating within a distance of ten paces.’’ Many people contracted the disease even though they had no contact with the sick, people who cared for the sick did not necessarily contract the illness, epidemics ended with the onset of cold weather, and people who ﬂed from affected cities did not carry the disease with them. All these observations suggested that yellow fever epidemics were generated and sustained by speciﬁc local conditions. These ideas about yellow fever were collected by Noah Webster (1758–1843), American lexicogra- pher, from questionnaires he sent to physicians in Philadelphia, New York, Baltimore, Norfolk, and New Haven. In 1796, he published this information along with his own comments and conclusions as A Col- lection of Papers on the Subject of Bilious Fever, prevalent in the United States for a Few Years Past. Federalist physicians and politicians generally accepted conta- gionist doctrines and favored quarantine and limitations on foreign trade. Blaming an epidemic on local conditions, they believed, was unpatriotic and detrimental to the economic well-being of American cities. Therefore, Hamiltonians insisted that yellow fever had been imported from Haiti, along with French refugees. In the West Indies, stimulants such as quinine and wine were traditionally prescribed for yellow fever. In the Philadelphia epidemic, this approach became known as the ‘‘Federalist cure.’’ At the beginning of the epidemic, Rush used relatively gentle purges and experimented with remedies used in the West Indies, but he soon decided that only strong purges and vigorous bleedings were effective. Some physicians resorted to chemical theories and tried to analyze the hypothetical vapors associated with putrefaction, as well as the much-feared black vomit that seemed to characterize the most lethal cases of the disease. Lacking specialized chemical tests, but not lacking in bravado, some doctors tasted the black vomit and survived.
This did not provide signiﬁcant chemical information, but it did show that even the most revolting product of the disease did not transmit the fever. Since yellow fever is caused by a virus, careful nursing, relief of symptoms, and rest might do the most good or the least damage to the patient. But eighteenth-century physicians were unlikely to meet a challenge like yellow fever with such timid measures as rest and ﬂuids. Innovative physicians prescribed everything from rattlesnake venom to castor oil and laudanum. Sir William Osler (1849–1919), author of the widely used textbook Principles and Practices of Medicine (1892), advised a course of therapy that included generous doses of cold car- bonated alkaline water, moderate doses of calomel, saline purges or enemas, cool baths for the fever, and perchloride of iron or oil of tur- pentine for the gastric hemorrhages. To relieve uremic symptoms, Osler suggested hot baths, hot packs, and hot enemas. Stimulants, such as strychnine, were prescribed to counter feeble heartbeat.
After the epidemic ended and those who had ﬂed returned to the city, Philadelphia observed a day of thanksgiving and remembrance: over four thousand had died out of a population of approximately forty thousand. Rush was overcome with ‘‘sublime joy’’ that his methods had ﬁnally conquered this formidable disease. Even the fact that the disease had killed three of his apprentices and his beloved sister did little to shake his faith in his therapeutics. The compulsion to ascribe success to medical treatment when recovery actually occurred in spite of the best efforts that medicine had to offer was certainly not unique to Benjamin Rush. A famous eyewitness account of the epidemic by Mathew Carey (1760–1839), A Short Account of the Malignant Fever, Lately Prevalent in Philadelphia, contains a vivid description of the symptoms of the disease, comments on the ‘‘astonishing’’ quantity of blood taken by medi- cal practitioners, and gives a list of those who died. In particular, Carey noted, the disease was ‘‘dreadfully destructive among the poor.’’ When the epidemic began, many physicians believed that blacks were less sus- ceptible to the disease than whites, but the list of the dead proved that this was not true. Nevertheless, Carey noted that during the early phase of the epidemic, when no white nurses would care for the sick, members of the African church offered to serve as nurses and to assist in burying the dead. Nurses were very important, Carey wrote, because many died from lack of care rather than the virulence of the disease itself. Determining the case fatality rate for yellow fever is difﬁcult because mild cases might be ignored or misdiagnosed. During the 1878 epidemic in New Orleans, the mortality rate in hospitals was over 50 percent among whites and 21 percent among blacks. However, physi- cians estimated the mortality rate among their private white patients at less than 10 percent. Presumably, these differences reﬂect the different health status of wealthy versus poor patients. Only the most impover- ished whites were likely to be taken to hospitals. Benjamin Henry Latrobe (1764–1820), an engineer who helped plan Washington, DC, believed that safe water systems would limit the threat of epidemic disease.
In 1798, Latrobe visited Philadelphia and concluded that pollution of wells with ‘‘noxious matter’’ from the city’s privies was the cause of epidemic disease. In 1801, after following Latrobe’s plans, Philadelphia had a citywide safe water system, with streetside pumps that provided free water to all, and private lines con- nected to the homes of the wealthy. A few other large cities, most notably New York and Boston, also invested in municipal water sys- tems in the ﬁrst half of the nineteenth century, but water, sewage and garbage disposal problems plagued many cities into the twentieth cen- tury. Although drinking contaminated water does not cause yellow fever, improved water supplies played a role in decreasing the danger of epidemic diseases, both directly and indirectly. Moreover, the elimi- nation of swamps, ditches, wells, and cisterns as cities grew and modern- ized decreased the areas available as mosquito breeding grounds.