C. Frederick Kittle
Chicago, Illinois, United States

 

Excerpted from the The Proceedings of the Institute of Medicine of Chicago, Vol. 34, 1981. Based on a paper presented at the annual meeting of the Alumni Association of Rush Medical College, September 13, 1976. Reprinted from Rush-Presbyterian-St. Luke’s “Magazine,” Winter 1976–77.

 

Benjamin Rush by Charles Wilson Peale. 1818. Independence National Historical Park. Via Wikimedia.

In his biographies it is stated simply: Benjamin Rush—Patriot, physician, and psychiatrist (1745–1813).

To some he was innovative and daring, while others thought him revolutionary; to some he was determined, to others compulsive and offensive; to some he was noble and compassionate, to others this was only his self-image of saintliness. He made countless friends and admirers, as well as innumerable bitter and angry enemies. His reputation is marked by controversy, and arguments abound regarding his role in any one of the numerous encounters that filled his life.

No one can deny, however, that he was the first great physician in the United States; no one can deny that for at least 100 years his influence and presence were felt in virtually every sickroom in the United States. He lived—and flourished—in a unique world, those years before, during, and after the Revolutionary War, in the new soil of this great democracy. He believed that God had selected the 18th Century as an age for an enlightened inquiry into truth, and that he, Rush, was His agent.

We should begin with Rush as the Revolutionary patriot, since this is what first brought him to fame. There were many crucial moments during the beginning days of this country, but none of more importance than one evening in the fall of 1775. Dr. Benjamin Rush, aged twenty-nine, had just finished seeing his last patient and was awaiting a visit from Englishman, Thomas Paine. Paine, at the suggestion of Benjamin Franklin, had been encouraged to come to America.

His articles on slavery impressed Rush and made him realize what a powerful writer Paine was. The question that concerned Rush now was whether Paine, an Englishman who had been in America less than a year, could and would write articles about English tyranny for America.

The war for Independence had been going on in earnest since April 19, 1775, and American colonists had shown their worth against the British professionals in war. But the people needed more courage, enthusiasm, and most of all, a feeling of patriotism.

Then the housekeeper announced Paine. Immediately, the two achieved a rapport based on Paine’s frankness, his interest in the “common people,” his background of working as a common laborer, and their common dislike for the British Constitution. As Paine expressed it:

“. . . if America wins her independence she can trade wherever she likes . . . and pay no tax tribute to England for the privilege. It is ridiculous that a little tail the size of England should wag a vast continental dog. Must 3 million people flock to the shore every time a vessel arrives from England to find out how much—or how little—liberty the British wish them to enjoy?”

But, as Rush pointed out, there were many Americans who did not favor independence and were content to have a friendly relationship with the English. What Rush thought should be done was to organize people in America to fight for America, not against the mother country. Rush gave Paine some notes he had jotted down that expressed thoughts about independence. Because Paine was a skilled writer and an excellent pamphleteer, Rush attempted to persuade him to write an article stressing the need for America to separate from England. Paine finally agreed.

“What will you call the pamphlet?” Rush asked. “Have you any idea?”

Paine considered. “It will contain nothing but the plain truth,” he said. “Perhaps that would be a good title.”

“Plain Truth,” Rush said, trying it out. “Yes, that’s good. But truth can be plain to some and not to others. We want a truth that is plain to everybody with common sense.” He snapped his fingers. “I think we’ve got it. Let’s call it ‘Common Sense.”’

And so Paine’s famous article was born. Its effect was immediate and profound. Thousands of early Americans who were wavering about independence, about the difficulties of winning, and other thousands who proclaimed their desire for America to remain a colony, were convinced by the brilliant persuasiveness of Paine that America should become a separate and free nation.

Benjamin Rush’s desire for independence did not arise suddenly or from a single source. He had entered the college of New Jersey at Princeton, later to become Princeton University, when he was 13. “I was an idle, playful, and I am sorry to add, mischievous boy,” yet he demonstrated such talents for public speaking that he decided to become either a lawyer or, second best, a minister. His uncle, the Rev. Dr. Samuel Finley, principal of Nottingham School, discouraged him.

“You are a close observer, Benjamin, and a painstaking workman. You also have a kind and gentle heart. These are qualities that grace a doctor of medicine. I think you ought to consider the medical profession.” And so Rush, at the age of 15, filled with enthusiasm, a graduate of Princeton, his ears ringing with compliments and admonitions, chose medicine as a career.

He became apprenticed to Dr. John Redman, an outstanding teacher and physician in Philadelphia. Redman’s initial advice and encounter with Rush was to be remembered throughout his life.

“Is it you custom to sleep all day, young man?” Redman asked and then continued, “As my apprentice—if you remain my apprentice—you will learn to live on very little sleep.”

And then he went further: “I am not sure that I was wise in accepting you. Oratory, they say, is your only claim to fame. A sickroom, the walks of a hospital, a surgical theater, are places of silence—except, of course, for screams of agony and groans. Eloquence has never set a broken leg or charmed away a fever. If you study under me you will be seen but not heard, a speak only when spoken to.” And Redman persisted with a comment, as true today as it was 200 years ago:

“. . . Medicine is above all the art of learning to live with discouragement and to keep on going—groping through darkness and superstition.”

Rush’s apprenticeship lasted five and a half years, each day filled to the brim with exhausting tasks: accompanying Redman on his rounds, preparing medications, studying and memorizing the classics in medicine, particularly Thomas Sydenham and Hermann Boerhaave. During these five and a half years, he was absent from Redman’s practice only 11 days and spent only three evenings away from his house.

Dr. Redman encouraged him to study abroad, and, in September, 1776, he was off to Edinburgh, at that time one of the outstanding medical centers of the world. He presented himself to Dr. William Cullen, professor of matera medica at the Medical College. Rush also furthered his knowledge of chemistry by attending the lectures of Joseph Black. He was 22 when he received his medical degree from the University of Edinburgh, after completing a doctoral dissertation based on self-experimentation about digestion in the stomach, “De Coctione Ciborum.” The conclusions were erroneous, but his ingenuity in experimentation inspired others.

Classes did not occupy all of his time, however, and at an evening dinner he met David Hume, the canny Scottish historian and philosopher. The logical and constant examination that Hume gave to every conversational topic undoubtedly influenced the approach of Benjamin Rush to new or controversial problems.

Cullen considered Rush a brilliant protege and gave him letters of introduction for a tour to London and Paris. He made new friends and acquaintances: William Hunter, Samuel Johnson, Oliver Goldsmith, James Boswell, and Augustine Roux, to mention only a few. Many were filled with revolutionary thoughts about the tyranny of kings and the virtues of democracy.

On his return to Philadelphia in 1769, Rush was admirably suited to cope with the problems of the English Colony in America: the burgeoning of Philadelphia as an international port and leading city in America, the continuing struggle against British oppression, and the almost hopeless confusion in the care of the sick patients. He was soon appointed professor of chemistry at the College of Philadelphia (now the University of Pennsylvania Medical College).¹

His first interest was in one of the social problems, slavery. In 1772 he published “On Slave-Keeping,” describing vividly the events in a slave market. This promptly brought forth much animosity from slave owners. Rush also helped to organize the first antislavery society in America in 1774, and succeeded Benjamin Franklin as its president several years later. These activities gave him the label of “political” doctor, and he was unpopular not only with the wealthy pro-slavery men, but also with his fellow doctors, who thought he should devote himself to the medical profession. His practice prospered, nonetheless.

His interest and participation in politics continued. He was adamant in his opposition to the taxation on tea, which, although not burdensome, was symbolic of continued British tyranny—taxation without representation. As Rush noted on October 10, 1773 (title “On Patriotism” and addressed “To His Fellow Countrymen”):

“Patriotism is as much a virtue, and is as necessary for the support of societies, as natural affection is for the support of families. . . . We are informed that vessels were freighted to bring over a quantity of tea taxed with a duty to raise revenue from America. Should it be landed, it is to be feared that it will find its way amongst us. Then farewell American Liberty. . . . Let us with one heart oppose the landing of it. The baneful chests . . . contain something worse than death—the seeds of slavery.”

Ships did arrive in Boston in December 1773, where a number of Bostonians disguised as Indians held the fateful Boston Tea Party. The British Parliament was quick to retaliate by passing the “Intolerable Acts,” including these: Boston harbor could not be opened until the tea had been paid for, and Bostonians were to quarter British troops in their homes. Outraged Americans asserted their rights. As Benjamin Franklin put it, “We shall hang together or hang separately,” and in his desire to “hang together” he was joined by Benjamin Rush, Samuel Adams, John Adams, John Hancock, George Washington, Thomas Jefferson, and Patrick Henry.

When the First Continental Congress convened in September 1774, with a total of 55 delegates from all the companies, Rush was on the committee to welcome them to Philadelphia. Some, such as John Adams, thought him too zealous, too radical in his thoughts about freedom. The Congress inspired Rush to the utmost in patriotism, and he wrote letter after letter to the press.

By the actions of this Congress, imports from England were drastically reduced. British trade declined throughout the colonies more than 90 percent from the previous year. After only a few months the famous encounter at Lexington took place on April 19, 1775, and the “shot heard around the world” was fired. The American Revolution had begun.

And now it was December 1775. Paine and Rush met for the second time. The small manuscript lay on the table between them. Paine looked at his friend and grinned.

“Well, doctor,” he said, “there’s our baby. Do you think it will live?” Rush replied, “I’m sure it will. It will live to make a big noise in the world. You have done a magnificent piece of writing.” Rush found publisher for the pamphlet “Common Sense” by Thomas Paine, and overnight the little book became famous. This was no humble remonstrance for independence; it breathed fire and brimstone. It singed the beards of kings everywhere: “The heathens paid divine honors to their deceased kings, and the Christian world has improved on the plan by doing the same to their living ones. . . . Of more worth is one honest man to society than all the crowned ruffians that ever lived.” Paine went further, and discussed the British constitution: “It is the most complicated, irrational, and ridiculous contrivance ever devised to govern enlightened men.”

Alone, this booklet written by Thomas Paine effected a profound change in the discouraged and uncertain early Americans. Their thoughts and support were solidified for the Revolution. As George Washington said: “I find ‘Common Sense’ is working a powerful change in the minds of men.”

Rush became even busier as the weeks and months advanced toward an open declaration of independence. He was primarily responsible for eradicating the Tory-dominated Pennsylvania Assembly and establishing a new body solidly in favor of independence.

And so the Continental Congress declared independence on July 2 and 3, 1776. The formal Declaration was adopted on July 4 and signed that day, but only by John Hancock with his bold and flamboyant signature. Rush,² a delegate from Pennsylvania to the Congress, signed the Declaration of independence on August 2, and thus joined the company of the 56 other illustrious Americans who did so.

In midsummer, 1776, General Washington took his Army from Boston to face the British on Long Island, and the war was begun. The next Spring, Rush was commissioned as surgeon general for the Middle Department, where the next 10 months were to be a strife-ridden period for him.

Health conditions among soldiers were abominable. Virtually no attention was given to their personal cleanliness, their foodstuffs, or to their care when disease occurred. Typhus fever was rampant and smallpox was common.

With his characteristic acumen, Rush noted that more illness occurred in crowded conditions than elsewhere, that disease ran concurrently with a previous state of ill health, and struck more poverty-stricken soldiers than those who were well-fed, well-clad, and well-housed.

It was not long before Rush published a military manual, “Directions for Preserving the Health of Soldiers.” This was a pioneer work in military hygiene. Reissued at least twice during the Civil War, it was reprinted as late as 1908. The advice would be considered elementary today—a soldier should wash his hands and face at least once a day, not sleep in wet clothes, garbage and waste should be disposed of properly, campsites should be some distance from marshes and swamps, the diet should include well-cooked vegetables, and exercise should be part of the army routine.

Hospital facilities during the American Revolution were hopelessly inadequate, and were made even worse by the poor organization of the Army Medical Department. The original plans for our Army of 20,000 men recommended only 29 doctors, assistants, and druggists, and one nurse for each 10 patients. When Rush discovered that the British hospitals under General Howe’s command were much better staffed, equipped, and supplied than the American hospitals were, he was even more exasperated.

Rush, enthusiastic gadfly that he was and appreciating what good military medical care should be, lost no time in starting a campaign against the corrupt medical system. It was inevitable that his letters, suggestions, and criticisms should irritate his superiors, notably Dr. William Shippen, and finally precipitate a Congressional hearing. In desperation, frustrated at his inability to institute what he believed were necessary and honest reforms, Rush resigned. General Washington was also disturbed by critical remarks Rush had made about him. The findings of a second hearing, held several years later, agreed with Rush’s claims, and Congress adopted many of the reforms he had suggested.

Although Rush was to retain a deep and undying interest in politics throughout his life, the pre-Revolutionary years saw the height of his patriotic activities. For the remaining part of his life, he devoted himself almost exclusively to medicine.

After the British left Philadelphia in 1778, Rush returned to his beloved city. The British had left Philadelphia a filthy mess, and there was sickness everywhere. Rush plunged into the care of the sick with his habitual energy and verve. A new system of medicine had been instituted by Rush before he left for the War. Early Colonial medicine was largely based on home remedies, and there was no such thing as a license to practice medicine. The practitioners who treated the sick generally did so according to the system set forth by the famous Dutch physician, Hermann Boerhaave.

Eighteenth-century medicine, like its poetry and theology, had little interest in the observation of Nature. According to Boerhaave, the body’s “humors” were the basis of therapy. All disease could be blamed on morbid acrimonies that could be purged from the body through the urine, through the pores of the skin, or by blood-letting.

While in Edinburgh, Rush had been persuaded by Cullen to discard Boerhaave’s notion as too speculative. According to Cullen, all diseases were due to disorders of “nerve force.” Also, since classification was fashionable at this time, Cullen had divided diseases, according to symptoms, into classes, genera, and species—1,387 in all. He opposed blood-letting, and put his faith in a hierarchy of drugs. A physician merely had to fit the patient’s symptoms into Cullen’s classifications and then apply the remedy he listed.

On his return to Philadelphia, Rush, an ardent discipline of Cullen, Convinced other physicians by his enthusiasm that they should adopt the Cullen system. His belief in Cullen’s system did not last long, however, and he soon developed his own system to replace that of Cullen.

Briefly, Rush maintained that every fever due to “excess excitability” of the blood vessels. All fevers were essentially the same. Thus Rush boldly reduced the hierarchy of fevers as described by Cullen from many to one, and reduced the materia medica from hundreds to about 20. Obviously with a fever or, as translated by Rush, increased excitability of the blood vessels, one should decrease the excitability by purges, salvations, and particularly by blood-letting. He speaks of withdrawing as much as 100 ounces of blood, and then returning to withdraw more.

In other areas, he sponsored many social reforms, criticizing unjust sentences imposed for minor civil offenses, and capital punishment, and urging temperance in the use of alcohol. In 1783, he became a member of the Pennsylvania Hospital staff.

Teaching at the University of Pennsylvania kept Rush busy. Later, he was to enlarge his medical practice by adding a mail-order advice service. It was by mail that he advised the treatment of Mary Washington’s carcinoma of the breast, a treatment that did not work well because Mary died one month later.

Rush was particularly concerned with medical care for the indigent, and treated thousands of them without charge. For years he attempted to obtain adequate hospital facilities for the poor, and finally, on April 12, 1786, the Philadelphia Dispensary was opened, the first free clinic America. Soon thereafter Rush became interested in General education, founding Dickinson Collee and campaigning extensively for free schools and education for women. In 1792, he became professor at the recently established (1791) University of Pennsylvania.

During the 1790s, Philadelphia had several epidemics of yellow fever. Indeed, in 1793, 10 percent of the city’s population died. To Rush, it was obvious that the foul sanitary conditions of the city were largely responsible, although he antagonized the city fathers and businessmen by such proclamations.

It is a tribute to the courage, devotion, and physical sacrifice of Rush that he remained in Philadelphia to care for the sick and dying during these great yellow fever epidemics. He racked his mind for some treatment that might lessen the high mortality rate. As he wrote his wife, “The common remedies for malignant fevers have all failed.” Then he recalled a paper written by Dr. John Mitchell describing the yellow fever epidemics in Virginia half a century before. Purging and bleeding were advised.

So Rush, initially over the objections of his colleagues but later with their support, began to purge and bleed. Calomel and blood-letting. Never mind the pulse. It could be weak, but if the fever persisted, take off more blood. The following years brought new epidemics, and Rush continued purging and bleeding with renewed vigor and, according to some, and increasing mortality rate.

Rush, the practitioner and clinician, was greater than Rush, the theorizer on the cause and cure of disease. His best attributes were astuteness of his bedside observations and the diligence of his medical care.

It was Rush who first stressed careful observation of patients and insisted on keeping careful records of their progress. This sounds elementary now, but these practices were innovations then. “One might as well try to swim by reading.” Thousands of students and colleagues were influenced and inspired by him. He exemplified the best qualities of his age: humanism, optimism, and a fervent belief in progress through knowledge.

As a staff member at the Pennsylvania Hospital, he developed an interest in psychiatry, undoubtedly accentuated when his young son John had to be hospitalized in the insane ward of the hospital. Two questions about psychiatry plagued Rush for many years of his life. How do people go mad? is it possible to cure madness?

At the time, people were thought to be mad because they were possessed by the devil (compare the interest in exorcism today) or because they were suffering for their sins. Rush was the first American to proclaim that mental illness was a disease and, for this alone, without regard to all his other contributions, he justly deserves the title, The Father of American Psychiatry.

As might be expected, Rush developed a theory, actually several theories, to explain mental illness. He believed there was an “inflammation” of the brain; he believed there were “disordered actions” in the blood vessels, but he also listed many other causes of insanity.

For treatment of mental illness, Rush thought the “morbid excitement” of the brain should be reduced. Previously, treatment for insanity was aimed chiefly at punishing the patients for their sins, often quite brutally. What would really help? Rush did not know, but he tried a variety of treatments: alternating hot and cold baths, immobilization to decrease blood flow, centrifuging to increase blood flow to the brain, and numerous types of sudden stimuli. In 1812, he attempted electric shock therapy, the first time this had been used. But for every patient, he insisted upon just and humane treatment, a pleasant surrounding, recreating and occupational therapy, the lack of undue stress, and the writing or talking by the patient of his symptoms, or, as we know it, mental catharsis.

His last years were distinguished by an increasing recognition of his medical fame not only by the profession in the United States, but also in Europe. His death came in 1813 after a short illness, probably pulmonary tuberculosis, and after he had insisted that he be bled.

 

Notes

1. His book (1770) “Syllabus of a Course of Lectures on Chemistry” helped earn him the title of first American chemistry teacher.
2. According to some Rush was the only physician with formal training, but there were three others who practiced medicine: Josiah Bartlett (New Hampshire), Lymann Hall (Georgeia), and Matthew Thornton (New Hampshire).

 

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C. FREDERICK KITTLE, MD, (1921–2015) was an accomplished thoracic surgeon, department head at the University of Chicago (1966) and Rush University (1973), a student of the humanities, and author of many papers on medical history.

 

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