Bleeding by the numbers Benjamin Rush Andrew G. Shuman, MD, Marc Edelman, JD, MA, and Joseph J. Fins, MD Dr. Shuman (AΩA, University of Michigan, 2004) was/ British journalist in post-Revolutionary America. Cobbett’s is a fellow in the Division of Medical Ethics at Weill Cornell literary foil and adversary was none other than the famous Medical College. He is currently assistant professor of Philadelphia physician and patriot, Benjamin Rush, who inad- Otolaryngology-Head and Neck Surgery and faculty in the vertently became the focus of one of the earliest applications Center for Bioethics and Social Sciences in Medicine at the of biostatistics in the history of medicine. University of Michigan Medical School. Mr. Edelman is asso- During the 1793 Philadelphia yellow fever epidemic, Rush ciate professor of Law at Zicklin School of Business, Baruch made liberal and publicly-touted use of bloodletting, which College, City University of New York. Dr. Fins (AΩA, Weill Cobbett argued was both dangerous and did not reduce the Cornell Medical College, 2011) is the E. William Davis Jr. MD death rate. After losing a libel suit to Rush, Cobbett defended Professor of Medical Ethics; chief of the Division of Medical himself with a novel weapon—data—and unwittingly opened Ethics; professor of Medicine, Public Health, and Medicine in the door to the modern concept of public health epidemiology. Psychiatry at Weill Cornell Medical College; and adjunct fac- Despite having the numbers and facts on his side, Cobbett’s ulty at the Rockefeller University. legacy is largely relegated to a historical footnote, whereas Rush’s continued support of bloodletting likely contributed to he emergence of statistics within the field of medicine many preventable deaths well into the nineteenth century. The is commonly traced to the French physician Pierre story is further enriched by its historical setting and political Charles Alexandre Louis, who, beginning in the 1820s, climate, challenging freedom of the press while the ink on the Tapplied a “numerical method” to determine whether bloodlet- Bill of Rights was still moist. ting effectively treated infections and fevers.1 A surprising predecessor to Louis was William Cobbett, a rabble-rousing 10 The Pharos/Autumn 2014 Rush versus Cobbett Bleeding by the numbers Illustration by Erica Aitken William Cobbett The protagonists president. He gained further notoriety when disease invaded Dr. Benjamin Rush remains one of the best known Philadelphia. American physicians of his time. The son of a local gun- In 1793, a virulent yellow fever epidemic wreaked havoc on smith, Rush signed the Declaration of Independence and Philadelphia, killing up to one-tenth of the city’s population. A later served as Chief Physician of the Revolutionary Army, disease with a variable clinical course and no definitive treat- and enjoyed international acclaim and esteem as a physician ment even today, physicians at the time were nearly helpless. and educator.2 After graduating from the College of New The etiology, a mosquito-borne virus, along with effective pre- Jersey (now Princeton University), Rush apprenticed with vention strategies, would not be discovered for over a century. a local physician before graduating from medical school in In the absence of scientific evidence, public health debates be- 1768 with the financial assistance of Benjamin Franklin.3 came intertwined with politics—“contagionists” believed yellow According to one student, Rush had a “voice, sweeter than fever was a communicable disease and generally sided with the a flute, [that] fell on [one’s] ears like droppings from a sanc- Federalists such as John Adams and Alexander Hamilton, while tuary . with his earnest, most sincere, most persuasive “anti-contagionists,” on the other hand, favored environmental accents, sunk so deep into my heart that neither time nor etiologies and tended to be Jeffersonian Republicans.5 change could eradicate.” 4 Rush was reform-minded, peti- Rush combated the yellow fever epidemic with his char- tioning for the abolition of slavery, education of women, acteristic fervor, converting his home into a hospital and and improvement of prisons. He was also a prolific writer seeing over a hundred patients daily.3 The idea for aggressive who authored the first essay in American history advocat- bloodletting, the crux of his treatment, was based on a medical ing for an entirely public school system, and boasted about publication from the 1740s given to him by none other than his writing the first article promoting George Washington for patron, Benjamin Franklin.6 By trial and error, Rush settled on The Pharos/Autumn 2014 11 Benjamin Rush by Richard W. Dodson. © Stapleton Collection/CORBIS a treatment regimen involving “depletion theory,” consisting of aggressive bleeding coupled with a mercury-based purgative.7 Convinced of its effectiveness, he publicized his treatment in newspapers and in impassioned pleas to medical colleagues, and intensely criticized physicians who spoke out against his ideas. The professional debate was relayed in communica- tions between Henry Knox, Secretary of War, to President Washington: “The different opinions of treatment incite great inquietude . But Rush bears down all before him.” 7 Doctor practicing bloodletting on a patient by artist James As both mercury-based purgatives and bloodletting were Gillray. © Historical Picture Archive/CORBIS very much a component of standard medical practice, it was these therapies’ applicability to yellow fever, the concordant use of aggressive emetics, and the sheer volume of blood removed physician himself, offered less than generous appraisals of that set Rush apart from his peers.8 A partial explanation for Rush’s contributions to the field: “In the whole vast compass the aggressiveness of Rush’s regimen involves his gross miscal- of medical literature, there cannot be found an equal number culation of the normal adult human blood volume, which he of pages containing a greater amount of utter nonsense and projected at twice the correct figure.6 unqualified absurdities.” 12 In fact, Rush applied his anecdotal Empiric study would eventually bring into question the prac- experiences with bleeding as a panacea for yellow fever widely, tice of routine bloodletting. To Rush’s credit, however, he did espousing the theory that all significant illnesses resulted from make substantive advances in the realm of public health with increased vascular tension that could be resolved with aggres- respect to yellow fever. His assertion that the disease was not sive bloodletting.10 This fallacy, popularized by his spirited transmitted among humans and his willingness to remain with rhetoric and prolific writings espousing the dangerous practice, the infirm served as a powerful example of medical profession- spread significantly throughout the global medical community, alism; moreover, while the insect vector would not be identified and was applied by his trainees along the eastern seaboard as until the twentieth century, his efforts to improve hygiene have late as the 1840s.10 been lauded.9 Rush urged the mayor of the city to establish William Cobbett, a British ex-marine and journalist resid- hospitals for management of the indigent.7 His memoir of the ing in Philadelphia, was an unlikely opponent. Cobbett had epidemic provided a personal and riveting account of the ill- received little formal education, but taught himself grammar ness and its effect upon the population.10 In addition, his sheer and literature.13 After the American Revolution, Cobbett settled determination and work ethic throughout the epidemic of 1793 in Philadelphia and assumed the pseudonym Peter Porcupine, were highly praised.11 writing the popular Porcupine’s Gazette. A loyal Briton active in Even though there were few satisfactory alternatives to American politics, Cobbett bitterly opposed the Republicans, Rush’s practice of bloodletting to treat yellow fever, some con- lending grudging support to Alexander Hamilton and the tend that Rush managed to “severely retard medical progress for Federalists.14 Cobbett’s writings were popular as both enter- almost fifty years after his death.” 4 Elisha Barlett, a renowned tainment and a source of news. Abigail Adams appreciated his 12 The Pharos/Autumn 2014 Portrait of William Cobbett by J.R.Smith. © Bettman/CORBIS work, commenting that Cobbett’s “shafts are always tipt with of his many barbs, Cobbett continued the Biblical metaphor: wit, and his humor is such as frequently to excite more of good “The Israelite slew his thousands, but the Rushites have slain than ill.” 15p8–9 Meanwhile, George Washington also offered their tens of thousands,” 20p131 followed by “The times are omi- guarded praise, despite his concern that the works contained nous indeed,/When quack to quack cries, Purge and bleed.” 20p167 “strong and coarse expressions” and “a want of official informa- In another broadside, Rush was given unholy company: “a mus- tion on many facts.” 15p18 quito, a horse-leech, a ferret, a pole cat, a weazel: for these are Cobbett ultimately chose Benjamin Rush as his main tar- all bleeders and understand their business full as well as Doctor get. While not the first to criticize Rush (Knox, Hamilton, and Rush does his.” 21pp288–89 others had already done so), Cobbett may have been the most The pamphlets were influential. In a personal letter in which acerbic. In Cobbett’s words, Rush “seized, with uncommon he disclosed his intent to file a legal suit, Rush admitted that alacrity