Independent Thinking on Independence Day
The evolution of clinical medicine that was true to empirical observations but was not mere empiricism, and simultaneously scientific, i.e., based on reproducible, objective measurements, both qualitative and quantitative, of our physical world, was a slow one. Vesalius and Willis helped lay the groundwork for the power and clinical utility of observed experiential data that were true from one observer to the other, on any given day, rather than the pronouncements from on high a la Galen. It was, in this writer’s opinion, Virchow and Koch who were the primary movers in ushering in the essential basis of evidence-based rules and dicta as validated by continued, measured, and objective observation, in the former, and rational rules for verifying the reproducibility of causation, in the latter. Before the mid-to-latter 19th Century, however, it was musical chairs for subjective theories validated only by the strength of the reputation of the physician proclaiming them. Anecdotal medicine ruled. Empiricism without objective or reproducible validation held sway. Theory was anyone’s purview since no objective proof was needed. Leave your independent skepticism at the door.
It is not surprising, then, that Benjamin Rush, a remarkable man by all accounts, regardless of his prescient opposition to slavery, support for educational opportunities for women (1), and a more rational understanding of the nature and causation of mental illness (2), fell prey to what I call “anecdotalism,” no matter how undergirded it was by much empirical support. Born in 1746, Rush went to Edinburgh where he obtained his medical education at the feet of the great William Cullen, a Scottish physician famous for his system of nosology, an anatomy of diseases he based on symptomatology and which he constructed in a format and organization analogous to the famous classification system of Linnaeus, and which makes for fascinating reading even today. (3) Rush was a polymath whose contributions include influencing Thomas Paine in his writing Common Sense, involvement in the Declaration of Independence as a signatory, and service as Surgeon General of the Middle Department of the Continental Army during the American Revolutionary War. In this blog, I wish to review some of Dr. Rush’s observations about medicine and medical events during the American Revolutionary War, and his conclusions thereto. Rush was the kind of writer one encounters only occasionally – like Anthony Trollope or Horace Walpole or Isaac Asimov, who once boasted that he had never had an unpublished thought. (4) Rush wrote prodigiously and left behind several published essays (sometimes soon revised) concerning his thoughts about medical phenomena during the Revolution.
Published in 1777 while he was Surgeon General, Rush wrote “Directions for Preserving the Health of Soldiers.” (5) In it, he advised what we would today call prophylactic hygienic measures, e.g., paying attention to the roles that hair, clothing, diet (he advocated no spirits and emphasized vegetables over too much meat in the soldier’s diet), and cleanliness play in illness, especially during wartime.
“The hair, by being long uncombed, is apt to accumulate the perspiration of the head, which by becoming putrid sometimes produces diseases. There are two methods of guarding against this evil: the first is by combing and dressing the hair every day; the second is by wearing it thin and short in the neck. The former is attended with delays often incompatible with the duty of a soldier; and therefore, the latter is to be preferred to it. This easy mode of wearing the hair is strongly recommended by count Saxe, and by all modern writers on the military art.”
“Upon this account, I could wish the rifle shirt was banished from our army. Besides accumulating putrid miasma, it conceals filth and prevents due regard from being paid to cleanliness. The Reman soldiers wore flannel shirts next to their skins. This was one among other causes of the healthiness of the Roman armies. During the last war in America, general (then colonel) Gage obliged the soldiers of his regiment to wear flannel shirts, from an accidental want of linen; and it was remarkable, during a sickly campaign on the lakes, not a single soldier, belonging to that regiment was ever seen in any of the military hospitals. I have known several instances where the yearly visits of the intermitting fever have been checked in the state of Pennsylvania, in places most subject to that disease, by nothing else but the use of flannel shirts.”
“Too much cannot be said in favor of Cleanliness. If soldiers grew as speedily and spontaneously as blades of grass on the continent of America, the want of cleanliness would reduce them in two or three campaigns to a handful of men. It should extend,
To the body of a soldier. He should be obliged to wash his hands and face at least once every day, and his whole body two or three times a week, especially in summer. The cold bath was part of the military discipline of the Roman soldiers and contributed much to preserve their health.
It should extend to the clothes of a soldier. Frequent changes of linen are indispensably necessary;”
In 1789, Rush published two essays on the medical aspects of the American Revolution: “An Account of the Influence of the Military and Political Events of the American Revolution upon the Human Body” (6) and “The Result of Observations made upon the Diseases which occurred in the Military Hospitals of the United States, during the Late War.” In the former, he wrote, among other observations:
“Militia officers and soldiers, who enjoyed good health during a campaign, were often affected by fevers and other disorders, as soon as they returned to their respective homes. I knew one instance of a militia captain, who was seized with convulsions the first night he lay on a feather bed, after sleeping several months on a mattress, or upon the ground. These affections of the body appeared to be produced only by the sudden abstraction of that tone in the system which was excited by a sense of danger, and the other invigorating objects of military life.”
“Many persons of infirm and delicate habits were restored to perfect health, by the change of place or occupation, to which the war exposed them. This was the case more especially with hysterical women, who were much interested in the successful issue of the contest. The same effects of a civil war upon the hysteria were observed by Doctor Cullen in Scotland in the years 1745 and 1746. It may perhaps help to extend our ideas of the influence of the passions upon diseases, to add, that when either love, jealousy, grief, or even devotion, wholly engross the female mind, they seldom fail, in like manner, to cure or to suspend hysterical complaints.”
To be fair to Rush, this diagnosis of women’s complaints as “hysterical” was accepted doctrine at the time and would be so for another century. Rush’s interest in the close relationships and interactions between and among our psychic, spiritual, and physical selves was an ongoing theme in his writings and saw even further elaboration in his earlier 1786 essay, “An Oration, delivered before the American Philosophical Society, held in Philadelphia on the 27th of February 1786; containing an Enquiry into the Influence of Physical causes upon the Moral Faculty.” (7) In this tract, for example, Rush wrote:
“Do we observe the memory, the imagination, and the judgment, to be affected by diseases, particularly by fevers, and madness? Where is the physician, who has not seen the moral faculty affected from the same causes! How often do we see the temper wholly changed by a fit of sickness! And how often do we hear persons of the most delicate virtue, utter speeches in the delirium of a fever, that are offensive to decency, or good manners!”
In “The Result of Observations made upon the Diseases which occurred in the Military Hospitals of the United States, during the Late War” (6), Rush continued to mint his observations into the coin of medical wisdom with only his observations as a quasi-scientific quasi-gold standard. To be fair, however, the common-sensical aspect of some of them establishes them as truisms no practicing physician, then or now, would readily dispute:
“Young men under twenty years of age were subject to the greatest number of camp diseases.”
“Those officers who wore flannel shirts or waistcoats next to their skins, in general, escaped fevers and diseases of all kinds.”
“The contagion of this fever was frequently conveyed from the hospital to the camp, by means of blankets and clothes.”
“In gunshot wounds of the joints, Mr. Ranby’s advice of amputating the limb was followed by success. I saw two cases of death where this advice was neglected.”
“In fevers and dysenteries, those soldiers recovered most certainly, and most speedily, who lay at the greatest distance from the walls of the hospitals. This important fact was communicated to me by the late Dr. Beardsley of Connecticut.”
“Soldiers are but little more than adult children. That officer, therefore, will best perform his duty to his men, who obliges them to take the most care of their health.”
“Hospitals are the sinks of human life in an army. They robbed the United States of more citizens than the sword. Humanity, economy, and philosophy, all concur in giving a preference to the conveniences and wholesome air of private houses; and should war continue to be the absurd and unchristian mode of deciding national disputes, it is to be hoped that the progress of science will so far mitigate one of its greatest calamities, as to produce an abolition of hospitals for acute diseases. Perhaps there are no cases of sickness in which reason and religion do not forbid the seclusion of our fellow-creatures from the offices of humanity in private families, except where they labor under the calamities of madness and the venereal disease, or where they are the subjects of some of the operations of surgery.”
Benjamin Rush was a very complex man ahead of his time in progressive ideas concerning public health and the rights of slaves, women, and those with mental illness. However, he was very much a theoretical physician of his time in his adhering to the culture and tradition of trying, like Cullen and others, to describe a dynamic phenomenon — human illness — using only an approach based on surface descriptors and the variable observational abilities of those using this approach. Abandoning Cullen’s nosology, Rush did not abandon his mentor’s approach of anecdotalism. Instead, he advanced this methodology to its extreme absurdity, reducing all febrile illnesses to variants of one another. (8) What Cullen and Rush and all those who relied on superficial observations at the expense of what philosophers rightly call “first causes” failed to appreciate was the deeper understanding of cause and effect when building a nosologic system.
One constructs a house of cards when one uses effects as cards. The brilliance of Koch and those who had the insight to tie microscopic findings to disease was to realize that different first causes could produce similar surface descriptors. Even a static taxonomy like that of Linnaeus was dependent on the realization that phylogeny is no predictor of genetic origins. Who in his right mind would think that a tiny hyrax (2 feet long and 5 pounds in weight) is closer, phylogenetically, to elephants and manatees than it is to a gopher or rodent, which it resembles?
It little behooves a 21st Century blogger to fault Rush for not being Koch. His accomplishments as Rush were considerable. He was also a man who, it strikes this observer of him qua observer, rarely doubted himself or his opinions. Not the first time anyone has said that of a revolutionary man during his revolutionary times.
(1) Benjamin Rush and Women’s Education. Dickinson College. http://chronicles.dickinson.edu/johnandmary/JMJVolume13/campbell.htm. Accessed 7/10/2016
(2) Dr. Benjamin Rush. Penn Medicine. History of Pennsylvania Hospital. http://www.uphs.upenn.edu/paharc/features/brush.html. Accessed 7/10/2016.
(3) Cullen, W., Lewis, E., Boissier de la Croix de Sauvages, F., & Sturtevant, C. (1808). A methodical system of nosology. Stockbridge [Mass.]: Printed by Cornelius Sturtevant, Jun., for the translator. WZ 270 C967s 1808
(4) Isaac Asimov on encyclopedia.com: http://www.encyclopedia.com/topic/Isaac_Asimov.aspx. Accessed 7/10/2016.
(5) Rush, Benjamin: “Directions for Preserving the Health of Soldiers.” On Archive.org: https://archive.org/details/2569012R.nlm.nih.gov. Accessed 7/3/2016.
(6) Rush, B., & Carey, M. (1815). Medical inquiries and observations (The fourth ed.). Philadelphia: Printed for M. Carey, no. 121, Chestnut Street; Griggs & Dickinsons, printers. WZ 270 R952m 1815
(7) https://books.google.com/books?id=autYAAAAYAAJ&printsec=frontcover&dq=benjamin+rush+An+Oration,+delivered+before+the+American+Philosophical+Society,+held+in+Philadelphia+on+the+27th+of+February,+1786;+containing+an+Enquiry+into+the+Influence+of+Physical+causes+upon+the+Moral+Faculty%22&hl=en&sa=X&ved=0ahUKEwiGx_T8gOzNAhVBSiYKHdtRApwQ6AEIHDAA#v=onepage&q=benjamin%20rush%20An%20Oration%2C%20delivered%20before%20the%20American%20Philosophical%20Society%2C%20held%20in%20Philadelphia%20on%20the%2027th%20of%20February%2C%201786%3B%20containing%20an%20Enquiry%20into%20the%20Influence%20of%20Physical%20causes%20upon%20the%20Moral%20Faculty%22&f=false. Accessed 7/3/2016.
(8) North RL. Benjamin Rush, MD: assassin or beloved healer? Proceedings (Baylor University Medical Center). 2000;13(1):45-49.