What the Doctor Ordered: Dr. Benjamin Rush Responds to Yellow Fever

Home Education Unit Plans Diagnosing and Treating Yellow Fever in Philadelphia, 1793 What the Doctor Ordered: Dr. Benjamin Rush Responds to Yellow Fever

What the Doctor Ordered: Dr. Benjamin Rush Responds to Yellow Fever

One of the most difficult concepts for students to grasp when studying the Yellow Fever epidemic of 1793 is why Philadelphia’s doctors—among the most accomplished in North America—failed to understand the disease’s origin and method of transmission. Even worse (and even more perplexing), some doctors prescribed treatments such as blood-letting, which may have proven as toxic to patients as Yellow Fever itself. 

This lesson uses primary sources owned by the Library Company of Philadelphia and the Historical Society of Pennsylvania to help students explore the complexities of medical thought in late eighteenth-century Philadelphia. The sources require students to use critical thinking skills to analyze why Philadelphians in 1793 managed the Yellow Fever epidemic the way they did—and empathize with the city’s political leaders, doctors, Yellow Fever patients, and victims. 

The figure of Dr. Benjamin Rush, prominent Founding Father and early America’s most famous doctor, looms large over the response of the city of Philadelphia and its vibrant medical community to the scourge of Yellow Fever. Rush’s extreme treatment methods, centering on purging the body via bloodletting and vomiting, eventually earned criticism from some of his peers, who doubted the methods’ effectiveness. Much scholarly debate has focused on how culpable modern historians should hold Rush for not noticing the ill effects of his treatments, versus how much historians should laud him for his unwavering commitment to Philadelphia during one of the city’s darkest hours. 

Rush and the eighteenth-century Anglo-American medical establishment operated under diverse theoretical perspectives about the causes and cures of diseases.  Some of the theories were grounded in ancient scholarship. Galen’s humoral theory, for example, held that illnesses were caused by imbalances among four bodily fluids: blood, phlegm, black bile, and yellow bile.  Restoration of proper humoral balance restored health. Doctors who embraced the humoral perspective studied fluids such as urine, vomit, and blood for signs of health, and prescribed treatments they hoped would influence the character of those fluids. Indeed, in an era before modern methods of peering into the human body (X-ray, for example), the body’s output was the only means of assessing its internal condition.

Rush was trained to practice medicine in academic and professional environments that embraced humoral theory.  Given this context, it is unsurprising that he looked to purging as the basic treatment for Yellow Fever. And yet, despite the fact that many of Rush’s patients did recover from both Yellow Fever and the doctor’s purgings, reports on patient symptoms and treatment results might have raised serious doubts in the doctor’s mind about the effectiveness of his methods. Other medical practitioners, including many of Rush’s peers in the College of Physicians of Philadelphia, openly questioned his treatments. French physicians with greater experience managing Caribbean Yellow Fever outbreaks through palliative (i.e. noninvasive) treatment methods proposed and implemented their alternative treatments in the beleaguered city, to some effect. These undercurrents of disagreement did not shake Rush’s confidence in his own practice, however.  If anything, he dug in his heels against his peers’ dissent. Firmly committed to the health and wellbeing of his patients, Rush treated Yellow Fever the best way he knew how. Why did Rush manage his cases the way he did? 

Grounded in laboratory science and clinical testing, mainstream modern medical practice has by and large abandoned precepts that governed treatment in the eighteenth century, including humoral theory. Yet modern observers ought not to judge Rush too quickly for his efforts. This lesson encourages students to engage with the multifaceted character of Benjamin Rush on the doctor’s own terms, by working with letters Rush’s patients wrote to him asking for assistance during the Yellow Fever epidemic. After a brief introduction to issues surrounding Yellow Fever diagnosis and treatment, students will hone their historical thinking skills by seeking to understand the perspective of Benjamin Rush as he met with and treated Yellow Fever patients. They will read letters Rush received during the outbreak, record observations and conclusions based on those primary sources, synthesize their findings, and understand the pitfalls of reaping anachronistic judgment on historical characters using modern scientific knowledge people in the past lacked. 


Essential Questions

What role do multiple causations play in describing a historic event?
What role does analysis have in historical construction?


Students will:
• Analyze primary sources by drawing factual information from them and assessing their merits as sources for historical evidence.
• Make conclusions about the appropriateness of Dr. Rush’s prescribed treatments during the Philadelphia Yellow Fever epidemic of 1793, as well as the physical and emotional impact of the epidemic on victims and their families, by synthesizing findings from many primary and secondary sources.
• Avoid anachronistic judgments of historical actors by imagining how their own decision-making processes would differ if they lived in past times. 


Other Materials

Part One -Teacher Introduction, Review, and Lecture

Chromo-lithographs from André Mazet, Observations sur la Fièvre Jaune, Faites à Cadix, en 1819 

History Making Productions Philadelphia: The Great Experiment -  Fever: 1793 Teacher Educational Materials and Student Educational Materials

Part Two - Teacher Modeling of Primary Source Analysis

Case Sheet for Students

Case Sheet Answer Key for Teachers

Case #1: Daughter of Elizabeth Ramsey and Document front and back

Part Three – Student Group Work

Vocabulary List

Case #2: Reverend Doctor Blackwell
Case #3: Pickering Household
Case #4: Mr. Meredith
Case #5: John Hart and Family
Case #6: Son of Mordecai Lewis
Case #7: Alexander Cochran

Part Four – Class Discussion, Review, and Assessment

Asessment Documents


Suggested Instructional Procedures

Note: This lesson plan is best implemented at the end of a general lesson or unit on Yellow Fever.  It assumes that students possess basic knowledge about the 1793 epidemic and are prepared to engage with primary-source materials related to the outbreak.  It is well suited to use after reading the young adult novel Fever 1793, by Laurie Halse Anderson.

The lesson may not require two full class periods to teach but contains too much material for one sixty-minute period. It is recommended to teach Part One in advance of Parts Two through Four, preferably no more than one day prior to finishing the lesson’s classroom portion. 

Part One: -Teacher Introduction, Review, and Lecture

1) Review the history of the 1793 Yellow Fever epidemic.  Ask students the following questions:
• What are the symptoms of Yellow Fever? (Show André Mazet fever symptom chromolithographs, 1819 - 1 and 2.)
• Did Philadelphians know what caused Yellow Fever?  What did they think might cause it?
• How did Philadelphians manage the outbreak?  (Show Dead House picture.)
• Who were some of the prominent local leaders during the outbreak?
2) Introduce students to Dr. Benjamin Rush (Show Rush portrait.)
• Share basic biographical information about Dr. Rush: Born in 1746, studied medicine in Edinburgh and earned a medical degree in 1768, influential patriot and signer of the Declaration of Independence
3) Define the historical problem the class will investigate together.  “No one in the 1700s knew exactly what caused Yellow Fever, and no one was sure how to treat it.  Why did doctors prescribe treatments that we know today were ineffective and even harmful, and why did patients believe they worked?”
4) If class time allows, History Making Productions film may be viewed to help achieve the instructional steps above.   
5) Following teacher-led review and/or watching of webisodes, ask the class to propose preliminary hypotheses regarding the following questions: How did Dr. Rush treat his patients?  How did the community feel about Dr. Rush’s treatments?  Why did Dr. Rush think his harsh treatments worked? 
6) Tell students that they will participate in an activity that will help them check if their proposed answers are right.  To understand the historical problem of diagnosing and treating Yellow Fever, students will work with primary sources to learn how people (including Dr. Rush) felt, thought, and acted about Yellow Fever in 1793.

Part Two -  Teacher Modeling of Primary Source Analysis

7) Review what primary sources are, and why historians use them.  Ask students to name examples of primary sources. 
8) Introduce students to the sources with which they will work: letters written to Dr. Benjamin Rush by Yellow Fever patients, as well as patients’ family.  They will use the letters to understand Yellow Fever victims’ experiences, and Dr. Rush’s treatments.  To provide context, inform students that, of all Yellow Fever patients discussed in Dr. Rush’s letters, approximately 78% recovered. 
9) Model primary-source analysis of a letter to Dr. Rush.  First, distribute a Case Sheet to each student.  (Case Sheet will also be used for the group work activity.)  Then, project the letter on a screen (front and back) Instruct students to try to decode the first two (or more) lines of script.  Ask them to raise their hands and share their findings.  Assist with decoding as necessary.  (Paper copies of the letter, with a transcription, may also be distributed to students.)  Ask students the following questions:
• What do we know about the author of the letter?  Why did the writer send it?
• What two Yellow Fever treatments does Elizabeth mention in the first two lines?
• What symptoms does the Yellow Fever victim show?
• How do you think Elizabeth felt as she wrote this letter?
• How do you think Elizabeth felt toward Dr. Rush?  
Instruct students to record their findings about this patient in the appropriate spaces on the Case Sheet (first row). 

Part Three - Student Group Work

10) Divide students into small groups.  Distribute one Document Packet (of 6 above under Other Materials) and Vocabulary Sheet to each group.  (Do not print Document Packets back-to-back as letter scans and their transcriptions may end up on different pages.)  Differentiated instruction: Cases 2 – 4 are significantly more challenging than Cases 5 – 7. 
11) Explain that each Document Packet contains letters written by one or more persons to Dr. Rush, regarding the condition of a Yellow Fever patient.  (Many of the typed transcriptions include only part of a full letter. Students should focus on the transcribed text, which is most important for the activity.  Spelling and punctuation were kept close to the original but modified to aid student comprehension.)  Groups must read all letters in their Document Packet and complete the section of the Case Sheet that deals with the victim about whom they read.   Each group must present its findings to the class.  Students should be ready to introduce the Yellow Fever victim, summarize the details of the victim’s illness, explain who wrote the letters to Dr. Rush, and interpret how Yellow Fever impacted the family’s life. 
12) Allow at least 5 minutes for materials distribution and instructions.  Allow 15 minutes for students to read the Document Packets and complete their case sheet sections. 

Part Four - Class Discussion, Review, and Assessment

13) Reconvene the class.  Ask each group to share its findings with the class.  All students should record other groups’ findings on their Case Sheets.  Emphasize that students must complete the entire Case Sheet for full credit.  (Note: If more than one group has the same Document Packet, ask the groups to report on different Case Sheet categories). 
14) After all groups have presented, encourage students to synthesize the entire class’s findings.  Ask the following discussion questions:
• What, if anything, surprised you about the cases, and how victims and their families responded to the Yellow Fever?
• What were the most common symptoms and treatments?
• Take out your vocabulary packets and look up the common treatments we read about (glyster, laudanum, Glauber salt, etc.).  What do they have in common? (They are all purgatives, designed to empty the body of infected fluids.)
• Did any of Dr. Rush’s patients question common treatment methods?
• How do you think Dr. Rush would feel if we could tell him that his treatments were, at best, ineffective, and at worst, dangerous and harmful? 
15) Distribute an “End of Unit Assessment Activity” packet to each student.  Review materials (per End of Unit Assessment instructions on the unit page).  Confirm that students understand the essay questions contained in the packet.  Students must hand in both the Case Sheet and essays for complete credit. 



This list only includes medical terms and other words directly related to descriptions of symptoms and treatments in the Rush letters.  A student version of this list is provided.

Asafoetida (also spelled “asafetida”): A dried latex found in the root of Ferula, an herb found in Iran and India.  Used medicinally as a digestive aid and antiflatulent.
Balm Tea:  A liquid or semi-liquid substance, often fragrant, that soothes through being applied to the skin, eaten, or drunk.  
Benjamin Rush: Famous Philadelphia patriot, doctor, and public figure who treated many patients during the 1793 Yellow Fever epidemic.
Blister: Pocket of fluid contained in the upper layers of the skin, usually caused by some form of irritant including burning, freezing, or chemical contact.  Eighteenth-century doctors purposefully gave patients blisters so that the blisters could be drained, believing that removing blister fluid from the body would also remove disease-causing toxins.
Bowels: The gastrointestinal tract.
Calomel: A chemical compound of mercury and chloride.  It was used as a diuretic and purgative in medicine until the 1860s.  Today it is considered highly toxic and is not used as medicine. 
Camphorated spirit: Better known as camphor spirit, a substance derived from the Asian camphor tree and mixed with some form of alcohol.  It is administered to the patient by inhaling or rubbing on the skin.
Chamomile [Camomile] Tea: A hot beverage made from the chamomile plant thought to relax those who drink it and encourage sleep. 
Cremor Tartar: Cream of tartar.  It is commonly used in modern cooking but was also administered as a diuretic or purgative in the eighteenth century.
College of Physicians of Philadelphia: An elite, private medical organization founded in Philadelphia in 1787.  Dr. Benjamin Rush and many other leading Philadelphia doctors were members. 
Consult: Discuss a problem with someone else.
Copious: Substantial, much, many, a lot.
Dejected: Sad, discouraged.
Diagnostics: A characteristic doctors use to know if a patient has a certain illness. 
Dregs: The last remaining small amounts of a liquid or solid, often found at the bottom of a holding vessel, like a cup or barrel.  The word is often used to describe something dirty or bad. 
Diuretic: A medicine meant to empty the body of sickness-causing toxins through the urine.   
Enema: A process by which a gas or liquid is injected into the rectum in order to empty its contents.
Excoriate: To remove part of the skin, through rubbing, cuts, or disease. 
Fatal: Deadly.
Feces: Solid human waste.
Fetid: Rotten.
Flatulency: Passing of gas.
Flaxseed Tea: A hot brewed beverage made from flax, also known as linseed.  Flax was thought to ease abdominal discomfort. 
Glauber [“Globber”] Salt: Sodium sulfate, or, the sodium salt of the sulfuric acid.  It was named after Dutch/German chemist Johann Rudolf Glauber (1604-1670), who discovered it in spring water.  Once used as a cathartic and diuretic, it is no longer used for medicinal purposes.
Glyster: An enema.  Also known as clyster, a substance injected into the lower intestines to encourage discharge of waste.  It was sometimes administered to patients who could not take swallow medicine due to sickness. 
Hazardous: Dangerous.
Hysteria: Excessive emotion; loss of touch with reality (perhaps because of illness).
Induce: Bring about.
Inflammation: Part of the body’s response to the presence of germs.  Common symptoms of inflammation include pain, redness, and swelling.
Jalap: The dried root of several plants from the morning glory family.  It traditionally has been used as a purgative. 
Laudanum: A mixture of opium and alcohol.  It was used to treat numerous sicknesses, especially coughs.  It is a powerful narcotic (or drug that influences the central nervous system) and is very addictive.  
Malignant Fever: Yellow Fever.
Mercury: A metallic chemical element sometimes called quicksilver.  Historically, mercury was used as a medicine in the form of chemical compounds including calomel (see below).  Today mercury is considered highly toxic.  Its use is carefully regulated by government agencies but does have some modern medical applications. 
Noxious: Toxic, highly unpleasant.
Opening: A movement of the bowels, resulting the excretion of solid human waste.
Opium: A drug made from the opium poppy.  It is also used to produce heroin.  While illegal for recreational use in many countries today, opium once was widely used in medicine.
Perspiration: Sweat.
Physician: A medical doctor.
Powder: Dried, crushed medicinal mixtures of various herbs and chemicals.  They were dissolved in liquids (either alcohols or water).  The medicines described in Rush’s letters as “powders” are most likely diuretics and/or purgatives designed to rid the body of Yellow Fever. 
Practice: Professional actions.  In this context, how doctors decide to treat their patients. 
Prevailing: Common, widespread.
Purgative: A medicine meant to empty the digestive tract of its contents through solid human waste.  It was thought that this process would also empty the body of sickness. 
Quill: A goose feather pen, up to a fourth of an inch in diameter.
Recipe: A description of the kinds and amounts of ingredients to use in making a medicinal drug, and how to combine them.
Reverend: A term used to indicate that a person is a pastor or priest.
Rhubarb: A plant commonly used in cooking and baking today.  When used as a medicine, dried rhubarb increases the flow of saliva.  Large doses are purgative.  It is generally administered medicinally in powder form. 
Secretaries: In this context, Irwin refers to the report drafted by the College of Physicians of Philadelphia regarding the cause and treatment of Yellow Fever.
Stool: Solid human waste.
Suffused: Spread all over.
Swoon: To feel faint.
Treachery: When a close friend whom you trust disagrees with you, or works against you.
Tumeric: A member of the ginger family.  It is a traditional medicine thought to be useful in curing fever and various stomach ailments.  It is also thought to be anti-inflammatory. 

Related Resources for Students

Halse Anderson, Laurie. Fever 1793. New York: Simon & Schuster Books for Young Readers, 2000.