Transcript Grand Rounds - "Benjamin Rush's Death"

Benjamin Rush’s
Death
W. Roy Smythe, M. D.
Professor and Chair, Department of Surgery
Texas A&M University HSC College of Medicine
Scott & White Memorial Hospital
Heads of an eulogium on Death
• It relieves unhappy and discontented husbands and wives
• It relieves children from parents who keep them too long out of their
estates
• It relieves physicians of incurable patients
• It relieves nations of tyrannical kings and blundering ministers who
are so riveted either in force or delusion upon the minds of the people
that there is no other way of getting rid of them
• It relieves the world of old men who keep the minds of men in chains to
old prejudices. These men do not die half fast enough. Few
clergymen, physicians or lawyers beyond 60 do any good to the world.
On the contrary, they check innovation and improvement.
Benjamin Rush, 1792
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Born on the Rush estate, 12 miles
north of Philadelphia
Father was a greengrocer, and died
when Benjamin was 6
Great grandfather commanded
calvary under Lord Oliver
Cromwell, and moved to American
in 1683
Undergraduate education at
Princeton – graduated at 14
6 year apprenticeship under Dr.
John Redman (1722-1808)
Medical school in Edinburghgraduated at 22
Thesis – Chemistry of Digestion
Worked in the labs of William and
John Hunter
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fourth founding father of the first
U.S. medical school at the U. of Pa.
(Shippen, Morgan, Kuhn) in 1769
Delegate to the first Continental
Congress
Signer of the Declaration of
Independence
Surgeon General of the Middle
Department of the Continental
Army
Professor of the Institutes of
Medicine 1792 – U. of Pa.
Professor of the Practice of Physic
1796 – U. of Pa.
Yellow Fever Epidemic fame
“Father of American Psychiatry”
University of Pennsylvania School
of Medicine in 1813
• Academic Chairs
– Benjamin Rush - Medicine
– Caspar Wistar - Anatomy
– Benjamin Smith Barton - Materia Medica
– John Redmon Coxe - Chemistry
– Thomas Chaulkey James - Midwifery
– Philip Syng Physick - Surgery
Past Medical History
Past Medical History
• Samuel Jackson writes (in Gross)…
– “In early life, he had slight hemorrhages of the lungs… During
several of his years, he had a slight cough, the tussus senilis, and
this increased during the last winter
Past Medical History
• Rush’s comments…
– I have conformed to that Spanish proverb of ‘being old when I was
young so that I might be young when I was old’ by living temperately.
This necessity was imposed on me at the age of eighteen, at which time I
was afflicted with a pulmonary complaint which continued, with
occasionally spitting of blood at longer or shorter intervals until I was
about 40 years of age…
– I have had several severe attacks of acute diseases, particularly pleurisy
and bilious fevers. I have suffered likewise for months with vertigo and
headache, since as well during the period mentioned
– Since my 58th year, I have enjoyed uninterrupted health, with the
exception now and then of a catarrh, such is common to persons of all
ages in our country
Past Medical History
• Rush’s comments…
– February 29, 1812… “this day I finished my lectures. During the whole
course it pleased God to give me such a degree of health that I did not
disappoint my pupils a single day…
Social History and Habits
• Rush’s comments –
– I generally sleep about seven hours in the four and twenty, and
spend from three to seven hours at my desk every day… I continue
to prefer tea and coffee with their usual accompaniments to all
other types of aliments.
– At dinner, but at no other time, I eat sparingly of animal food, with
the common garden vegetables of our country, and generally drink
one glass or a glass and a half of old Madiera wine after them. I
never drink ardent spirits in any way, nor at any time. I see well
with my spectacles and my hearing is unimpaired.
History of the Present Illness
History of present illness
• Samuel Jackson – “He was above middle height,
very erect and rather slender, small boned and
finely formed. His face was thin, his nose
aquiline and his eyes beautifully set, large blue
mild and benevolent. His forehead was broad
and high and his head, which was long, was
nearly bald…Although his complexion was
healthy,… his cheeks were fallen in and many of
his front teeth were missing and his face was
wrinkled with care and age…”
History of the Present Illness
• Gross
– “The typhus pneumonoides, morever, appeared
in March, and gave him, most opportunely, an oppressive
increase in business. Thus by incessant exertions of body
and mind, now debilitated by cough and low diet, he
became an easy prey to the prevailing fever”
History of the Present Illness
• James Mease (visited him on the day prior to his acute
symptoms) “ He had been attacked by a cough several months
previously to his last illness and in consequence of it he had abridged
his customary proportions of animal food… and left off entirely the
use of wine. The effects of these retrenchments alone, are felt by
frames more vigorous than that of Dr. Rush; but in his case, and at
his time of life, they could not fail greatly to diminish his muscular
power, and increase the excitability of his system by the causes that
produced the fatal disease…
The Attending Physician
John Syng Dorsey, M. D. (1783-1818)
John Syng Dorsey (1783-1818)
• Grandfather - Edmund Physick
– Last Receiver-General and keeper of the Great Seal of the
British Province of Pennsylvania
• Uncle - Philip Syng Physick
– First Professor and Chair of Department of Surgery - The
University of Pennsylvania
• Apprenticed to Physick at age 11
• Graduated from The University of
Pennsylvania School of Medicine in 1802
at age 19
John Syng Dorsey (1783-1818)
• Traveled to European centers of surgery
1803-1805
– Home (London), DuBois and Boyer (Paris)
• Named University of Pennsylvania Adjunct
Professor of Surgery - 1807
• The Elements of Surgery
– commenced 1807-1808
– published 1813
John Syng Dorsey (1783-1818)
• Named Chair of Materia Medica - 1816
• Named Chair of Anatomy - 1818
• Death at age 33 from “typhus” - 1818
– only 11 days after accepting Chair of
Anatomy
The Medical Record
On the 15th May 1813, I visited Dr. Jas. Rush (Benjamin Rush’s son)
whom I was attending with an abcess, and was requested by his
mother to see Dr. Rush, who was in distress…
On entering his chamber, he informed me that he had been attacked
after drinking his tea on the previous evening with a violent chill…
IN THE MARGIN… (he was previously in excellent health, I saw him
in the morning at a consult and he was in very good spirits)
To relieve this he took some strong brandy and water and the chill went
off and he went to bed – in the middle of the night he was attacked
with severe pain in the right side of his breast & great difficulty of
breathing which increased to a very great degree of anxiety and
suffocation
He sent for Mr. Perry the bleeder, and ordered him to take 8 or 10
ounces of blood he was bled and felt great relief from the operation –
the blood drawn amounted to I think 3 ounces and was coagulated
without (?) size, but with a deposition of red particles (Sydenham’s
fiery particiles)
When I saw Dr. Rush, he was afflicted with great difficulty of
breathing and with some pain in the breast and side but his pulse
was distressed extremely and very frequent
I was alarmed at the weakness of his pulse and his manner of
breathing, I asked him to take some warm whey wine (Whey
pouring milk into a certain quantity of vinegar and boiling it, used
as a demulcent and refrigernt (Coxe - The American
Dispensary1806)
…and (he) was greatly relieved by it
His warmth was increased, perspiration excited, respiration improved,
his pain vanished and all his feeings were greatly improved
Having derived benefit of the bleeding and persuaded of the inflammatory nature of his
disease, he wished strongly a repitition of it. This I opposed and he consented to giving
me my own way and omit the bleeding. I ordered laudenum 15 drops which he took and
applied a large blister to his chest
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Laudenum was tincture of opium… “an article capable of mitigating pain, inducing
sleep and diminishing morbid sensibility.
Blistering… not heat, but by a local irritant with an occlusive dressing over the area of
interest – often cantharidin “by the increased action it excites, the primary effect of the
remedy is undoubtedly stimulant, though from the quantity of fluid poured out it appears
to be ultimately evacuant (Dorsey)
16th May I found that he had a tolerable night but some difficulty of breathing had occurred
which was now abated much and he passed the day apparently greatly better, took some
laxative medicine. Blister had risen well.
17th Saturday… he had passed a restless night and had been
attacked with great pain and dysphorea “You must bleed
me” said he, “I shall suffocate if I am not relieved soon”. I
found his pulse very feeble, his wrists cold and his skin
moist. I objected to the bleeding mildly, yet firmly. I felt
uneasy, however, and requested a consultation – Dr.
Physick was sent for he approved the cupping but insisted
that he should be bled
Why did Dorsey object to bleeding?
• “for the cure of numerous morbid affectations,
blood must be evacuated
– DorseyElements of Surgery 1813 - Of cupping and bleeding
• Surgeons of the greatest respectability differ as to
the propriety of the measure. Having never
witnessed any ill effects from it, but on the
contrary, having seen it successful, I have no
hesitation in recommending it…
– Dorsey, Elements of Surgery 1813 – Of hernia
I wanted to supervise the operation ( LINED THROUGH
IN TEXT - and to prevent more blood than intended
from being drawn).
He lost by cups about three ounces of blood which relieved
his breathing considerably. Dr. Physick and I ordered
him to take porter and water, beef tea (beef gall -bile)
and wine whey occasionally.
Sunday 18th – in the morning I was informed that he had
slept better…”Comfortable refreshing sleep doctor”…
was his phrase
His pulse, however was feeble and his breathing not what I
had wished – he expectorated mucus in great sheets and
some difficulty. He was cheerful and his family
delighted with his appearance and conversation… from
this time he gradually sunk until Monday afternoon
when he calmly expired at 7 minutes past 5 o’clock…
Underlying Pulmonary Disorder ?
(recurrent hemoptysis, cough)
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Neoplasm?
Bronchiectasis?
Sequestration
Coagulapathy?
AVM?
Goodpasture’s, Wegener’s?
Underlying Pulmonary Disorder ?
(recurrent hemoptysis, cough)
• Mycobacterium TB…
– Paroxysmal, non massive hemoptysis
secondary to degenerated granulomata,
bronchiectasis, Rasmussen’s
aneurysm, etc.
– Intermittent vertigo – anemia?
– Spontaneous improvement after a
number of symptomatic years when
younger…
Differential Diagnosis
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Pneumothorax
Pulmonary embolism
Myocardial infarction
Ruptured Aneurysm
Acute bacterial pneumonia
• ? History of Tuberculosis with
damaged parenchyma…?
Differential Diagnosis
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Pneumothorax
Pulmonary embolism
Myocardial infarction
Ruptured Aneurysm
Acute bacterial pneumonia
• ? History of Tuberculosis with
damaged parenchyma…?
Differential Diagnosis
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Pneumothorax
Pulmonary embolism
Myocardial infarction
Ruptured Aneurysm
Acute bacterial pneumonia
• ? History of Tuberculosis with
damaged parenchyma…?
Differential Diagnosis
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Pneumothorax
Pulmonary embolism
Myocardial infarction
Ruptured Aneurysm
Acute bacterial pneumonia
• ? History of Tuberculosis with
damaged parenchyma…?
Differential Diagnosis
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Pneumothorax
Pulmonary embolism
Myocardial infarction
Ruptured Aneurysm
Acute bacterial pneumonia
• ? History of Tuberculosis with
damaged parenchyma…?
Differential Diagnosis
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Pneumothorax
Pulmonary embolism
Myocardial infarction
Ruptured Aneurysm
Acute bacterial pneumonia
• ? History of Tuberculosis with
damaged parenchyma…? -
What About Foul Play???
• Rush was involved in a number of bitter
conflicts with the medical school faculty,
and a pamphleteer – William Cobbett
“He had been attacked after drinking
his tea on the previous evening…”
Medical Faculty
Conflicts…
• Disputes with his U. of Pa. colleagues
regarding the colonial medical service
– Testified against Shippen in court !
• His comments regarding Woodhouse
(former U. of Pa. Chemistry Chair) at time
of his death…
– (From Rush’s journal –
– “He was an open and rude infidel… his manners were
gross and vulgar…”)
Conflict with
Cobbett…
• Cobbett was a devout monarchist…
• After a report in papers that Rush might take a
position at Columbia, and that he as a man “born
to be useful to society”, Cobbett wrote:
“ and so is a mosquito, a horse leach, a ferret, a pole cat, a
weasel: for those are all bleeders, and understand their
business full as well as Dr. Rush…”
Conflict with
Cobbett…
• Cobbett was successfully fined $5000.00 in a
libel suit brought by Rush
• The Rush Light 1800
• Cobbett departs for Europe to avoid a second
libel suit, which was pending
Heavy Metal Poisoning??
• A large acute dose could manifest as
chest pain, fever and chills…
• Arsenic, Mercury and other candidates
were readily available at the time…
“Knowing that my time is short and that the night of
imbecility of mind or death is fast approaching, I have sat
down to prepare two small tracts for the press… One of
them will contain the outlines or elements of my specific
opinions in medicine as far as they relate to the nature of
diseases. It will be accomodated to all classes of
readers…”
Rush, written one month before his final acute illness…
Had any or all of my ancestors
and kinsmen risen up from
their graves and surrounded me
in their homespun working
dresses and they would have
looked at each other with some
surprise and said, “what means
that gentlemen by thus
intruding upon us?” Be not
offended of me,..I come to claim
affinity with you and to pay
homage to your Christian and
rural values…
“Dream”… Letter to John Adams
from Rush, July 13, 1812
The End
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Proceed to the post test
Print the post test
Complete the post test
Return the post test to
Dr. Sandra Oliver 407i TAMUII
Post test question 1
Dr. Benjamin Rush was which of the following?
• A. A founding father of the first U.S. medical
school at the U. of Pa.
• B. Delegate to the first Continental Congress
• C. Signer of the Declaration of Independence
• D. All of the above
• E. None of the above
Post test question 2
Which of the following were the main indications for
bloodletting of Dr. Rush?
1. For stagnation of blood on the right side of the
heart with constant dyspnoea, cyanosis, as in the
early stages of acute pneumonia, pleurisy and
bronchitis.
2. To lower arterial tension, as in the early stages of
cerebral hemorrhage
3. In convulsive attacks as in acute uremia
4. Removal of impure blood which is the root cause
of all ailments
Post test question 3
Rush and Dorsey completed their
medical education at which of
the following?
A. Less than 18 years old
B. 19-22 years old
C. 23-25 years old
D. 26-28 years old