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Destroying Angel: Benjamin Rush,

Yellow Fever and the Birth of Modern Medicine

by Bob Arnebeck

Chapter Four

Before dawn on Saturday, market day, farmers' carts heavy with produce rolled into the city, except for ripe peaches. Joseph Cooper, who owned an orchard on the outskirts of town, made the market girls carry his peaches, ripened to perfection, on their heads - a precaution to prevent bruising.(1) If the talk of the market mirrored the concerns expressed in the newspapers then there was worry about the need to make sure the corpses of fever victims were buried properly, to fill holes in Water Street with quicklime, to shut the tanneries, and don't forget "the Asiatic remedy of myrrh and black peppers." But the lead paragraph in the Federal Gazette that evening was reassuring. The editor was "happy" to pass on "the assurances of several respectable physicians, that the progress of the infectious fever... is considerably abated."(2) Benjamin Smith quoted and endorsed the Gazette's opinion in a letter to his father. He was busy with a ship from Liverpool - the first cargo of the new goods from Britain that flooded the market every fall. Only one person he knew was sick, Richard Stansbury.(3)

Then Dr. Hutchinson awoke with a sharp pain in his head.(4) The night before he had dined with Secretary of State Jefferson at an estate along the Schuylkill. Famous as the former ambassador to France's wine cellar was, Hutchinson knew he did not have a hangover. When Rush heard the news he commented knowingly that by going out to Jefferson's and returning in the cool night air, Hutchinson had excited the infectious matter which was doubtlessly in his system. Rush congratulated himself for at least persuading Wistar not to accept Jefferson's invitation. Rush had dined there two weeks earlier and at least three of the secretary of state's guests suffered as the "cool air awakened the contagion influenza."(5)

Hutchinson summoned Dr. Adam Kuhn, considered by many the city's best practitioner, and explained how "he had gone to bed about 11 o'clock perfectly well and he indeed never felt better or in higher spirits." At three, he woke with "a most violent headache attended with fever." A few days before, Kuhn had told Margaret Morris that only 9 people had died of yellow fever in the city.(6) So he quizzed Hutchinson sharply, asking several times if he had a chill, a pain in the back or uneasiness in the stomach. "He declared that he had no chill, sickness, or pain any where but in his head, which he described as excruciating." Kuhn noted that his skin was dry, his pulse "not much more frequent and not fuller than in health."

Kuhn suggested that Hutchinson take a lenient purge. The two doctors decided that cream of tartar would be best. Hutchinson's wife, who was in her ninth month of pregnancy,(7) was an uneasy bystander during this consultation. "With great anxiety," Kuhn recalled, she asked him if her husband had yellow fever. Hutchinson saw Kuhn's embarrassment and "immediately answered there was no doubt of it. A week ago he had examined the houses along Water Street." Kuhn did not disagree.

That evening Kuhn returned to his patient. He had had one bowel movement "of a putrid nature." Once the stomach and bowels were evacuated, Kuhn treated putrid fever by using remedies that would "produce a fermentation in the stomach and correct putrefaction."(8) He suggested wine whey and water, or lemonade, and ripe fruit. Once putrefaction was checked he would "restore tone to the system." Hutchinson indicated he wanted a tonic and chose elixir of vitriol, sulfuric acid in wine with cinnamon and ginger which thanks to it's "grateful acid taste," had been a popular pick-me-up at least since 75 B.C.(9) Kuhn also suggested a cold bath of which doctors with experience in the West Indies spoke so highly. When Kuhn left, Hutchinson had himself splashed with cold water and found it refreshing. He also decided he didn't feel adequately purged. He took more cream of tartar and passed a restless Saturday night. Neither doctor thought of mercury. In his lectures at the medical school Kuhn cautioned against mercury. It would bring on incessant salivation, with hawking and spitting, "a very disagreeable companion."(10)

That weekend Rush set out to see if mercury could save the city, where "thirty-eight persons have died in eleven families in nine days in Water Street, and many more in different parts of the city." Of his patients, Stansbury and Spain both had good pulses and were less delirious on Saturday. On Sunday spots appeared on Stansbury's thigh, definitely not mosquito bites. Rush thought that a mortal sign, and gave the lad 40 drops of laudanum, opium dissolved in wine, to make death easy. Stansbury was "a sweet youth," a little older than his son Richard. Many of the dead had been boys between the ages of 16 and 19, so he was thankful that his sons had left the city. Richard Spain survived. Stall reported that the blockmaker would get his 8th dose of calomel. He had not yet been purged. At least it was evident that large doses of calomel were not as poisonous as commonly feared.(11)

The patient Rush devoted most attention to Sunday morning was the wife of Captain Bethel, a ship's chandler on North Front Street. Rush decided to use the new remedies on her and invited Wistar to observe the power of calomel. She was experiencing the restlessness characteristic of the early stages of the fever. Rush told her to "drink copiously of chicken water," i.e. a very weak broth, and lie in her bed. Still searching for quicker action Rush made pills different than those Stall had been giving Spain, mixing 10 grains of calomel with 15 grains of rhubarb. She took the first dose, and the two doctors did not have long to wait for a reaction. She vomited "a large quantity of bile."

Wistar was taken aback by the violence of the reaction. Of course after such short treatment there could be no suspicion that the liver was yet affected so Wistar was shocked that Rush approved of the rapid reaction clearing the stomach and not the intestines which they had agreed was where the poison secreted by the liver was collecting. Rush assured him that while the target was the bowels, the seat of putrefaction, the puking was a good sign showing that the medicine provided "more speedy service." Like his teacher Cullen, Rush thought a large dose of medicine would still affect the underlying systematic complaint despite its being vomited back up. Missing that point, Wistar argued that if relief came from vomiting, a medicine with less bothersome side effects could have been used. Rush ended the discussion by giving Mrs. Bethel another dose. Wistar left and recollected that he thought Mrs. Bethel looked "very unwell."(12)

Rush later told Wistar that he waited until the pill brought on a copious purge followed by a sweat. Then he thought she was "much relieved." That same day, Sunday, Stall's patient had "two copious, foetid stools. His pulse rose immediately afterwards, and a universal moisture on his skin succeeded the cold sweat on his limbs."(13) Rush was still cautious about the cure. That evening he received a note from Samuel Powel, the speaker of the state senate, which was then meeting. If Rush could not allay the senators' fears, "it will be impracticable to keep the members in town." Rush scrawled on the back of Powel's note, "I know of but one certain preventative of the disorder, & that is to keep at a distance from infected persons and places."(14)

Meanwhile Dr. Hutchinson had not been inactive. The cream of tartar inspired three bowel movements that Sunday and the whale of a man who weighed over 300 pounds had gone down two flights of stairs and his back steps so that he could do it in the out house. Kuhn thought Hutchinson was too weak for such exertion, and expressed "extreme regret." During the night Hutchinson could not stop his bowels, and had eight more movements. Kuhn thought that very dangerous in a putrid fever and tried to stop it with laudanum. He also prescribed one ounce of bark as a tonic.

Hutchinson passed 10 stools on Monday and had bleeding hemorrhoids. Kuhn was not sanguine, as he explained to Samuel Coates, president of the Pennsylvania Hospital, whom he met in the streets: "What would you think of him venturing down three pairs of stairs, after such a severe illness. He would have whipped one of his own patients for such an act of impudence." Kuhn said he had great hopes of recovery, but no more, "Hutchinson must submit to his fate." Coates told his friend Rush the news, which seemed to highlight the success of his mercurial purges.(15)

In the letter he wrote to his wife on Tuesday, Rush reported that on Monday he was called to 12 patients, and "eight are out of danger, from the powerful operation of the medicine I mentioned in my letter of yesterday." (That letter is missing.)(16) Rush was ready to announce a cure for yellow fever. By modern standards he had a meager clinical basis for his claims. But one of his principal cures had been witnessed by Wistar. One of those he cured was Dr. William McIlvaine who credited Rush with saving his life.(17)

It bears noting that we have meager a clinical basis for our criticisms of him. In 1986 the Pan American Health Organization sponsored a conference on the treatment of yellow fever. The participants were struck by the fact that none of the assembled experts had ever actually treated a case of yellow fever.(18)

Historians fault Rush for dogmatically prescribing calomel and jalap.(19) While Rush lacked the experimental controls and analytical tools modern doctors have, he had observed what happened to yellow fever victims under various treatments or who were untreated. He continually adjusted the dosage of the purges in which he began to place hope. What is criticized as adherence to dogma is no more than his tenacious hold on ground he thought he had won from the disease. He had determined its seat, the liver and intestines, and found that a purgative reputed to treat hepatic infections, when combined with one that quickly cleared the intestines, worked more often than not.

He would never admit that his use of calomel and jalap had been wrong, an admission he readily made in regards to the earlier medicines he had used. If that is dogmatism, then it seemed to have a firm clinical basis. Clearly Rush was beguiled by the fact that what he predicted would happen did happen, in all but one case. Rush did not suddenly become a zealot desperate to proclaim a cure. He had simply, thanks to scientific reasoning, moved beyond frustrating trial and error into a mode of practice that was showing results. One of the most enduring therapies in American medical history, that would reign for upwards of 50 years, was born not in spite of clinical evidence but because of it.(20)

It was not uncommon then for doctors to use art to conceal their science, to their great profit. In the 1690s Dr. Cockburn in London became wealthy selling his secret remedy for dysentery.(21) Sutton tried to conceal his method of inoculation.(22) In the 1780s Dr. Fowler promoted his cure for agues as "Fowler's pill," a nice way to conceal that its basic ingredient was the poison arsenic.(23) Rush didn't even think of concealing his ingredients even though mercury's reputation was not good. However he gets no credit for that modern stance. In the view of historians the way he developed his treatment is bad, but worse still is the way he promoted it. Indeed some historians ascribe the reign of mercury primarily to Rush's prestige as a celebrity and his skill as a propagandist.(24)

Yet as well as readily sharing his discovery with other doctors, Rush submitted his research to what passed for peer review. The crisis did not allow for publication, but the college was scheduled to meet on Tuesday to discuss treatments. To be sure Rush approached his colleagues not for criticism, but to enlist them to do their duty and use remedies so plainly successful. But Rush did adjust his remedies in the face of implied, if not explicit, criticism of their harshness.

The main speaker at the meeting was Dr. John Redman who was asked to explain the treatments he used during the yellow fever epidemic of 1762. Rush and Redman had a great deal of respect for each other,(25) and at the meeting they managed to finesse their different approaches to the disease. Redman had looked over his day book from the 1762 epidemic and spoke to patients who had survived. He recollected that doctors avoided bloodletting, emetics, laudanum and bark, preferring salts to open and cordials to restore the body. The purge he used was mild: "one ounce of salts, 2 drams of chamomile flower, and 2 drams of snake-root - these steeped together and the decocttion mixed with good old spirits or brandy and vinegar." He admitted that in talking about salts, snakeroot, chamomile tea, and lemonade punches, he was not talking modern medicine. Those remedies had been gleaned by Dr. Kearsley, then the city's leading practitioner, from "an old author." But while the ancients had to be given due respect and credit, nothing he said should deter doctors from using modern methods.(26)

After that introduction Rush spoke.(27) He never published what he said, but judging from a letter he wrote to a doctor in Trenton that same day, and what Wistar recollects Rush telling him, he was quite sanguine. "I set down with great pleasure to inform you that the fever which has ravaged our city for some weeks past is at last arrested in its fatality. The medicine which has performed this office is calomel." He explained the medicine's operation by referring to Mitchell's dissections. Calomel expelled the bile and opened the passages from the liver and gall bladder. Then Rush made his gesture to Redman. In his letter to the Trenton doctor, which Rush certainly expected to be published, he did not discard the cures of 1762 altogether. He recommended using calomel and jalap every other day if the fever continued, alternating the new remedies with "infusions of camomile flowers, snake root, bark, wine, &c., on the intermediate days."(28) Redman reduced his talk into an essay which he gave to a printer at the end of the week. In it he endorsed Rush's methods.

Since this was the first medical crisis the college ever faced, there was no precedent for what action it should take. Already one leader of the college, William Shippen, had left the city.(29) Of course, Rush had long made clear in his lectures his belief in a doctor's moral duty not to abandon the sick during an epidemic. Now he realized a scientific duty, that is an obligation arising from man's understanding and power over nature. For example, at the same time he called his colleagues to action armed with his new discovery, he recollected an old scientific observation that enabled him to prompt the city's African-American community to come to aid of fever victims.

Panic in that regard was unabated. "The almost certain estrangement of relations and friends, when their services are most wanted, is truly shocking," the store clerk John Welsh wrote, "people shun each other as if death was the invariable follower of a touch, or as if they perceived a baneful fume breathed from the others nostrils."(30) Those who were providing care in the 89 degree heat were faltering. Many had constant headaches. Rush thought from incautiously caring for the sick. (He blamed his own headache on too many preventatives, a vinegar headache.)(31) The city had not yet made provisions to care for the poor. The overseers' resolve to seek out the sick and give them succor failed because most of the overseers themselves began fleeing the city.(32)

Rush decided to enlist the support of the city's African American community. After Charleston's 1742 yellow fever epidemic, Dr. John Lining published his observations. What most struck Rush, as he annually noted in his medical school lecture, was Lining's observation that blacks were immune to the fever.(33) Rush wrote to Absalom Jones, founder of the African Church, and Richard Allen, a cobbler by trade but famed as a Methodist preacher, who had organized the Free African Society to foster mutual assistance for the city's blacks. Rush explained that Lining had shown that their race was immune to the disease. He asked if that "exception... which God has granted you does not lay you under an obligation to offer your services to attend the sick."(34)

Then in Monday's American Daily Advertiser, writing under the pseudonym of Anthony Benezet, a Quaker emancipationist who had died in 1784, Rush quoted Dr. Lining and recalled blacks, not to their duty to God, but to their obligation to white Philadelphians. They should help those who had "first planned their emancipation from slavery, and who have since afforded them as much protection and support, as to place them, in point of civil and religious privileges, upon a footing with themselves."(35) The black leaders discussed the call with their society, and offered their services to the mayor.(36)

Rush's colleagues did not accept their marching orders as readily as the African Society. In faulting Rush, historians have gone too far in giving credit to doctors who were cool to his discovery.(37) These doctors did not argue that Rush's remedies had not been properly tested. They did not argue that calomel and jalap were ineffective medicines. They did not argue that there was no cure and therefore purely supportive treatment was alone of any benefit. They argued, as they had been since the beginning of the epidemic, that there were actually few yellow fever cases, and that the dose Rush prescribed was dangerous. On the streets, backbiters said it would kill a horse. They were wrong on both counts. The prevalence of yellow fever soon became evident. Doses far in excess of what Rush prescribed would soon become common.(38) Evidently those criticism were not voiced at the meeting. Rush's enthusiasm just after it was at such a level that one assumes that he assumed his colleagues would give the remedies fair trail. There are examples of 18th century doctors giving a new medicines a long trial. Dr. William Withering meticulous case histories of the effects of foxglove, which contains digitalis, on heart disease is the best example.(39) But it bares remembering that his work persuaded few of his colleagues to follow his example.

Although there seems to have been no generally understood protocol, it's evident that further trials of the remedy were as much the responsibility of his colleagues as it was Rush's. Indeed it seems tacitly understood at that time when quackery abounded, that Rush was not the man to prove the efficacy of his medicine. His role was as an advocate endeavoring to convince expert opinion. He decided that the best ways to effect that were not to work on the medical theories that might convince colleagues, who after all were steeped in theory, but to give the medicine to as many people as possible in hopes of checking the epidemic and to see that every sick doctor gave it a trial. Already Dr. McIlvaine, who credited Rush for saving his life, was his most effective supporter.(40)

His change in role is best exemplified by how his relationship with Wistar changed. For a week they had been brainstorming together. When Wistar succumbed to the fever, Rush was soon at his side not to elicit fresh insights from his colleague, but to insist that he take calomel. Rush told Wistar that calomel and jalap made the fever as manageable as an intermittent, that mild malaria so endemic since the settling of the colonies that people had learned to live with it. Wistar had been dosing himself with ipecac, and several vomits ensued which didn't relieve. So he followed Rush's orders, and, when he was able, sent word that the purge operated and relieved him. However, he didn't tell Rush that his fever returned sharply and he felt miserable.(41)

We know now that it takes 12 to 18 days for the yellow fever virus to incubate in a mosquito. After that period the insect is a deadly vector for the rest of its life. It takes 3 to 4 days for the virus to incubate in a person bitten by an infected mosquito, and then the symptoms of the fever occur.(42) So the epidemic in Philadelphia developed slowly. At the early stage of the epidemic it was easy for the community to focus on a few cases like Hutchinson's and Wistar's. Rush's discovery put enormous pressure on the medical community to endeavor, in a way unprecedented in medical history, to prove the possibility of scientific medicine. Wistar and Hutchinson were being asked to be experimental subjects, an honor usually accorded to the poor, and judges of the experiment as well.

The more characteristic role of trained doctors during an epidemic was to pass judgment on the excessive claims of quacks.(43) Rush denied doctors the safety of that passive role. He opened the door of modern medicine, a world of decisive definite reactions to the ravages of diseases, and tried to turn his back on the nuances of the healing art, the tricks and trumpeting that had stood the test of time. He was not promoting snake oil or himself, but a process that opened the way to a new era of health.

Wistar participated in Rush's program but not with candor. To Rush, Hutchinson seemed destined to take a decisive role in medical history. Kuhn, who had given him up for dead anyway, got sick with a fever. Not the prevailing fever Kuhn insisted.(44) However instead of calling for Rush, Hutchinson summoned two younger doctors, William Currie and Benjamin Barton. Currie came Tuesday evening, Hutchinson was sitting up talking, lucid enough to describe his own case and give Currie permission to write about it.(45)

After Rush, no man would write more on yellow fever than Currie. Yet from all his writings one gets little sense of a disease capable of eliciting great panic. Rush, of course, became a master of recreating what must have been the essential reality of terror. Historians have given Currie great credit for not following Rush(46) (as we shall see, eventually he did,) but any candid review of his effort to treat Hutchinson shows his deficiencies as a doctor and observer of the epidemic. Currie and for that matter Hutchinson and Kuhn seemed to have no sense of what the disease could do. Rush rapidly gained an appreciation that momentary well being was illusory in yellow fever.

Hutchinson told Currie that he liked the baths and vitriolic salt tonics. When he felt well, as he did then, he took no medicine but lime juice punch. In the essay Currie would send to the printer at the end of the week, Hutchinson's treatment was held up as a model. (Currie did allow that six grains of calomel might be useful as a vomit in some cases, and added that that remedy was suggested by a Delaware doctor.)(47)

After Currie left him on Tuesday night, Hutchinson walked downstairs. When he came back up, his nose bled until "he was much debilitated and faint." He took 45 drops of laudanum, got to sleep, and rested well until he awoke "with sickness and great distress." Currie came back at 10 o'clock Wednesday morning and found Hutchinson with a low pulse, and cold and dry skin. His face was bloated and livid. "His mind was considerably deranged -his thirst became insatiable - he cast up all he drank, as soon as his stomach became full, with straining and noise." When he wasn't puking he was hiccupping. No matter what medicine Currie suggested, Hutchinson "obstinately" refused it, claiming that "nothing was the matter." Currie sent his manuscript to the printer anyway.

On Thursday the 5th Rush forgot past differences and went to Hutchinson. He found the massive doctor "sitting in a chair near the head of his bed, with all his clothes on, as if he had been in his usual health." But he wasn't. Rush saw that he was delirious with a face "suffused with blood." Rush urged "a strong mercurial purge," explaining that it had saved 29 out of 30 who had taken it.(48) Hutchinson refused for the moment, but did send one of his apprentices to Kuhn. "Rush should know," Kuhn replied sharply, "that Hutchinson had 30 stools in three days." He did not need further purging.(49)

Ironically given subsequent attacks on Rush as a theorist, it was his inability to articulate a theoretical justification for his remedy that allowed Hutchinson not to become a statistic in his experiment. To be sure Rush quickly blamed Hutchinson's long bitterness toward him and the advice of the young doctors for his refusal.(50) (He scoffed at their prescribing a rectal injection of claret to meet the crisis.)(51) But he did not know Kuhn had been consulted and had provided a medical reason to avoid the experiment. Rivalry does explain what happened, but that should not obscure the risk each man confronted. Rush hazarded his discovery on the cure of a man obviously in mortal danger. Hutchinson hazarded his life on the accepted medical principles of the day which his rival wanted to overturn.

Rush would soon have recourse to theory to bolster his discovery, but for the moment, his other strategy of promotion, wide dissemination of his medicine promised success. When Treasury secretary Alexander Hamilton sent a note Friday morning informing the president that he would miss the scheduled cabinet meeting because he feared that he was "in the first stages of the prevailing fever," Washington expressed "extreme concern" but shared the optimism then current. He lived across the street from the recovering Wistar. Noting that "the malignity of the disorder is so much abated, as with proper & timely applications not much is to be dreaded," he hoped Hamilton and his wife could still make it for dinner.(52)

Rush was convinced that his medicines were in a large part responsible for the lack of deaths. "Fewer deaths have occurred I believe this day than on several days last week, and yet many hundred people more have the fever now than had it last week," he explained to his wife on Thursday. He also observed that those with the fever who were not treated invariably died. He gave a purge to many going into the country, "to subdue the disease if it should break out."

However, Rush was so confident of his ability to control the disease that he no longer recommended that people leave the city. "I now advise them to remain where they are, to avoid going out of their houses, and to send for a mercurial physician as soon as they are infected," he wrote to his wife on Friday, and could even joke about the crisis. "No other metal in a physician's head will do any good now, not even gold any more than lead. My medicine has got the name of an inoculating powder, for it as certainly and as universally deprives the yellow fever of its mortality as inoculation does the smallpox." "Out of 100 persons who have taken [mercury] from me on the first day, not one has died. The deaths which now occur are chiefly of poor people who have no doctors, or of respectable people who are in the hands of quacks or of the enemies of mercury."(53)

As Hutchinson lay dying, Wistar recovered, which Rush counted a major victory for mercurial purges. He tried to elicit a testimonial for his cure. He went to the extreme of suggesting to his languishing colleague that it was he, Rush, who faced imminent death, and he worried about who would carry on his work. "You cannot die now, Doctor," Wistar replied tactfully. "The pleasure of your discovery must like a cordial keep you alive."(54) (For the moment Wistar kept to himself what remedy he thought most beneficial. When the breeze from the window was too hot, his two apprentices took turns fanning their master.)(55)

On Thursday Hutchinson lapsed into a coma. On Saturday he died. Before retiring at night Rush was in the habit of reading psalms in order. He opened the Bible to the 52nd Psalm: "Thy tongue deviseth mischiefs; like a sharp razor, working deceitfully.... God shall likewise destroy thee for ever, he shall take thee away, and pluck thee out of thy dwelling place, and root thee out of the land of the living." It reminded him of Hutchinson. "Poor fellow!" Rush wrote to his wife. "He died as well as lived my enemy."(56)

The next day, Dr. McIlvaine, whom he had cured with mercury, told Rush that Kuhn insisted that calomel and jalap only cured remittent fevers, not yellow fever. Rush remarked in his notebook that "there was more malignity in his heart towards me than was in the contagion of yellow fever."(57)

Go to Chapter 5

1. Rush Papers vol. 3, p 95.

2. Gen. Adv. Aug. 30, 1793; Fed. Gaz. Aug. 31, 1793.

3. B. Smith to D. Smith, Aug. 30 & 31, 1793, Haverford.

4. unless otherwise noted, information on Hutchinson's case comes from Kuhn lecture 1793, College of Physicians.

5. Butterfield p 654; Rush Notebook Aug. 31, 1793.

6. Morris to sister, Sept. 3, 1793, Haverford.

7. Bell, p 112.

8. Kuhn lecture ca 1785, NLM.

9. Wood pp 737-8.

10. Kuhn lecture ca 1785, NLM.

11. Butterfield p 646; Rush Notebook Sept. 1, 1793.

12. Wistar to Rush, Nov. 1, 1793, Rush Papers.

13. Rush 1793 p 202.

14. Rush Papers, vol. 38, p 21; Powell, pp 66-7.

15. Coates to Rush, Dec. 4, 1795, College of Physicians.

16. Butterfield p 649.

17. Butterfield p 648.

18. Monath, p 165.

19. Powell p 124; Binger p 215; Shryock (1) p 212.

20. Warner is the best source on the use of calomel in the 19th century.

21. Creighton, p 777

22. Crookshank, p 51.

23. Creighton, p 268.

24. Duffy (1), p 67; Shryock (1), p 206.

25. Corner pp 37,38.

26. Redman.

27. I assume the featured speaker would have gone first at the meeting.

28. Butterfield p 648.

29. Powell p 84.

30. Welsh, Sept. 3 & 4, 1793, HSP.

31. Rush Notebook Sept. 2, 1793.

32. Powell p 69.

33. Smith's notes.

34. Rush papers vol. 38, p 32.

35. Amer. Daily Adv. Sept. 2, 1793.

36. Allen p 3; on immunity see, Humphreys. p 7.

37. Duffy p 67.

38. Rush Notebook Sept. 8, 1793; Caldwell, p 184.

39. Mann, pp 164ff.

40. Butterfield p 648.

41. Wistar to Rush, Nov. 1 & 8, 1793, Rush Papers; Gen. Adv. Sept. 26, 1793.

42. Herms, p 237.

43. Dewhurst, p 31.

44. Kuhn lecture 1793

45. subsequent observations on Hutchinson's case come from Currie's description of it in the College papers

46. Duffy p 67; Blanton p 53.

47. Currie 1793 p 20.

48. Rush 1793 p 306; Rush Notebook Sept. 5, 1793.

49. Kuhn lecture 1793.

50. Butterfield p 651.

51. Rush Notebook Sept. 5, 1793.

52. Syrett, vol. 15, pp 324-5.

53. Butterfield pp 651, 653, 654.

54. Butterfield p 653.

55. Gen Adv. Sept. 26, 1793.

56. Butterfield p 654.

57. Rush Notebook Sept. 8, 1793.