Destroying Angel: Benjamin Rush,

Yellow Fever and the Birth of Modern Medicine

by Bob Arnebeck

Chapter Nine

In a preface to a new edition of Powell's Bring Out Your Dead, three historians suggest that we should not be too critical of Rush's remedies given the harshness and ineffectiveness of some modern treatments of disease.(1) Looking at Rush's performance in that way, one might suggest that he was modern because of his faith in medicine and propensity to over-medicate. However if there is to be any value in the thesis that Rush helped create the modern medical culture, it is necessary to go beyond merely showing the Rush replicated many of the failings of modern medicine.

What is generally valued in modern medicine is its ability to translate an understanding of disease gained through scientific research into measures to prevent disease and therapies that alleviate the suffering caused by disease. Most of us use modern medicine with confidence that, despite its many failings, compared to no medicine or so called alternative medicines, it works better. By scientific research we mean essentially the effort to share observations and theories and invite replication and feedback. There are no secret formulas, no magic touches or incantations, no basing happy results on some mysterious personal qualities of the care giver, and no reliance on traditional measures without constant analysis of their usefulness in the light of on-going research and observation.

It can be argued that many practitioners in Philadelphia during the epidemic were modern in the ways described above. What distinguished Rush from them, as the past eight chapters have tried to show, was his aggressiveness and creativity. Rush recognized his own achievement as revolutionary. After the epidemic he continued to fight for his gains. His modern critics are quick to note the enormous steps backward he took as he fashioned his new system of medicine. While Rush rashly simplified, to scientists in Europe it was becoming clearer how complex nature really is.

Yet it is his activities after the epidemic, and the reaction of his colleagues to them, that proved Rush modern. He failed to create the forms of modern medicine, but over the next six years he defined the functions of modern medicine. His long term achievement is obscured by his short term successes. His therapeutic approach which dominated American medicine for 30 years, we find distasteful. His medical theories which entertained a generation of medical students, we find ludicrous. The program he set before the nation, exhaustive observation and research aimed at preventing disease, constant experimenting to discover new and fine tune established therapies, creating a climate in which decisive and universal care for the sick can be provided, remains the program of the nation. But that hardly captures the Promethean dimension. At Rush it's easy to find that line between the acceptance of death, and the lust to conquer it. That impulse seems natural to us, but in the days after the epidemic he had to create the demand for it.(2)

Much like later historians of the 1793 epidemic, many contemporaries applauded Rush for his sacrifices and then waited for him to come to his senses. However, contemporary critics were not motivated by scientific principles. They insisted that he suborn science to the commercial needs of the city. Many were alarmed that his theory on the origins of the fever would cripple the city's economy. Richard Peters, a federal judge then in the countryside, had a townhouse a few doors down from Rush. He well knew the passion and persistence his neighbor brought to any controversy. On October 23 he warned Pickering that Rush's "assertion that the Philadelphia hot beds produced this deadly plant is I believe unfounded and I am sure very mischievous," and would be "eagerly caught at by the anti-Philadelphians."(3)

Rush received an anonymous letter imploring him not "to act so much the enemy of this place. Will it alter the nature of things, or be of the least advantage to mankind to know from whence it did arise, other than importation? Will not the New Yorkers, the Baltimoreans, and all other enemies of this town rejoice...?" Upon publication of his theory "all real property would fall in a little while 20 or more percent.... Let it not be said, we have the greatest of our enemies in our own city. Think O Think Seriously."(4)

The stock broker Matthew McConnell wrote a friendly but blunt letter to Rush reminding him that his theory was "a dangerous one to advance if not true considering the consequences that might result therefrom to the city as the seat of the government." Rush replied that "the good opinion of the citizens of Philadelphia was now of little consequence to me." Rush lumped opponents of local origin with those who attacked purging and bleeding. McConnell assured him that he had "numerous" friends. "In the company I was in,... you were spoken of respectfully and no suggestions thrown out against your practice."(5)

If political pressure wasn't enough, another distracting controversy over the origin of epidemic also tried to push scientific reasoning into the background. The city's religious leaders renewed their attempt to permanently close theatres in the state to appease an evidently aroused and righteous God. With his relish for Old Testament prophets, Rush probably wrestled with himself before deciding not to enter the fray. On November 2 a list of 7 reasons why God visited an epidemic on the city signed by Jeremiah was published by the Federal Gazette. Jeremiah was his favorite prophet and the first two reasons were Rush's particular peeves: lust for wealth "excited by our systems of paper credit," and "rack rents." The first reason condemned his nemesis Alexander Hamilton. And Rush was mad because his landlord had just raised his rent.(6) The five other reasons were more traditional: attending the circus and theater, breaking the Sabbath, swearing, neglect of religious instruction in schools and pride in luxuries.(7)

Judging from his letters to his wife, Rush believed in God's agency in the epidemic. But Rush must have sensed that publishing moral lessons from the epidemic would distort his scientific analysis. The anti-scientific bias of the religious side of the argument was evident. On November 8, "An Earnest Call Occasioned by the Alarming Pestilential Contagion," did not mince matters: "I know there are many who attribute this awful contagion to natural causes, and ridicule the idea of a supernatural agent: but I conceive we may clearly trace the finger of God in our chastisement."(8) In December an anti-theater "dialogue" in the newspapers had "A" asking "B" what the "natural or physical causes" of the epidemic were. "It is not yet ascertained, and perhaps never will be." As for the "moral" cause, it was "sin unrepented of, no doubt." The best way to prevent another epidemic was to "let the legislature enact suitable laws for the suppression of vice and immorality."(9)

Defenders of the theatre did not try to enlist the support of the city's scientific minds. They replied with constitutional arguments, interestingly not based on the recently ratified Bill of Rights, but on the provision against ex post facto laws abridging contracts. The managers of the New Theatre had hired actors in England and it would be unconstitutional to close them down because then they could not honor those contracts.(10) The pro-theater forces, however, kept the theatres open because they could out vote Quaker and rural members in the legislature.(11)

Blaming the epidemic on the city's immorality was not beyond secular writers. In the introduction to his instant history of the epidemic which was out in book form on November 14, Mathew Carey described the boom times of the city, replete with high rents and "alarming" luxury, and allowed that few "will pretend to deny that something was wanting to humble the pride of a city, which was running in full career, to the goal of prodigality and dissipation."(12) This did not differ much from Rev. Helmuth's analysis. He recalled the throngs who went to Rickett's Circus. Then "after such a merry, sinful summer, by the just judgment of God, a most mournful autumn followed." The dying poor were brought to the vacated circus and the place once filled with "clappings of levity, was now filled with the lamentations and groans of the dying." God was trying to teach the city a lesson.(13)

Rush was careful to begin his history of the epidemic with a short account of the weather and diseases that preceded it. The scientific stakes were too high to pander to religious feeling. However, uncharacteristically, Rush was not quickly in print to defend his position. In his book, Carey continued his attack on Rush's rotting coffee theory. Carey blamed the privateer Sans Culottes and her prize the Flora. The privateer's "filth was emptied at a wharf between Arch and Race Streets," and dead bodies were seen taken off the ships.(14)

An exchange began that became characteristic of almost every succeeding epidemic. James Vanuxem, who owned the Flora, asserted that no one on her nor on the Sans Culottes had been sick. The ships had come from Britain and France respectively, not the West Indies. It was true that a body had been removed from the Flora on July 27, but that Frenchman had been boarding on Water Street, where he got the fever. After being kicked out of his boarding house, he had come to Vanuxem's wharf, and was placed on the Flora's deck where he died in the night.(15)

Drs. Currie and Cathrall countered Vanuxem's letter with proof that the fever came from the Sans Culottes, Flora, or the Amelia. Every crewman of the Amelia, which came from Haiti, arrived sick; and Cathrall had treated one of the crew from the Sans Culottes, which had captured several other ships who had crew members with yellow fever. The doctors demonstrated how Mrs. Parkinson, Cathrall's first fever patient who died August 6, could have gotten the disease from a sick Frenchman. The evidence was conclusive: just as in 1762, the epidemic had come from the West Indies.(16)

In rebuttal Dr. James Mease pointed out that every seaman who got the fever had been exposed to the rotting coffee. Plus it was insulting to the late port physician, Hutchinson, to think that he would have let any sick seamen or passengers get into the port.(17) Another writer reminded that Rush first recognized the epidemic and developed the best treatment, so it was best to wait for his promised proof for the local origins of the disease.(18)

At the end of October the governor had asked the College of Physicians what caused the epidemic and how to prevent another. In mid-November the College, from which Rush had resigned, endorsed the importation theory. There was no evidence that yellow fever had ever been generated in the city or state, "but there have been frequent instances of its having been imported." They thought it had come to the city in some vessels after the middle of July. Quarantines could prevent future epidemics.(19)

Although challenged by his erstwhile colleagues, still Rush hung fire. Rush sought the advice of friends. Treasury official Samuel Meredith urged him not to publish his theory. Bishop William White and Federalist lawyer William Lewis thought he should. Tench Coxe, a Treasury official and land speculator, begged him to at least delay his pamphlet until after Congress convened.(20)

Rush had never stinted in his efforts to promote Philadelphia.(21) He well knew as he developed his "proofs" that they did not particularly indict Philadelphia. Still he waited until the city was truly back to normal, after the President moved back on November 30 and Congress convened on December 2. Meanwhile Rush assured politicians who asked that "a greater degree of health had never prevailed in this city than at present."(22)

Rush presented his proofs in a long letter to Dr. Redman, written on December 7 and published the 11th. Admitting that both sides of the controversy failed to appreciate the complexity of etiological factors, it behooves us to appreciate how each side framed the debate. The importationist focused on the particular moment of the first infection of the city and suggested traditional, seemingly feasible remedies. Rush recognized the epidemic as evidence that the nation had entered a period where threats of death en mass would become commonplace. Prevention required comprehensive reform of the environment and life styles.

There was nothing revolutionary in this. Rush was maintaining the gains of 18th century medical thinkers, and not jettisoning them to assuage the colonial and commercial mentalities. He remained true to Cullen's emphasis on the environment and examined as best he could whether similar environmental conditions elsewhere caused a similar epidemic. He went back to basics. Yellow fever was endemic to the West Indies where, all authorities agreed, it was produced by "vegetable putrefaction." Since "the same causes (under like circumstances) must always produce the same effect," and since Philadelphia's summer had been of tropical intensity, putrefying vegetables near Water Street could have engendered a disease of tropical intensity.(23)

To prove his point Rush showed that fevers of the same intensity as that in Philadelphia were found that sickly season in other parts of the country where ships from the West Indies didn't land and refugees from Philadelphia didn't flee. An old student in Caroline County, Maryland, saw fevers there more "obstinate and inflammatory" than usual, with head pains and black and yellow vomit, including a man "in a laughing delirium," who "died in about five minutes laughing to the last." A correspondent in Dover, Delaware, wrote of an epidemic of "bilious colic... unprecedented in the medical records or popular traditions of this country." A doctor in Connecticut thought 33 fevers in Wethersfield near Hartford were "analogous" to the fevers in Philadelphia.(24)

Philadelphia's contagion was most deadly because of the greater concentration of putrefaction along the docks. The rotting coffee increased that to a level which allowed the deadly epidemic to begin, and the disease spread just as the stench of the rotting coffee was blown down streets and alleys. The annals of medicine were filled with similar situations. Putrefied potatoes killed 14 in Tortola, West Indies, "vast quantities of cabbage thrown in a heap" killed many in Oxford, England. Rush dismissed the recently published arguments of two French doctors, Nassy and Robert, that blamed diet and greasy, dirty skin obstructing perspiration, for causing the disease.(25) "Without the matrix of putrid vegetable matters," Rush insisted, "there can no more be a bilious, or yellow fever generated amongst us, than there can be vegetables without earth, water, or air."

Rush did not deny that in rare cases, as in 1762, an epidemic could begin from yellow fever brought to the port by a sick sailor from the West Indies. But isolated yellow fever cases were common every year in Philadelphia, produced by "active but limited miasmata." Rush argued that establishing that fact did not harm the city. "While the cause of a malignant fever is obvious to the senses, it will be easy to guard against." To deny the senses and the dictates of conscience would hazard "the lives of millions that are yet unborn." He recalled the campaign he led to cover Dock Creek which when done added much to the health of the city. Far better than exciting the fear that any ship from the West Indies could desolate the city would be to know that the city was safe as long as it was kept clean.(26)

Rush's own nascent medical theory also influenced his investigation. His experience with yellow fever seemed to confirm his theory that all fevers were gradations of the same disease. Yellow fever filled out his spectrum of disease. It made sense that the worsening environment engendered a higher grade of bilious fever instead of the typical bilious fever.

The modern bias is to lend a more sympathetic ear to the College's arguments. Yellow fever is a specific disease. But both sides failed to prove a source for the disease. The importationist's mechanism for the disease's spread came close to conceding Rush his point. In his account of the epidemic Currie explained that refugees from the city did not spread the fever to the people they saw in the countryside, because air deprived of oxygen, found only in the city, was necessary for the spread of the contagion.(27) Rush's mephitic matrix of environmental causes seemed to get to the fundamental problem.

The program of action urged by the importationists was little more than more vigorous enforcement of one of the oldest preventative measures known to civilization, quarantine. In a public letter to a state legislator Rush amplified his call to civic action: the docks and wharves should be cleaned and all "offal matters... carefully removed from gardens, yards, and cellars." During dry weather the streets should be washed with the fire engines until water could be brought in for that purpose from the soon to be completed Delaware and Schuylkill canal (a project on which work had been continuing that summer.) Trees should be planted to "absorb impure air," exhale fresh air and cool the city with shade.(28) Rush stirred the blood of enlightened folk.

Rush was wrong, but since Currie could not prove himself right and no one would accurately prove an etiology even similar to that of yellow fever's for another hundred years, it bears noting that Rush's mistake was more useful to society. To suggest that yellow fever was a specific disease imported from the West Indies was to suggest that 4000 people died from a quirk of nature that likely won't happen again, especially if more precautions are taken, for another 30 years. Rush had that thoroughly modern anxiety: if 4,000 people die in one city in three months, then something is horribly wrong and what happened must be understood in all its ramifications and there must be fundamental changes to protect all towns similarly situated.

Rush did not create a public health movement. Uninfluenced by Rush, officials in New York City made civic cleanliness one of their lines of defense against yellow fever.(29) The idea that filth caused and spread disease was long standing. Rush's contribution was the sense of anxiety, a daring display of scientifically based doom saying. Yellow fever had not only struck in 1762 and 1793. Rush discovered that there was some cases of yellow fever in the city every year, and another epidemic a clear and present danger.

In January Rush began seeing the symptoms of yellow fever, "particularly puking of bile, dark-colored stools, and a yellow eye." Dr. Griffitts told him of a patient with yellow skin. In February he bled John Coxe who had pneumonia and found his blood "dissolved" like the blood of yellow fever victims.(30) The College stoutly denied that the rumors of yellow fever had any basis.(31) Rather than raise an alarm, Rush merely pointed out to students that Sydenham taught that just such a similarity of symptoms in diseases succeeding an epidemic should occur. Rush however did not emit any calming reports. Alarms, he thought, inspired the citizens to clean-up the city, which was all for the good.(32)

Modern critics point to Rush's infatuation with Sydenham as his downfall, the inspiration that placed him on the slippery slope that led to such ludicrous conclusions. Lester King, on the whole a most sympathetic writer on pre-modern medicine, has no patience for Rush, and while recognizing that Sydenham is in the scientific tradition, displays little patience for him either.(33) This reflects King's inability to see any validity in a medical system based not on physiology and morbid anatomy but on epidemic diseases. To him Sydenham is notable chiefly for clinical observation, for example, he made the first clinical description of measles and distinguished it from smallpox.(34)

Rush admired Sydenham for entirely different reasons. At about the time his letter to Redman was published, Rush began his medical school lectures. Over 52 years later, one of his students, Charles Caldwell, recalled Rush's first lecture as "a performance of deep and touching interest, and never... to be forgotten." Rush described the "terrible sweep" of the pestilence, his dejection at the failure of his cures, the joy of finding a successful remedy, and his persecution by the College of Physicians. Caldwell remembered that Rush had been "sufficiently sarcastic and trenchant" in ridiculing his enemies.(35)

The topic of the lecture was actually Sydenham. He explained to his students that Sydenham produced a complete revolution in medicine, which, involved in its consequences a new era in the life and happiness of the human race.(36) In investigating the character of an obscure epidemic, Sydenham took a retrospect of the epidemics which preceded it. He reviewed the remedies which had been used in them with success, and applied them to the reigning disease, and thus acquired his knowledge of the nature of the plague. It had been preceded by pleurisies, quinsies, and inflammatory pestilential fevers, all of which had yielded to plentiful bloodletting. He perceived that the constitution of the air, which produced these diseases, was not changed, He applied therefore the remedy of copious bleeding to the plague, and if its efficacy was not universally successful, it was owing to the prejudices which were excited against it, by his contemporary physicians.(37) Rush added that "it is our duty to live in peace with all men, but when this cannot be effected, but at the expense of truth, and the lives of our fellow creatures, our obligations to preserve peace with all men, are canceled and destroyed."(38)

As we have seen, this was not how Rush developed his therapies, and we can question why he so avidly sought justification from a source over 100 years old. What he found in Sydenham was decisiveness in an atmosphere of crisis. Boerhaave's and Cullen's management of disease did not serve any more. Rush explained to his students that Sydenham took treatment of acute disease out of hands of nature.(39) In his recommendation of bleeding in the plague, he advised that it should be copious or not used at all, "either take the cure wholly out of hands of nature, or leave her wholly to her own operations."(40)

The emphasis on the constitution of the atmosphere and the pervasive influence of the reigning epidemic were indeed steps backward, and Rush recognized them as such. But they reflected the reality of life in Philadelphia in December 1793, and at the same time provided a framework for Rush's own pet theory that most fevers were gradations of one fundamental disease. Historians impatient with all three theories demonstrate their misunderstanding of the scientific process. In his discussion of the contributions of the French doctor Broussais, who like Rush believed in one disease and copious bleeding, Foucault rightly points out the necessity for decisive destruction of the 18th century classification of diseases to make way for the germ theory of disease.(41) Believing that people died because doctors paid more attention to Cullen than to symptoms and environmental changes, Rush destroyed Cullen's work in order to allow a fresh look a fevers.

Rush was not alone in lecturing about the epidemic. How appealing he was is evident from Kuhn's doomed effort to regain standing among students well aware that he had fled the disease. Kuhn tried in vain to deflect the applause for Rush with a brand of cynicism that usually appealed to students. He told how Dr. Young of ten and ten fame killed himself with that murderous dose. Kuhn insisted that mortality was greatest among those profusely bled and purged, and alluded to a German druggist who kept track.(42) Rush would soon have testimony from Mr. Keihmle that endorsed bleeding and purging. The druggist only lost 47 out of 501 patients.(43) The crucial difference between Rush and Kuhn was that the latter talked about the epidemic that had ravaged the city but a few months before as a freak of nature, a thing of the past. Rush invited every medical student to be a sentinel.

His monumental account of the epidemic was, in its simplest terms, a guide to the anticipated hazards of the coming summer. While much is made of Rush the theorist, that was not the point of this work. His previously published ideas on etiology were elaborated upon in the book, but what immediately impresses the modern reader is the richness of detail. The bias was to be inclusive, not conclusive. At first glance the man setting out to simplify medicine is nowhere to be seen.

Rush listed three causes of "indirect debility" that predisposed one to the disease: fatigue, heat and intemperance; then there were five causes of "direct debility" that excited the fever: fear, grief, cold, sleep, and immoderate evacuations;(44) then he listed the "history" of symptoms in the blood vessels, liver and brain, stomach and bowels, secretions and excretions, nervous system, senses and appetites, lymphatic and glandular system, skin and blood.(45) The fever affected patients in three different ways. In some it produced coma, languor, sighing, yawning and a weak pulse; in others, pains, delirium, vomiting, heat, thirst, quick pulse with remissions in the fever; in many "the contagion acted so feebly as not to confine them to their beds or houses."(46)

Statistics were rudimentary, seemingly done more for effect than to prove anything. All criticisms leveled at mercury during the epidemic were unfounded, Rush insisted, because "hundreds who took it declared they had never taken so mild a purge."(47) As for his bleeding being too copious he did not "lose a single patient whom I bled seven times or more."(48) There was no sense of statistics forcing detail to be sorted out much less discarded as not relevant. But why should he edit himself. Medical works were written for practitioners in an era when practice was a constant struggle. The contribution of Rush's book to the literature was considerable as he wrote about a disease about which there was relatively little written. The details Rush provided about the effects of purging, blood letting, blisters, cold air, cold water, drinks, diet, etc., all rich in particulars, broke new ground.

The most interesting form of medical observation then and now is the case study. In some previous works he had included case studies.(49) But during the epidemic he faced a crisis, constantly on call and himself getting weaker. To establish a reality to his observations as compelling as that of the case study and autopsy, Rush had to violate one of the canons of scientific writing. In discussing symptoms and cures, and in some cases causes of the disease, Rush included the names of the patients. Rush discussed Hutchinson's obstinacy,(50) Samuel Powel's dying smile,(51) and quoted personal letters that documented Mrs. William Smith's profound depression.(52) Joseph Coates bled from his left eye;(53) Dr. Fisher forgot everything that happened during his six days of fever, etc.(54) Ethical considerations aside, that approach added some powerful new dimensions to his book, giving it a social context that many other medical books loss by trying to appear scientific.

It also increased the heroic aura of the author. It made the conclusion of his book, which Rush subtitled "A narrative of the state of the body and mind of the author, during the prevalence of the fever," not only fitting, but an argument for the redeeming value of science. Rush described a cause as much as he described a disease. The attitude he took in his medical school lectures was sustained. He included all the controversial letters and articles of his colleagues and his replies at the time and further observations on their mistakes. And he included rallying cries as it were. Statistical evidence forms the telling points of modern medical writing. In Rush what the sympathetic reader grabs onto are the analogies that cut complexity down to understandable size. Systems that multiplied the number of diseases were "as repugnant to truth in medicine, as polytheism is to truth in religion."(55) To describe why the disease's great force mocked the stimulating remedies used in treating lesser fevers, Rush explained that yellow fever "resembles a man struggling beneath a load of two hundred weight, who is only able to lift one hundred and seventy five...." Trying to increase the man's strength with tonics was of no avail. One had to slowly decrease the load, i.e. abstract the stimulus of the disease.(56)

Fueled by such rhetorical powers over nature, Rush was not shy in making claims and charting the revolution in medicine. He estimated that his methods saved the lives of 6,000 people.(57) Yet God did more than provide a remedy for one fever. He provided a system so successful that medicine in the future would "consist more in a new application of established principles, and in new modes of exhibiting old medicines, than in the discovery of new theories, or of new articles of the materia medica."(58)

He pushed on and suggested the implications of that. Bush Hill had complete provisions and country air, still 448 out of 807 patients died.(59) In the next epidemic, people had to prescribe for themselves. "At the expense of an immense load of obloquy, I have addressed my publications to the people. The appeal though hazardous, in the present state of general knowledge in medicine, has succeeded.... (T)he pride and formalities of medicine, as far as they relate to this disease, are now completely discarded in our city, as the deceptions of witchcraft were, above a century ago." It only remained to increase the general knowledge of medicine. "The time must and will come, when... the general use of calomel, jalap, and the lancet, shall be considered among the most essential articles of the knowledge and rights of man.... All the knowledge that is necessary to discover when blood letting is proper, might be taught to a boy or girl of twelve years old in a few hours." As soon as yellow fever makes its appearance, a description of all symptoms which are the precursors to the disease should be published and people directed to purge and bleed immediately upon the onset of symptoms.(60)

Rush's achievement was to make a local tragedy a national alarm, a quite proper extrapolation with any infectious disease. The onslaught of such a deadly epidemic in the most civilized square mile in the country forced a rethinking. Rush made Philadelphia's particular crisis, a passage for all Americans. The deadly fever was but the worst form of the common, nagging, debilitating fevers that chilled and shook all the milk and honey tomorrows, the promise of America. In conquering yellow fever he found the key to conquering the endemic discomforts that confronted all Europeans in the new land. And as was only proper in a universe created and continued through divine inspiration, there was a moral lesson implicit in his discovery. The land dealer's paradigm of plenty, the pursuit of happiness through engorgement, had to give way to denial, depletion, and enforced starvation to the point of letting the stuff of life drain out of the body. Here was the Spirit of '76 that encouraged self-denial applied to the hazards that every change in season brought. Prevention depended on communal discipline directed toward scrupulous cleanliness and morality.

Rush's book was out in early June.(61) The next sickly season was fast approaching. Rush and his contemporaries recognized that cock-sure as his book was, it proved nothing unless it predicted the future.

Go to Chapter 10

1. Powell p xiii; like most modern commentators Foster, Jenkins and Toogood, following Powell, react favorably to the treatment used at Bush Hill. However, Deveze's principal strategy, raising blisters to treat fevers, a procedure Powell didn't note, seems as daunting as purging and bleeding.

2. Applying this thesis outside the American context is more difficult. In The Birth of the Clinic, Foucault discusses the work of many French doctors who knew little about Rush and his work, although to my knowledge no one has examined what influence the American yellow fever experience might have had on French medical practices and research. Rush did correspond with at least one French doctor, see Butterfield pp 980-1, and incidently claimed to read French medical books with greater pleasure than British, and lauded French doctors for not adhering to one system in medicine. The new look to medicine that this group of French doctors created is decidedly more relevant to the discoveries, principally in France, that formed the basis of the germ theory and modern pathology. However Rush's superior skill as a communicator allowed him to create a body of work that when put in the proper context grows on one as genuinely modern in its motivation.

European and American attitudes to medicine are different. The contrast, for example, between the American and French approach to the isolation of the HIV virus mirrors the differences between Rush and the French pathologists 200 years before. In Rush and Gallo we see the researcher as the heroic dragon slayer. In the early pathologists and the Pasteur Institute we see a glorification of the power inherent in a group pursuing a problem with a shared sense of the logical way to go about it. To be sure, Americans share the same logic and create the same group ethos, but we glorify the hero.

3. Butterfield p 730n.

4. Anon. to Rush Nov. 23, 1793, Rush Papers.

5. McConnell to Rush Oct. 26 & 29, 1793 Rush papers.

6. Butterfield p 727.

7. Fed Gaz Nov 2, 1793.

8. Evans #25427

9. Gaz. of U.S. Dec. 30, 1793.

10. Amer. Daily Adv. Dec. 16 & 18, 1793.

11. Pernick p 572 argues that partisan politics informed the religious reaction to the epidemic. He makes much of three articles in Freneau's National Gazette as putting a Republican spin on the attacks on the theatre. For a contemporary view that Freneau was writing a "burlesque" to embarrass fundamentalist rhetoric inspired by the epidemic see Q in Amer. Daily Adv. Jan. 8, 1794. For cooperation between Republican leaders and the theatre managers on a charity event during the controversy see Phil. Gaz. Mar. 25, 1794. For votes in the legislature see Journals of House of Reps., Evans # 27480, pp 334-335.

12. Carey p 10.

13. Helmuth p 15.

14. Carey p 19.

15. Fed. Gaz. Nov. 18, 1793.

16. Fed. Gaz. Nov. 19, 1793.

17. Gen. Adv. Dec. 10, 1793.

18. Ind. Gaz. Nov. 23, 1793.

19. Rush 1793 p 146.

20. Rush Notebook Nov. 22, 1793.

21. Hawke p 383.

22. Beckley to Madison Nov. 20, 1793, Rutland.

23. "Inquiry into the Origin of the late Epidemic Fever in Philadelphia in a Letter to Dr. John Redman," 1793.

24. Ibid., for original letters see Rush Papers.

25. Nassy, p 17; Robert letter Fed. Gaz. Dec. 1793.

26. Rush letter to Redman.

27. Currie 1794 pp 8-9.

28. Amer. Daily Adv. Dec. 19, 1793.

29. NY Health Committee Minutes 1793, NYHS.

30. Rush 1815 vol 3 p102.

31. Phil. Gaz. Jan. 26, 1794.

32. Rush 1815 vol. 3. pp 102-102.

33. King (1) pp 147ff.

34. King (2) pp 113ff.

35. Caldwell p 183.

36. Rush 1977 p 42.

37. Ibid p 46-47.

38. Ibid p 60.

39. Ibid. p 48.

40. Ibid. p 50.

41. Foucault p 192.

42. Kuhn lecture.

43. Rush 1793 p. 321.

44. Rush 1793 pp 28-36.

45. Ibid. pp 40-81.

46. Ibid. p 82.

47. Ibid. p 249.

48. Ibid. p 275.

49. Rush 1793 (a) pp 212ff.

50. Ibid. p 306.

51. Ibid. p 78.

52. Ibid. pp 313-4.

53. Ibid. p 47.

54. Ibid. p 64.

55. Ibid. p 92.

56. Ibid. pp 282-3.

57. Ibid. p 319.

58. Ibid. p 284.

59. Ibid. pp 319-20.

60. Ibid. pp 328-332.

61. The prefatory letter is dated June; sale of the book was first advertised in April 4, 1793 Phil. Gaz.