Destroying Angel: Benjamin Rush,

Yellow Fever and the Birth of Modern Medicine

by Bob Arnebeck

Chapter Seventeen

Despite advances made in educating the public, as the eighteenth century ended, too few worshipped at the altar of science to truly make Rush's way smooth. Because of that resistance provoking Rush's paranoia and prompting more preaching than proofs, he seems less of a scientist to us. The pamphlet he wrote on the eve of the 1799 epidemic exhibited both of those insupportable traits. To sustain a modern reputation, Rush shared far too much of his personal frustrations.

However, it is to Rush's credit that he shared with the public the strain the battle placed on him. He elevated American science from the neat bagatelles of discovery perfected by Franklin to the epic task of the control and understanding of nature. As the verdict in his suit against Cobbett would demonstrate, by the end of 1799, that quest earned the respect of his contemporaries.

Rush did not operate in an unsophisticated day when it was thought truth had to be branded with personality. He could have discreetly compiled his medical inquiries and observations, or, like Noah Webster, essayed a larger work on yellow fever without letting his personality intrude. Webster was as adamant as Rush. His correlation of epidemics over the past 2,000 years with other phenomena proved to him that the constitution of the atmosphere, as affected by earthquakes and volcanic eruptions, was the all-important cause of epidemics.(1) In an open letter to the citizens of New York and Philadelphia, he cautioned that no matter how clean a city might be, epidemics were probable given the continued unfavorable state of the atmosphere initiated by an eruption of Mt. Etna in 1789. This was no "airy speculation," but was "authorized by the steady operation of the laws of nature."(2)

In his two volume book on epidemics, published in 1799, Webster elucidated those laws. Consciously scientific, he made clear that he built his case on statistics and facts gleaned from medical literature, newspapers, and, in some cases solicited from the keepers of death records in various localities. Rush made clear that his case was built on observations leavened by personal sacrifice. In its form, Webster's work is still acceptable, while Rush's isn't. But Rush had to be didactic and personal as he tried to inspire in his fellow citizens a greater awareness of the changes in their environment and their duty to react to it.

More importantly Webster's work, elegant and comprehensive as it was, evidently inspired little regard among future researchers. Rush's work informed future research in two ways. His often messy compilation of observations encouraged more observation not deductions from revealed laws. His admission of past mistakes, this year recognizing that yellow fever was not contagious, thrilled students, and reminded them that the new medicine entailed more than memorizing Boerhaave's aphorisms or Cullen's first principles. It was a continual process of discovery necessitated by the nature of disease.

For example, Rush agreed with much of what Webster tried to prove but he was careful to find the evidence of an epidemic constitution in his clinical work. "The inflammatory constitution of our atmosphere has not yet passed away," he wrote to Webster in the summer of 1799. "The diseases of the late spring were all tinged with bile and yielded only to powerful remedies."(3)

However he was careful not to let his pursuit of the nature of the epidemic constitution dominate the pamphlet he wrote to his fellow citizens a few weeks later. Rush began his pamphlet with the characteristic self righteousness of the martyr and paranoid: "Having labored nearly six years to no purpose, to persuade the citizens of Philadelphia that the yellow fever is of domestic origin, I had concluded to desist from all further attempts to produce conviction upon this subject." But the prospect of renewed "scenes of distress" induced him "to make one more effort to prevent them, by pointing out their causes, and remedies." He anticipated more "calumnies," but they would be easier to bear "than the suppression of truths which involve in their consequences the prosperity of our city, and the lives of many thousand people...."(4)

After six years of fighting epidemics Rush had honed his truths into simple lists. He listed three factors necessary for an epidemic: putrid exhalations; "an inflammatory constitution of the atmosphere;" and "an exciting cause."(5) Unimpressed by Webster's search for scientific laws, he directed attention to the ways nature operated. That enabled him to recognize that little could be done about the state of the atmosphere, and at the same time argue that the city could save itself by other reforms.

Docks should be immediately cleaned and eventually paved; ships should be required to have ventilators; sewers should be washed with pump water and opened to prevent foul air from concentrating; gutters should be washed every evening in warm weather; filth should be removed from yards and sties banned in the city; privies should be emptied frequently so they would not foul the water pumps; the brick kilns and ponds that ringed the city should be filled in; and no more houses should be built in alleys. The ninth measure suggested a way to avoid exciting causes of the fever. People should live chiefly on broths and fresh vegetables, with a bit of salted meat, and not neglect "bodily cleanliness."(6)

He expanded his usual list of exciting causes, the avoidance of which increased chances of avoiding disease despite an epidemic constitution and local generation of mephitic air: "great heats, cold, fatigue from riding, walking, swimming, gunning, or unusual labor, intemperance in eating, or drinking, ice creams, indigestible aliment, or a violent emotion of the mind."(7) Rush probably included "ice creams" because it had lately been cited as a cause of death by a physician loath to identify any case as yellow fever.(8)

From the modern perspective, one might have wished that after six years of observing epidemics Rush would have made at least one telling association of cause and effect. For example, that one should avoid areas with an unusual number of insects because they signified a sickly atmosphere. But of course insects were every where, and as signs, grasshoppers would seem to be as frightening as mosquitoes in the city. As we shall see, Rush's intuition increasingly began to suspect that there was something out there in the animal or vegetable kingdom that was the key cause, but in this life saving pamphlet he remained mired in the idea of a nexus of causes each difficult to isolate and quantify.

This confusion wasn't caused by his theories. One curiosity in 1798's debate over etiology is that while the Academy argued that yellow fever was not contagious, and while Rush revealed his new thinking in his lectures, he refrained from publishing that he had changed his views. He was loath to win a point in the argument against quarantines by diminishing perhaps the most terrifying trait of the disease, that to be in its presence was to risk getting it. Rush embraced Sydenham's sense that etiology and therapeutics could not be divorced. That one disease could drive out all others was crucial to his view of treatment during an epidemic. Thus while disciples like Smith and Seaman(9) quickly adopted the idea that yellow fever was not contagious, Rush would hem and haw about contagiousness not being its "essential character." Which is not to say, contagiousness could not still be an essential character of a yellow fever epidemic.

Having observed the complete lack of contagious spread of yellow fever in the hospital, Rush began reviewing the literature and reanalyzing his ideas so that he could square this new observation with his previous observations on epidemics. He had to distinguish the power of an epidemic from the nature of the epidemic disease. He saw that, misled by earlier authors, he had overemphasized "the extent of excreted matter in producing the disease."(10) The feeling of sickness that so often arose in the presence of victims was a feeling commonly experienced in all sickrooms no matter what kind of fever the patient had. He also saw from his reading that the most widely feared pandemic disease, plague, had not been contagious from person to person.(11) We might argue that if he had recognized that each disease was distinct and then asked how it could then spread, he might have better been able to discern the environmental factor causing the spread instead of imbuing the atmosphere with the power to spontaneously generate all the various grades of fever from common cold to plague. But colleagues like Currie, who did think yellow fever a distinct disease, were unable to analyze the problem in that way.

At least Rush deserves credit for changing an old view. He regretted insisting in 1793 that the fever was contagious. There was a "smell" about yellow fever, but many diseases gave off a disagreeable smell. It could cause discomfort but not illness.(12) Once he knew that yellow fever was not contagious, he could argue with a completely clear conscience that quarantine and excessive fear of infected bedding and clothing, unless they were obvious sources of putrefaction, were useless. Epidemics ended when there was a frost, he explained, and frost affected the air outside houses, not clothing and bedding inside houses. People in the same house got the fever because of fatigue and grief.(13)

Perhaps mindful of the character of the new president of the health committee, Rush reminded his fellow citizens that God wanted man to use his "reason" to promote his "physical happiness." Rush gave Biblical justifications for his program. In Deuteronomy 23:14 God enjoined the Jews to keep their camp clean.(14) Rush also flattered the city's progressives by finally endorsing Latrobe's plan to bring fresh water to the city.(15)

In conclusion he reminded his fellow citizens that for five years quarantines had failed to prevent epidemics and warned that unless Philadelphia recognized that yellow fever was "engendered in her own bowels,... she must renounce her character for knowledge and policy, and perhaps with it, her existence as a commercial city."(16)

The Philadelphia Gazette printed a long anonymous rebuttal. Since the city's docks and gutters had been much filthier before 1793, Rush's argument really rested completely on the so-called inflammatory constitution of the atmosphere. That was a "mere speculative hypothesis, unsupported by solid data or even solid arguments." People got yellow fever on ocean voyages so the atmosphere of the city was not necessary. Rush's reasoning was circular: if there was an epidemic, the epidemic atmosphere was there; if not, it wasn't. The writer supported measures to clean the city, but quarantines against known sources of the disease must continue.(17)

In Fenno's Gazette two writers faulted Rush for undermining the quarantine.(18) Indeed in mid-August the health committee confessed its irritation at sailors jumping off ships at quarantine and swimming to shore. And judging from newspaper comment most people attributed the continuing health of the city to stricter quarantines.(19)

The debate over the pamphlet ended quickly when the number of fever cases increased enough to cause panic. Rush noted on August 16 that the fever "revived." On the 17th he saw five private patients with yellow fever.(20) For a week newspapers published desperate hopes that it wasn't really an epidemic. But the College and Academy both agreed that there was.(21) "Great terror," Rush jotted in his notebook on the 23rd, "but great apparent incredulity in some of the citizens." Thomas Willing couldn't believe the quarantines had failed. The city was soon deserted, Rush thought, as never before.(22)

That Rush's pamphlet did not prevent the epidemic and panic of 1799 did not give him pause. Events did not challenge his analysis because too few in the city followed his injunctions. Worse still, too many people simply didn't believe him and that was the key to the city's distress. Otherwise they would be coping with the same fortitude and sense of duty as he was. What he couldn't tolerate was the continued lack of conviction of his fellow men, their lack of engagement, their shirking their duty in times of epidemics.

In late August Rush stopped his carriage to talk with Latrobe who was walking down Chestnut Street. Rush warmly affirmed his affection for Philadelphia, and lamented how the poor would suffer especially since the legislature's short sightedness in not reimbursing last year's expenses would dry up charity this year. "We have now lost by the fever 10,000 of our citizens," Latrobe quoted the doctor as saying, "more will now be sacrificed, terror in every house, fear wings the arrows of death, and even to escape is only to be left to deplore the loss of all that were loved by the survivor. In the mean time our trade seeks healthier ports, our capital is wasted in the expense of removals, the character of our city is lost, and what is more calamitous than any thing I have yet mentioned, all that I have said and written has not been able to convince our citizens that the disease originates here, and is not imported!" (23)

More crucial than the sacrifice of lives, capital and reputation was the sacrifice of truth. But, it must emphasized, not the truth of some dogma. The truth lay in the process of observation and the deductions drawn from it. The truth was not scientific dogma but the scientific method.

As specious as his etiology may seem to us, as another epidemic threatened Rush again tried to show how tenaciously science could engage natural phenomena and as a result fulfill the moral imperative to serve humanity. The valiants this sickly season were all impelled by reason. Most Quakers fled along with civic leaders.(24)

Edward Garrigues did stay but only on terms of complete submission to God and nature. Unlike Warner Mifflin or the Scattergoods or Snowdens the year before, he did not stay to capture the moral high ground. Unlike the men on the health committee in 1798, he did not use the opportunity of the epidemic to reform the morals and living conditions of the poor. Observing the doctors in town he concluded "plainly... they know nothing about this fatal disease." He thought it was unknowable. He only sought to give solace to the dying.(25)

Rush performed in this epidemic in his most workmanlike fashion. Which is to say his efforts were not as obscured by controversy and paranoia. But first we should appreciate the level of his sacrifice. He was the most famous doctor in America. His missing an epidemic, like many a preacher and politician had, would not have raised comment, not even from Cobbett who with every other newspaper editor quickly left the city. Archbishop Carroll in Baltimore advised Catholics not to expect the services of priests during yellow fever epidemics. The church had already lost too many to the disease.(26) Samuel Mitchill, himself anticipating discovering the true nature of yellow fever, frankly wrote that to endanger his life by treating those foolish enough to stay in New York during the epidemic would be to endanger humanity's future.(27)

Rush had even more elaborate intellectual gifts to not put in harm's way, not just the conquest of one disease but a whole system of medicine. Given the current disdain of that system, the point to make here perhaps is the enormity of human vanity. But to a large degree Rush's continued heroism, so modern in its commitment and tenacity, flowed from that system of medicine.

In 1799 just prior to the first alarms of the epidemic, Rush published Lectures Upon Animal Life, a new physiology by which he meant "the laws of the human body in its healthy state." There is little in it about the structure and workings of bodily organs. Really it is a guide, not to the body, but to living.

Briefly put, Rush argued that the principle of life was excitability, and the principle of health was to control stimuli that depress or over-excite the system. "The true means of promoting health and longevity" was "by proportioning the number and force of stimuli to the age, climate, situation, habits, and temperament of the human body." He listed seven external stimuli: air, light, sound, odors, heat, exercise, and "the pleasures we derive from our senses." He listed five internal stimuli: food, chyle, blood, "a certain tension of the glands," and "the exercises of the faculties of the mind."(28) He then examined stages of life from sleep to old age when there is an absence of various stimuli. Finally he examined life in different "circumstances of civilization, diet, situation, and climate."(29)

From this physiology, he argued, one gains "a knowledge of the causes of all diseases. These consist in excessive or preternatural excitement in certain parts of the human body, accompanied generally with irregular motions, and induced by natural or artificial stimuli." One also learns the principle of curing: "simply... the abstraction of stimuli from the whole, or from a part of the body, when the motions excited by them are in excess; and in the increase of their number and force, when motions are of a moderate nature."(30)

After rejecting Cullen in the face of the intractable nature of American fevers, it would seem that in ten years Rush had wound up making medicine much as Cullen did, simply a question of managing life forces prone to get out of balance. But his "physiology" was an idealization unencumbered with anatomy. This was not Cullen's quest, nor ours, these were not principles to be logically applied to explaining how life worked, but principles which, if logically adhered to, enabled one to live life better for oneself and humanity.(31)

From his physiology he proved the existence of God by rejecting vitalism and the notion of innate ideas, and showing the influence of stimuli even on the mind and the influence of the will on the body. Thus God's intercession is necessary for the continuance of life. He relished his arguments against atheistic philosophies because "the best criterion of the truth of a philosophical opinion is its tendency to produce exalted ideas of the Divine Being, and humble views of ourselves."(32)

Here the preachiness of Rush seems intolerably unscientific. Clearly like other prominent educators at the time, Timothy Dwight at Yale and Stanhope Smith at Princeton, for example, Rush tried to combat the atheistical doctrines of the French revolution.(33) However Rush's piety was not a check on reason but an effort to move it in the right direction.

In his lectures, Rush made the point as dramatically as possible. Samuel Jackson, writing years after Rush's death, recalled Rush looking up from the lectern and explaining that by dividing excitement into healthy and morbid, "revelation and reason embrace each other, and Moses and the Prophets shake hands with Dr. Brown and all those physicians who maintain the sublime truth which he had promulgated. Think of it, gentlemen, in your closets and in your beds, and talk of it, gentlemen, in your closets and in your beds, talk of it in your walks and by your firesides. It is the active and wide-spreading seminal principle of all truth in medicine."(34)

Those handshakes seem meaningless today. The importance of a distinction between good and evil is lost on a medical ethic which profits from the promise that even the ill we consciously do to ourselves can be counteracted. But in 1799, just as the attack on Cullen's nosology was necessary to clarify clinical practices, so tying the fervor of Christian millennialism to medical science inspired a generation of students to persist in fighting and trying to explain the deadly epidemics that plagued the country.

Once again Rush's reaction to an epidemic was fearless and exemplary. Despite the shocks and equivocal results of hospital work in 1798, Rush went back, not as a consultant but as one of the staff physicians.(35) Between 1793 and 1799 this was the most significant advance in public health in Philadelphia, and, at last, established a tradition that was already common in London and Paris. In 1793 the city's youngest physicians were loath to serve at a fever hospital and by their lackadaisical use of Bush Hill allowed a completely unknown emigre doctor who could hardly speak English take over. Rush was arguably the most famous physician in America. He accepted the duty to serve in the hospital where no physician had ever brought the mortality rate under 50%.

In addition Rush chose to serve in part for the same reason that motivated the founders of modern pathology like Bichat in Paris to serve in urban clinics, an intense curiosity about the morbid anatomy of disease.(36) Judging from his notebook which describes one autopsy he participated in, he was most curious to see the state of the gall bladder.(37)

But at the main task, saving lives, Rush and Physick once again were unable to make a dent in mortality. There were 324 admissions and 193 died.(38) But they were proud enough of the care they provided to write about it in a letter to the publisher William Young.(39) The letter evidently does not survive in any extant publication, but it likely mirrored what Rush said about treatment in a private letter he wrote to Timothy Pickering.

He and Physick realized that "the great variety in the force, seat, and symptoms" of the fever "forbids it from being attacked by any one medicine...." He was satisfied that only the depleting remedies could cure the fever in its "malignant form." The imperative was to "act immediately upon the stomach, bowels, pores, salivary glands, or blood vessels," in a word, to "evacuate." That said, he admitted that he and Physick had "yielded to public prejudice and importunity by prescribing yeast, limewater and milk, and several other simples, but all to no other purpose than now and then easing a troublesome symptom."(40)

Treating hospital patients frustrated Rush. Once again achieving salivation with mercury was difficult. Out of 44 cases, only one person salivated.(41) He also observed that in his private practice vomits were "very useful," but evidently not at the hospital.(42) He bled one private patient upwards of 200 ounces, and wrote that most cases required bleeding and when performed had "its usual good effects."(43) But he never characterized his use of bleeding at the hospital. In the daily newspaper reports on hospital deaths, the length of time the victim had been sick before being admitted to the hospital was noted. Yet in his notebook Rush pondered why, of the 26 admitted on the first day of their fever, 7 died. He decided it was due to the motion of being brought to the hospital.(44) To explain why his remedies did not work on those who survived the trip, Rush decided that a patient needed "familial" society to assure a cure. There was no other way to explain why he lost 4% of his private patients, 2 out of 50, while 60% died at the hospital.(45)

Much to the detriment of Rush's reputation, his rather sensitive 1799 assessment of the possibilities of successfully treating yellow fever has been ignored by historians, most likely because the epidemic of 1799 was mild. Elisha Perkins was the only doctor to die.(46) The official death toll in Philadelphia was 720, less than the 1797 epidemic. In New York the board of health counted 356 deaths.(47) But in many ways this was Rush's finest moment, the future path of medicine and public health clearly indicated. He even realized the importance of not moving the patient, and of trying to relieve symptoms in lieu of battering the body with harsh medicines in an attempt to actually curing the disease. Both ideas form the basis of the modern treatment of the disease.(48)

Rush had the first post-epidemic analysis in print. He expanded the pamphlet he had published in July still intent on taking advantage of "the partial change" which the epidemic had made in the public mind, and try to make "a more general conviction" about the origin of yellow fever which he thought crucial to understanding how to treat the disease.(49)

There was no West Indian fever in Philadelphia, he argued, and no need for West Indian remedies suited to a different climate and people of different constitutions.(50) The local origin of the fever proved the necessity of his depleting remedies. Importationists denied that fevers occurring away from ships were yellow fevers. In reality all disease occurring after June were manifestations of one fever caused by putrid exhalations made inflammatory by the atmosphere. Understanding that saved one from falling into the trap of thinking that yellow fever was a specific contagious disease for which their could be one remedy.(51)

The various manifestations of this summer fever had to be treated by various degrees of depletion. Purges, salivation, sweats, all had their place, but bleeding was easiest on the patient, most under the control of the physician, and most effective. He had no new statistics to support the claim (such as lessening the mortality at the hospital,) but fetching analogies. A puddle could be drained by evaporation, but it could be drained more quickly by drawing the water out of it. He concluded with a claim that had been muted for two years. If a patient was treated from the first day of the fever with judicious application of the depleting remedies, and had good nursing, "familial society and exemption from terror," there was "good reason to believe" that deaths from yellow fever "would not be greater than from a common pleurisy."(52)

He also made clear that the principle purveyors of terror, the source of all anxieties about the fever, were the importationists. If it was imported "the condition of our city is hopeless. It can never be eradicated. Our beds, clothing, and even the timbers of our houses will retain it till the end of time. The sooner therefore we destroy our capital, and consign the spot upon which it stands, to pasture ground, the better."(53) The pamphlet then reprised the familiar calls for reforms of the city and its citizens.(54)

Rush had an ulterior motives for this publication, especially its quick publication. Rush v. Cobbett, the long delayed libel suit was coming to trial in December. He wanted to highlight his continued service to the city in the fight against yellow fever.(55) On December 14, a jury finally heard the arguments and evidence in the case. While sorting out the relative importance of arguments in a trial is difficult, a good case can be made that the principal and convincing argument of Rush's lawyers was that scientific research deserved protection.

Americans then prized argument over evidence. In Rush v. Cobbett there were seven lawyers and three witnesses, and those witnesses appeared briefly. Each lawyer spoke and reexamined the case anew, artfully rebutting what opposing lawyers said and amplifying the salient points supporting lawyers made.

Cobbett's lawyers argued that since ridicule was often employed in debate on public topics, Cobbett's attacks were not libelous.(56) Saying Rush's methods had slain thousands was such an exaggeration that a candid observer had to agree that Cobbett did not seriously think that Rush was a murderer. Rush himself was prone to use ridicule and invective in attacking his opponents. Finally Rush's eminence in his profession was proof that he had not been damaged by Cobbett's attacks. Rush's lawyers retorted that their client's account books could prove that he had lost business. Cobbett's lawyers did not address the medical issues except to impugn bleeding by reminding the jurors that in 1793 bleeding and purging to the extent Rush recommended were unprecedented in Philadelphia, and that Rush himself in a recent pamphlet had confessed that it was not always effective.

Rush's lawyers sang of his sacrifices and undeserved martyrdom by Cobbett's pen. To cinch a judgment in libel there had to be proof of malice. The three witnesses, Drs. Mease, Coxe and Dewees, Rushites all, gave testimony designed to show that Cobbett confessed to knowing nothing about the medical issues involved and was solely interested in making Rush pay for his offensive republican views. Cobbett told Coxe that he doubted his attacks on bleeding would carry any weight because everyone knew he wasn't a doctor. Cobbett also told Coxe that he would not have attacked bleeding and purging if it had not been proposed by Rush. Dr. Dewees said he became Cobbett's family doctor in 1798, and well knowing that he used Rush's methods, Cobbett even recommended him to friends.

Having established that Cobbett had no pretence to a serious examination of bleeding, Rush's lawyers contrasted scenes of Rush's sacrifices with Cobbett's scurrilous attacks. Some of the myths of the '93 epidemic, which still have currency, were coined at the trial. In the desolate city Rush virtually stood alone to battle the scourge and save the poor who remained. With the return of the fever in '97 Cobbett set out to satisfy his political spite by libeling a physician hard at work saving the distressed.

Throughout these arguments no opportunity was lost to impress upon the jury that Cobbett was a foreigner. But the lawyers had to do more than play to the patriotism and political biases of the jury. They endeavored to show that the attacks were unwarranted in themselves, regardless of the character of the defendant, and argued that ridiculing a man in the midst of scientific investigations that may one day save the city from future attacks was unconscionable. The practicing physician and the scientific researcher deserved protection from abusive attacks, even if their work and ideas were topics of public debate.

The jury agreed, and awarded Rush damages of an unprecedented amount, $5,000, a good years earnings for a prominent doctor or lawyer. In giving their verdict the jury did not have to give their reasons for supporting Rush. It's quite possible that they were only expressing their displeasure with Cobbett's journalism and not endorsing the sanctity of scientific research. But Cobbett had already folded his gazette, left Philadelphia and was preparing to return to England.(57) The failure of America to declare war on France convinced him that the ex-colony was a lost cause. Thanks to the sedition law passed in 1798, journalists were already being chastened for their excesses.

However after five epidemics in the past seven years, the jurors more likely welcomed the opportunity to make public health the cause, especially when the lawyers showed them, as Rush had demonstrated in his adjustments to the successive epidemics, that bleeding wasn't the issue. As bad as we may think his medicine was, we cannot deny that Rush showed society the way to accepting what remains the modern attitude toward medical research. The process of scientific observation and experimentation is the best hope for curing our ills and deserves a privileged status even in the give and take of a democratic society.

Go to Chapter 18

1. Winslow pp 207-34.

2. Comm. Adv. Mar. 23, 1799.

3. Butterfield p 811. I think Winslow wrong when he credits Webster for persuading Rush that yellow fever was not contagious. Winslow p 207. Rush does cite Webster's influence in persuading him that the plague was not contagious, see, Rush 1815 vol. 4, p 168.

4. Rush July 1799 p 3.

5. Ibid. p 6.

6. Ibid. pp 21ff.

7. Ibid. p 6.

8. Rush to Webster July 19, 1799, Ford p 473.

9. Webster 1796 pp 109ff; Seaman pp 14ff.

10. Rush 1815 vol. 4, p 168.

11. Ibid. pp 169-70.

12. Rush July 1799 p 13.

13. Ibid. p 16.

14. Ibid. p 26.

15. Ibid. p 24.

16. Ibid. p 28.

17. Phil. Gaz. Aug 14, 1799.

18. Gaz of US, Aug ? & ?, 1799

19. e.g. Phil. Gaz. July 31, 1799.

20. Rush notebook.

21. Phi. Gaz. Aug. 19 & 23, 1799; True Amer. Aug. 22 & 24, 1799.

22. Rush notebook; Rush vol. 4 p 57.

23. Latrobe Journal vol. 3, p. 9.

24. e.g. the Scattergoods and Snowdens left, and no yearly or quarterly meetings were held, see Scattergood and Jones papers for Aug. and Sept. 1799 letters; half of the health committee left the city, see Garrigues diary Aug. 21, 1799.

25. Garrigues diary Sept. 12, 1799, HSP.

26. Carroll papers

27. Mitchill to Rush Aug. 11, 1799, Rush papers.

28. Carlson p 88.

29. Rush 1815 vol. 1, p 36.

30. Ibid. p 51.

31. on Cullen's physiology see Thomson pp 261ff.

32. 32 Rush 1815 vol. 1, p 52.

33. Sandoz p 1364.

34. Gross pp 61ff; and Rush 1815 vol. 1, p 47.

35. Butterfield p 814.

36. Foucault p 122.

37. Rush notebook undated 1799.

38. ?

39. Rush notebook Aug. 29, 1799.

40. Butterfield p 815.

41. Rush notebook Sept. 13, 1799.

42. Ibid. undated.

43. Rush 1815 vol. 4 p 58.

44. Rush Notebook Sept. 13, 1799.

45. Rush Nov. 1799 p 39.

46. Comm. Adv. Sept. 9, 1799.

47. on death tolls see

48. Strode p 421.

49. Rush Nov. 1799 p 5.

50. Ibid. pp 5, 6, 32, 33.

51. Ibid. pp 24ff.

52. Ibid. p 39.

53. Ibid. p 6.

54. Ibid. pp 24ff.

55. for other pre-trail publicity in Rush's favor see True Amer. Nov. 23, 26 and Dec. 7, 1799.

56. "Important Trial" has no page number. It is 70 pages long.

57. Butterfield pp 1215-6.