Destroying Angel: Benjamin Rush,

Yellow Fever and the Birth of Modern Medicine

by Bob Arnebeck

Chapter Eighteen

The death of George Washington from a malignant sore throat while under the care of bleeding doctors on the same day that the verdict was rendered, spurred Cobbett into action. He promised a pamphlet to provide the defense his lawyers failed to give him. For the moment he couldn't resist blaming Rush for Washington's death. He quoted in toto a report of the attending physicians, calculated that the national hero lost 9 pounds of blood in less than twenty four hours and marveled that "in the very same hour that a Philadelphia court & jury were laying on me a ruinous fine for having reprobated the practice of Rush, GENERAL WASHINGTON was expiring while under the operation of that very practice! On that day the victory of RUSH and of DEATH was complete...."(1)

Cobbett missed the point Washington's death and of the verdict. Like historians ever since, he missed the point of Rush's career. Cobbett's myopia was understandable. Rush's minions were after his person and his property in an effort to collect damages.(2) History's myopia is more interesting.

No historian disputes the importance of Rush's influence on the medicine of his day. At issue is his influence on the medical life of our day. Historians are unanimous that Rush's contributions to and influence on modern medicine are nil. Their prime evidence is the complete lack of relevance of Rush's medical writings. By re-associating those writings with Rush's and America's experience with yellow fever, I've tried to breath life into the writings and more importantly into the experience.

Rush helped direct the fear of yellow fever into a national obsession with critical observations of the environment and man's behavior in it. Rush did his might to steer the crusade away from religious fatalism and from the demands of commerce and politics. His mistakes arose not so much from the naivete of his science as from the complex nature of disease in general, yellow fever in particular. He helped create the modern context of man's trust in medical science.

However, there were facts and arguments hurled at Rush when he lived, that seem to cut his pretensions down to size and suggest that his foibles can indeed be laughed at and his influence regarded merely a forgettable fashion. Cobbett published a magazine, "The Rush-Light," whose sole purpose was to attack Rush, his allies and their practices. (A rush-light was a wisp of straw or other quick burning material used to light candles and lanterns.)(3) He juxtaposed the glowing phrases of Rush's lawyers with telling anecdotes of the doctor's life. The "saving angel" of '93 was recalled by Dr. Glentworth. Rush genially squeezed the sick Glentworth's hand, congratulated him on looking better and then added "'but... my dear friend, you must lose a little MORE BLOOD.' 'Lose more blood!' replied Glentworth, 'when I am so faint I can hardly support myself!' Upon this, Rush started from the bed-side, caught up his hat, called his 'dear friend' an assassin, told him he was leagued with Wistar to ruin his reputation, and ran down stairs bawling out: 'you're a dead man! you're a dead man! you'll be buried before tomorrow night!'"(4)

Printed in New York, the Rush-Light reached Philadelphia on February 28. Six days later Rush's son Richard, a future attorney general and secretary of state, assaulted Dr. Glentworth and was summoned to appear at the mayor's court. John Rush hopped in a stage for New York resolved to get satisfaction from Cobbett. Rush hired a New York lawyer to prevent John from getting thrown in a jail and to get injunctions to stop Cobbett from publishing more. The lawyer kept John out of jail,(5) but Alexander Hamilton offered to protect Cobbett from legal measures and the second Rush-Light was soon out.(6) In it Cobbett wrote a damning critique of Rush's life long scramble to shock his way to greatness.

He held up for derision Rush's recent publication speculating that black skin in Africans was a result of disease, and that mercury purges, as well as other medicines, might make blacks white.(7) Cobbett accused Rush of seeing the '93 epidemic as his chance to be a great doctor and that's why within weeks he proclaimed that he had conquered the disease. Yet he offered no proof that he had cured 99 out of 100, claiming that he had been too busy to record the names of his poor patients.

"Can you imagine," Cobbett asked, "that this man, who was laboring with might and main to establish his reputation on the success of his discovery... would omit to note down the names of those he cured?" Cobbett joked that while most of Rush's apprentices died, enough survived to have at least kept a list. When his claim became a matter of controversy, Rush could have advertised in the newspaper asking those he cured to step forward. Cobbett quoted the official statistics showing how deaths increased after Rush announced on September 12 that the fever was under the control of medicine.(8) This was the charge Shryock would quote approvingly 150 years later to demonstrate Cobbett's skill as an epidemiologist.(9)

The Rush-Light was a sensation. Cobbett printed 3,000 copies and couldn't satisfy demand. However fearing legal action that would keep him in the country, not the least Rush's pursuit of damages and injunctions to prevent further libels, Cobbett sailed for England on June 1. In 1801 Rush collected $4,250 in damages.(10)

Rush seemed to take the last spasms of Cobbett scurrility with uncharacteristic aplomb. He simply saw the verdict in the case as a final vindication. Bradford's The True American published a complete transcript of the trial, and made it available as a pamphlet.(11) In response to Cobbett's characterization of his career, Rush decided to provide a record of his life, only for his family, he insisted. He ended the narrative with Cobbett's libels, explaining that he had grown "too much accustomed to defamation and ingratitude to be affected by them in the degree that was expected." He continued his work and drew "upon the comforts and support with which Christianity abounds to those who suffer persecution in the cause of truth and humanity." In a few months Cobbett's attacks were "neglected and forgotten." He concluded that no doctor in Philadelphia had profited more from his practice than he. Plus he had the "pleasure" of "investigation, discovery and promulgation of truth." So his persecutions seemed light indeed. He only remembered them to prove to his sons that God ordained the triumph of good over evil.(12)

A mighty fortress was Rush's science. Cobbett's attack appeals to us because bleeding and purging seem so distasteful in the light of our science. However, bleeding and purging became the dominant therapies in early 19th century American medical practice.(13) Contemporaries had a facile explanation for the triumph. In the mid-19th century as the popularity of bleeding waned, doctors like Samuel Jackson simply ascribed the rise and fall of the procedure to the changing nature of diseases. Dangerous inflammatory systems prompted physicians to bleed. Fevers later in the century did not seem so inflammatory.(14)

Historians have created a more complex model. To begin with they blame the perception that diseases were more dangerous in great part on the affects of bleeding and purging on patients.(15) Also doctors' observations were colored by a need to flatter their theories and exalt their special professional knowledge.(16)

Historians fault Rush for resurrecting these old unpopular therapies, giving cachet to them through the simplicity of his writings and example of his heroism and patriotism.(17) They argue that scientifically invalid and violent therapies gained a staying power because by producing an immediate and predictable affect they give the impression that the physician knows what he is doing and is doing something.(18) Further fortifying the fad was the association of heroic remedies with exclusively American fevers.(19) Bleeding became literal patriotic gore. The decline of bleeding arose from a patient revolt aided by the rise of Homeopathy and other systems based on herbal remedies,(20) thus closing a not pleasant chapter in American medicine.

The danger of the modern model is that it turns medical history into mere illustration of the benefits of modern medicine. After reading an earlier draft of this work, one scholar worried that any published version should include a clear advisory that bleeding and calomel are not good for you. Evidence of disaffection with the standard interpretations of medical history raises doubts about just what hidden agenda an author might have.

But we must be careful not to make heroes out of the critics of medicine we don't like, and then contrive to explain how doctors seduced people into torturing themselves for no evident good for so long. There is simply no evidence that contemporaries of Rush were blinded by anything he did or said to such a degree that they acted irrationally because of it. To side with Cobbett and blame the doctors for killing George Washington by bleeding and purging might be medically correct today but it blinds us to the true purport of the event.

There is no evidence that Cobbett's or others' accusation vis-a-vis the death of Washington, which perhaps was the most widely publicized death in American history, found any significant resonance in society then. The reason it didn't is not because doctors and laymen then were unscientific and ignored evidence that contradicted their theories. The problem was that people then were being consciously scientific as never before.

If medicine was essentially fashion, if it was a field dominated by personality, then the death of a man like Washington should have made a difference. It didn't because, in a large measure thanks to Rush, the death of one man did not make a difference. The continuing research and experimentation of the medical profession did.

Writing to Webster over two months after Washington's death, Rush reported that in treating the violent fevers of winter, including the same throat condition that had killed Washington, "bloodletting and other depleting remedies have been used in the treatment of them by all our practitioners, hence but little mortality has attended." "This," he added proudly, "has been a reaction in the public mind from the conviction and punishment of Cobbett upon the subject of depleting remedies. I have felt it in the most sensible manner in my business."(21)

The marvel is that because of almost a decade of medical discussions in the newspapers, laymen respected this research and shared its hopes. For historians to strain to find comment after Washington's death that indicates second thoughts about bleeding and purging illuminates little. John Duffy for example quotes the 1817 observation of an obscure military surgeon that mercury was overused in an 1812 yellow fever epidemic in New Orleans,(22) while he ignores the work of John Warren who helped establish the Harvard Medical School.

In 1813 Warren documented the rise of "the mercurial medicine" throughout the world, noting that never was a medicine "so thoroughly tested in different countries." He credited the yellow fever epidemics for "bringing mercury into vogue, as a febrifuge, and of elevating it to the high rank it sustains in the materia medica of the present day."(23) Warren discussed the use of mercury in smallpox, measles, throat-distemper, croup, hydrocephalus internus, pneumonia and pleurisy, consumption, dysentery, and rheumatism. He described his own use of mercury as a prophylactic, using a grain of calomel daily to keep his gums constantly sore.(24)

Warren's comments on the international scope of research on mercury contradicts the thesis that heroic medicine was a uniquely American response. To be sure contemporaries couldn't resist making the association themselves. A book review in the Medical Repository demonstrated how easily Fourth of July oratory infected medical commentary: "Under the desolating influence of this distemper [yellow fever,] the Americans grew vigilant, and suffered none of its accompaniments to escape their notice. They beheld its rise, progress and decline, year after year, under circumstances the most favorable to its investigation. Their feelings, their hopes and their interests, all prompted them to be correct in their observations, clear in their narratives, and fair in their reasonings."

Noting the lack of experience that European trained physicians would have of American fevers, the Medical Repository repeatedly ridiculed those who left America for a medical education. However, as Warren's comments show there were limits to this medical nationalism. Rush, who had long sought to put an American stamp on medical progress, sent his son James to the medical college in Edinburgh.(25)

Of modern scholars, John Harley Warner demonstrates the greatest sensitivity to the reality that 19th century doctors responded too. However he rejects their model for the rise and fall of bleeding and agrees with other historians that the heroic therapeutics of the early 19th century were "to a large extent informed by medical systems."(26) Which is to say therapeutics was not informed, as it is today, by a process of medical research responding to the needs of patients. (Obviously any medical practice then or now is informed by a systematized view of the workings of the body and the nature of disease.)

This same critique of medicine in 1800 being top heavy with theory was made by contemporaries. In a widely quoted excerpt, Thomas Jefferson criticizes basing treatment of disease on "some fanciful theory of corpuscular attraction, of chemical agency, of mechanical powers, of stimuli, of irritability accumulated or exhausted, of depletion by the lancet and repletion by mercury, or some other ingenious dream, which lets him into all nature's secrets at shorthand." He specifically scored the disciples of "Hoffman, Boerhaave, Stahl, Cullen, (and) Brown...." Historians suggest that Rush was omitted only because he was a personal friend.

However, Jefferson goes on to describe common sense medicine that he follows, essentially bleeding, purging and bark. Finally he advises that "the only sure foundations of medicine are, an intimate knowledge of the human body, and observation on the effects of medicinal substances on that. The anatomical and clinical schools, therefore, are those in which the young physician should be formed."(27) Which is exactly what Rush, after laying a ground work of theory designed primarily to demonstrate the high purpose of medicine, preached and demonstrated especially by his indefatigable efforts to understand yellow fever. Rush demonstrated in his continual fine tuning of his remedies for yellow fever that theory was never a bar to changes in therapy. By making Sydenham's works, as opposed to Cullen's or Boerhaave's, the Bible of medicine, Rush steered therapy away from theory, and once again made theory invalid unless it was based on the reality of disease.

In the wake of the yellow fever epidemics, doctors created medical journals dedicated to assuring that American medical practice would progress along scientific lines. To be sure testing of therapies was limited to personal observations on a handful of patients, but as never before in American medicine, these observations were given wide publicity and open to discussion.

In 1801 Rush wrote several letters to the Medical Repository on work he did at the Pennsylvania hospital on salivation in consumption,(28) and bloodletting to save a man who attempted suicide with an over dose of opium.(29) Researchers tried to explain mercury's effectiveness.(30) Warren suggested it aided in the oxygenation of the blood which in turn speeded up cure.(31)

Of course one can go through these journals and belittle every article in them. "It was, in brief," Shryock writes of them, "still the day of cures and curiosities in American medical journalism."(32) But that observation tells us little, as it flatters the seemingly rational march to scientific truth in current medical journals. Contemporaries understood the difference between the state of medicine after the yellow fever epidemics and before, and no contemporary doctor regretted the changes in general, especially since the process itself allowed for eventual corrections and recognition of error.

To prove Rush's irrelevance Shryock quotes Nathaniel Chapman, a successor of Rush at the medical school: "'Our school was right in rejecting an archaic humoralism, and also in discarding the artificial nosographies. But we were wrong in our intemperate generalizations about the unity of illness. We had better hereafter identify disease only in some approximate arrangement relating to the body parts, until we have become more enlightened in pathology."(33)

Rather than damning Rush these observations flatter the process he unleashed and the good sense of his students. Only when associated with Shryock's mistaken insistence that Rush was opposed to morbid anatomy and the French school of pathology would Chapman's quote damn Rush.(34)

However, while Rush misunderstood the significance of morbid anatomy, he never down played it importance. In the introduction to his 1804 lectures he discussed "the causes which have retarded the progress of medicine." They included "neglect of the study of natural history, comparative anatomy, and physiology;" "an exclusive dependence on one medicine, or one class of remedies;" and "the neglect to dissect and examine, morbid bodies after death;" but with this proviso, "where this has been done, mistaking the effects, for the causes of disease." It was in this lecture that Rush suggested that "suspended animation, if it should occur in that enlightened state of the world, shall no more expose the subjects of it to premature internment." And the lecture ended with a call for skepticism: "let no part, nor function of the body, and no law of the animal economy, escape a second investigation."(35)

His students understood his message. While the pages of medical journals then are crammed with clinical notes, there is little systems building. One exception was provided by a student who Rush encouraged to write a thesis comparing and contrasting the medical systems of Cullen, Brown, Erasmus Darwin, and Rush. Not surprisingly the student came down heavily in Rush's favor. While we view Rush's simplifications as the height of theoretical chicanery, contemporaries recognized their utility in deconstructing preceding systems. Based on "concise observations" and "studied" in its "simplicity," it "broke down those artificial barriers which have subdivided disease, and draws the mind of the student from the complexity of nosology to view with less confusion the simplicity of morbid excitement."(36)

Of course it is difficult to accept that therapy we know is bad was deemed good and progressive, and it's easy to suppose that Rush's winning theory persuaded practitioners to subvert their observations to its siren song. However, first there is little evidence that Rush's theory was that highly prized, and certainly far less prized then the clinical insights he shared in his fight against yellow fever. Secondly there is no evidence that anyone did subvert their observations. The trials of mercury on other diseases were not informed by a theory of fevers, but by the same pragmatic response exhibited by today's researchers. What might work in one kind of cancer, might work in another.

Admittedly these researchers could not conceive of double blind testing, were unable to chemically analyze the blood, and lacked most of the techniques that turned what they called morbid anatomy into what we call pathology. What makes this enthusiasm for "mercurial medicine" the first failure of modern American medicine rather than the last absurdity of ancient medicine is that the culture in which the researchers operated featured open inquiry and the moral support of society, as well as the basic ethic of scientific research.

A gauge with which to judge the kinship of the movement Rush initiated with modern medicine is to contrast it with the progress of Homeopathy in the United States. Apparently Hahnemann's work never came to Rush's attention and Rush died before Hahnemann's disciples came to America.(37) Since modern historians have used a framework that favors critics of Rush's therapeutics, the rise of Homeopathy in the early 19th century is usually characterized as a sane response to the excesses of doctors influenced by Rush. The Homeopaths' deducing treatments for the sick from the testing of medicine on the healthy may seem ludicrous, but since it recognized some valid therapies, it was better than bleeding and mercury.(38)

In Hahnemann's system testing was in essence a ritual celebrating the truth promulgated by the master that like cured like. With Rush, as with modern medicine, research was a process of discovery in which theory was placed at risk in the interest of better understanding and controlling the reality of disease. And by the way, while homeopaths turned their backs on non-herbal medicines and bleeding, Rush remained open minded. In 1803, on President Jefferson's invitation, he provided the Lewis and Clark expedition with questions to ask the Indians. Rush was most interested in their use of depleting remedies, sweats, purges and bleeding, but did ask open ended questions about their practices.(39)

Certainly Rush longed for a simplification of medicine, but bleeding and purging were not sufficient, especially in yellow fever. In 1803 he promoted eupatorium perfoliatum, the plant boneset, as the best sudorific for yellow fever cases.(40) He said nothing to discourage the continued investigation of medicines of all sort. The pharmacopeia's published after his death provide as detailed an investigation of herbal remedies as the publications of Mrs. Grieve and other herbal stalwarts, and they also include chemical medicines.(41)

What also distinguished Rush from the Homeopaths was that he believed in heroic medicine. In essence when a patient was dying, or suffering a disease in which death was too likely a prognosis, he insisted that the doctor not rely on natural processes to effect a cure. Some historians distinguish invalid therapies like Rush's with therapies since validated by modern medical science and suggest that invalid therapies tended toward the heroic because doctors understood that patients wanted medicine that had an obvious effect. To be effective in 18th century terms most medicines had to act like a poison in modern terms. Thus the reflex of the doctor was to save face by increasing the poisonous dose.(42)

Actually Rush had nothing in principle against small doses. Following his dicta of apportioning the force of the medicine to the force of the disease, he treated two young women with "alarming catarrhs" by "gently touching the mouth with calomel."(43)

Of course that touch of calomel begs the point. Rush's therapies certainly were heroic. But they were not driven by theory, nor by patient demand for depletion. Rush's frustrations both in the development and use of his therapies make that clear. If less reliance were placed on the reminiscences of doctors promoting a new therapy in contrast to Rush's, historians could better see that Rush reacted conscientiously to the reality of the diseases of his day. Bleeding and purging were a valid scientifically based reaction to the nature of fevers in the late 18th and early 19th centuries. The therapies fell by the wayside because the nature of fevers changed.

Recent experience has shown that the nature of individual diseases are not static. Bacterial diseases like scarlet fever which medicine boasted of controlling are now exhibiting more severe symptoms and greater virulence.(44) Viral diseases like chicken pox which were best left to run their course, now exhibit a severity that makes development of a vaccine advisable. AIDS, which at this writing remains epidemic and incurable, has shown how a fearsome killer can change perceptions of all diseases. Of course it is impossible to prove that diseases were in fact more severe then. But in the light of recent failures to control disease once thought to be treatable, we should be less critical of the diagnostics of Rush and his disciples.

By freeing the observations of Rush and his disciples from implication that they were falsified to suit theories, a window on the reality of American life in the late 18th and early 19th century is opened. The research into etiology that Rush inspired failed to explain the cause of disease as much as research inspired by his therapies failed to cure them. But it provided the first critical look at the American environment by native born citizens.

The imperative to prove the new country viable meant that death counted a great deal more in America than it did in London and Paris. The colonial reaction had been to conceal epidemics. Rush gave death by epidemic wide publicity in an effort to prompt preventative measures and public health reforms. The way Rush raised alarms and hopes by opening his heart and mind to his fellow citizens is as important to the development of modern medicine as the way Bichat opened a corpse. He proved that a doctor could be a hero and not be a quack. He defeated efforts to isolate the importance of his experience by insisting that there was a relationship between a death-bed in Philadelphia and a fever in Connecticut, or Maryland, or the Genesee Valley. Death was not God's judgment but his challenge, and in fighting it all things must be considered. The encyclopedia, the highest fruit Enlightenment learning, must serve as the armory at the Battle of Armageddon.

Even the end of yellow fever epidemics north of the Potomac between 1805 and 1819 did not cool this hot engagement. The decline of yellow fever did not lead to a general perception that the country was getting any healthier. The same journals that publicized the extension of the depleting therapy to other diseases, chronicled epidemics of other fevers. In 1804 there was widespread sickness in the hinterlands that reportedly kept many farmers from bringing in the harvest.(45) In 1807 there was a nationwide influenza epidemic.(46) From 1812 to 1814 the country was ravaged by what was called the winter epidemic.(47) Medical science achieved a tone, which it has maintained to the present day, challenging any complacency about health and death.

The fear of disease also explains why patients put up with harsh heroic therapies. As much as the AIDS pandemic has made local outbreaks of Ebola fever a cause for widespread foreboding, the yellow fever epidemics of the 1790s made all fevers dreadful. Rush's theories did not create the fear, the death tolls did that, but his theories did little to dispel fear. In that respect however they cannot be invidiously compared to the use of theories of etiology by modern medicine. With the continuing fear of cancer combining with the fear of infectious diseases spawned by the AIDS epidemic, today the environment remains almost totally suspect, personal cleanliness an imperative and avoidance of personal debility, physical and emotional, the first line of defense.

Of course this is a recent phenomena. For most of the 20th century, man has thought the environmental causes of disease were increasingly under control and that medicine was getting better and better at saving dangerous lifestyles from ultimate consequences.

So as much as blaming rotting coffee seems silly, the conviction inspired by Rush that a wider and wider network of observers would eventually unlock the laws of epidemics was serious science. Some disciples made the inherent inscrutability of the epidemic constitution a given. "Can your powerful glass," one wrote, "distinguish between an atmosphere loaded with contagion, and one that is not contaminated? No, surely, it cannot, and yet, as surely, an important difference does exist."(48)

That was not Rush's feeling. He welcomed a line of argument that if pursued as research might have hit on the right answer. Dr. John Crawford in Baltimore suggested in 1807 that "amiculae" caused fevers. He even associated insects with the process. Remarking on the incredible ability of insects to multiply over swamps, he drew the analogy with smaller pests multiplying inside the body.(49)

Rush welcomed the new ideas as more support for the local origin of disease and commiserated with Crawford over the ridicule heaped upon him.(50) Insects could still not rival more noticeable noisome influences. In the medical journals there were frequent observations associating fevers with putrefying matter from a patch of rotting cabbage in Washington(51) to dead fish in New England.(52)

Until his death Rush kept correlating inflammatory fevers with changes in the environment. In 1801 New York had enough fever to force evacuation but Philadelphia only had sporadic cases away from the waterfront. Rush speculated that spring rains coupled with a dry June and July which made the filth in the gutters less moist, saved Philadelphia from an epidemic.(53) In 1802, June and July were moist and there was an epidemic. In 1803 the pattern didn't hold, so he blamed the epidemic constitution of the atmosphere for allowing miasmata to concentrate one year and dissipate the next.(54)

In 1809 Cadwalader Evans suggested that epidemic yellow fever was not probable when the average temperature in June and July was under 79 degrees. The only exception was 1802 when the city had one of its mildest epidemics and the average temperature was 78. Rush was not impressed and could cite English authors for evidence of epidemics of malignant fever in the winter. Rush would not allow any theory to save the city from the imperative of cleanliness. At best he would allow that an epidemic did not appear because there was a pattern of rains or winds that saved the city from the affects of its filth for that one season.(55)

As we have shown the nature of yellow fever thoroughly bedeviled scientists in the late 18th century. It continued to perplex scientists throughout the 19th century. Much of Rush's work, especially his observations, stood the test of time for one hundred years. That perhaps is credit enough for Rush without going on to insist that the great debate between local origin or importation, contagious or not contagious, unleashed forces which enabled Pasteur and Reed to do their work. Yet Rush did contribute by doing his mite to make disease an unacceptable part of nature.

Rush did not live to identify a change in the epidemic constitution. But there is ample evidence that the nature of diseases did change. There was a growing consensus in the 1820s and 1830s that disease were becoming less severe.(56) This may have arisen because of the broad retreat of malarial fevers in the 19th century, most likely caused by a change in climate that killed off disease-bearing species of mosquitoes and the malaria plasmodium. By the mid-1830s even the marshes of Baltimore were healthier. Fort McHenry no longer had to be abandoned in the sickly season.(57) Then epidemics of cholera or typhoid fever once again made heroic remedies fashionable. Chapman who in 1820 regretted the influences of Rush's theories reaffirmed the power of calomel and bleeding to treat cholera in 1832.(58)

To examine how the yellow fever experience prepared or ill-prepared society to cope with cholera is beyond the scope of this book. However it bears noting that cholera never eclipsed yellow fever as a subject for research and speculation. Yellow fever returned to the north between 1819-1821 and also in 1854 and recurred with greater frequency in the south, but while paralyzing the Mississippi Valley in 1878, it never threatened the country as a whole the way cholera did in 1834, 1849 and 1866.(59)

That yellow fever maintained such prestige despite becoming less of a present danger is another gauge of how critical the early studies of it were on the development of medicine. Exotic as we may view the disease now, in the 19th century it raised the right questions about etiology and therapeutics. Unfortunately it concealed the answers far better than other diseases.

The models for the spread of cholera, typhoid, tuberculosis, and malaria were all proven before that of yellow fever. The offending germs in those diseases were all isolated in the 19th century while the yellow fever virus was not isolated until 1929.(60)

John Harley Warner has aptly noted that "nineteenth century therapeutic practice is certainly an unappealing vehicle for hagiographic celebration...."(61) So the suspicion might arise that by trying to elevate regard for Rush what one is really doing is lowering regard for modern medicine, and, with far less directness, joining its Homeopath critics. However arguing that Rush played a major role in creating the modern medical culture is not to argue the relevance of his theories, only the relevance of his experience.

The lesson to be drawn is that the nature of disease determines the nature of medicine, especially when the fight against disease is waged openly. A disease that objectively is a minor threat to society can because of its nature dominate the fears of the public and direct the path of medical research and practice. Culturally there is a always a reigning epidemic that affects the perception of all other diseases. Over reaction to the reigning malignant disease can prompt patients and doctors to over react in dealing with benign diseases.

At his end Rush had a taste of his own medicine. He died in his 68th year, 1813, not in the sickly season, but on April 19. There was some confusion about his last illness. His friend Dr. Dewees was so intimidated by Rush's gradations of the world's one fever that he slotted his master's chest pains and lassitude as symptoms of fever. Rush himself knew better. His lungs, which had always been his weak point, were giving way. Before he died a bleeder took three ounces of blood, and Rush had a taste of calomel.(62)

Yellow fever, remains, alive in the jungle monkeys of South America and Africa,(63) waiting for some re-constitution of the atmosphere to once again mount the pale horse, disguised as a tiny mosquito, and ride the warm winds north. Of course, we have vaccine, scarcely enough for a good size city, but more can be made. Mosquitoes can be controlled, the Aedes aegypti as well as the tiger mosquito which is now in the United States and can carry yellow fever.(64) But if not yellow fever, other diseases will find their Rush.

1. Por. Gaz. Jan. 15, 1800.

2. Rush-Light Feb. 15, 1800, p 2.

3. Ibid. p 3.

4. Ibid. p 12.

5. Butterfield p 1217.

6. ?

7. Rush-Light p 39; for original see, Proc of Am Phil Assoc vol 4, 1799

8. Rush-Light pp 66ff.

9. Butterfield p 1217.

10. Ibid.

11. "Important Trial," 1800.

12. Corner pp 104, 108.

13. Rothstein pp 46-52; Duffy p 70.

14. Rosenberg p 28.

15. Rothstein p 45; Shryock (2) p 111.

16. Warner p 54.

17. Duffy p 67; Shryock (1) p 206.

18. Rosenberg p 17.

19. Cassedy p 81.

20. Duffy p 80.

21. Rush to Webster, Feb 21, 1800.

22. Duffy p 74.

23. Warren pp 7, 187.

24. Ibid. ; see review in MR vol. , p 45.

25. MR vol. 4 p 401; vol. 3 p 414; vol. 5 p 331; 1814

p 323; 1816 p 324ff; Corner p 371.

26. Warner p 93.

27. Bedini p 506

28. MR vol. 5, pp 5-10.

29. MR vol. 5, p 124.

30. MR vol. 6, pp 232ff "Wiley on Mercurial Salivation."

31. Warren

32. Shryock (1) p 215.

33. Shryock (1) p 219.

34. Shryock (1) p 212.

35. Rush 1977, pp 148,149, 162, 163.

36. Rees, p .

37. Duffy p 83.

38. Rothstein p 157.

39. Corner pp 265-6.

40. Rush 1815 vol. 4, p 86.

41. e.g. Wood's and Bache's 1833 Dispensatory.

42. Rothstein pp 10, 44.

43. MR vol. 5 p 8.

44. Kiple p 991.

45. Rush 1815 vol. 4, p 92.

46. MR vol. 5 pp 190ff.

47. MR 1817 vol. 3, p 1.

48. Rees p 17.

49. Crawford in Balto. Med. Rpt. vols. 1-2, pp 31, 40, 81, 206.

50. Corner p 274.

51. MR

52. MR

53. Rush 1815 vol. 4, p 70. 1801

54. Ibid. p 88.

55. Rush 1815 vol. 4, p 103.

56. Warner p 68.

57. Gillett p 88.

58. Hazard's Reg. of Pa. vol. 10, p 198.

59. Humphreys p 60.

60. Burnet p 243.

61. Warner p 2.

62. Goodman pp 346ff.

63. Burnet p 245.

64. Powell p xiv, (preface to 1993 edition.)