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Homework for Aug 19

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Background reading material for Dr. Neff's August 19th presentation:
"The Beginning and End of It All: The Acute Inflammatory Response - Or, Why Jane Lived, but Dick Didn't"

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Below is an article from the New England Journal of Medicine that Dr. Neff would like our members to read prior to his presentation on August 19th. It is more of a vignette on inflammation and how it relates to the death of our first President. Another more detailed article on acute inflammatory response is at http://www.fleshandbones.com/readingroom/pdf/221.pdf. This article is not required reading since it is quite technical however, some of our members may find it interesting.

Death of a President

It was the best of times. The last war had ended a generation earlier, and a European war had just been avoided. Prosperity was visible. There were new medicines for frightening diseases. As snow blanketed the Virginia countryside, the young nation's future seemed bright. It was the last month of the century: December 1799.

But on a frigid afternoon, three physicians, gathered around a dying man, were not so optimistic. The man's wife looked on as he gasped for air, constantly shifting position. His aide lay on the bed beside him, repositioning him, propping up his exhausted frame. Christopher Sheels, a slave valet, stood beside the dying man. A porcelain bleeding bowl rested nearby. After lighting a fire to warm him, slave housemaid Caroline Branham joined slave seamstress Charlotte and slave housemaid Molly (surnames unknown) just inside the doorway. The patient's eyes were alert and comprehending. George Washington, who had recently retired as president of the United States, was preparing to die.1,2

Each physician knew him well. The 69-year-old, Edinburgh-trained James Craik had frequently visited the president's Mount Vernon estate. He and Washington had fought together in the French and Indian Wars. Gustavus Richard Brown, also trained in Edinburgh, was a wealthy, 52-year-old physician from Port Tobacco, Maryland, who had just cofounded the Medical and Chirurgical Faculty of Maryland. Elisha Cullen Dick, a 37-year-old physician trained in Pennsylvania, was a former quarantine superintendent and board-of-health physician in Alexandria, Virginia. He knew the latest medical literature and was clinically aggressive. He had been appointed coroner the previous year.

Craik, the first physician to arrive, at 9 a.m., obtained the medical history.1,2 On Friday, December 13, Washington had "taken a cold," with mild hoarseness. At 2 the next morning, he awoke and had difficulty breathing. By 6 a.m., he was febrile, with throat pain and respiratory distress. Unable to swallow, he spoke with difficulty. His aide, Colonel Tobias Lear, sent for Craik and bloodletter George Rawlins. At about 7:30 a.m., Rawlins removed 12 to 14 oz (355 to 414 ml) of blood, with Washington requesting additional bloodletting. The mixture of molasses, vinegar, and butter Lear gave him brought on nearly fatal choking.

Craik applied a blister of cantharides to Washington's throat and removed approximately 18 oz (532 ml) of blood at 9:30 a.m., with a similar amount removed at 11 a.m. Washington repeatedly gargled sage tea with vinegar. Tilting his head back to drip the mixture down his throat, he nearly suffocated, unable to cough the fluid up. Still alert, he rose and walked about the bedroom, then sat upright in a chair for two hours. Returning to bed, he squirmed to find a comfortable position.

Arriving at 3 p.m., Dick argued that further bleeding might weaken Washington. Craik nevertheless ordered a fourth bleeding, with the removal of 32 oz (946 ml) of blood. Brown arrived at 4 p.m., at which time calomel (mercurous chloride) and tartar emetic (antimony potassium tartrate) were administered.

Awaiting a therapeutic effect (Figure 1), the physicians might well have thought about Benjamin Rush, a medical colleague and friend of Washington whose professional fate was being decided that day. Craik had served with Rush in the Revolutionary War, Brown had been his classmate in Edinburgh (class of 1768), and Dick had been his student in Pennsylvania. America's most famous physician and a signer of the Declaration of Independence, Rush was fighting allegations of medical malpractice.

The legal case concerned bloodletting, which Rush championed. Journalist William Cobbett had charged Rush with killing patients. Rush had sued. In their opening statements, the lawyers for the two men traded blood-tinged metaphors. Rush's lawyer argued, "[A physician's] reputation is a fabric delicate as air, the slightest gust of popular prejudice or caprice dissipates it. . . . Virtue, bleeding at every pore, calls for justice on her despoiler."5 Cobbett's lawyer quoted his client, "The times are ominous indeed, when quack to quack cries purge and bleed."5 The verdict was scheduled for December 14, as Washington lay dying.

After the fourth bloodletting, Washington's condition improved, and he was able to swallow. He examined his will. Realizing that Sheels had been standing for hours, Washington motioned him to sit down. Around 5 p.m., Washington again sat up in a chair but soon returned to bed and was helped into an upright position. He continued to struggle for air, and his condition began to deteriorate. At 8 p.m., the physicians applied blisters of cantharides to his feet, arms, and legs and then applied wheat-bran cataplasms (poultices) to his throat. His condition deteriorated further. At around 10 p.m., Washington whispered burial instructions to Lear.

At 10:20 p.m., George Washington died. Sheels, Branham, Charlotte, and Molly looked on. Craik closed his friend's eyelids, while Dick stopped the bedroom clock. The body was carried downstairs and laid on a table in the unheated dining room.

News of Washington's death spread quickly. Symbolic funeral services held in hundreds of cities featured elaborate cortèges with empty coffins, riderless horses, and tolling bells.6 Newspapers published heroic poems by grieving women. People made pilgrimages to Mount Vernon. In France, Napoleon ordered the hanging of black crêpe from flags and standards, and the marquis de Fontanes delivered a stirring éloge (official eulogy) at the temple de Mars (Hôtel des Invalides).7 In the American capital, Reverend Richard Allen, minister of the African Methodist Episcopal Church, announced that Washington's slaves would eventually be free. Americans dressed in black or wore mourning badges for months.

But amid the sorrow there was controversy over Washington's medical care. Rush's victory in the bloodletting suit, on the day of Washington's death, could not eliminate popular suspicion that overuse of bloodletting was harmful.

Craik and Dick chose a preemptive strike. In an open letter to the nation,8 they attributed Washington's death to "cynanche trachealis," reviewing the onset and course of the illness and describing their treatment. Apparently the first justification of a medical practice to the American public, the explanation backfired. That Washington had died at the hands of his physicians was immediately suggested by his friends,9 as well as by American and British medical scholars10,11 and the press.12,13 Some 20th-century authors have charged that he was murdered.14,15,16

Why was 80 oz (2365 ml) of blood removed in 12 hours, and was such treatment helpful or harmful? The physicians, who did not provide a rationale for this treatment, were nevertheless using accepted "heroic" therapy. They understood that Washington's condition was inflammatory (subsuming what we now know as infection) and that inflammation was associated with tissue swelling, which in turn was related to transudation. But they lacked modern antiinflammatory therapy. According to some 19th-century historians, Washington's physicians might have reasoned that because bloodletting caused visible dermal vasoconstriction, it would also constrict the vessels associated with swelling in the windpipe17,18 and that the dehydrating effects of "purging" (with the use of calomel), diaphoresis (with sage tea and subemetic doses of antimony), and blistering (with cantharides) would potentiate the effect. This speculation may reflect the historians' a posteriori reasoning.19,20

In any case, Washington's blood eventually became viscous and flowed slowly,1 presumably reflecting dehydration and hypovolemia. Modern physicians would doubt the beneficial effects of such therapy on local inflammatory swelling and would worry that aggressive bleeding might cause weakness and worsen the hypoxia associated with partial airway obstruction; they would also worry that iatrogenic dehydration might lead to electrolyte imbalance. Lacking such modern concepts, Washington's physicians may have reasoned that with death approaching, "heroic depletion" was their only option.

What disorder led to Washington's death? Dick rejected Craik's diagnosis of "inflammatory quinsy" and proposed three alternatives: "stridula suffocatis," "laryngea," or "cynanche tracheitis [sic]"21; the third, as corrected, eventually prevailed.

Cynanche trachealis (literally, "dog strangulation") was a relatively new diagnostic entity at the time. Beginning in the late 1770s, Brown's teacher, the great Edinburgh nosologist William Cullen, defined it as "inflammation of the glottis, larynx, or upper part of the trachea . . . a rare occurrence . . . [producing] such an obstruction of the passage of the air, as suffocates, and thereby proves suddenly fatal."22

Cynanche could not have been unknown to Washington's physicians. Dick and Craik had been discussing diagnostic possibilities during a "croup" epidemic that winter.21 Moreover, one of the earliest and most authoritative descriptions of cynanche was reported in 1770 by Brown's own nephew, also named Gustavus Brown,23 with subsequent reports by Dick's teacher, Benjamin Rush.24,25 Brown, Craik, and Dick, who probably knew as much about cynanche as any three physicians in the United States, even summoned Brown's nephew to Washington's bedside.26 He lived in St. Mary's County, Maryland, however, and failed to arrive in time.

Although historians do not agree on the cause of Washington's death, the signs and symptoms1,18,19 point to acute bacterial epiglottitis. This diagnosis, proposed first in 183827 and several times since,28,29 is consistent with current clinical and epidemiologic information.30,31,32 Medical reports during the period from 1776 to 1826 suggest that cynanche trachealis corresponded to the modern diagnosis of bacterial epiglottitis, but the term was probably also used to refer to some cases of laryngeal diphtheria and viral croup.

Other suggested diagnoses seem less likely. Quinsy33 causes unilateral neck swelling, which Washington did not have, and is seen almost exclusively in children. Washington had probably been exposed to streptococci as a child34 and had also apparently had diphtheria.35 Laryngeal diphtheria was a slowly progressive disease largely confined to childhood, as it is now, and diphtheria was not prevalent in Virginia in 1799.28,35 Pneumonia, Ludwig's angina, Vincent's angina, and other proposed diagnoses have largely been ruled out.28,36,37,38

Could Washington have survived epiglottitis? Dick, overruled in his opposition to bloodletting, next argued for tracheotomy.21,39 In 1799, even elective tracheotomy, let alone tracheotomy performed on an emergency basis, was rarely undertaken. It is improbable that, at the time of Washington's illness, tracheotomy had not been performed in the United States, as has been claimed,40 although a workable procedure had been described in surgical detail only the year before.41 Undoubtedly, the specter of failure with a grisly, painful (in the absence of anesthesia), and untried surgical experiment on the former president weighed heavily in Craik's decision to veto this radical suggestion.

One historian has defended Craik by arguing that tracheotomy with the patient in the supine position would have led to positional ball-and-valve airway closure and rapid death.42 But Dick's later comments on tracheotomy specified the upright position.39 Tracheotomy may have been the only lifesaving option left, but it was not attempted.

After Washington's death, his physicians spent the night at Mount Vernon. In the morning, Dick measured the frozen corpse; it was 1.9 m (6 ft, 3 1/2 in.) long. Craik declined payment but recommended that Lear pay each of the other two physicians $40 (about $375 in 1999 dollars), after which they left. Several hours later, the last physician who had been summoned arrived. William Thornton, a physician trained in Edinburgh and a family friend, had been called the previous evening, as Washington's illness became critical. Thornton had rushed to Mount Vernon with the same idea as Dick: to perform an emergency tracheotomy.

Too late, Thornton still hoped that Washington might be in a suspended state from which he could be aroused. After conducting a careful examination of the corpse, Thornton proposed that the body be thawed gradually, first in cool water and then with warm blankets and rubbing of the skin, with the subsequent performance of a tracheotomy, artificial respiration at the tracheotomy site, and transfusion of lamb's blood.43 Although Martha Washington must have known that her husband had once revived a frozen slave thought to be dead, she refused this proposal.

Thornton and Craik persuaded the family to encase the coffin in lead because of the risk of communicable disease.9,44 At the funeral, one of Washington's closest friends, Bryan, Lord Fairfax, "caught" a cynanche-like disease. He attributed his survival to copious bloodletting.45


James Craik apparently never again spoke about the events of December 14. But he did have second thoughts about declining payment, submitting to the estate on December 24 a bill for the same fee Brown and Dick had received at his suggestion. He was also bequeathed Washington's valuable tambour secretary and circular chair. Craik, who had named one of his sons George Washington, attended the death of Martha Washington two years later. He died in 1814. One of his grandsons, William Craik, became a U.S. congressman.

Meeting over the holidays, Gustavus Richard Brown praised Elisha Cullen Dick and said that he wished they had heeded his advice about bloodletting.26,46 Dick, who initially talked of "putting [away] his lancet forever" to become a nurse,26 was less charitable to his colleagues, later criticizing Brown explicitly and Craik implicitly.21,39 Brown made no further comments about Washington's treatment. Gustavus Brown died in 1801, and Gustavus Richard Brown in 1804.

Dick seems never to have given up revisiting the events of December 14. Despite his strenuous arguments against bloodletting and in favor of tracheotomy, he later reversed himself, arguing that in patients with cynanche, bloodletting ad deliquium (to the point of syncope) was so effective it removed the need for tracheotomy.39 Later still, his preferred treatment regressed to a "strong toddy" with red pepper. Dick and Rush became national experts on bloodletting as a treatment for cynanche and other diseases, ignoring evidence against its use.47 Dick, who became mayor of Alexandria, Virginia, in 1804, remained devoted to Washington's memory, spearheading both a movement to make his birthday a national holiday and the erection of a national monument. He died in 1825. His grandson, James Alfred Pearce, became a U.S. senator.

Benjamin Rush's legal victory invited further attack. His tormentor, Cobbett, subsequently accused Rush's pupil, Dick, of causing Washington's death. Chased by Rush's son, Cobbett escaped a duel and fled to England, where he became a member of Parliament. Rush, who gave the proceeds from his $5,000 judgment ($47,000 in 1999 dollars) to charity, died in 1813. He is remembered today as one of America's greatest physicians, a father of psychiatry, and a founder of the liberal humanist tradition in American medicine.

William Thornton pursued a career as an inventor and architect, designing the nation's first Capitol and developing the city of Washington. He also directed the patent office, wrote a seminal work on teaching deaf–mute persons, codeveloped the first steamboat, and was involved in many social causes. He died in 1828.

Washington's will specified that on his wife's death, the slaves he owned at Mount Vernon (about half the total number) were to be freed. Persuaded by family members that this provision of the will might provoke a slave to murder her, Martha Washington freed them all. Sadly, Sheels, Branham, Charlotte, and Molly had been owned by Mrs. Washington, who was prevented by inheritance laws from freeing them. On her death in 1802, they and the remaining slave families were dispersed according to those laws.

Around 1830, as historian Jared Sparks prepared to write his biography of Washington,48 he tracked down Caroline Branham, who was at that time owned by Washington's grandson. The elderly woman gave Sparks the last eyewitness account of George Washington's death in exchange for the freedom of her enslaved grandson.49 As a free man, the grandson, Robert Robinson, left a menial job in a cracker bakery, educated himself, and moved to Alexandria, near Mount Vernon, where his grandmother had lived as Washington's slave. Appointed minister of the Methodist Church on South Washington Street, he became an influential African-American leader.

In considering the final illness of George Washington, it is worth remembering that he received prompt and expert medical care that reflected then-current concepts. In questioning his physicians' treatment decisions, we should also reflect on the balance between art and science in medicine, especially in the context of modern therapy for diseases whose pathogenesis and natural history are poorly understood (e.g., atherosclerosis and diabetes mellitus). In 1999, the treatment of many medical conditions still lacks a sound scientific or empirical basis. Advances in science permit us to uncover pitfalls in prior medical practice but do not by themselves advance the art. Thus, physicians must not only continue to develop the science of medicine but also maintain and strengthen its problem-solving aspects and practice as an art.

The last 16 hours of Washington's life must have been agonizing as he fought for air, unable to find a comfortable position. His chief concern was apparently that his physicians "enable him to die easy."50 Though not a Christian, he must have been impatient to reach a "hereafter" with as little trouble as possible. According to Lear's notes, at the very end, Washington settled back in bed and appeared calm. His last act in life was a medical one: he felt his own pulse, a practice that he had probably picked up in ministering to his slaves and family. Not even his physicians learned the result as his fingers slipped from his wrist and his breathing stopped.

David M. Morens, M.D.
University of Hawaii
Honolulu, HI 96822

A bibliography (244 entries) on the death of George Washington and related subjects addressed in this report is available from the author on request. (Please provide a complete address, including e-mail address.)

I am indebted to Mary V. Thompson and Barbara McMillan of the Mount Vernon Ladies' Association of the Union; Stephen J. Greenberg, Elizabeth Tunis, and the staff of the History of Medicine Division, National Library of Medicine; George K. Combs of the Lloyd House, Alexandria Library; Virginia M. Tanji of the University of Hawaii; Erlinda Tacadena of Tripler Army Medical Center; Ratna Soetjahja Morens; and numerous staff members at the Library of Congress for research assistance; to Robert J. Littman for translating important passages from the Latin; and to Philip K. Wilson and Peter R. Henriques for valuable suggestions on the manuscript.

Source Information

University of Hawaii
Honolulu, HI 96822


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2. A comparative critique of Washington's last illness. In: Carroll JA, Ashworth MW. George Washington. Vol. 7. First in peace. New York: Charles Scribner's Sons, 1957:637-53. (Appendix VII-2.)

3. Wilson W. George Washington. New York: Harper & Brothers, 1897: (plate illustration follows page 304).

4. Harding WG II. Oral surgery and the presidents -- a century of contrast. J Oral Surg 1974;32:490-493. [Medline]

5. (Taken in shorthand by T. Carpenter.) A report of an action for a libel, brought by Dr. Benjamin Rush, against William Cobbett, in the Supreme Court of Pennsylvania, December term, 1799, for certain defamatory publications in a news-paper, entitled Porcupine's Gazette, of which the said William Cobbett was editor. Philadelphia: W.W. Woodward, 1800.

6. George Washington's invisible corpse and the beaver hat. In: Laderman G. The sacred remains: American attitudes toward death, 1799–1883. New Haven, Conn.: Yale University Press, 1996:15-21, 180.

7. Fontanes L-J-P. Éloge funèbre de Washington, prononcé dans le temple de Mars, le 20 pluviôse, an 8. Paris: H. Agasse, 1800.

8. Craik J, Dick EC. From "The Times [and District of Columbia Advertiser]," a newspaper printed in Alexandria (Virginia), dated in December, 1799. Med Repos 1800;3:311-2.

9. Boyd TM. Death of a hero, death of a friend: George Washington's last hours. Virginia Cavalcade 1984;33:136-43.

10. Brickell J. Observations on the medical treatment of General Washington, in his last illness, addressed to his physicians Messrs. Craik and Dick. In: Porcupine P. The Rush-Light. No. II. New York: William Cobbett, February 28, 1800:81-5.

11. Reid J. Observations on the medical treatment of General Washington's last illness. Med Phys J 1800;3(January–June):473-5.

12. A note to Dr. Dick. In: Porcupine P. The Rush-Light. No. II. New York: William Cobbett, February 28, 1800:85-6.

13. Porcupine P. The American Rush-Light; by the help of which, wayward and disaffected Britons may see a complete specimen of the baseness, dishonesty, ingratitude, and perfidy of Republicans, and of the profligacy, injustice, and tyranny of Republican governments. London: J. Wright, 1800.

14. Lloyd JU. Who killed George Washington? Eclectic Med J 1923;83:353-6, 403-8, 453-6.

15. Marx R. A medical profile of George Washington. American Heritage 1955;6:43-7, 106-7.

16. Pirrucello F. How the doctors killed George Washington. Chicago Tribune Magazine. February 20, 1977.

17. Jackson J. Memoir on the last sickness of General Washington and its treatment by the attendant physicians. (Privately printed), 1860.

18. Solis-Cohen S. Washington's death and the doctors. Lippincott's Monthly Magazine 1899;64:945-52.

19. Reflections on blood-letting. In: King LS. Medical thinking: a historical preface. Princeton, N.J.: Princeton University Press, 1982:227-44, 327.

20. Therapeutic change. In: Warner JH. The therapeutic perspective: medical practice, knowledge, and identity in America, 1820–1885. Cambridge, Mass: Harvard University Press, 1986:83-161.

21. Nydegger JA. The last illness of George Washington. Med Rec 1917;92:1128.

22. Of the quinsy, or cynanche. In: Cullen W. First lines of the practice of physic. Vol. 1. Chapter 5. Edinburgh, Scotland: C. Elliott, 1784:278-306.

23. Brown G. Disputatio medica inauguralis de cynanche phlogistica. Edinburgi, Scotland: Balfour, Auld, et Smellie, 1770.

24. Rush B. (Unfound newspaper article on cynanche trachialis [sic]). In: Corner GW, ed. The autobiography of Benjamin Rush: his "Travels through Life" together with his Commonplace Book for 1789-1813. Westport, Conn.: Greenwood Press, 1948:82.

25. Observations on the cynanche trachealis. In: Rush B. Medical inquiries and observations. Vol. 2. 3rd ed. Philadelphia: Thomas and William Bradford et al., 1809:373-81.

26. Washington's physicians, diseases and death. In: Blanton WB. Medicine in Virginia in the 18th century. Richmond, Va.: Garrett & Massie, 1931:297-312.

27. Marsh H. Cases of acute inflammation confined to the epiglottis. Dublin J Med Sci 1838;13:1-23.

28. Wells WA. Last illness and death of Washington. Va Med Mon 1927;53:629-642.

29. Estes JW. George Washington and the doctors: treating America's first superhero. Med Heritage 1985;1:44-57.

30. Frantz TD, Rasgon BM, Quesenberry CP Jr. Acute epiglottitis in adults: analysis of 129 cases. JAMA 1994;272:1358-1360. [Abstract]

31. Berg S, Trollfors B, Nylén O, Hugosson S, Prellner K, Carenfelt C. Incidence, aetiology, and prognosis of acute epiglottitis in children and adults in Sweden. Scand J Infect Dis 1996;28:261-264. [Medline]

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34. Katz AR, Morens DM. Severe streptococcal infections in historical perspective. Clin Infect Dis 1992;14:298-307. [Medline]

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37. Barker C. A case report. Yale J Biol Med 1936;9:185-187.

38. George Washington: 1732-1799. In: Wold KC. Mr. President — how is your health? St. Paul, Minn.: Bruce Publishing, 1948:1-17.

39. Dick EC. Facts and observations relative to the disease of cynanche trachealis, or croup. Philadelphia Med Physical J 1809(May, Suppl 3):242-55.

40. Reece RL. George Washington: his death and his doctors. Minnesota Med 1966;49:1185-90.

41. Desault PJ. Mémoire sur la bronchotomie & sur les moyens d'y suppléer en certains cas. In: Bichat M-F-X, ed. Oeuvres chirurgicales de P.J. Desault, chirurgien en chef du grand Hospice d'Humanité, ci-devant Hôtel-Dieu de Paris; ou tableau de sa doctrine & de sa pratique dans le traitement des maladies externes. Seconde Partie. Maladies des parties molles. Paris: C.Ve. Desault, 1798:212-53.

42. Scheidemandel HH. Did George Washington die of quinsy? Arch Otolaryngol 1976;102:519-521.

43. Thornton W. (Untitled manuscript catalogued as "Miscellaneous writing on sleep.") Library of Congress, The Papers of William Thornton, document page 3057.

44. Thornton W. (Untitled letter to John Marshall, dated from the City of Washington, January 2, 1800.) Library of Congress, The Papers of William Thornton, document pages 378-9.

45. Fairfax B. (Untitled letter, probably to the Earl of Buchan, dated from Mount Eagle, near Alexandria, Virginia, 18 January 1800.) Original in the Bodleian Library, Oxford, England. Accession no. RM-100. Catalog no. PS-2261. (Photostat copy at the Mount Vernon Ladies' Association of the Union, Mount Vernon, Va.)

46. Brown GR. (Letter designated "Dr. Brown to Dr. Craik," January 2, 1800.) In: Ford WC, ed. Last illness and death: the writings of George Washington. Vol. 14. New York: G.P. Putnam's Sons, 1893:243-67[257f].

47. Smith TW. Observations on the medical treatment of the croup. Philadelphia Medical Museum 1808;4:31-5.

48. Sparks J. The life of George Washington. Boston: Ferdinand Andrews, 1839.

49. The Custis family. In: Powell MG. The history of old Alexandria, Virginia, from July 13, 1749 to May 24, 1861. Book II. Richmond, Va.: William Byrd Press, 1928:241-9.

50. Corner GW, ed. The autobiography of Benjamin Rush: his "Travels through Life" together with his Commonplace Book for 1789-1813. Westport, Conn.: Greenwood Press, 1948:245-9.

Posted by pking
Aug. 01, 2007