There was by no means mass flight from the city, yet. Margaret Morris lived on that same block. She had not needed Rush to tell her that something was amiss in the city. She had seen three coffins carried past her window with no or few attendants. Burials so early and so furtive were a sign of infectious disease. But she trusted that Sunday's rain would, as her son-in-law Benjamin Smith put it in a letter to his father that morning, destroy "those noxious particles which it is generally allowed have of late charged our atmosphere." Plus Margaret had an invalid sister to care for.
With his wife complaining of stomach discomfort, for which her brother Dr. John
Morris prescribed ipecac, Benjamin Smith could not take his family out of town either. He was not inclined to in any case. He wrote to his father that accounts from the city were exaggerated. It was "a very awful visitation;" the disease was so putrid "that in some instances persons still living have been deserted by their assistants on account of the smell;" many were fleeing, and some domestics left behind had been "swept away by the contagion;" one young woman was found dead that morning, "a loathsome object," but all the deaths were near Water Street between Arch and Race. He had only heard of six buried that morning, and there couldn't have been many more, surely not the "60 or 100" of flying reports.
The powers-that-be did what they could to keep citizens calm. In his letter to the governor, Hutchinson did not directly address the panic around him, but he put the disorder in a perspective that suggested that people should stay put and stay calm. He reported that he had discovered 67 people with a fever, most of them non-fatal remittents or influenza. By Monday evening 13 of them were dead. He factored in Dr. Say's experience in Kensington and admitted that "the disorder is spreading" and had reached 2nd Street.
But by his calculations only 40 had died of the yellow fever. (He also couldn't resist impugning Rush's theory on the fever's origin, and noted that Say's reports on the Kensington cases challenged the theory that miasma from rotting coffee was the cause.)
Triumphant at the meeting the day before, Rush did not take exception when Hutchinson read his letter to the College of Physicians Monday night. He would settle that score later. The college adopted both Hutchinson's letter and Rush's directions and sent them to the mayor and governor for publication in Tuesday's newspapers. Rush wrote to his wife that while he hoped the directions would do good, "I fear no efforts will totally subdue the fever before the heavy rains or frost of October," as was the case in 1762.
It is evident from newspapers and letters that preventatives were in vogue before publication of the College's directions. Margaret Morris made "a plentiful use of vinegar, onions, and a little wine between whiles." She burned tar in her rooms and put camphor in her bosom, "and strew wormwood, tansy-rue, and other strong herbs, on the beds, tables and floor of our houses."
The strategy of prevention was simple. Counteract the smells. Today we don't think of odor as being a cause of disease. Then a certain odor was thought to be the disease itself. Charles Brockden Brown lived in a little house on the southern edge of the city near the confluence of two small streams that drained into the Delaware River. From his window he saw "one flat, uniform, unsightly... marsh from which the rays of the sun exhale the most noisome and unwholesome vapors." It was an excellent place to leave in the late summer and Brown left that August for Connecticut. So Brown missed the 1793 epidemic and would not experience the terror of yellow fever until 1798 when he lived in New York City.
In his novel Arthur Mervyn, set during the 1793 epidemic, Brown described the sensation on first encountering an infected corpse: "... a vapour, infectious and deadly, assailed my senses. It resembled nothing of which I had ever before been sensible. Many odours had been met with, even since my arrival in the city, less supportable than this. I seemed not so much to smell as to taste the element that encompassed me. I felt as if I had inhaled a poisonous and subtle fluid, whose power instantly bereft my stomach of all vigour. Some fatal influence appeared to seize upon my vitals, and the work of corrosion and decomposition to be busily begun."
For the English speaking world the last deadly epidemic to register on the broad contours of culture had been the 1665 plague in London. Not surprisingly the weapons of that war were again made ready. Rush observed that a washerwoman's husband who came to the city from New Jersey had a bag of tar and a bag of camphor around his neck, "rue in his mouth and a roll of brimstone between his teeth."
Advertisements and articles in Philadelphia newspapers urged preventatives that sounded much like the nostrums with which Shakespeare was familiar. William Delaney, a druggist on North Second Street, offered "Aromatic Distilled Vinegar," warmly approved by "the most eminent physicians of the city as a useful preventative." With a "grateful and agreeably pungent" odor, it excited "spirits and temper" when "applied to the temple and nose" with a sponge. To make the concoction, as his ad explained, Delaney warmed handfuls of rue, wormwood and lavender in a pot of vinegar for 8 days, then strained it into quart bottles containing an ounce of camphor. Soon competing with Delaney's blend was the Four Thieves Vinegar that had been used by a gang that robbed every house during the 1722 plague in Marseilles without getting infected.
To rue, lavender and wormwood, were added sage, mint and rosemary. It was "digested" for at least three weeks, and garlic as well as camphor were added to the bottles.
As much attention was paid to defeating noxious urban odors at their source. Dirty streets, "if not the cause, [have] very much contributed to the present unhealthfulness of the place," argued one correspondent in a newspaper out on Monday, the day before publication of the College's directions. Another argued that the supposed malignant fever was only the influenza made more malignant by Water Street's houses "half buried underground," its "sailor taverns and huxter's shops, which are the receptacles of all kinds of filth, dirt and nastiness."
The city had no sewage system. Another writer urged that the scavengers hired by the city be required to come more than once a week so households would not store "bones, with some flesh on them, the entrails of poultry, and many other corruptive matters in a barrel, in the yard, and in some cases in cellars, where they putrefy,... sowing the seeds of death."
There was some attention paid to the actual, though entirely unsuspected, sowers of the seeds of death. One newspaper correspondent suggested that fresh pennyroyal, a weed abundant along the Schuylkill, might ward off the fever because a sprig of it was so effective in keeping away mosquitoes (a virtue of the plant that had been known to the ancient Romans.) Not that he blamed the mosquito for the fever. If pennyroyal was so powerful against that pest it "may be a good preventative against infectious disorders."
Another correspondent suggested a way to kill mosquitoes so "distressing" to the sick: pouring a cup of oil in the casks behind most houses that were used to store clean water. A most effective measure to control an epidemic spread by mosquitoes if done by everyone, evidently it wasn't. In his notebook Rush observed on August 26 that mosquitoes were very plentiful, but urged no measures to subdue them.
City and state officials made a show to encourage citizens that the epidemic was manageable. Governor Mifflin announced that he saw no reason to postpone the session of the state legislature scheduled to open on Wednesday. The State house was four blocks away from the contagion. (The governor personally lived a block farther away.)
He also wrote a rousing letter to Mayor Matthew Clarkson calling for "the most vigorous and decisive exertions of the police." The mayor must "omit no lawful measure to prevent the extension, and to destroy the evil." The state would pay for gunpowder to "be flashed through the infected streets."
There were no municipal police forces in 18th century America. When the governor called for exertions by the police, he meant all government officials, aldermen, street commissioners, market inspectors, as well as the city's two constables, who had the power to tell citizens to act. On Wednesday, well prior to its usual monthly meeting, Clarkson convened the city corporation, made up of himself and the 14 other aldermen and 30 common council members, to address the crisis. Twenty-eight of the 45 members attended, about the same as last meeting. As Clarkson explained in a letter he sent to the governor, they prodded the street commissioners to clean the streets "as much oftener as may be necessary;" instructed the officers in charge of the market to see that the market, the meat stalls especially, was cleaned and kept clean; instructed the constables to visit all wharves and report on "any offensive, noxious substances remaining there;" formed a committee to meet with the overseers of the poor to address the needs of those people who generally were the chief victims of an epidemic; and arranged for gunpowder to be flashed in the streets.
The overseers of the poor, a group of 20 men selected to distribute the money raised by the poor tax, met on Thursday and resolved to employ people in each district of the city to scout out the sick poor and alert an overseer. They pledged to provide the "care and attention of one or more physicians, appointed by the board." If necessary the sick person would be sent to a fever hospital, a house they would designate away from the center of the city where victims could get constant care.
The letters of the governor and mayor, and resolves of the overseers were in all the papers that week. The commissioners in charge of the scavengers and night watchmen were not silent either. They published, repeatedly, section XXII of the city code: householders must clean the footway and gutter in front of their houses before the scavengers came. (Federal officials took no action. President Washington lived and worked in a large house on Market Street near the corner with 6th Street. With Congress not in session he did little entertaining, and quietly reacted to the current international crisis trying to keep the country out of the war between Britain and France. Having no responsibility or power to fight the epidemic, he saw no reason to postpone his plan to leave on September 10 so that he could help lay the cornerstone of the Capitol in the new City of Washington.)
Some took exception to the official measures to fight the epidemic, especially to the College's directions. Benjamin Smith feared that quiet, seemingly secret, burials would allow the number of deaths to be exaggerated. An anonymous writer in a newspaper criticized the policy of marking the houses of victims as "unadvised and cruel," causing "unnecessary terror," that "will prevent marketing,... and restrain all commercial intercourse along the wharves."
The house the overseers of the poor found for a hospital did not please either. They chose Rickett's Circus, on the western outskirts of town, 13th and Market Streets, where a month before Rickett's equestrian exhibition had entertained hundreds from President Washington on down.
No characterization of the overseer's first seven fever patients has been written. They could have been unfortunates found in the streets, or house servants sent by families fearful of harboring the fever in their house. There were few people living near Rickett's Circus. The financier and former U.S. Senator from Pennsylvania, Robert Morris, had workmen building a colossal marble mansion at 10th and Market Streets, but he still lived next door to the President, But there enough residents scattered at the end of the city to fuel a small riot. Angry neighbors threatened to burn down the so-called hospital after three of the seven patients died. The overseers quickly agreed to shut down operations there. Carey's account of the crisis at Rickett's Circus
On Saturday a group of overseers rode out to Bush Hill, the large estate of William Hamilton about two miles northwest of the city. It had not been occupied since Vice President John Adams stopped renting it the year before. The owner was in Britain and the overseers got permission from the mayor and governor to take the house to accommodate the poor. Bush Hill was surrounded by a pine forest, not angry neighbors.
By week's end the official measures bolstered the confidence of many. Samuel H. Smith, a young Republican printer wrote to his sister, as a small cannon was being hauled through the streets and fired, that "the force of the disease" had been spent. Everyone infected had had contact with the Water Street victims. "Since proper precautions have been taken, the disease has assumed a much more harmless shape, and little, if any danger, can be rationally entertained, except where a person unnecessarily exposes himself to entering sickrooms, attending funerals, and touching or very nearly approaching the infected body." Hutchinson had explained to him that in the past two weeks only 8 people had been buried in the Arch Street church burying ground, hardly a high number for that time of year. Before 3 out of 4 victims had died, now 1 out of 3. Seventy had died and at that moment 70 had the disease. While it was true that people had fled, it was mostly families with children who could not be trusted to take proper precautions. Smith noticed "no visible diminution of the inhabitants."
Mayor Clarkson told the press that the number of deaths in August was quite in line with the usual number. The 40 who died of fever could easily have died of something else. Another writer urged citizens to look at other excesses of the season as the cause for any greater mortality, "...the quantity of melons, and other green trash of the same kind, that are at present devoured with so much keenness."
Such brave talk impressed enough state legislators to form a quorum on Wednesday, but they promptly adjourned on Thursday until Monday. One legislator from the city explained in his diary, "owing... in particular as a young man by the name of Fry is lying dead at the west end of the State House." The thought of getting a whiff of the boy, the son of the door keeper of the state House of Representatives, was too much for most members.
No one was becoming more familiar with this mortal stench than Rush, and it had him out of sorts. He had visited Fry's son on Monday. Rush saw no amelioration of the city's crisis. He wrote in his notebook that there was "great mortality from want of caution among friends and nurses." He also observed that he "felt burning in stomach after entering into infected room." When Rush's sons said they were afraid that they would catch the infection from the clothes he wore while visiting patients, he agreed and sent the boys to Trenton to stay with an uncle. A niece took baby Ben and his nurse maid out to the farm of one of Julia's cousins just outside of town. One of Rush's five apprentices, Johnny Stall, moved into the house. The doctor needed help. The knocks on his door began at 5:30 in the morning.
He was so busy that it was not until the end of the week that he was able to defend his theory of the fever's origin. In reply to Hutchinson's letter, "R" explained in Friday's American Daily Advertiser, that three of the Danish seamen ill in Kensington, whom he had treated, "received the seeds of the disease on board their ship, while she lay at or near Race-street wharf." He added that "it is no new thing for the effluvia of putrid vegetables to produce malignant fevers. Cabbage, onions, black pepper, and even the mild patotoe, when in a state of putrefaction, have all been the remote causes of malignant fever."
Rush was usually not shy about signing what he wrote in the newspapers. But at this time, he knew he was debating a point that was not really the burning question. Explaining how the fever began was important, but the task at that moment was to cure it. As with so many viral diseases, even today there is no cure for yellow fever. We do have a vaccine to prevent it. Treatment consists of trying to keep the patient quiet and taking supportive measures short of drug therapy. So in retrospect Rush's great contribution in 1793 was recognizing the existence of an epidemic and understanding how devastating it could be. He scarcely recognized that as a contribution. No one was thanking him for his perspicacity. One friend later wrote that when Rush told him to fly from the contagion, thus possibly saving his life, still he hated Rush for destroying confidence in the city.
There was no greater city booster than Rush. His many calls for reforms over the years were always couched in language lauding the city as one destined to lead the world. His inability to fill the role of civic protector seemed almost to paralyze the doctor. It was not like Rush to let his opponents lull the governor - a man of 1776 like himself - and mayor into a sense of optimism when he saw the city in mortal danger. Simply put, he could not act until he had a cure.
On Thursday, August 29th, at the nadir of his depression, he wrote an uncharacteristically gloomy letter to his wife. Rush usually did not dwell on the negative, and had a palliative for every problem. He began this letter worrying about how to pay for her board, adding "providing my life be spared - for to live a week now in Philadelphia as I now live is to be the subject of a miracle." After crossing that out, he promised to tell her if he got the fever so she could come to him, agreeing that it would be as wrong for her to desert him as it would be for him to desert his patients at the present moment.
He did not conceal the terrors of the disease from her. One patient, the stonecutter William Stiles who lived on South 3rd Street, "exhibited signs of the plague before he died." Some doctors apprehended that it was the plague, but Rush knew it wasn't, though "it comes nearer to it in violence and mortality than any disease we have ever before had in this country." He listed its various symptoms: "Sometimes it come on with a chilly fit and a high fever, but more frequently it steals on with headache, languor, and sick stomach. These symptoms are followed by stupor, delirium, vomiting, a dry skin, cool or cold hands and feet, a feeble slow pulse, sometimes below in frequency the pulse of
health. The eyes are at first suffused with blood, they afterwards become yellow, and in most cases a yellowness covers the whole skin on the 3rd or 4th day. Few survive the 5th day, but more die on the 2nd and 3rd days. In some cases the patients possess their reason to the last and discover much less weakness than in the last stage of common fevers. One of my patients stood up and shaved himself on the morning of the day he died. Livid spots on the body, a bleeding at the nose, from the gums, from the bowels, and a vomiting of black matter in some instances close the scenes of life."
He chronicled his frustrating search for a cure. "The common remedies for malignant fever have all failed. Bark, wine, and blisters make no impression upon it. Baths of hot vinegar applied by means of blankets, and the cold bath have relieved and saved some. Mrs. Chaloner owes her life to the former remedy. She caught it from her husband, who caught it in Water Street near the place where it originated. He too is upon the recovery. This day I have given mercury, and I think with some advantage. Dr. Wistar and myself consult much together, and I derive great support and assistance from him in all my attempts to stop the progress of this terrible malady. He is an excellent man, and rises in his humanity and activity with the danger and distress of his fellow citizens. I have advised all the families that I attend, that can move, to quit the city. There is but one preventative that is certain, and that is 'to fly from it.'"
The idea to wrap patients in blankets soaked with vinegar came from a 50 year old book by an obscure British army surgeon. Rush tried cold baths after he talked to Dr. Edward Stevens, who had just arrived from the West Indian island of St. Croix, where he had treated yellow fever cases. Bathing was not common in the United States and bathtubs were rare. So by cold baths, Stevens meant standing the patient in a tub and having cold water poured over the body. In one patient Rush injected bark "into the bowels every four hours." He had "buckets full of cold water" thrown "frequently" upon his patients. Three out of four died. He recollected his success in treating Polly Bradford with the mercury compound calomel, and tried that once again.
He was "baffled" by such "malignity" and "obstinacy" which he had never before observed in any disease. "Heaven alone bore witness to the anguish of my soul in this awful situation," he wrote a few months later. "But I did not abandon a hope that the disease might yet be cured. I had long believed, that good was commensurate with evil, and that there does not exist a disease for which the goodness of Providence has not provided a remedy." Indeed in an address he gave in 1787 on the objectives of the newly formed College of Physicians he alluded to the Millennium: "Many disorders, once deemed incurable, now yield to medicine. No wonder then that a general expectation prevails - that a revolution is soon to take place in favor of human happiness." Thanks to America's republican institutions he hoped that American physicians would take a leading role in the new discoveries.
Not that Rush commenced a haphazard search through the pharmacopeia of the day. Fame in his day was won by the promulgation of theories. A naval doctor named Lind who suggested limes as a preventative for scurvy labored in obscurity, while John Brown was the medical tyro of the western world. So Rush tried a new theory dictating a bold departure from accepted practice.
Despite the weak state of his patients, he would deplete them further with double the common dose of the strongest purgative, calomel. A few months later he wrote that he decided upon that course after re-reading the monograph of the doctor who inspired one of the treatments he had discarded, a vomit followed by the bark. What impressed Rush on a second reading of Dr. John Mitchell's 1747 essay on an epidemic in Virginia was not his remedies but his analysis of the disease.
For ages doctors had noted that a profuse sweat often marked the favorable climax of a fever. This favorable sweat had a special character which doctors called "natural," that is, it did not arise from any morbid paroxysms of the system. Indeed some schools of medicine held that only nature could bring on this natural sweat and that medicine was only to be used to support the patient until the "crisis." There were guides alerting physicians as to when the crisis could be expected in various fevers. Rush thought medicine could induce the crisis and the curing natural sweat.
Mitchell had performed autopsies on some of the slaves who had died in the epidemic and found the walls of the stomach coated with the putrid matter which he envisioned as arising from the fermentation of miasmata which permeated all the systems of the body. It was as if the body were sweating poison internally. Not until those poisons were removed could "sweat break out of its own accord."
Mitchell's reasoning was novel. His essay had never been published. Rush got a copy of it from Benjamin Franklin just before he died in 1790. Franklin had gotten it in answer to a
question he had posed to Cadwalader Colden, the Lieutenant Governor of New York who had written about New York City's 1742 yellow fever epidemic. Most doctors used herbal teas to induce a natural sweat, not further depletion which promised only the cold clamminess to be avoided in fevers. Indeed at the meeting of the college, Hutchinson had mentioned the rapid death of a patient of his who developed a spontaneous diarrhea. However, Rush found Mitchell's argument persuasive. As Rush would soon quote to his colleagues, "an ill-timed scrupulousness about the weakness of the body is of bad consequence in these urging circumstances."
However, Mitchell had not used a purge as strong as calomel. Rush noted that in his dissections, Mitchell often found the gall bladder and intestines filled with bile. Evidently in those cases his purges had not been strong enough. Rush had begun his career in Philadelphia as an opponent of using mercury to prepare patients, especially children, for inoculation with small pox. He thought other purges as efficacious in assuring the patient got a light case of the pox and none had mercury's side effects. Rush gained more respect for mercury, for cases other than syphilis for which it was a wonder drug, during the war. Rush worked with an army surgeon, Dr. Thomas Young of Boston, who treated bilious fevers with a dose of 10 grains of calomel
and 10 grains of jalap or rhubarb, the Mexican and Russian roots which were powerful purgatives in their own right. Young gave the dose once or twice a day until it procured a large evacuation of the bowels. Rush had argued that the large doses were unsafe but after seeing their effects, he could not consider them more dangerous than cream of tartar or Glauber's salt, a sodium sulphate compound discovered by a German doctor.
On Thursday, Rush gave doses of calomel and jalap to the Danish sailors and thought it helped them. He discussed the matter with Dr. Wistar, whose library he had been consulting and whose brain he had been picking. Both agreed that the evident excess of bile meant that the disease primarily affected the liver and so purges were in order. However, to avoid violent evacuation from an already depleted patient, Wistar wanted to use mercury as an ointment to be rubbed on the skin over the liver. That might stimulate that organ to expel poisonous bile.
Given the power of the disease they faced, much more powerful than common bilious fever, Rush wanted quicker action. He gave his apprentice Johnny Stall pills of 10 grains of calomel and 10 grains of jalap, as well as mercury ointment, and told him to give doses every 6 hours to Richard Spain, a block maker on 3rd Street with a case so malignant that a neighbor had angrily insisted that Rush instruct the family to prepare for rapid burial of the corpse. Rush had first seen him on Wednesday. That Friday Spain lay "without a pulse, and with a cold sweat on all his limbs." By the accepted canons of medicine further depletion would be tantamount to murder. Rush also gave Richard Stansbury, a Quaker teenager as badly off as Spain, calomel and jalap. By Saturday morning the boy had had 20 and the blockmaker 30 grains of calomel. Both were less delirious and had good pulses. Rush continued the dose through the day. By night Spain had a sweat.
Judging from the letter he wrote to Julia on Sunday morning, Rush was once again energized. Like a good Christian, when he was feeling all-powerful, Rush preached humility. "O! the littleness of greatness! Thrones, titles, splendid and even commodious houses, wealth, friends - what are they all when viewed through the medium of a relentless and desolating fever? Help me, my dear Julia, by your prayers to `be always ready.' I have cut out much work for my divine master, to be performed in months or years to come, but if he means to have it completed by other hands, 'his will be done.'... If I survive the present dangers to which I am exposed, what offering of gratitude will ever equal the infinite weight of my obligations to my gracious deliverer? You must help me to be more humble, more patient, more devout, and more self-denied in everything."
Go to Chapter Four
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