Wednesday, January 13, 2021

No, Rush did not trudge, and other liberties Powell took with facts in Bring Out Your Dead

In his 1949 history of the 1793 epidemic, Bring Out Your Dead, J. H. Powell begins his narrative on page 8 with a description of Dr. Benjamin Rush on his way to see a patient on August 19: "Rush turned down Walnut Street, passed Judge Peters' fine place on the corner, and began to purposefully stride toward the river."

In an autobiographical essay written in 1800, Rush answered a question often put to him. How did he find the time to accomplish all he had done? He listed six reasons and number five was: "By visiting my patients in a carriage, I lost but little time out of doors. I was carried to them with more quickness, and was less liable to interruptions and delays in the streets when I visited them on foot." (page 91, Corner, Autobiography of Benjamin Rush)

There is no evidence that because of the increase in his business in August 1793, he decided to walk instead. Indeed, Dr. Charles Caldwell, in his autobiography written in 18--, recalled Rush's sarcastic jokes in his medical school lecture after the epidemic. Rush had shocked his colleagues by urging them to give patients doses of ten grains of calomel and ten grains of jalap. The former was an mercury compound and the latter a root from Mexico both evacuated the body "up and down." His students, Caldwell especially, favored what was called "ten and ten." Caldwell found it effective when he treated patients with it during the epidemic. So, Rush sassed his colleagues to an appreciative audience. Caldwell remembered:

"Dr. K[uh] n ," said [Rush], "called it a murderous dose! Dr. H[od]ge called it a dose for a horse! And Dr. B[ar]t[o]n called it a devil of a dose! - Dr. Hutchinson]." he continued , “who is nearly as large as Goliath of Gath, and quite ├ís vauntful and malignant, even threatened to give me a flogging. Dr. H. flog me! -Why, gentlemen, if a horse kicks me, I will not kick him back again. But here is my man Ben " ( his coachman ) “whose trade is to beat beasts. He is willing to meet Dr. H. in my place, and play brute with him as soon as he pleases. I have that to do which belongs to a man." (page 184)

Powell has Rush "stride" on page 8, then he "trudged" on page 9, and finally "plodded" at the bottom of page 10. All the while, Ben stayed home with the horse and carriage. Of course, Powell used a well established literary technique as a convenient way to begin to describe the city. But Powell is not trying to see the epidemic through Rush's eyes. Quite the opposite, beginning on page one, Powell uses information in Rush's account of the epidemic, without attribution, and tweaks that information to make a point Powell wants to make which is often the opposite of the point Rush was trying to make.

Rush begins his account by describing the weather and diseases observed during from December 1792 to September 1793:

The weather for the first two or three weeks in August was temperate, and pleasant. The colera morbus, and remitting fevers were now common. The latter were attended with some inflammatory action in the pulse, and a determination to the breast. Several dysenteries appeared at this time, both in the city and in its neighbourhood. During the latter part of July, and the beginning of this month, a number of the distressed inhabitants of St Domingo, who had escaped the desolation of fire and sword, arrived in the city. Soon after their arrival, the influenza made its appearance, and spread rapidly among our citizens. The scarlatina still kept up a feeble existence among children. The above diseases were universal, but they were not attended with much mortality. They prevailed in different parts of the city, and each seemed to appear occasionally to be the ruling epidemic. The weather continued to be warm and dry. There was a heavy rain on the 25th of the month, which was remembered by the citizens of Philadelphia as the last that fell, for many weeks afterwards.

Rush was following a time-honored way to describe an epidemic. Hippocrates himself advised it. Rush included tables compiled by the clockmaker David Rittenhouse of the months from January to November 1793 giving the daily temperature in the morning and afternoon, wind direction and whether it was fair, cloudy or rained.

Powell's introduction used information Rush provided but not for future scientific reference. Powell shaped it to foreshadowed catastrophe. For example:: " Sweltering and dusty in the August heat, Philadelphians endured the summer ills and waited for the fall." Rush had written: "The weather for the first two or three weeks in August was temperate, and pleasant."

Powell and Rush also differ on what May was like. Rush remembered that "There were several warm days in May, but the city was in general healthy." Powell writes that May "was uncommonly wet. Day after day, a dismal driving rain, cold and relentless, poured from the northeast." The weather tables show otherwise. Only on two days was it raining all day,  May 3 and May 26. On the former day it was 60F and 63F at 7 and 2, and 61F and 66F on the latter. It rained in the morning or afternoon on several other days. All in all, a rather normal May.

Powell rarely cites sources, and he may have had several for his description of the drought. But one observation clearly came from Rush's account:

There was something in the heat and drought of the summer months, which was uncommon, in their influence upon the human body. Labourers every where gave out (to use the country phrase) in harvest, and frequently too when the mercury in Fahrenheit's thermometer was under 84°. It was ascribed by the country people to the calmness of the weather, which left the sweat produced by heat and labour, to dry slowly upon the body. The crops of grain and grass were impaired by the drought. The summer fruits were as plentiful as usual, particularly the melons, which were of an excellent quality.

Powell adjusted that curious observation into another dire foreboding: "In the great heat farmers dropped in the fields, because, the country folk said, there was no wind and the sweat dried slowly on their bodies."

Farmers recruited laborers from cities and villages to help in the harvest. The farmers didn't faint in the fields. Powell doesn't note the relatively cool temperature and never mentions the melons.

After noting the fainting farmers, Powell continues: "country folk could tell the auguries of other signs - large numbers of wild pigeons had always meant unhealthy air, and never had the city markets scene so many wild pigeons as were sold in the stalls in 1793. Strange diseases were attacking animals, diseases like the 'yellow water' afflicting horses in New Jersey and cows in Virginia."

Powell collected those auguries from Rush. On page 180 of his account, the doctor wrote: "The wild pidgeons were common during the winter of 1793 in many parts of Pennsylvania. But they have occasionally appeared in great stocks in our state in former winters, without having been the harbingers of a sickly autumn."

While Powell collected suspected harbingers for atmospherics, Rush had to take them seriously as indications of the “state of the air” which doctor since Hippocrates had blamed for diseases. Rush wrote on page 153:

...such was the state of the air in the summer of 1793, that it predisposed other animals to diseases, besides the human species. In some parts of New Jersey, a disorder prevailed with great mortality among the horses, and in Virginia among the cows, during the last autumn. The urine in both was yellow.—Large abscesses appeared in different parts of the body in the latter animals, which when opened, discharged a yellow serous fluid. From the colour of these discharges, and of the urine, the disease got the name of the yellow water.

His point was that the "state of the air" shared by horses and men might have fostered both yellow fever and yellow water. Rush suggest the same state inspired an unusual number of “moshettos.” Powell mixes mosquitoes and yellow water into his cauldron of auguries like one of the witches in MacBeth.

Powell had other accounts to glean for auguries. The Lutheran minister Henry Helmuth wrote several pages on occurrences that fated the city to have a deadly epidemic. Powell quoted only Helmuth's suggestion that “a merry sinful summer" preceded the epidemic.

For some strange reason, Powell associated the merriment of the summer with the influx of refugees from what would become the black Republic of Haiti. He had previously noted that the refugees were “guant, hungry, sickly.”

Philadelphia was a new and fresh experience for the refugees; so were they for Philadelphia. Their insouciance, their cleverness in occupations, their street games and songs, their ready adjustment, their avid participation in the cock fighting, rope dancing, gambling, taverns, theatres, and alehouses of Philadelphia contributed to give the city, in spite of the heat and drought, what the Reverend J. Henry C. Helmuth termed "a merry sinful summer."

Scholars now estimate that upwards of 2000 white refugees came with 800 slaves mostly servants. In no shape or form did Helmuth suggest that the refugees in particular had anything to do with the "sinful summer." He wrote in A Short Account of the Yellow Fever in Philadelphia for the Reflecting Christian:

Philadelphia far exceeded most of the cities of North-America, in luxury and dissipation among all classes of people. It was Philadelphia, that did not rest, until the performing of theatrical exhibitions was authorised by law. It was Philadelphia that refined so much on this species of vanity, as to erect: one of the largest houses upon the continent for theatrical exhibitions and engaged actors at a prodigious expence ; as if one house, that existed before were not sufficient to ruin our young people,too much neglected already. It was Philadelphia that imported from luxurious Europe, the number of 70 or 80 actors and retainers to the stage, who actually arrived here exactly at the time, when the fever raged with the utmost violence. It was Philadelphia, that contained those parents who had given willingly 300 dollars to obtain a perpetual right of free access with wife and children to the plays, in order to obliterate in their hearts all taste for what is serious and useful, I will not say godly and heavenly....
It was Philadelphia, that during the whole of last summer was so eager to fee the rope-dancing and other mews exhibited in the city, that one hardly knew how to pass along, for the immense number of people, who were either going to these diversions or returning therefrom. Many a one carried thither, that money which he wanted exceedingly for the support of his family. Most of them distracted their hearts, there in such a manner, that on the following Sunday they either did not go to church at all, or else could have no benefit from the explanation of the word of God, every part of their minds being so filled with those follies, that it was impossible, that any thing serious could find room therein. After such a merry, sinful summer, by the just judgment of God, a most mournful autumn followed, which commenced when the much esteemed and celebrated Circus was hardly closed.
Powell not only neglects those signs that the godly could easily interpret as boding ill for the city, he ignores the campaign to ban theatrical entertainment that was mounted immediately after the epidemic.

Powell uses Helmuth's account in his description of visits to the sick at the peak of epidemic. Like Rush, Helmuth also trudged:

Through the awful loneliness of the night, the Reverend J. Henry C. Helmuth trudged 'with a trembling heart' going from one victim to another, raising a fearful din in the city as he raised a door knocker, radiating a saintly calm as he entered a sickroom, facilitating many a passage into eternity. Down streets empty as a wasted desert... hear no sound but the doleful creaking of the dead cart as it went on its ceaseless rounds.

To begin with, in his account, Helmuth uses the phrase "with a trembling heart" not to describe himself but a man fleeing Water Sreet, where the fever first struck the city in August: "he would go with a trembling heart and hasten away." Helmuth doesn't mention a "door knocker," or "desert" but does mention the dead cart: "the constant going backward and forward of the dead-cart, especially its doleful noise in the night time...."

To be sure, despite a "trudge" here and there, Powell sweeps us along with his narrative, but especially in the 18th century religious writers were practiced at stopping the narrative with images to make the reader reflect. "The constant going backward and forward of the dead-cart" does that, while "ceaseless rounds" doesn't.

Helmuth only uses the word "eternity" three time and not in the context of his "facilitating many a passage into eternity." Powell uses that cliches phrase to dodge describing what pastoral care Helmuth did give.

In Bring Out Your Dead, a phrase which Helmuth nor anyone else reported ever hearing in Philadelphia, Powell hails the ad hoc civic response but devotes only a few pages to what for many was an intense religious experience. Powell graduated from Swarthmore College, a premiere Quaker liberal arts college that has a manuscript collection of letters from Quakers who suffered through the epidemic. Despite that, Powell ignores the Quaker response to epidemic, not even mentioning their Yearly Meeting held in Philadelphia in September. He shows scant interest in the response of other denominations. The Lutherans get more space because Helmuth's account provided grist for Powell's secular mill.

That ignoring religion likely pleases modern readers doesn't make Bring Out Your Dead good history. Merely quoting first hand accounts doesn't make good history either, which brings us back to Rush striding, trudging and plodding on August 19. He was going to consult with Drs. Hodge and Foulke about one of their patients. Between the time Rush's walk changed from a stride to a plod, Powell has him thinking about his recent cases, which, Powell writes, Rush had found to be “puzzling medical problems.”

Since people in the 18th century had no concept of viruses and did not know that mosquitoes spread yellow fever, it is easy for a 20th century historian to describe them as puzzled. We are almost certain that they had no cure or preventative for the disease. There is still no cure and a vaccine is the only preventative. From that almost sure ground, we can belittle anyone who confronted the epidemic, but even if Rush was putting on a brave front to hide his nagging doubts, a historian should at least show us that brave front.

In his account, Rush didn't allude to being puzzled. He wrote: “None of the cases which I have mentioned, excited the least apprehension of the existence of a yellow fever in our city; for I had frequently seen sporadic cases in which the common bilious fever of Philadelphia, had put on symptoms of great ma|lignity, and terminated fatally in a few days, and now and then with a yellow colour on the skin, before, or immediately after death.

Beginning in the mid-20th century, infectious diseases were exceptional. In the 18th century they ruled.

Only Rush left an account of his consultation with Hodge and Foulke. He wrote:

On the 19th of [August] I was requested to visit the wife of Mr Peter Le Maigre, in Water-street, between Arch and Race-streets, in consul|tation with Dr Foulke and Dr Hodge. I found her in the last stage of a highly bilious fever. She vomited constantly, and complained of great heat and burning in her stomach. The most powerful cordials, and tonics were prescribed, but to no purpose. She died on the evening of the next day.

Upon coming out of Mrs Le Maigre's room, I remarked to Dr Foulke and Dr Hodge, that I had seen an unusual number of bilious fevers, accompanied with symptoms of uncommon malignity, and that I suspected all was not right in our city.

Dr Hodge immediately replied, that a fever of a most malignant kind had carried off four or five persons within sight of Mr Le Maigre's door, and that one of them had died in twelve hours af|ter the attack of the disorder. This information satisfied me that my apprehensions were well found|ed. The origin of this fever was discovered to me at the same time, from the account which Dr Foulke gave me of a quantity of damaged coffee which had been thrown upon Mr Ball's wharf, and in the adjoining dock, on the 24th of July, nearly in a line with Mr Le Maigre's house, and which had putrefied there to the great annoyance of the whole neighbourhood....

Upon my leaving Mrs Le Maigre's, I expressed my distress at what I had discovered, to several of my fellow citizens. The report of a malignant and contagious fever being in town, spread in every direction....

Powell recounts the conversation as Rush described it, and then throws a lightning bolt: "The news brought Rush up short, and he seized upon it avidly. All his patients... had been in this neighborhood. infections could obviously be traced to the noxious effluvia of the rotting coffee." Several sentences on, Powell sums up: "There in Cathy LeMaigre 's parlor, he had his revelation. He did not hesitate to pronounce the disease the bilious remitting yellow fever." Powell then has Rush go to tell Mayor Clarkson and Governor Mifflin. (With such dire news to spread, this would have been a good time for Ben and his carriage to appear.)

According to Rush, he had more thinking to do:

After this consultation I was soon able to trace all the cases of fever which I have mentioned to this source. Dr Hodge lived a few doors above Mr Le Maigre's, where his child had been exposed to the exhalation from the coffee for several days. Mrs Bradford had spent an afternoon in a house directly opposite to the wharf and dock on which the putrid coffee had emitted its noxious effluvia, a few days before her sickness, and had been much incommoded by it. Her sister Mrs Leaming had visited her during her illness, and probably caught the fever from her, for she perfectly recollected perceiving a peculiar smell unlike to any thing she had been accustomed to in a sick room, as soon as she entered the chamber where her sister lay. Young Mr M'Nair and Mrs Palmer's two sons had spent whole days in a compting house, near where the coffee was exposed, and each of them had complained of having been made sick by its offensive smell, and Mr Aston had frequently been in Water-street near the source of the exhalation.

This discovery of the malignity—extent—and origin of a fever which I knew to be highly contagious, as well as mortal, gave me great pain. I did not hesitate to name it, the Bilious remitting Yellow Fever. I had once seen it epidemic in Philadelphia, in the year 1762....

Rush left us four sources of information on the epidemic: his account published in February 1794, his letters to the newspaper, his brief clinical notes, and his letters to his wife. She and some of their children were spending the summer at her brother's place in Princeton, New Jersey, the family's usual summer retreat. Rush wrote to her on August 21with an addendum in the morning of the 22d. He did not sound like the man Powell described on August 19:

To prevent your being deceived by reports respecting the sickliness of our city, I sit down at a late hour, and much fatigued, to inform you that a malignant fever has broken out in Water Street, between Arch and Race Streets, which has already carried off twelve persons within the space which has been mentioned. It is supposed to have been produced by some damaged coffee which had putrefied on one of the wharves near the middle of the above district. The disease is violent and of short duration. In one case it killed in twelve hours, and in no case has it lasted more than four days. Among its victims is Mrs. LeMaigre. I have attended three of the persons who have died with it, and seven or eight who have survived or who are I hope recovering from it.

As yet it has not spread through any parts of the city which are beyond the reach of the putrid exhalation which first produced it. If it should, I shall give you notice, that you may remain where you are till you receive further advice and information from me. The influenza continues to spread, and with more violent symptoms than when it made its first appearance. I did more business in 1780 than I do at present, but with much less anxiety, for few of the diseases of that year were attended with any danger, whereas now most of the cases I attend are acute and alarming, and require an uncommon degree of vigilance and attention He added a P.S.: “John [their son] should come home as soon as his vacation expires.”

He does not use the words “yellow fever.” He recalls 1780, not 1762. Rush wrote a short account of the 1780 epidemic. That August there were several days when the temperature was about 90F. Laborers died in the heat. Then it turned cold on the 19th and a fever swept the city that was commonly called “the break-bone fever.” Dengue fever which is spread by the same mosquito that carries yellow fever is still commonly called break-bone fever. Fortunately, few died of the fever.

Back to 1793: It is not certain when Rush did his epidemiological research that tied his recent cases of malignant fever to the rotting coffee, but the letter suggests that he did not do it not while with his colleagues on the 19th. The letter also suggest that he was not trying to prove how the disease had spread but to show that those who got it had been exposed to the smell. He first was pleased with that limit on the disease. Only in retrospect, did that initial research prove how insidiously the disease spread. There is no mention of seeing the mayor or governor. 

A revelation is the sudden realization of what should have already been apparent. It can be at once gratifying and embarrassing. Judging from what he wrote on the 21st, Rush did not have a revelation. The fevers he treated at the beginning of August were not puzzling, but the LeMaigre consultation gave him a clearer understanding of what was going on and good reason to advise people to stay away from that block of Water Street. But in his mind at the time, it wasn't even an augury of a city wide epidemic. He was waiting for more information including how several patients would respond to treatments he recommended. Confirmation that there was a dangerous epidemic came so quickly, within 5 days, that Rush was certainly justified in highlighting his assessment of the situation on the 19th in his account of the epidemic. 

But a historian has to account for his equivocal letter to his wife. Powell doesn't do that. He also doesn't simply congratulate Rush for having the “revelation.” He takes what only can be described as a sentimental digression.  

Powell keeps harping on the presence of the refugees from St. Dominque. He is certain they brought the disease to the city, and, like most modern commentators, scoffs at the anyone blaming rotting coffee. He turns the clock back two weeks and describes what were the first two documented cases on Water Street. Philip Syng Physick made notes of the autopsy of the first victim, an Englishman, who died the day the doctor came. He feared that he might have been poisoned. Isaac Cathrall made notes of the symptoms an Irish woman, who roomed one door down from the Englishman, suffered over four days before she died. On August 5th, while Cathrall was treating his patient, Rush visited the dying child of Dr. Hodge who lived across the street. Powell writes: “If only Rush had stumbled into Cathrall back on August when he went up Water Street to see Dr. Hodge's child!” 

Powell suggests that class differences kept Rush from hobnobbing with refugees, French sailors, poor folk on Water Street, and the doctors like Cathrall who treated them. He gives Rush a character of which his contemporaries were completely unaware. Powell did not report on what Rush did on August 22. He sat at the head table for the dinner celebrating raising the roof on the new African Church. On the way, he had fresh melons sent to the prisoners in the jail nearby who were watching the work on the church all to remind them that God cared for them too. Rush prided himself for helping the dispossessed.  

Powell also assumes that Rush was loath to associate with young doctors. That is more nonsense. Both Cathrall and Physick had recently earned their M. D.s at Edinburgh just as Rush had. Such shared experiences always create a bond. He mentions both in his account of the epidemic using information from autopsies they performed on fever victims.  

Cathrall wrote a monograph on yellow fever in October 1794 in which he pinpoints French sailors, not refugees, as the source of disease. He also explains why the first cases of the epidemic were misinterpreted: “During the first two weeks of it's appearance in this city, it was almost entirely confined to that part of Water-street where it commenced; and the inhabitants of that neighbourhood were seized in succession. For the first ten days there were seldom two attacked with the disease in the same house, which induced some to think that it was not contagious;...” Neither the Irish woman's husband nor their two daughters got sick.  

In August, Cathrall shared his observations with an older doctor. Powell makes Dr. William Currie a bit of a hero because he became one of Rush's most persistent critics. Currie wrote a monograph about the deaths on Water Street and had it at the printers on September 3. While he didn't treat a patient there he talked with Cathrall and put his case notes in his monograph, He talked with Physick and summarized his autopsy report. He talked to the Catholic priest who attended some of the dying. He talked to the daughters of the owners of the boarding house. Their parents were the next to die there. He could not find the French physician who treated one of the sailors who died. At that early date, he stubbornly resisted having a revelation: “That the disease made its first appearance in the house already mentioned, is clearly established; but whether it was imported and introduced there by the Irish family, or by the French lads, or was generated there, I have not been able to collect a sufficiency of evidence to determine.” 

Evidently, none of the West Indian refugees in Philadelphia showed symptoms of yellow fever, none died of it. As the epidemic wore on, they demoralized others by walking the streets with impunity. Previous exposure to the disease had given them immunity. Blaming them for the epidemic, as Powell insists doctors should have, would have created a useless, if not dangerous, horror. With their superior knowledge, historians should be careful what they wish. Rush's theory blaming the rotting coffee is a more accurate assessment than Powell's. 

The problem then and now are the mosquitoes. One species, the Aedes aegypti, which has never been identified as endemic to Philadelphia, spreads the disease. It has a short range and breeds in relatively clean water. So both sides of the argument were partially right. Those mosquitoes were probably imported in the casks of fresh water always found on sailing ships. Enough of the those moquitoes sucked the blood of passengers, probably sick sailors and not refugees who were immune by prior exposure, and then within a radius of 500 feet began infecting people on shore. In the first two weeks they went as far as the smell from that coffee. Especially after the heavy rain on August 25, they found places to breed throughout the city. Many contemporaries intuitively understood that. The doctors, Rush included, can be faulted for debating the issue, but even they waited until after the epidemic. 

The newspaper editor Matthew Carey came out with the first instant history is early November. While composing it, he asked Rush what evidence he had that the fever had been generated in the city. Rush promised to get the evidence to him. Mercifully, the likes of Powell were not on the scene. The 800 people of color, truly of all shades, who had just landed, would have taken the brunt of the city's anger. The reaction to the epidemic would have been another racist stain on American history. 

That rain on the 25th was widely misinterpreted at the time. Powell has doctors “trudging through the fury of the northeast storm,” while almost everybody else packed up, closed their houses and “a huge throng...streamed out to the country.” If he had only read the letters left by Quakers still to be found in the Swarthmore and Haverford College libraries!  

The Quaker merchant Benjamin Smith on Front Street, just up from Water Street, was recovering from the influenza. All that remained of it was a troublesome cough. His wife Debby seemed to be coming down with the same bug. At least he was well prepared to be her physician. He would see that she soaked her feet in hot water, sipped chamomile tea until it brought on a sweat, drank plenty of "gruel water" and kept her body "open" with purging salts. Then that evening, Debby's fever became worse and she complained of "a violent pain in the head." Smith sent for Debbie's mother, Margaret Morris, who gave her Peruvian bark which seemed to lessen her attack and by morning she seemed out of danger. Margaret also opined that the rain would rid the city of sickness. They didn't pack up and leave the city.


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