and The Risk of Dying
This is a study of the incidence of epidemic disease in Philadelphia from 1699 to 1799. A general discussion of epidemiology in eighteenth century Philadelphia precedes the review of individual diseases. Contemporary accounts of diagnoses and treatment are included when such are available. Comparison mortality and risk of dying during epidemic and non-epidemic years appears in the summary.
Epidemics contributed to the difficulties of survival for the first settlers in British America and later hampered the growth of the American colonies.1 Epidemics struck with relentless regularity, leaving a train of death and debility in their wake. The cyclic waves of disease can be explained in part by poor understanding of the causes which led to inept or erroneous therapies. Basic infection control practices such as hand washing and basic sanitation practices such as sewage disposal were not practiced. Principles of sanitation were for all intents absent. Environment, too, contributed to epidemic disease; frequently settlement sites were less than ideal, e.g. near low tide water areas, or stagnant and marshy ground. Dietary deficiencies were legion owing to the privations experienced by the immigrants on their ship passage to the new world. At least initially, these food shortages would have continued until working farms could be established and sufficient food production organized.
Philadelphia, planned by William Penn to be a spacious green country town, was born in 1682. It was settled on low marshy ground in an area where summers were and are sultry and hot. Mosquitoes naturally bred in such a suitable setting and, as we have learned during the twentieth century, are vectors of some of the most devastating diseases. Benjamin Rush, a renowned physician as well as climatologist once remarked, “We have the humidity of Great Britain in the spring; the heat of Africa in the summer; the temperature of Italy in June; the sky of Egypt in autumn; the snows of Norway and the ice of Holland in the winter; the tempests of the West Indies in each season; the variable winds of Great Britain every month of the year.” 2 Philadelphia was one of the hottest and dampest towns on the American east coast.
The absence of proper sewage and waste disposal must have been singularly unsavory in itself during the summer months, but the inadequacies also invited a number of unpleasant gastrointestinal and febrile illnesses. Powell describes the Philadelphia of 1793.
Wharves jutted out into the river and cut off the current; high tide deposited rotting stuff on the banks and in the mud. Below the city were swamps, marshes, pools in clay pits, stagnant water. Most of the streets were unpaved. There was no water system, and only one sewer, under the serpentine of Dock Street. Elsewhere holes were dug, as at Market and Fourth Streets, to receive water from the gutters. These “sinks” exhaled noxious effluvia, for dead animals and all kinds of nauseous matters were hurled into them to putrefy. All the wells were shallow; citizens continually pronounced them polluted. 3
Before Penn’s second visit to the colony in 1699, people had begun to divide the large blocks in half by introducing narrow streets called alleys. The tiny, dark, airless row houses erected along them invited filth and disease. Middleton cites Noah Webster’s comment that the position and alterations made in Philadelphia doomed the city to calamity. Webster believed that the cross streets and back alleys should be destroyed. 4 In addition, Philadelphia was a port city where importation of foreign diseases such as Dutch distemper and Palatine fever came by ship with the new colonists.
Philadelphia experienced more than fifty epidemics, on average about one every two years, from 1699 to 1799. This paper traces and catalogs those epidemics, defines the diseases in terms by which they were known from a contemporary observer’s account if possible, and looks at the estimated mortality in relation to the population of the city when these figures are available.
Smallpox was a highly communicable European disease imported to the colony by the early English, Dutch, and Swedish settlers. Although officially eradicated today, it was a dreaded disease among the first several generations, easily recognized by the skin eruptions that sometimes led to pitting and scarring. The incidence of smallpox throughout the century 1699-1799 was cyclic, striking when the numbers of susceptible, unexposed individuals increased. Philadelphia experienced more than ten outbreaks during this time.
Smallpox was seasonal, usually appearing during the winter months and extending into the spring. Based on today’s statistics, classic smallpox must have resulted in a thirty percent to fifty percent mortality rate among unvariolated individuals, while variola minor, a milder form, in only one percent to 1.5 percent. It seems probable that colonial mortality closely paralleled 1950-1960 third world country rates.5 There is some indication that a more virulent type may have affected some Indian tribes, however, their decimation by smallpox may have been related to lack of seasoning or lack of natural immunity. 6,7
Smallpox was highly infectious and transmission from person to person occurred by direct contact. The disease presented with fever, headache, muscle ache, backache and arthralgias. Nausea and vomiting were often noted with onset. Between the second and fourth days, the typical smallpox skin eruptions appeared and lasted through its several stages for twelve to twenty days. Permanent pockmarks and scarring were often visible evidence of smallpox visitation. Complications might be as fearsome as the disease itself, resulting in bacterial skin infections and fatal pneumonia. 8
The treatment, once the disease was contracted, would have been optimally achieved through hygienic conditions. Prevention was obviously the best option, but variolation (introduction of the live virus to produce a mild illness) was not without danger or controversy. This new preventative carried the threat of mortality either because the illness it produced was too virulent or because people who were inoculated went about their daily business while carrying an active, albeit mild, case of the pox to all those with whom they came in contact. In 1736, John Kearsley, a Philadelphia physician and an advocate of inoculation, recognized that the procedure seemed to spread the disease. 9 Nevertheless, Doctors Kearsley, Zachary, Hooper, Cadwalader, Shippen, Bond, and Sommers continued to support inoculation 10 as did Benjamin Franklin through his newspaper.
In her diary, Elizabeth Drinker reported the inoculation of her children Sally (1763), Nancy and Polly (1765), Henry (1773) and Molly (1779) by Dr. John Redman. None of the Drinker children contracted smallpox naturally but the ordeal of inoculation meant nearly two months of illness. It began with preparation, using emetics and purges, followed by the introduction of the smallpox into an incision on both arms. In about four to five days a rash appeared, accompanied by fever and generalized illness that lasted about five to six weeks before the patient achieved full recovery. 11
The early smallpox epidemics resulted in large numbers of fatalities 12 and control in Philadelphia was difficult because of the constant influx of immigrants; 288 died in 1731 and 158 in 1736. The 1756 outbreak was rendered more serious by the presence of British troops under Colonel Bouquet quartered in the city; mortality was estimated at between 800 and 900. 13 In 1759, between 500 and 600 succumbed and another 300 died during the 1773 epidemic. 14 During the Revolutionary War, General Washington mandated inoculation for all troops in 1777 which included all Continental troops in Philadelphia. 15 From that date to the end of the century, Philadelphia was spared any further smallpox of epidemic proportions.
Elizabeth Drinker reported that her daughter, Nancy, contracted measles about October 15, 1772 and the other children succumbed shortly thereafter.
1772 October 15. Nancy has the Measles coming out on her, though not so kindly as could be wished, little Henry they are just appearing on although he has been very unwell for a week past, they are both very poorly; Sally took a dose Physick today, and seems, through Mercy bravely… Dr. Redman tends us. October 18. My dear little Henry very much oppressed, his fever very high the Measles have never come out as they should have done.
October 26, 1772. Billy has had a high Fever for 3 days past, but no Measles has yet come out. October 28. Billy very full of the Measles, little Henry continues very poorly. 16
Benjamin Rush provides a contemporary description of a measles outbreak in “An Account of the Measles as they appeared in Philadelphia in the Spring of 1789” in Medical Inquires and Observations. 17
The measles appeared in December and spread slowly throughout January. By February and March, the disease was universal in the city. The onset of measles was preceded by a gumboil and then pains in the head, swelling eyelids, toothache, nose bleeds, tinnitus, deafness, coma, and convulsions. Other symptoms noted were sore throat and hoarseness, painful cough, pneumonia-like signs, vomiting and possibly diarrhea. In general the disease interval from contact to fever was fourteen days. Fever usually began on the third or fourth day accompanied by skin rash of red blotches or eruptions like smallpox, “rubiola varioloides,” of between three or four to nine days duration. Symptoms after recession (of the rash?) included cough, hoarseness, aphonia and diarrhea. Measles were fatal to one of three children. Rush noted that measles – like smallpox – were more superficial the second time. “From these facts, I have taken the liberty of calling it internal measles, to distinguish it from those which are external. I think the discovery of this new state of this disorder of some application to practice.” 18
Rush prescribed treatments including bloodletting, vomiting, demulcent and diluting drinks, blisters, and opiates.
Benjamin Rush provided “An Account of the Influenza as it appeared in Philadelphia in the Autumn of 1789 – In the Spring of 1790 – and in the Winter of 1791” in Medical Inquiries and Observations. 19
In October 1789, Congress arrived in Philadelphia much indisposed with colds, which they ascribed to fatigue, night air and travel. The influenza rapidly spread through the city. Symptoms included the following: hoarseness, sore throat, fatigue, chills, fever, head pains, swollen eyelids, watery eyes, ear ache and possible abscess of the frontal sinus. Sneezing was universal (“no less than fifty times in a day”) 20 as was cough. Other complaints were nose bleeds, nasal discharge, loss of appetite, nausea and sometimes vomiting, limb pain – especially back and thighs, sweating and a remitting fever.
Both sexes were equally affected but it usually passed children under eight years of age. It crossed all occupations but seemed to attack those who worked out of doors more severely than those indoors; surveyors of the eastern woods suffered terribly with influenza. There was no previous disease protection and many people were reinfected. It was usually fatal only to older people, drinkers, asthmatics and those with tuberculosis.
Common treatments included bleeding, antiphlogistic medicines, cordial drinks, and diet, but no cathartics.
Rush made the following observations about influenza: 1. It was as contagious as the smallpox, 2. It spread very rapidly, and 3. Neither climate nor state of society produced any change in the disease.
Scarlet Fever and Scarlatina Anginosa
Scarlatina anginosa refers to scarlet fever with tonsillar enlargement and/or peritonsillar abscess.
William Douglass, a colonial Boston physician, is best known for his work on scarlet fever entitled “The practical history of a New England epidemical eruptive military fever, with an angina ulcusculosa, which prevailed in New-England in the years 1735 and 1736.” He estimated that 4000 people in Boston had the disease and 114 died. 21 Douglass called this disease fever with angina ulcusculosa but noted that it was also called “plague in the throat.” He said that “some died of a sudden or acute necrosis; but most of them by symptomatic affection of the fauces [throat] and neck… by sphacelations [gangrenous] or corrosive ulcerations in the fauces, or by an infiltration and tumefaction [swelling] in the chops and forepart of the neck, so turged, as to bring all upon a level between the chin and sternum, occasioning a strangulation of the patient in a very short time.” 22
Douglass noted that patients had “soreness in the throat, tonsils swelled and speckt [speckled], uvula relaxed, slight fever, flush in the face, and an erysipelas-like efflorescence on the neck, chest and extremities.” 23 It was called scarlet fever. The symptoms he described were (1) great prostration of strength, (2) listlessness, (3) chill, (4) headache, (5) nausea (6) inflamed and tumified uvula and tonsils, (7) flushed face, (8) furred tongue, and (9) fever. Flushing, he noted, receded gradually with itching and scaling of the extremities and cream colored sloughs in the throat. Douglass described three patient classes of the distemper: those who die on the first through third day of illness; those where the disease follows an ordinary course with universal dark reddish eruptions which resolve in six or seven days; and those in whom there are “consequential ails” or complications of having survived the disease. 24
The disease occurred year round and did not appear to be personally infecting like plague or smallpox. 25
Parenthetically, Rush observed in his essay on the scarlatina anginosa epidemic of 1783-1784 in Philadelphia, “A considerable shock of an earthquake was felt on the 29th of this month at ten o’clock at night, in the city of Philadelphia; but no change was perceived in the disease, in consequence of it.” 26 In December the disease abated but reappeared with great violence in January, finally disappearing altogether in the spring. The disease recurred in Philadelphia in 1786, 1787, and 1788. Rush’s treatment consisted of emetics, calomel, purges, gargles, perspiring and diluting drinks.
Without doubt, yellow fever epidemics in Philadelphia were among the most fearsome and deadly of the early American plagues. Two in particular have achieved notoriety through the writings of contemporaries as well as medical historians, those of 1762 and 1793.
Yellow fever is one of a number of the arbovirus diseases carried by arthropod vectors, especially mosquitoes and ticks, to man. Overwintering of mosquitoes can carry the virus from one year to the next, but breeding depends upon suitable amounts of rainfall. 27 Other diseases that closely resemble yellow fever are malaria, which was endemic in Philadelphia during 1699-1799; louse-borne relapsing fever, sometimes called Palatine fever because it was recognized in German immigrants; infectious hepatitis, spread by the fecal-oral route possibly through polluted wells; and leptospirosis, a spirochetal disease acquired from infected animals, sewers or abattoirs. Philadelphia physicians ceased to consider other diseases during the crisis of 1793. Benjamin Rush declared that it was a “monarchical disorder” and that it had chased influenza from the city. All diseases were treated as if they were the yellow fever. 28
Only two accounts of the Philadelphia yellow fever epidemic of 1762 were written, one by Dr. John Redman and the other by his apprentice, Dr. Benjamin Rush. On August 28, 1762, Dr. Redman saw his first yellow fever patient. The disease peaked in September and nearly ceased by the end of October. Dr. Redman believed that the fever originated in the following areas:
[S]mall back tenements, forming a kind of court, the entrance to which was by two narrow alleys from Front and Pine Streets, and where sailors often had their lodgings, to which a sick sailor from on board a vessel from the Havannah (where it then raged) was brought privately after night, before the vessel had come up to town, to the house of one Leadbetter, where he soon died, and was secretly buried; and I believe Leadbetter, with most of his family and many others in that court, soon after fell a sacrifice to the distemper. 29
Dr. Redman discussed the symptoms of the fever and his method of treatment. He used saline purgatives, cordials and wine with antiemetics to control the gastrointestinal symptoms. He used a stomach plaster throughout the illness and kept a bowl of vinegar in the patient’s room to lessen the contagion. 30
Rush published his notes on the 1762 yellow fever epidemic in “An Account of the Bilious Remitting Yellow Fever, as it appeared in the City of Philadelphia in the year 1793” in Medical Inquiries and Observations. 31
Several cases of yellow fever in August appeared to have been caused by a quantity of damaged coffee “thrown upon Mr. Ball’s wharf and in the adjoining dock…and which had putrefied there to the great annoyance of the whole neighborhood.” 32 The 1793 symptoms reminded Rush of the bilious remitting yellow fever epidemic of 1762.
In the year 1762, in the months of August, September, October, November, and December, the bilious yellow fever prevailed in Philadelphia, after a very hot summer, and spread like a plague, carrying off daily, for some time, upwards of twenty persons.
These patients were generally seized with rigors, which were succeeded with a violent fever and pains in the head and back. The pulse was full, and sometimes irregular. The eyes were inflamed, and had a yellow cast, and vomiting almost always attended.
The third, fifth, and seventh days were mostly critical, and the disease generally terminated in one of them, in life or death.
An eruption on the third or seventh day over the body, proved salutary.
An excessive heat, and burning about the region of the liver, with cold extremities, portended death to be at hand. 33
On August 24, 1793, Rush sent a letter to Dr. Hutchinson, port physician for Philadelphia, about the fever and its presumed origin in damaged coffee putrefying on the wharf near Arch Street. He wrote, “I have not seen a fever of so much malignity, so general, since the year 1762.”
The College of Physicians responded by adopting a series of eleven preventive measures for the city of Philadelphia on August 26, 1793:
- Avoid every infected person, as much as possible.
- Avoid fatigue in body and mind. Don’t stand or sit in a draft, or in the sun, or in the evening air.
- Dress according to the weather. Avoid intemperance. Drink sparingly of wine, beer, or cider.
- When visiting the sick, use vinegar or camphor on your handkerchief, carry it in smelling bottles, use it frequently.
- Somehow mark every house with sickness in it, on the door or window.
- Place your patients in the center of your biggest, airiest room, in beds without curtains. Change their clothes and bed linen often. Remove all offensive matter as quickly as possible.
- Stop the tolling of the bells at once.
- Bury the dead in closed carriages, as privately as possible.
- Clean the streets, and keep them clean.
- Stop building fires in your houses, or on the streets. They have no useful effect. But burn gunpowder. It clears the air. And use vinegar and camphor generally.
- Most important of all, let a large and airy hospital be provided near the city, to receive poor people stricken with the disease who cannot otherwise be cared for. 34
Rush noted that certain factors predisposed to yellow fever, and these he called indirect debility (fatigue, intemperance, and heat) and direct debility (fear, grief, cold, night air, wet feet, sleep, and immoderate evacuations.)
Yellow fever symptoms include hemorrhage from the nose and mouth, pain in the liver, copious expectoration from lungs, dilatation of the pupils, nausea and vomiting (black vomit), costive dry-gripes and at other times bloody diarrhea, apoplexy, coma, convulsions, inguinal and parotid swelling, and jaundice by the third to the fifth day. The fever usually remitted about the third day, but was back violently on the fourth, followed by death on the fifth to seventh day.
At first, the Rush method of treatment consisted of purging, but not mercurial, moderate bloodletting, and low diet. As the disease continued unabated into September, physicians began to dispute therapeutic effectiveness of the various regimens available. The Rush method of treatment became more aggressive, employing violent purges of mercury and jalap along with copious bloodletting, low diet, and fluids. Using Rush’s correspondence from the time of the epidemic, Holmes was able to identify fifty people who were patients and another twenty-two who were probably patients. Of the fifty, thirty-nine recovered, ten died and one was lost to follow-up. Of the twenty-two probables, twenty died and two were lost to follow-up. The combined mortality rate for these patients under Rush’s treatment was forty-two to forty-six percent. 35
Matthew Carey’s A Short Account of the Malignant Fever, Lately Prevalent in Philadelphia 36 differs from Rush’s scholarly presentation in that it is a collection of brief observations about the disease written for public consumption. The chief recommendations of the pamphlet are the burial lists compiled by churchyard, the alphabetical list of the names of the 4041 deceased and David Rittenhouse’s weather tables for August, September, October, and November 1793. Rush also used the Rittenhouse charts in his volume.
Benjamin Rush also gave accounts of the yellow fever epidemics of 1797, 1798, and 1799 in Philadelphia. In each of these, the reported symptoms were similar to those of 1793. In “An Account of the Bilious Remitting and Intermitting Yellow Fever as it appeared in Philadelphia in 1797,” the origin of the fever was traced to “foul air of a ship which had just arrived from Marseilles, and which discharged her cargo at Pine-street wharf.” 37 The fever of 1798 was also attributed in part to the coming of a ship from the West Indies. “The origin of this fever was from the exhalations of gutters, docks, cellars, common sewers, ponds of stagnating water, and from the foul air of the ship formerly mentions.” 38 In addition, Rush, as was his custom, observed the effects of weather on the course of disease.
The weather was hot and dry in August and September, during the prevalence of this fever. Its influence upon animal and vegetable life are worthy of notice. Moschetoes abounded, as usual in sickly seasons; grasshoppers covered the ground…On the 29th of September there was a white frost. Its effects upon the fever were obvious and general. It declined, in every part of the city, to such a degree as to induce many people to return from the country. In the beginning of October the weather again became warm, and the disease revived… 39
Yet again in 1799, the recurrent yellow fever was attributed to the coming of a vessel from the West Indies. In July several cases of yellow fever appeared at Penn-street near the water. Rush assumed that the disease did not spread by contagion because it gradually disappeared from the city in July and August, but he noted that the weather was dry throughout those two months and sickly animals and flies died in great numbers. “In no year, since the prevalence of the fever, was the desertion of the city so general.” 40
Yellow fever continued to plague Philadelphia into the early part of the nineteenth century.
The author, Suzanne M. Shultz is Director of Library Services Philip A. Hoover, M.D. Library York Hospital.
- I am indebted to and acknowledge the help of Jeffrey S. Pontius, PhD, Associate Professor, Department of Statistics, Kansas State University, in interpreting the statistical materials. He worked with the figures I supplied and, therefore, if there are any errors they are solely mine.
- Struthers Burt, Philadelphia, Holy Experiment (Garden City: Doubleday, Doran and Company, 1945), p. 325.
- John Harvey Powell, Bring Out Your Dead: The Great Plague of Yellow Fever in Philadelphia in 1793 (Philadelphia: University of Pennsylvania Press, 1949), p. vi.
- William S.Middleton, “The yellow fever epidemic of 1793 in Philadelphia,” Annals of Medical History 10 (1928): 434-450.
- Franklin H.Top and Paul F.Wehrle, Communicable and Infectious Diseases (Saint Louis: Mosby, 1976), p. 623-628.
- Larry L. Burkhart, The Good Fight: Medicine in Colonial Pennsylvania (New York: Garland Pub Com, 1989), p. 60-61.
- John H. Duffy, Epidemics in Colonial America (Port Washington, NY: Kennikat Press, 1972), p. 23,88
- Top, Communicable Disease, 623-8.
- Roslyn S. Wolman, “A tale of two colonial cities: inoculation against smallpox in Philadelphia and Boston,” Transactions and Studies of the College of Physicians of Philadelphia 45 (October 1978) :338-347.
- John F.Watson, Annals of Philadelphia and Pennsylvania in the Olden Time (Philadelphia: Edwin S. Stuart, 1897), p. 373.
- Elaine F. Crane, ed., The Diary of Elizabeth Drinker (Boston: Northeastern University Press, 1991), p.125-127, 147-148, 188-189.
- Gerald N. Grob, The Deadly Truth: A History of Disease in America (Cambridge, MA: Harvard University Press, 2002), p.74
- Francis R. Packard, History of Medicine in the United States (New York: Hafner, 1963), p. 88. Chap 2, p. 61-159 is devoted to epidemics in colonial America.
- Wolman, “A tale of two cities,” p. 340.
- Richard B. Stark, “Immunization saves Washington’s army,” Surgery, Gynecology and Obstetrics 144 (1977): 425-431.
- Drinker, p. 180.
- Benjamin Rush, Medical Inquiries and Observations 4th ed. (Philadelphia: M. Carey, 1815) 4 volumes. vol.2, p. 255-261.
- Rush, Medical Inquiries vol 2, p. 259.
- Rush, Medical Inquiries, vol 2 p. 265-273.
- Rush, Medical Inquiries, vol 2, p. 266.
- Howard A. Kelly and Walter L. Burrage, Dictionary of American Medical Biography; lives of eminent physicians of the United States and Canada from the earliest times (New York: D. Appleton and Company, 1928), p. 340-1.
- William Douglass, “The practical history of a new epidemical eruptive military fever, with an angina ulcusculosa, which prevailed in New-England in the Years 1735 and 1736,” New England Journal of Medicine and Surgery 14 (1825): 1-13.
- Douglass, “The practical history,” p. 2.
- Douglass, “The practical history,” p. 7-9.
- Douglass, “The practical history,” p. 9.
- Rush, Medical Inquiries, vol 2, p. 246.
- Richard L. Guerrant, David H. Walker and Peter F. Weller, Tropical Infectious Diseases: Principles Pathogens and Practice. (Philadelphia: Churchill-Livingstone, 1999), Chap 116. Thomas P. Monath, “Yellow fever,” p. 1255, 1258.
- Powell, Bring Out Your Dead, p. 92.
- John Redman, An Account of the Yellow Fever as it Prevailed in Philadelphia in the Autumn of 1762 (Philadelphia: College of Physicians of Philadelphia, 1865), p. 12.
- Packard, History of Medicine, p. 117-118.
- Rush, Medical Inquiries, vol 3, 37-193.
- Rush, Medical Inquiries, vol 3, p. 43.
- Rush, Medical Inquiries, vol 3, p. 44.
- Middleton, “The yellow fever epidemic.”
- Chris Holmes, “Benjamin Rush and the yellow fever,” Bulletin of the Hitsory of Medicine 40(1966): 246-262.
- Matthew Carey, A Short Account of the Malignant Fever, Lately Prevalent in Philadelphia Reprint of 1794 edition. (New York: Arno, 1970), p. 113-116,117,121-163, 118-120.
- Rush, Medical Inquiries, vol 4, p. 3.
- Rush, Medical Inquiries, vol 4, p. 45.
- Rush, Medical Inquiries, vol 4, p. 44-45.
- Rush, Medical Inquiries, vol 4, p. 57.