Some Observations On Responses To Disease Epidemics In The United States In The Eighteenth And Nineteenth Centuries

Disease epidemics are not new to the American scene.  In fact, of all the historic threats to national and local security, they are the type with which we probably have the most experience.  During the eighteenth, nineteenth, and early twentieth centuries, the United States faced and dealt with outbreaks of scarlet fever, yellow fever, cholera, smallpox, tuberculosis, malaria, and influenza.  And while the innovations of medical science were often insufficient to banish these plagues, the people handled such infections with the tools available at their disposal.  National economic life did not grind to a halt; communities were not paralyzed by fear; the press did not consciously stoke the flames of hysteria; and the political system did not descend into bickering, factionalism and recrimination.  Diseases were understood to be part of the natural order of things, to be confronted with resolution and grim determination while the rhythms of life continued to strum.

Among men of science in the nineteenth century, there prevailed an attitude not of resignation and defeat, but of optimism and confidence.  Consider, for example, these extraordinary introductory paragraphs to John B. Davidge’s An Essay on the Disease Called Yellow Fever, with Observations Concerning Febrile Contagion, Typhus Fever, Dystentery, and the Plague, which was published in Baltimore in 1821:

Whatever obstructs the progress of science, or throws a shade over the research of philosophy, is a subject of fair and legitimate criticism.  Truth, physical, moral, or political, is the common property of society; and every member of the literary whole, may, according to taste and ability, enlarge its bounds, or promote its interests.  Where motive is ingenuous, it is commendable; and manner, though awkward, may be pardonable.  But before we write, we should think; and before we publish, we should at least understand the nature, if not the extent of the subject, on which we are about to admonish the world. The public, however ready to learn, is impatient of unprofitable intrusion.  Vanity may invite derision, but knowledge alone communicates information…

Nature, in her general scheme, is uniform; otherwise ruin would invade the universe.  But one part of nature may fall into collision with another part, and the regularity and uniformity of particular laws be disturbed.  In lifeless nature, we style such disturbance and irregularity disorder, or disarray.  In enlivened nature, we denominate such disturbance of function, or alteration of structure, disease.  And although disease be not a part of the natural healthy functions of the body, yet it must be viewed as the natural result of agents acting on these functions.

The nobility of the tone conveyed bespeaks the optimism of the era.  We will focus our attention here on past outbreaks of cholera and yellow fever, with references to other diseases as appropriate.

Yellow Fever

The “saffron scourge” is an insidious disease.  Fever and chills are accompanied by a yellow color that spreads over the skin.  While two thirds of the infected would recover, the remainder would suffer organ failure and slip into a coma.  The disease apparently did not exist in the Americas before the advent of Columbus.  By the early 1700s it had made appearances in Philadelphia (1699), Charleston (1699), and New York (1702).  Philadelphia suffered a severe yellow fever epidemic in 1792 that left over 8% of the population dead (5,000 out of 60,000).  At that time, Philadelphia was the nation’s capital.  President Washington handled the crisis coolly; he recommended that key government offices be removed from the city until the outbreak had subsided.  Although a quarantine was established, it did little to control the progress of the disease, since it was not understood until 1900 that the fever was carried by mosquitoes.  At the time, it was believed that unsanitary conditions and rotting garbage were the sources of the contagion.  Alexander Hamilton contracted the disease and relocated to upstate New York; he was at one point forced to stay under armed guard until his carriage had been disinfected and his personal baggage burned as a precaution.

However primitive may have been the efforts to control the outbreak in Philadelphia, there was at least an observable response by the authorities.  Communities dealt with the situation as best they could, and life went on.  One of the best first-hand narratives of the contagion is Dr. Benjamin Rush’s An Account of the Bilious Remitting Yellow Fever, as It Appeared in the City of Philadelphia in the Year 1793.  Rush was a professor at the University of Pennsylvania, and his book was published in 1794.  He noted the following recommendations made by the College of Physicians to control the epidemic:

THE college of physicians having taken into consideration the malignant and contagious fever that now now prevails in this city, have agreed to recommend to their fellow citizens the following means of preventing its progress.

1st.  That all unnecessary intercourse should be avoided with such persons as are infected by it.

2nd.  To place a mark upon the door or window of such houses as have any infected persons in it.

3rd.  To place the persons infected in the centre of large and airy rooms, in beds without curtains, and to pay the strictest regard to cleanliness, by frequently changing their body and bed linen, also by removing as speedily as possible, all offensive matters from their rooms.

4th.  To provide a large and airy hospital, in the neighbourhood of the city, for the reception of such poor persons as cannot be accommodated with the above advantages in private houses.

5th.  To put a stop to the tolling of the bells.

6th.  To bury such persons as die of this fever in carriages, and in as private a manner as possible.

7th.  To keep the streets and wharfs of the city as clean as possible.  As the contagion of the disease may be taken into the body and pass out of it, without producing the fever, unless it be rendered active by some occasional cause, the following means should be attended to, to prevent the contagion being excited into action in the body.

8th.  To avoid all fatigue of body and mind.

9th.  To avoid standing or sitting in the sun; also in a current of air, or in the evening air.

10th.  To accommodate the dress to the weather; and to exceed rather in warm than in cool cloathing.

11th.  To avoid intemperance, but to use fermented liquors, such as wine, beer, and cyder, in moderation.

[p. 21 et. seq.]

These measures tell us a great deal.  They show an understanding of the following:  (1) the fact that the sick or vulnerable should be quarantined (by placing a mark on the door or window of an infected household); (2) that the authorities had an obligation to care for the public (by constructing a “large and airy hospital” for the poor); and (3) that fear and panic must be minimized by burying the dead “in as private a manner as possible.”  We see here a sense of maturity and public accountability.  What strikes the modern reader of Dr. Rush’s account is the courage with which he went about his medical duties in the crisis.  Here, for example, he recounts some of his actions:

For the first two weeks after I visited patients in the yellow fever, I carried a rag wetted with  vinegar and smelled it occasionally in sick rooms:  but after I saw and felt the signs of the universal presence of the contagion in my system, I laid aside this, and all other precautions.  I rested myself on the bed-side of my patients, and I drank milk, or eat fruit in their sick rooms. Besides being saturated with the contagion, I had another security against being infected by my patients, and that was, I went into scarcely a house which was more infected than my own. Most of the people who called upon me for advice, left a portion of contagion behind them.

Four persons died next door to me on the east; three a few doors above me on the west; and five in a small frame house on the opposite side of the street, towards the south.  On the north side, and about 150 feet from my house, the fever prevailed with great malignity in the family of Mr. James Cresson.  But this was not all.  Many of the poor people who called upon me for advice, were bled by my pupils in my shop, and in the yard, which was between it, and the street…

But life went on.  Philadelphia not only survived, but prospered.  We now turn to the case of cholera.

The Cholera Epidemic of 1873

All diseases are loathsome, but cholera stands out as a pitiless destroyer of the human form.  It begins with mild cramping, but this soon escalates to violent outpourings of fluid from the body through the rectum.  The body curls into the fetal position, into which death then freezes it.  By the 1850s, scientists new that the disease was caused by unsanitary conditions; the publication in 1849 of London physician John Snow’s On the Mode of Communication of Cholera made this clear.

The two maps above, from “The Cholera Epidemic of 1873 in the United States” (1875), show the global movement of the disease.

It took a great deal of time for municipal water departments to understand the need to keep sewage as far away from water supplies as possible.  In the 1870s, cholera originating in Asia spread to America; according to the US government’s official The Cholera Epidemic of 1873 in the United States, which was published in 1875, the epidemic originated in India, spreading from there to the Middle East, Europe, and then the Americas.  This report is remarkable in that it examined the epidemic state by state, even county by county within each state, in a systematic attempt at scientific and medical precision.  Consider the following representative passage:

An extract from the US government’s report of the cholera epidemic, showing the level of detail that was given in the collection of information.

The government’s 1875 report led to a greater focus on public hygiene.  When New York City faced a cholera outbreak in 1892, public health officials sprang into action.  According to Irwin Sherman’s study Twelve Diseases That Changed Our World, New York public health officials in September of 1892 inspected more than 39,000 tenements on the Lower East Side in an attempt to control the spread of cholera.  When a cholera case was reported, teams of sanitary workers dressed in rubber suits would appear and inspect the premises.  The dead “were wrapped in sheets saturated with bichloride of mercury disinfectant and removed for autopsy,” according to Sherman.  These kinds of measures have been derided by some as ineffective and “anti-immigrant,” but they at least showed an attempt to mount a coordinated, determined response to a public health problem.  And they likely led to an increased focus on sanitary working and living conditions among the poor.

We may mention, as a final example, the disease of influenza.  R. Russell’s Epidemics, Plagues, and Fevers: Their Causes and Prevention, published in London in 1892, states the following:

We have very good ground for supposing that, if ordinary precautions were taken, as in measles or scarlet fever, to isolate the influenza patient, and to guard above all against the infection from early cases, and against free introduction and dissemination from foreign countries, influenza would claim very few victims, and anything approaching a national epidemic would become improbable.

This is sound advice even today; had it been followed in early 2020 by some governments, the course of the resulting pandemic may have been severely curtailed.  Russell also notes that quarantine stations exist in the United States for the specific prevention of noxious diseases.  These stations included:

The main requirements for a quarantine station are held to be as follows:  1.  A boarding station, so placed as to command the channel leading to the port.  2.  A boarding steamer, fitted with hospital cabins for landing the sick, and with appliances for disinfecting in the offing ships’ hospitals with the mercuric chloride drench, and with steam, when such disinfection is found to be all that the vessel requires.  3.  A reserve steamer to replace the usual boarding steamer on emergency, and—where the station is isolated—to act as supply and mail steamer, for the forwarding of convalescents, etc.  4.  An anchorage for vessels under quarantine of observation. It should be placed conveniently for the main establishment, and safely remote from the track of commerce.  5.  A deep-water pier.  The depth of water at low tide at its end should be at least equal to the draught of the largest vessels coming to the port, with a frontage sufficient for such vessels to moor to it if required. Upon this pier there should be constructed: (a) A warehouse; (b) elevated tanks for disinfecting solutions; (c) a disinfecting house containing steam disinfecting cylinders; (d) Sulphur furnaces, engine, exhaust fans, etc., for fumigation.  6.  A lazaretto or hospital for the treatment of infectious diseases.  7.  Separate accommodation for non-infectious cases from infected vessels in quarantine.  8.  Detention houses for the detention under observation, in groups, of “suspects” or persons who have been exposed to infection.  9.  Quarters for officers and staff. 10.  Telegraphic communication with the rest of the world.  Telephonic communication between the different parts of the station.  11.  A bacteriological laboratory. 12.  A cremation furnace for the disposal of the bodies of those who have died of infectious diseases.

[p. 425]

Where are such stations today?  If they were once used, why were they dismantled?  What investment has been made in the American public health infrastructure in the past thirty, forty, or fifty years?  Has anything at all been done?  The examples in this article demonstrate that disease pandemics used to be part of the general consciousness of the American population and government in the eighteenth and nineteenth centuries.  The tools for dealing with epidemics have always been here, if only leaders would take the effort to find them.  We have only given two examples, yellow fever and cholera; we have not even discussed here the incidence of other diseases.  Yet knowledge unused for a long period of time slips from the public memory.   Ease promotes lassitude, and lassitude nurtures carelessness.  It has been over one hundred years since the last disease pandemic, which occurred in 1918.  Most Americans have no idea what real disease even is:  phrases like scarlet fever, yellow fever, whooping cough, and smallpox, mean nothing to most citizens in 2020.  They remain as remote and irrelevant as constellations in distant galaxies.

We have seen that, while science and technology was not always up to the task, there was at least an attempt to respond intelligently to virulent outbreaks in the past.  Public health officials communicated, or attempted to communicate, with local populations.  Attempts to mitigate fear and panic were made.  The national economy was not deliberately shut down; political factionalism did not play a role in outbreaks; and the print media did not engage in gratuitous fear-mongering.  City officials, state governors, and federal authorities the United States—those who craft public health policy—would be well-advised to examine the history of past disease pandemics, and take what useful lessons may be learned from them.  Maturity, courage, and resolute action from public officials are absolutely essential.  Hysteria, thoughtlessness, and panic are deadly, and may indeed be more deleterious than any viral contagion.



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