The Mercantile Custodian of Bush Hill

The ledger for September 21, 1793, recorded the day’s disbursements with the precision of a mercantile house: coffins, so many; lime, so many bushels; cartage, so many shillings. The numbers accumulated in their columns, orderly and remote. The clerk’s page was clean. The city was not.

Four miles north, at the abandoned estate called Bush Hill, a wagon of clean straw was being unloaded by a man in a linen shirt who had not slept in his own bed for three days. Stephen Girard directed the workers to carry the straw to the second-floor wards, where patients had been lying on bare boards because the mattresses were soaked through with vomit and sweat. The floors had already been scrubbed with vinegar. A cart had already gone to the prison for bedding, so patients would not have to lie on the floor. Now Girard stood in the yard watching the straw bales come off the wagon, counting them against the order he had placed the day before. When one bale split open and spilled its contents across the mud, he did not curse. He knelt and gathered the straw by the armful.

The contrast was total. At the committee’s rooms on the south side of the city, the epidemic was a ledger of costs and disbursements, each line item a gesture of governance at a distance. At Bush Hill, the epidemic was straw and bedding and the sound of retching and the smell of a house that had been a gentleman’s residence three weeks earlier and was now a hospital holding more than a hundred patients in various stages of dissolution. The committee kept accounts. Girard kept people.

A French-born merchant who had immigrated to Philadelphia by way of Saint-Domingue and New York, Girard had built his fortune in trade, shipping, and banking. The counting houses of Front Street knew him for exacting habits, a precise correspondence, and a trader’s clarity about the relationship between risk and return. Privateering losses and the collapse of credit markets had tested that clarity, and it had held. Not a physician, not a clergyman, not an elected official, Girard was a businessman who had stayed in the city when the federal government left, when the merchants left, when the physicians who could afford to leave did so.

The decision to stay was not, so far as the record reveals, a dramatic one. No announcement preceded it. Girard simply remained at his post, and when the Committee of Twenty, desperate for someone to take command of the failing hospital at Bush Hill, looked for a man willing to accept the appointment, he accepted. On September 15, the merchant and shipowner Stephen Girard, alongside barrel maker Peter Helm, volunteered to manage the hospital and represent the Committee personally. The committee’s minutes recorded the transfer of authority in their usual fashion, a line among lines. The estate had been commandeered as a fever hospital early in the epidemic, a rambling stone house on a hill outside the built-up city, chosen for its distance from the congested center. What the committee had not provided was a plan for running it.

Before Girard’s arrival, Bush Hill was a place of rumor and dread. Patients lay uncared for in their own filth. The nurses hired at the committee’s expense were reported to be drunk, indifferent, or themselves stricken. Food was scarce. Water was scarce. The dead and the dying occupied the same rooms. Residents of the surrounding district had complained about the smells, the carts, the sight of bodies carried out through the gates. Managers had been appointed, but they struggled to impose order on an estate designed for the leisure of a single family and now holding the sick of an entire ward.

Girard changed the nature of the place by treating it as what it was: a logistical problem. No treatises on the nature of the fever came from his pen. No debates about its origins appeared in the medical societies or the newspapers under his name. Instead, he procured supplies. He organized the wards. He separated patients by the severity of their illness, placing the convalescent in one area and the actively dying in another. A barn was converted into a convalescent facility for patients who were recovering but too weak to be discharged. Bedding was ordered from the prison so patients would not have to lie on the floor. On September 17, the managers hired nine female nurses, and Girard oversaw their assignment to the wards, ensuring that each room had a designated attendant answerable for the patients under her care.

The hiring of nurses was itself a small revolution. Before Girard’s reorganization, nursing at Bush Hill had been ad hoc, a rotation of women hired for a day or two who arrived, were appalled by the conditions, and left. Some stole from the patients. Some drank. Some contracted the fever and died. By bringing the nurses under a structured system of assignment and oversight, Girard introduced the principle that had governed his mercantile operations: reliability depended on accountability, and accountability required a chain of command. Each nurse knew which ward she was responsible for. Each ward had a nurse. The arrangement was not glamorous. It worked.

Girard’s daily presence at Bush Hill was the most striking feature of his administration. He walked the wards. He inspected the kitchens. He checked the supplies of wine, bark, and clean water. Orders went out for the procurement of fresh food, bread, and broth. When carts arrived from the committee with provisions, he signed for them in the same methodical hand that had signed for cargoes of coffee and sugar at the wharves. The hospital was his counting house now, and the patients were his ledger, and he kept the books with the exactitude he had applied to his commercial accounts.

Alongside him stood Jean Devèze, a French physician whose approach to the fever could not have been more different from that of Benjamin Rush. Where Rush bled and purged, administering mercury and jalap in quantities that left patients debilitated and gasping, Devèze prescribed rest, mild cordials, and the application of cool cloths to the forehead and wrists. Where Rush spoke of the fever as a crisis to be met with heroic intervention, a battle in which the physician must attack the disease with every weapon at his disposal, Devèze treated it as a condition to be endured, managed, and soothed. His method was palliative. The body’s own recuperative powers, if supported rather than assaulted, could carry a patient through the crisis.

Devèze had been trained in the French medical tradition, which in the late eighteenth century was moving away from the heroic interventions associated with the Edinburgh school that had shaped Rush’s education. French physicians of the period emphasized careful observation, the monitoring of pulse and temperature, and the adjustment of treatment to the individual patient’s condition rather than the application of a single theoretical framework to every case. At Bush Hill, Devèze found a setting where this approach could be practiced without interference. Girard, who was not a physician and had no investment in the theoretical disputes that divided the medical establishment, gave Devèze the freedom to practice as he saw fit. The result was a hospital that operated on principles diametrically opposed to those governing the treatment of patients elsewhere in the city.

The partnership between Girard and Devèze was never formalized in a contract or a charter. Two men found themselves in the same place at the same time and discovered that their competences were complementary. Girard handled the procurement, the staffing, the physical plant, and the finances. Devèze handled the medical decisions. Neither encroached on the other’s domain. The division of labor was clean, and it worked.

Elsewhere, the arrangement was not so clean. At the College of Physicians, the debate over the nature and treatment of the fever had produced a series of public disputes that filled the newspapers and alarmed the public. Rush had published his recommendations for mercury and bloodletting with the urgency of a man who believed he had discovered the single effective treatment. Other physicians disagreed, prescribing cooling regimens, purgatives of a milder kind, or nothing at all. The disagreements were not merely academic. Patients who changed physicians midcourse might find themselves bled by one doctor and soothed by another, the two treatments canceling each other out or, in the worst cases, compounding the damage. The medical establishment was at war with itself, and the casualties of that war were the people it was supposed to be treating.

At Bush Hill, the war was suspended. Girard’s authority over the hospital’s operations and Devèze’s authority over its medical practice created a zone of coherence in a city that had lost the ability to coordinate its own response. The committee, for its part, was grateful. The minutes recorded their approval of Girard’s management in the same flat prose they used for everything. But the approval was genuine. Girard had taken a problem the committee could not solve and solved it, not by theorizing about the nature of fever but by ensuring that patients had clean straw to lie on, nurses to attend them, and food to eat.

The committee’s own position was paradoxical. They had been appointed to manage the crisis, and they had managed it, but their management was increasingly abstract. They raised funds. They authorized expenditures. They dispatched carts for the dead and ordered coffins from the carpenters. They published notices in the newspapers. They kept the ledger. But the actual work of care, the physical, exhausting, dangerous work of tending to the sick and the dying, was being done by others. The Free African Society, under Absalom Jones and Richard Allen, had organized Black Philadelphians to serve as nurses and gravediggers, laboring under the false belief that people of African descent were immune to the fever. They were not immune. They sickened and died at rates comparable to the white population. But they worked, because the work needed doing and no one else was doing it.

Rush had personally appealed to Jones and Allen to mobilize Black Philadelphians as nurses and bearers, believing that people of African descent possessed a natural resistance to the disease. The belief was false, and the consequences were fatal for many who answered the call. After the epidemic, Jones and Allen published a refutation of censures thrown upon them in some late publications, defending their community against charges of extortion and profiteering that had surfaced in print. The very existence of the pamphlet revealed how credit and blame were being contested even as the crisis continued.

The committee’s minutes were part of that same contest. They were administrative records, but they were also a careful narration of management, a document that would, when published in March 1794, present the committee’s work as competent, transparent, and deserving of public gratitude. The minutes told the story of civic responsibility fulfilled. They did not tell the story of Black labor exploited, of medical theory imposed without consent, or of a city that had abandoned its poorest residents to die in rooms without nurses. The ledger was a form of narrative triage, selecting what would be remembered and what would be omitted.

Girard’s work at Bush Hill existed outside this framework. No defense of his conduct appeared in print. No engagement in the public disputes that consumed the medical establishment and the committee alike can be found in his record. He worked. The evidence of his work was in the hospital itself: the clean wards, the separated patients, the regular meals, the nurses at their posts, the barn converted to a convalescent ward, the straw replaced when it was soiled, the dead removed promptly and decently. His administration was not a theory of crisis management. It was the practice of it.

The philosophy that governed Bush Hill was one of material comfort. Devèze’s medical approach and Girard’s administrative approach converged on the same principle: that the patient’s experience of the illness mattered, that suffering could be reduced even when the disease could not be cured, and that the physician’s first duty was not to attack the fever but to support the patient. This was not a heroic posture. It did not produce dramatic recoveries that could be attributed to a single intervention. It was quiet, incremental, and difficult to narrate. A patient who was given clean bedding, cool water, and mild nourishment, and who survived, did not provide the same kind of story as a patient who was bled twelve times and survived. The survival could be attributed to the bleeding. It could also be attributed to the bedding.

The ambiguity was the point. No one knew what cured yellow fever, because no one knew what caused it. The vector, the mosquito, would not be identified for more than a century. In the absence of knowledge, the medical establishments of the Atlantic world had developed theories, and the theories had produced treatments, and the treatments had become the basis of professional identity and public authority. Rush’s mercury and bloodletting were interventions, but they were also arguments. Each prescription was a statement about the nature of the fever, the role of the physician, and the legitimacy of a particular medical philosophy. To challenge the treatment was to challenge the philosophy, and to challenge the philosophy was to challenge the physician.

Devèze’s palliative approach was a challenge. It did not confront Rush directly. It did not need to. Its very existence at Bush Hill, its success in a setting where patients were receiving care and surviving at rates that compared favorably to the city’s other hospitals, was an implicit refutation of the heroic method. The contrast was not abstract. It was visible. A patient at Bush Hill could see the difference between a ward where nurses attended him and a ward where he lay untended. A visitor who entered the hospital could smell the difference between a building where the floors had been scrubbed and one where they had not.

Girard’s role in this contrast was structural. Not a physician, he made no claim to be one. But he had created the conditions under which Devèze’s method could be practiced. Without the nurses, the clean wards, the regular meals, and the organized separation of patients by condition, Devèze’s prescriptions would have been words without a context. The wine and the bark and the cool cloths required a functioning institution to administer them. Girard provided that institution. He built it from the wreckage of an abandoned estate and the labor of women he had hired and supplies he had procured and a barn he had converted. The institution was not elegant. It was effective.

The effectiveness was measurable, though the measurements were imperfect. The committee’s records, when published, would show the number of patients admitted to Bush Hill, the number discharged, the number who died. The figures would be contested, as all figures in this epidemic were contested. But the broad pattern was clear. Under Girard and Devèze, Bush Hill became a place where patients were more likely to survive than they had been before. The improvement was not a miracle. It was the product of clean straw, attentive nursing, adequate food, and a medical philosophy that did not assault the body it was trying to save.

The committee, for all its careful record-keeping, could not claim credit for this. The committee had appointed Girard. The committee had authorized the expenditures. But the transformation of Bush Hill from a charnel house into a functioning hospital was not the committee’s achievement. It was the achievement of a merchant who treated a crisis as a logistics problem and a physician who treated a disease as a condition to be managed rather than attacked. Between them, they had established something the committee had not: a working institution in the heart of the catastrophe.

The sovereignty they exercised was not delegated by any constitution or statute. It was the sovereignty of competence in a vacuum. The federal government had left. The state government had retreated. The municipal government had collapsed. The committee existed as an improvisation, a body of citizens who had stepped into the space left by the flight of the official order. But the committee governed at a distance, through resolutions and expenditures and the pages of a ledger. Girard governed at close range, through the daily inspection of wards and the personal supervision of supply deliveries and the hiring of nurses and the conversion of barns. His authority was not theoretical. It was physical. He was there.

The distinction mattered because the epidemic was not, at its core, a failure of medical knowledge. It was a failure of institutions. The physicians did not know what caused the fever, but they did not need to know what caused it to provide clean bedding and adequate food. The committee did not have a plan for the crisis, but the absence of a plan did not prevent individual members from acting. The catastrophe was not that the theory was wrong. The catastrophe was that the institutions that should have provided care could not, or would not, and that the people who stepped into the gap did so under conditions of extraordinary danger and with resources that were pathetically inadequate.

Girard’s transformation from private businessman to public administrator was not a conversion in the religious sense. No crisis of conscience turned him from commerce to charity. He applied the skills he had. Supplies were procured with the same efficiency he had applied to procuring cargoes. Staff were managed with the same expectations of accountability he had imposed on his clerks. Records were kept with the precision he had maintained in his counting house. The difference was not in the method. It was in the object. He was no longer managing trade. He was managing survival.

The Enlightenment idealism that some historians have attributed to Girard’s decision to accept the Bush Hill appointment is not wrong, but it may be incomplete. A man of his age, a reader of Voltaire and Rousseau, a believer in the capacity of reason to address human problems, Girard was also a merchant. A merchant understood something that the philosophers did not: a problem of supply and demand could not be solved by theory alone. It required wagons and straw and nurses and food and wine and a man willing to stand in the yard and count the bales as they came off the cart. The merchant’s understanding of catastrophe was material. It began with what was needed and ended with what was available, and it did not waste time on what ought to have been.

The ought was the province of the medical establishment and the committee. Rush believed the fever ought to yield to depletion. The committee believed the crisis ought to yield to governance. At Bush Hill, the ought was suspended. Girard and Devèze dealt with what was. The patients were sick. They needed care. The care required nurses, bedding, food, and a physician who would not bleed them until they fainted. These things were provided. The provision was not a theory. It was an act.

The act had consequences that extended beyond the immediate survival of the patients under Girard’s care. Bush Hill became, for the duration of the epidemic, an alternative center of authority in a city that had lost its official center. The committee governed from its rooms. Rush governed from his study and his pen. The Free African Society governed from the streets and the graveyards. Girard and Devèze governed from the wards of a converted estate on a hill outside the city. Each center claimed a different kind of authority. The committee claimed the authority of civic responsibility. Rush claimed the authority of medical theory. Jones and Allen claimed the authority of labor and service. Girard and Devèze claimed the authority of competence.

The claim was not made in words. It was made in the daily operation of a hospital that worked. When a cart arrived at Bush Hill with a load of patients who had been found in the streets, the patients were taken in, examined, assigned to a ward, given a bed, and attended by a nurse. When a patient died, the body was removed and the bed was cleaned and a new patient was placed in it. The cycle was relentless. It required the kind of stamina that could not be sustained by idealism alone. It required the stamina of a man who treated each day as a series of tasks to be completed and who completed them.

The epidemic was not over. The deaths continued to mount through late September and into October. The committee’s ledger grew thicker. The streets emptied further. The carts continued their rounds. At Bush Hill, the straw was replaced, the nurses attended their wards, and Devèze walked the rooms with a physician’s eye, adjusting his prescriptions to the condition of each patient, noting who was improving and who was declining, and making the small, careful decisions that constituted his method. The method was not dramatic. It was not heroic. It did not produce the kind of story that filled newspapers or inspired sermons. It simply worked.

What it produced, in the end, was a platform. The wards were clean. The nurses were in place. The supplies were adequate. The kitchen was functioning. The barn was converted. The system was running. What it needed now was the thing Girard could not provide and Devèze could not impose: a resolution of the medical dispute that had divided the city’s physicians into armed camps, each defending its method as the only method, each dismissing the other’s approach as dangerous quackery. The platform at Bush Hill was ready. The question was what would fill it.

Girard stood in the yard at Bush Hill and watched the last bale of straw carried through the door. The wagon driver waited for his receipt. Girard signed it, folded it, and placed it in his coat pocket. The pocket already held a list of supplies needed for the following day: more wine, more bark, more bread, more nurses. The list was in his own hand. It was the hand of a merchant, and it was steady.