The Coffee-House Exchange and the Waterfront Stench

He was thinking about the truth. Benjamin Rush sat at his writing desk on a humid evening late in July 1793, composing a lecture on the unity of disease. All illness was one. The same morbid agent expressed itself differently depending on the constitution of the patient, the climate, the season. Fever was fever. The distinctions doctors drew between typhus and malaria and the putrid fevers of tropical ports—these were surface phenomena. Beneath them lay a single disorder of the vascular system, a single excess of bile. He had been working toward this conclusion for years, through the chaos of military hospitals during the war and the epidemics that swept the city every few summers. Now, at forty-seven, with a flourishing practice and a reputation that extended across the Atlantic, he believed he had grasped the principle that would simplify medicine and save thousands of lives.

Outside his window on Walnut Street, the city went about its business. Philadelphia in the summer of 1793 was the temporary capital of a nation still learning to govern itself, a port of roughly fifty thousand people crowded onto a narrow peninsula between two rivers. The Delaware side faced the shipping channels and the world beyond. The Schuylkill side faced the farms and mills of the interior. Most of the city’s houses stood within seven blocks of the major wharves on the Delaware. Masts rose like a forest along the waterfront. The streets smelled of tar and horses and the refuse that accumulated in gutters during hot weather. Prosperity hung in that smell, and Rush had no reason to think this summer would be different from any other.

Three blocks away, at the City Tavern on Second Street, a merchant sat with a cup of coffee and a newspaper. The American Daily Advertiser for July 25 contained a brief item reprinted from a Kingston journal: fever had appeared among the troops in Saint-Domingue, the French colony in the Caribbean. The merchant read the report with mild interest. He traded in coffee and sugar. Fever in the islands meant disrupted harvests, which meant higher prices for the merchants who could get their goods out. He made a mental note to inquire about a shipment expected from Cap-Français. Then he turned the page to a more pressing matter: the debate in Congress over the national debt.

The fever in Saint-Domingue was a colonial problem, a West Indian problem, a problem of plantations and slaves and tropical heat. Philadelphia was temperate. Philadelphia was well-drained, at least compared to the swampy lowlands of the South. The city had suffered epidemics before—the fever years of the 1740s, the outbreak in 1762 that Rush remembered from his apprenticeship—but those had been decades ago. The port was busier now, the streets cleaner, the doctors better trained. The merchant finished his coffee, paid his reckoning, and walked out into the sunshine, thinking about nothing more serious than the heat.

Near the Arch Street wharf, in a cramped room above a chandler’s shop, a dockworker’s wife lay in bed, burning. She had been fine three days earlier. Then came the headache, the back pain, the nausea. Her husband had seen similar symptoms before. August was the sickly season. People called it the bilious fever, the autumnal fever, the fever of the dog days. It passed. She was strong. She had borne four children and buried two. He wetted a cloth and laid it on her forehead. She did not open her eyes.

The city that summer was a layered thing, its life organized into distinct but permeable zones. At the top sat the federal government, still finding its footing in its Philadelphia home. President George Washington occupied a rented house on Market Street. Congress was not in session, which meant that the political class had dispersed—some to their home states, some to country houses outside the city, some simply taking the air at the fashionable boarding houses along the Schuylkill.

Below the political layer sat the commercial class: the merchants, insurers, shipowners, and brokers who gathered at the City Tavern and the coffee-houses to exchange news and negotiate deals. Their world was a web of paper and trust. A ship arriving from the West Indies carried not just sugar and coffee but also bills of exchange, letters of credit, commercial intelligence. The coffee-house was the nerve center where this information was processed. A captain walked in with a report of unrest in Paris, and the price of assignats shifted. A letter arrived from London describing a new tax on imports, and merchants adjusted their orders. The system worked because the men who operated it trusted each other and trusted the flow of information. They did not expect surprises.

Below the merchants sat the artisans and shopkeepers: the carpenters, blacksmiths, tailors, innkeepers, and small manufacturers who made Philadelphia the workshop of the new nation. Their lives were organized around craft and neighborhood. A cabinetmaker on Chestnut Street knew every other cabinetmaker within six blocks. A baker’s wife could recite the genealogy of every family on her street. They lived above their shops or in small houses nearby. They sent their children to charity schools or apprenticed them to trades. They attended the churches that anchored each neighborhood—Christ Church for the Anglicans, St. Mary’s for the Catholics, the meeting houses for the Quakers and Methodists and Baptists. Theirs was a world of face-to-face relations, of credit extended on a handshake, of reputations built over decades.

Below them, at the margins, lived the laborers: the dockworkers, carters, sailors between ships, widows who took in washing, families who crowded into the cheapest rooms near the wharves. They unloaded the ships and hauled the goods and cleaned the streets. They also lived closest to the water, in the lowest-lying districts, where the drainage was poor and the air was thick with the smell of decaying matter. The city’s refuse flowed downhill toward the river. The laborers lived at the bottom of that flow.

Layered, interconnected, humming with activity: that was the civic body of Philadelphia in the summer of 1793. The layers were not sealed. A successful merchant might marry his daughter to a shipowner’s son. A carpenter’s apprentice might rise to become a master. A laborer’s child might be sent to school and enter a trade. But the distinctions mattered. They shaped where you lived, what you ate, how you died.

Rush knew most of these layers, though he moved primarily among the top three. His patients included wealthy merchants and political figures, but also artisans and the occasional poor family from the waterfront districts. He had walked the streets near the wharves during previous epidemics. He had seen how disease could spread through the crowded rooms and inadequate privies of the poorest neighborhoods. Poverty and overcrowding created the conditions for fever, he believed; the “putrid exhalations” from decaying matter poisoned the air and entered the bodies of those who lived nearby. This was why the poor died in greater numbers. They breathed worse air.

What Rush did not know—what no one in Philadelphia knew—was that the air was not the problem. The fever that was even now beginning to spread through the rooms above the Arch Street wharf traveled by a different vector. It arrived in the blood of the mosquito, a creature so common as to escape notice. The mosquitoes that bred in the standing water of the waterfront, in the casks and puddles and discarded containers that accumulated near every dock, carried within them a virus that had crossed the ocean in the bodies of infected sailors. The virus needed only a warm body and a proboscis to spread.

The dockworker’s wife died on August 3. Her husband buried her two days later in the churchyard of St. Paul’s. The burial record listed the cause of death as “fever.” There was nothing unusual about this. People died of fever in August. The heat brought it out, or the bad air, or the excess of fruit and vegetables that some doctors blamed for the seasonal sickness. He returned to work on the docks. He had no money for mourning. Within a week, he too was sick.

By the first week of August, the pattern had begun to establish itself, though no one yet saw it as a pattern. Rush recorded in his case notes that he had treated a young man on August 7 for symptoms that included fever, headache, and vomiting. He diagnosed it as a “bilious remitting fever”—a common seasonal ailment. He prescribed a mild purge and expected the patient to recover. The young man died three days later. Rush noted the death without comment. Patients sometimes died, even under the best care.

Meanwhile, the commercial intelligence loop continued its quiet operation. The coffee-houses received reports of continuing trouble in Saint-Domingue. The slave uprising that had begun in 1791 had thrown the colony into chaos. Refugees were streaming into American ports—Charleston, Baltimore, Philadelphia. Some were planters and their families, fleeing with what wealth they could carry. Others were servants and slaves, their status uncertain. The ships that carried them also carried goods: sugar, coffee, indigo, cotton. The trade did not stop because of revolution. If anything, the chaos created opportunities for merchants who could move quickly.

A ship had arrived in late July, carrying passengers from the West Indies. The port physician, Dr. James Hutchinson, had examined the vessel and found no evidence of contagious disease. The passengers were allowed to disembark. They dispersed into the city, some finding lodging with friends or relatives, others taking rooms at boarding houses near the waterfront. No one thought to track where they went or whom they encountered. Philadelphia was a busy port. Ships arrived every day. The idea that a single vessel might carry a plague was not part of the mental framework through which merchants and officials understood their world.

Hutchinson was a competent physician, a former army surgeon who had served with distinction during the war. He knew what contagious fever looked like. He had examined the holds and the passengers. He had found nothing to alarm him. The passengers showed no signs of illness. The ship was clean. He allowed it to dock.

What Hutchinson could not see was the virus incubating in the blood of a mosquito that had boarded the ship in the West Indies and now made its home in the stagnant water near the Arch Street wharf. What he could not know was that the passengers who appeared healthy might be carrying the infection in a latent form, that the disease could take several days to manifest, that a person could seem well and still be contagious. The medical knowledge of 1793 did not include the concept of asymptomatic carriers. It did not include the concept of insect vectors. It did not include the concept of viruses at all.

The city’s newspapers, meanwhile, continued their coverage of the matters that seemed important. The National Gazette and the American Daily Advertiser debated the policies of the Washington administration. There were reports of Indian wars on the frontier, of treaty negotiations with the European powers, of the ongoing revolution in France and its implications for American commerce. Buried in the back pages of the August 6 Advertiser was a brief notice that several persons had died lately of a malignant fever in the neighborhood of Water Street. The item was three lines long. It appeared below an advertisement for a shipment of Madeira wine.

Rush read the notice. He had been hearing rumors of unusual deaths near the waterfront. He asked Hutchinson to investigate. The port physician walked through the streets near the Arch Street wharf, knocking on doors, asking about illness. What he found alarmed him. Of roughly four hundred residents, sixty-seven were sick. Twelve of them showed what Hutchinson called “malignant fevers”—fevers with the dark vomit, the yellowed skin, the hemorrhages that marked the most severe cases. He reported his findings to Rush.

Rush did not yet see the pattern. He was still thinking about bile, about the unity of disease, about the theoretical framework that would organize his practice and his reputation. The cases near the wharf were consistent with the seasonal fevers he had treated for years. The symptoms were severe, yes, but severity was a matter of degree, not of kind. He advised Hutchinson to monitor the situation. He continued his rounds.

The heat continued. August in Philadelphia was often brutal, but this August was worse than most. The temperature climbed into the nineties and stayed there. The air was thick and still. At night, people opened their windows and lay on pallets, sweating. Mosquitoes came out in clouds. They bred in the cisterns and rain barrels that collected water for household use, in the puddles that formed in the unpaved streets after rain, in the bilge water of ships tied up at the wharves. No one connected them to disease. They were a nuisance, nothing more.

Near the waterfront, the smell was particularly bad. The tanneries and slaughterhouses dumped their waste into the gutters. The privies overflowed. The refuse from the ships—rotting produce, spoiled cargo, the sweepings of holds—accumulated on the docks. In the heat, the decomposition accelerated. The air seemed to thicken with it. Residents complained, as they always complained in summer, and the city fathers promised improvements that never came. The poor, who lived closest to the stench, had no choice but to breathe it.

A neighbor of the dead dockworker’s wife fell ill on August 8. She had helped tend the dying woman in her final days. She had washed the body for burial. Now she lay in her own bed, her skin turning dark, her vomit black with blood. A doctor came—another doctor, not Rush—and prescribed bark and wine. It did no good. She died on August 12. Her husband, a sailmaker, buried her next to the dockworker’s wife. The two graves lay within a few yards of each other.

By mid-August, the deaths were coming faster. A carpenter on Front Street. A baker’s apprentice on Water Street. A sailor from a ship tied up at the wharf, who died on board before he could be carried ashore. The clustering was clear: the cases were concentrated in the narrow streets near the river, the district where the poorest residents lived in the closest quarters. But the pattern was still obscured by the noise of ordinary summer mortality. People died of many things in August. The heat killed the old and the weak. The “autumnal fever” carried off those whose constitutions were already compromised. The doctors who attended the sick saw nothing to connect the cases, nothing to suggest that they were facing anything more than the usual seasonal affliction.

Rush was beginning to feel uneasy. He had seen the reports from Hutchinson. He had heard the rumors spreading through the city—that a strange fever was carrying off whole families near the wharves, that the disease had come from the West Indies, that it was the same plague that had ravaged the Caribbean ports. He remembered the epidemic of 1762, when he was a boy of sixteen apprenticed to Dr. John Redman. He remembered the fear that swept through the city, the carts carrying the dead to mass graves, the houses shuttered and abandoned. He had thought those days were past.

On August 15, he visited a patient on Water Street. The man was a cooper, a sturdy fellow in his thirties who had never been seriously ill in his life. Now he lay in bed, his skin the color of mustard, his eyes bleeding into the whites. Rush examined him. The pulse was rapid and weak. The stomach was distended. When Rush pressed on the abdomen, the man cried out in pain. The vomit in the basin beside the bed was black and foul-smelling—the so-called “coffee ground” vomit that marked the most severe cases.

Rush had seen this before. In books, in the accounts of epidemics in other cities, in his memories of 1762. He knew what it meant. He also knew that the medical establishment was divided on the nature of such fevers. Some doctors believed they were contagious, spread from person to person like smallpox. Others believed they arose spontaneously from putrid air, from the “miasma” that accumulated in hot weather. Rush subscribed to the latter view.

He had built his theory of disease around it. If fever arose from bad air, then the solution was to clean the air—by removing sources of putrefaction, by ventilating houses, by avoiding the districts where the miasma was thickest. If, on the other hand, the disease was contagious, spread by contact with the sick or their belongings, then entirely different measures would be required—quarantine, isolation, the kind of draconian controls that cities imposed during plague years.

Rush was not ready to believe that Philadelphia faced a plague. He diagnosed the cooper with “bilious remitting yellow fever”—a diagnosis that acknowledged the severity of the symptoms while still fitting them into his existing framework. He prescribed his usual treatment: purging, to remove the excess bile that was causing the fever. He gave the man a dose of calomel, a mercury compound that induced violent diarrhea. He drew blood, a pint, to reduce the inflammation in the vascular system. He ordered the windows opened, to let in fresh air. He told the family to clean the room, to remove any sources of putrefaction.

The cooper died the next day. Rush noted the death in his records. He was not surprised. The most severe cases often ended badly. What troubled him was the number of such cases he was beginning to see.

The commercial class, meanwhile, continued to operate as if nothing were wrong. The coffee-houses were still full. The ships still arrived and departed. The newspapers still carried advertisements for goods and services, notices of sales and auctions, reports of political debates. The fever was a topic of conversation, certainly. Merchants discussed it over their coffee and their newspapers. But they discussed it as a local phenomenon, a problem of the waterfront districts, something that affected the poor and the marginal but not the substantial citizens who lived on the high ground near the State House. The city had seen sickly seasons before. This one would pass.

Mathew Carey, the publisher and bookseller, was an exception. He was a careful observer of the city’s moods, a man whose livelihood depended on understanding what people wanted to read. He had noticed the anxiety spreading through the streets, the way people avoided certain neighborhoods, the way conversation turned to fever and death. He had heard the rumors about the “malignant fever” near the wharves, the reports of whole households sickening and dying. He was not a doctor, but he knew what fear looked like. He began to think about publishing an account of the epidemic, a narrative that would inform the public and, perhaps, calm the growing panic.

Carey was also a businessman. He knew that a sensational account of a deadly plague would sell copies. But he was also a civic-minded man, a patriot who had risked his life for the cause of independence. He believed that accurate information was the best defense against fear. He began to gather reports, to interview doctors and residents, to compile a record of what was happening. He would call it “A Short Account of the Malignant Fever.” It would be the first draft of history, the first attempt to make sense of what the city was experiencing.

But that was still weeks away. In mid-August, the epidemic was still invisible to most of the city. The federal government was preoccupied with other matters. Washington was preparing to return to Mount Vernon for his annual respite. The idea that a fever might drive officials from the city, might empty the capital of its government and its commerce, had not yet occurred to anyone.

The deaths continued. A widow on Front Street. A laborer on Water Street. A child in a room above a tavern on Arch. The burial records began to show a pattern: more deaths in August than in previous months, more deaths than in previous Augusts, more deaths clustered in the narrow streets near the river. The clerks who kept the records noticed, but they said nothing. Raising alarms was not their place.

Rush was now seeing several fever patients a day. He had begun to suspect that the disease was spreading, that the cases near the waterfront were not isolated incidents but part of a larger outbreak. He consulted with his colleagues. Some agreed with him. Others dismissed his concerns as alarmism. The medical profession was divided, as it always was, into competing schools and competing theories. Rush’s doctrine of the unity of disease had its adherents, but it also had its critics. The suggestion that Philadelphia faced a yellow fever epidemic—a disease associated with the tropics, with slave ships and tropical ports—was not one that most doctors were prepared to accept.

On August 19, Rush made a decision. He would go public. He would announce to the city’s authorities and to his fellow physicians that an epidemic was underway. He would urge the government to take action—to clean the streets, to evacuate the sick, to establish a hospital where fever patients could be isolated and treated. He knew the risks. If he was wrong, he would be ridiculed as an alarmist, a man who had panicked over a routine seasonal outbreak. If he was right, he would be blamed for the panic that would follow. But he had taken an oath. He was a physician. His duty was to protect the public health, even if that meant destroying his own reputation.

He wrote a letter to the mayor, Matthew Clarkson, describing the cases he had seen and the conclusions he had drawn. He asked for a meeting of the College of Physicians, the city’s leading medical society, to discuss the situation. He prepared himself for the battle ahead.

The meeting was held on August 20. Rush presented his evidence: the clustering of cases near the waterfront, the severity of the symptoms, the rapid spread of the disease through households and neighborhoods. He argued that the city faced an epidemic of yellow fever, that immediate action was required to contain it. His colleagues listened. Some nodded in agreement. Others shook their heads. Dr. William Currie, a respected physician with a large practice, argued that the disease was not yellow fever but a severe form of the usual autumnal fever. Dr. Adam Kuhn, another prominent physician, suggested that Rush was overreacting, that the cases he described were unusual but not unprecedented.

The debate went on for hours. The physicians examined the evidence, argued about the symptoms, disagreed about the diagnosis. In the end, they reached a compromise. They would issue a statement advising the public to take precautions—avoid the infected districts, keep houses clean and ventilated, avoid excessive heat and excessive drinking—but they would not declare an epidemic. Not yet. The evidence was not conclusive. The panic that would follow such a declaration might be worse than the disease itself.

Rush left the meeting frustrated. He knew what he had seen. He knew what was coming. But he had been overruled. The medical establishment had chosen caution over action, silence over alarm. He would have to wait for more evidence, more deaths, more proof that the disease was spreading beyond the waterfront districts.

The city, meanwhile, continued its summer routines. The heat showed no sign of breaking. Mosquitoes continued their silent work, moving from house to house, from body to body, spreading the virus that no one could see. The poor continued to die, in the crowded rooms near the wharves, in the narrow streets where the air was thickest and the stench was worst. The burial records continued to accumulate, a silent tally of the disaster that was unfolding.

On August 21, the clerk at Christ Church burial ground recorded four interments. All were listed as “fever.” The day before, there had been three. The day before that, two. The numbers were still small, but they were growing. In a city that usually saw a handful of deaths per week in summer, four burials in a single day was unusual. The clerk noted it in his register, in the column reserved for cause of death. He did not comment. He did not raise an alarm. He simply recorded the names and the dates and the causes, as he had been trained to do.

The dead were not numbers. They were people: a mother of four, a dockworker with a bad leg, a child who had not yet learned to walk, a sailor whose ship was still moored at the wharf. They had names, histories, families. They had lived in the city, worked in the city, loved and suffered in the city. Now they were buried in the churchyards, in the graveyards, in the pits that the city had dug for the poor. Their stories would be told later, in the pamphlets and memoirs and letters that survivors would write. For now, they were simply the dead, the first of what would become thousands.

Rush went home that night and wrote in his journal. He recorded the day’s events, the meeting, the debate, the decision to wait. He expressed his frustration, his fear, his certainty that the disease would spread. He thought again about his theory, about the unity of disease, about the key that turned in the lock. The theory would be tested in the weeks ahead. He would be tested. The city would be tested. Everything he believed about medicine, about the body, about the nature of disease, would be thrown into the crucible of the epidemic.

The burial records for the third week of August showed twenty-seven deaths attributed to fever.