The First Deaths on Water Street

The boy came running up Arch Street just past dawn on a Thursday in early August, bareheaded, his shirt untucked, looking for a doctor. He was perhaps fourteen, a dockworker’s son or a boardinghouse servant, and he was looking for anyone. The houses on Water Street behind him were waking to something they did not have a name for. A man was sick in one of the rooms above a cooper’s shop, and by the time the boy reached Second Street, he had already been told at two doorsteps to try elsewhere. Philadelphia’s mornings were loud with commerce in those first days of August, the cranes and winches at the wharves grinding through cargo from a hundred ships, and a boy looking for a doctor was not yet remarkable. But the boy was frightened. He said the sick man had turned a color that sick men did not turn.

Water Street ran parallel to the Delaware, one block inland from the wharves, a narrow canyon of two- and three-story brick dwellings pressed together along a gutter that never drained properly. The street was the city’s seam with its own port. Sailors slept in its boardinghouses. Stevedores rented rooms above its shops. Merchants kept counting houses on Front Street and lived within walking distance, on better streets, but the laborers who carried their coffee and sugar lived here, in rooms that held four or six to a bed.

The buildings were old by Philadelphia standards, some of them dating to before the Revolution, and their cellars took the river’s damp. In late summer the air on Water Street stood thick and close, carrying the smell of the tidal flats at low water, the privy overflow that ran in the gutters, and the heavy, sweet rot of spoiled cargo left too long on the wharves. People who lived there did not remark on it. The smell was simply where they lived.

The man who was sick in the room above the cooper’s shop was a sailor, or a stevedore—the accounts of the first week varied, and the city’s record-keepers had not yet begun to keep careful records, because nothing yet demanded them. He had been well enough the day before, seen on the wharf or in a tavern, carrying something or drinking something. Now he lay in a soaked bed, his skin the color of saffron, his eyes yellow, vomiting something dark. A neighbor had come in and found him. The neighbor sent the boy.

This case would later be counted among the first, though no one was counting yet. A doctor came, eventually, and examined the sailor and prescribed what doctors prescribed for fevers of unknown origin: a purge, a cooling regimen, perhaps a bleeding if the pulse ran high. The diagnosis, if it was given a name, was bilious fever—a catch-all that covered any illness involving vomiting and derangement of the bowels. Bilious fever was common in Philadelphia in late summer. The city’s physicians saw it every year, along with the autumnal intermittents that came with the bad air from the marshes south of the city. A man sick with bilious fever in a boardinghouse on Water Street was a private misfortune. It was not a signal.

Three blocks south, in a house on Front Street near the market, a merchant’s family was also falling ill. The merchant traded in Caribbean goods—sugar, molasses, coffee—and his warehouse stood at the end of the same wharf where the sailor had worked. His wife took sick first, then a child, then the merchant himself.

The symptoms ran the same course: a sudden onset, headache and back pain that bent the sufferer double, a fever that climbed through the first day and into the night, and then the yellowing. The vomit turned dark, the color of coffee grounds.

A physician was called. He noted the symptoms and treated them as he had been trained to treat autumnal fevers, with purgatives and cooling draughts, and he noted in his own mind, perhaps, that the cases were unusually severe. But August was early for the autumnal fevers, and the severity was striking. He said nothing publicly. There was no mechanism for a physician to say something publicly about a private case.

The disease moved through the block the way fire moves through dry timber—not in a line but in clusters, jumping from one house to the next, appearing in a boardinghouse, skipping a shop, taking three people in a single dwelling. A dockworker collapsed at the foot of Race Street wharf on a Tuesday and was carried to his room on Water Street, where he died within forty-eight hours. A woman who kept a cookshop near the corner of Water and Arch Street fell ill on a Wednesday and was dead by Friday. A child in the house next door sickened the same day the woman was buried.

The minister who read the burial service noted nothing unusual in his register. People died in August in Philadelphia. The marsh air carried its annual miasma. Well water on the block tasted of the river. Crowding made every dwelling a vector for whatever was going around. Death was the cost of living near the river.

What no one on Water Street could see was that these were not separate events. They were one event, seen in fragments.

The pathogen had found its first human hosts in the crowded dwellings near the Arch Street wharf, and it was moving through them with the efficiency of a disease that had evolved to do exactly this. The mosquito that carried it bred in the standing water that collected in every cistern and rain barrel on the block, in the puddles that stood for days in the gutters, in the bilge that sloshed in the holds of the ships tied up at the wharves.

It bit the sailor in the boardinghouse and then bit the man sleeping in the next bed. It bit the merchant’s wife and then bit the child. It flew from house to house through the open windows that every dwelling kept open in August, because to close them was to suffocate. The disease did not need names or announcements. Proximity and water and warmth were enough, and Water Street provided all three.

Dr. Benjamin Rush, the city’s most prominent physician, had been watching. Rush was a man who saw patterns where others saw incidents, and he had been trained in Edinburgh and London to believe that the careful observation of cases was the foundation of medical knowledge. In the first days of August, he began to hear about the cases on Water Street.

He asked the port physician, Dr. James Hutchinson, to assess the conditions. Hutchinson walked the streets near the wharves and counted the sick. He found that sixty-seven of about four hundred residents near the Arch Street wharf were ill, but only twelve had what he called “malignant fevers.” The distinction mattered.

Sixty-seven sick people in a crowded waterfront district was within the ordinary range of August illness. Twelve with malignant fevers was something else. Hutchinson’s count was the first systematic observation of the epidemic, though neither he nor Rush yet understood what they were looking at.

Rush treated his own first case on August 7. The patient was a young man, and Rush noted the symptoms with the precision that would later make his written account the central clinical narrative of the epidemic. The young man had the fever, the headache, the back pain, the yellow skin, the dark vomit.

Rush had seen bilious fevers before, had treated them for years, and he recognized that this was different. The violence of the onset, the rapid progression, the particular color of the skin and the vomit—these were not the features of the common autumnal ailment.

But Rush was one physician treating one patient, and the infrastructure of public health in Philadelphia in 1793 had no mechanism for translating one physician’s observation into a civic alarm. The city had a Board of Health, theoretically, but it had been allowed to lapse. The port physician had authority to quarantine ships, but the political will to enforce quarantine had eroded in the years since the Revolution, when Philadelphia’s merchants had successfully argued that restrictions on trade damaged the city’s commerce more than disease damaged its population. The sovereignty of care—the authority to impose life-and-death restrictions like quarantine in the name of public safety—was contested ground, and in the summer of 1793 the merchants had won. The port stayed open.

The cases continued. They did not announce themselves. They appeared in private rooms, in boardinghouses and family dwellings, and they were treated as private tragedies by the families who suffered them and the physicians who attended them. A sailor died in a room above a cooper’s shop. A merchant’s wife died in a bed on Front Street. A dockworker died at the foot of Race Street wharf. A cookshop keeper died on Water Street. A child died in the house next door. Each death was a specific, particular grief, attended by a doctor who prescribed what he knew and a family that buried what it had lost. The deaths did not cohere into a pattern because no one was standing far enough back to see the pattern. The observers were inside the event, attending to its particulars, and the particulars were overwhelming.

The treatments failed. This was the second failure, after the failure of recognition. Philadelphia’s physicians in August 1793 had a pharmacopoeia for fevers, and it was not small. They had calomel and jalap for purging, Peruvian bark for the intermittent fevers, cooling draughts and warm baths, and the ancient recourse of bloodletting, which reduced the patient’s pulse and was thought to relieve the congestion of the vital organs.

None of these treatments had any effect on yellow fever. The disease was viral, transmitted by mosquito, and the interventions of eighteenth-century medicine were irrelevant to its mechanism. But irrelevance is not always visible in the moment. A physician who purged a patient and saw the patient die could conclude that the purge had been insufficient, or too late, or that the patient’s constitution had been too weakened by prior illness. He could conclude that the treatment was right but the disease was worse. He could not conclude that the treatment was wrong, because the framework that justified the treatment was the framework he used to understand the disease. To abandon the treatment was to abandon the medicine.

So the physicians on Water Street purged and bled and cooled, and their patients died, and the physicians recorded the deaths and attended the next case and purged and bled and cooled again. The families who could afford a doctor paid for treatments that did not work. The families who could not afford a doctor relied on neighbors and folk remedies and prayer. The distance between these two responses was not as great as it appeared. Both were operating in the dark. The physician with his calomel and the neighbor with her herb tea were both guessing, and the disease did not care which guess was made.

The civic machinery of Philadelphia, such as it was, turned without engaging the crisis. The city’s newspapers printed shipping news and political commentary and advertisements for goods and services, and they did not yet print news of the deaths on Water Street, because the deaths on Water Street were not yet news. They were private events, occurring in private dwellings, attended by private physicians.

The concept of a public health emergency—the idea that a cluster of severe, unexplained deaths in a specific neighborhood might constitute a civic crisis requiring collective action—was available in the eighteenth century. Philadelphia had survived epidemics before.

But the recognition of an epidemic required a threshold of cases that had not yet been crossed, or a physician willing to declare one, or a civic authority willing to act on the declaration. In the first two weeks of August, none of these thresholds was reached. The cases accumulated, and the city’s observational and diagnostic frameworks continued to categorize them as bilious fever, autumnal fever, common fever, the ordinary illness of the season.

The gap between the biological reality and the civic capacity was the epidemic’s first advantage. Yellow fever was a novel disease in the sense that Philadelphia’s physicians had not seen it in their city in their lifetimes, and the diagnostic categories they carried were built from diseases they had seen.

Bilious fever was a real category. Autumnal fever was a real category. They described real illnesses that occurred every year and that were not, in most cases, fatal. The physicians who used these categories were not ignorant or incompetent. They were applying the best knowledge they had to a disease that their knowledge had not been built to accommodate.

The failure was not individual. It was structural. The system of observation, diagnosis, and response that Philadelphia had built over decades of treating the ordinary fevers of a port city was a system designed for ordinary fevers. It was not designed for a disease that killed in days, that yellowed the skin and blackened the vomit, that moved from house to house through a vector no one could see.

On Water Street, the families who lived nearest the wharves were the first to understand, in the way that families understand before institutions do, that something was wrong. They did not have a name for it. They did not have a diagnosis. But they had the evidence of their own eyes: neighbors dying in days, the same symptoms in house after house, the same yellow skin and dark vomit, the same failure of every treatment that was tried.

Some of them began to leave. Not in the mass exodus that would come later, not in the panicked flight that would empty the city, but in the small, private departures of families who packed what they could carry and went to relatives in Germantown or the country. A boardinghouse keeper closed her doors. A stevedore sent his wife and children to her sister’s house in New Jersey. These were individual decisions, made without coordination, without public alarm, without any announcement that the block was becoming dangerous. They were the first, small evaporations of the population that would later become a flood.

The civic evaporation had begun before anyone recognized it as such. The consensus on communal responsibility—the shared assumption that a neighborhood’s sick were the neighborhood’s concern, that a city’s dead were the city’s responsibility—was thinning under the pressure of fear. Families who stayed on Water Street helped their neighbors when they could, carried water, changed soiled beds, called for doctors.

But the helping was getting harder. The disease was contagious in the way that all terrifying diseases are contagious: not necessarily through direct transmission, but through the fear of proximity. A man who helped carry his neighbor to a bed might not catch the fever, but he did not know that. He knew only that the neighbor was yellow and vomiting and that three other people on the block had died the same way. The willingness to help was not gone, but it was being tested, and the test was just beginning.

Mathew Carey, the printer and publisher who would later write one of the most widely read contemporary accounts of the epidemic, was working in his shop on Front Street during these first weeks of August. He was close enough to Water Street to hear the sounds of the block—the carts, the voices, the crying that came from the houses where people were sick. He was close enough to see the first departures.

But he did not yet understand what he was seeing. Like everyone else in the city, he saw the incidents, not the pattern. He saw a sick man carried to a cart, a family leaving with trunks on a wagon, a physician walking quickly between houses. He saw the ordinary life of a port city in summer, with its ordinary miseries, and he did not yet know that what he was watching was the beginning of the catastrophe that would later compel him to write.

The disease was doing what diseases do. It was finding hosts and replicating and moving on. It did not need the city to recognize it. The crowding on Water Street was dense enough. Standing water collected in every cistern, every rain barrel, every gutter that failed to drain. August warmth held the air thick against the brick walls. Human bodies lay close together in rooms above shops and boardinghouses, sharing beds and breath and privies. The open windows let the night air in, and the night air carried what it carried. The ships at the wharves held bilge and damp cargo, and the sailors who slept in those holds brought whatever was breeding there onto the block. The disease was perfectly adapted to the city’s substrate, and the city’s substrate was perfectly adapted to the disease, and neither knew anything about the other.

What the city knew was that people were dying. The burial returns from the churches and the burial grounds listed the deaths in the ordinary way: name, date, cause if known, age if known. The causes listed for the early August deaths on Water Street were the causes that physicians had given: fever, bilious fever, malignant fever. The returns did not distinguish between the ordinary fevers of August and the disease that would kill five thousand people by October, because the physicians who certified the deaths had not yet made the distinction. The records were accurate in the sense that they recorded what was known. They were inaccurate in the sense that what was known was not enough.

The first deaths on Water Street were not a dramatic event. There was no single moment of recognition, no physician standing in a sickroom and realizing with horror that the disease before him was yellow fever. There was no public announcement, no alarm, no gathering of civic authorities. There were private tragedies, attended by physicians who did their best with what they had, and families who grieved, and neighbors who helped or fled, and a city that continued its business because its business did not yet include the deaths on Water Street. The epidemic’s true beginning was not a dramatic announcement but a scattered, misperceived series of medical emergencies, each one treated as a private case, each one diagnosed with the categories that were available, each one failing to register as what it was.

The failure was not a failure of individual intelligence. Rush was one of the most learned physicians in America. Hutchinson was experienced and conscientious. The men who treated the early cases on Water Street were not fools. They were working within a framework of medical knowledge that had been built over centuries and that was, in many respects, effective for the diseases it was designed to address. Yellow fever was not one of those diseases. The framework had no place for it. The diagnostic categories did not fit. The treatments did not work. The civic mechanisms for response did not engage. And the disease, moving silently through the mosquitoes and the water and the crowded rooms of Water Street, did not need any of these things to fail. It needed only to continue doing what it was already doing.

By the middle of August, the cases on Water Street had multiplied beyond the capacity of any single physician to track. Rush was seeing more patients. Other physicians were seeing more patients. The boardinghouses near the wharves were reporting deaths at a rate that exceeded the ordinary August mortality, and the burial returns from the churches were beginning to show a pattern that could not be explained by the common fevers of the season. The pattern was severe, unexplained, and accelerating. The deaths were no longer isolated. They were a cluster. And the cluster was growing.

The city’s observational framework had failed to catch the epidemic in its first days, when the cases were few and the disease might have been contained by quarantine and sanitation, if anyone had known to try. Now the cases were too many, and the disease was too deep in the city’s substrate, and the window for early intervention had closed without anyone knowing it had been open. The epidemic had won its first battle, which was the battle of recognition. It had moved through the city’s defenses not by overwhelming them but by passing beneath them, moving at a scale and through a vector that the defenses were not built to detect. The first failure of civic response was not a failure of will or courage. It was a failure of vision—of the instruments and categories through which the city watched its own health.

The block was sick and getting sicker. The boy who had run up Arch Street looking for a doctor had found one, and the doctor had come and prescribed and left, and the man in the room above the cooper’s shop had died, and the boy himself had moved on, back to the wharf or the tavern or wherever boys who ran errands went when the errand was done. The room was empty for a day, and then another sailor took the bed, because the boardinghouses near the wharves always had tenants, and the room was cheap, and the man who had died in it was not there to warn him.

The cases accumulated. A pattern of severe, unexplained deaths was emerging on Water Street, and it was creating, for the first time, a pressure that the city’s diagnostic frameworks could not absorb. Physicians who had treated the early cases as bilious fever were beginning to doubt their own diagnoses. The symptoms did not match. The treatments did not work. The deaths were too many and too fast and too violent for the common autumnal ailment. Something was moving through the block that the physicians had not seen before, and the need for an authoritative diagnosis was becoming urgent. The city needed someone to look at the cases on Water Street and say what they were. It needed someone to give the disease a name.