Epidemics in the United States

The history of physician conduct in epidemics in the United States from the 1790s to the 1850s illustrates the same themes that characterize the examples from Italian cities. Physicians' behavior in epidemics has been a result of their negotiations with civic authority, and as a re-

sult of such negotiations, plague doctors—temporary specialists—often balanced their opportunities against their risks. These themes transcend enormous changes in medicine and society.

Americans may not have known the details of how physicians behaved during epidemics in Italian cities, but they reacted similarly in similar situations. Some may have drawn analogies to events in London during the outbreaks of plague in the seventeenth century.^[12] More important, however, were the similarities in the conditions confronting medical and civic leaders in early modern Italy and the United States in the late eighteenth and early nineteenth centuries. In both situations, doctors were uncertain about the etiology and treatment of infectious disease. In both, city governments dominated by merchants developed policy to contain epidemics.

The most frequently described epidemic in American history before the twentieth century may be the outbreak of yellow fever in Philadelphia in 1793. Its fame derives partly from its severity but also from its occurrence in what was then the national capital, where it sharply curtailed the affairs of government, and mainly from the heroic—if in retrospect dogmatically wrongheaded—behavior of Dr. Benjamin Rush. The slightest exposure to medical history is likely to include the story of Rush racing about Philadelphia trying to bleed patients back to health while many of his colleagues in the distinguished College of Physicians fled the city.

This is caricature, of course, but it links events in the young American republic with those in the Italian city-states. The conventional American accounts of epidemics, like those generated in late medieval and early modern Europe, portray both brave and cowardly doctors against a background of descriptions of contagion, suffering, and death. The American accounts, like the earlier European ones, are misleading in their emphases, not necessarily wrong in detail.

In Philadelphia in 1793 Rush's heroics were less significant than the decisiveness of the merchants who exerted civic authority. These highly political merchants "viewed the plague with a larger perspective" than did Dr. Rush.^[13] Indeed, the important medical story concerns the hospital created by these merchants during the height of the plague. The hospital, which was two miles outside the city, was initially staffed by four young physicians, who had found time to make only twelve visits, collectively, in two weeks to visit the sixty to two hundred patients in each day's census. The civic leaders, led by Steven Girard, then decided to employ a full-time physician. They found a recent refugee from Santo

Domingo, a French physician who preferred to treat yellow fever with stimulants and quinine rather than by venesection. After six days of conflict between some leading Philadelphia physicians and the merchants, the French physician's appointment was confirmed. He was soon joined by a full-time volunteer from the Philadelphia medical elite who, for whatever mixture of motives, was delighted to have allies in a dispute with his colleagues about medical policy. Again, civic authority and a negotiated contract with a physician who saw a personal opportunity in the epidemic determined the organization of medical care.

This pattern also appears in an anonymous contemporary account of a yellow fever outbreak in Natchez, Mississippi, in the summer of 1823. As usual, many affluent citizens and their physicians left the city. The author, using conventions for describing plagues that had become part of the Western literary heritage in the works of Boccaccio and Defoe, reported that the "practicing physicians of the city (one excepted) had prudently withdrawn themselves to the country with the citizens of better circumstances . . . leaving the dead to bury their dead." In contrast, civic leaders, the trustees of the Natchez hospital, "invited the sick poor to resort thither." The superintending trustee then "solicited an intelligent and well read physician to abide with the trustee's family and attend the hospital and sick poor . . . without fee or reward."^[14] More than likely, internal evidence suggests, the anonymous author was himself the plague physician and took his reward in local esteem.

Eyewitness accounts of cholera epidemics in New York City in 1832 and 1849 exemplify the linkage of civic and medical authority in somewhat different ways. In 1832, the resident physician of the port—the highest-ranking public physician—denied that an epidemic of Asiatic cholera had begun. He angered the leadership of the New York Medical Society by refusing to make a night call to a patient who later died of the disease. In this instance, medical leaders, claiming that they were not "restrained" by "fear," successfully pressed the civic authorities to take action against the epidemic.^[15]

In the epidemic of 1849, much of the burden of communicating with the public in New York City was carried by three physicians serving as "medical counsel" to the Board of Health. In a public notice early in the epidemic, these physicians insisted that "in this city no difficulty in obtaining the speedy assistance of a physician can exist." Nevertheless, in a report three months later, the city Sanitary Committee regretted the death, as a "result of exhaustion in attendance on cholera cases of a physician who had been appointed to the Third Ward [Police] Station

House." Despite the claim of medical counsel about the availability of speedy assistance, New York was employing plague doctors.^[16]

The final example from the nineteenth century is the yellow fever epidemic in New Orleans in 1853, in which 10 percent of the population died. As in Philadelphia in 1793, overtreatment was more of a risk than abandonment for more affluent patients. Once again, the interests of the civic authorities and of individual physicians seeking opportunity converged. A group of young businessmen, calling themselves the Howard Association, raised funds and advised the city government on public health policy. According to a recent historian of the epidemic, "As the cases mounted with increasing rapidity the Howard Association eagerly hired all available medical men." He estimated that "dozens of young doctors seeking fame and fortune entered New Orleans."^[17]