Abstract and Keywords
This introductory chapter explores the intimate links between health and politics in colonial Philadelphia. The term “epidemic constitution”, used here, was coined by English physician Thomas Sydenham (1624–1689), who used it to describe the mixture of atmospheres that determined what diseases could be expected in a particular territory. In matters of state, the constitution was the framework under which government structured the lives of individuals and the control of territories. This ambiguously overlapping language suggests how thoroughly ideas about health infused concurrent political developments. In Philadelphia, the most significant of those collaborations was the establishment of the city's public health infrastructure. And by making wellness public, public health helped make Philadelphians, Pennsylvanians, Britons, and Americans.
In 1777, Pierre Nicole was a captain of the guards in the British army, stationed in occupied Philadelphia. The clever Swiss-born officer was “well-acquainted with the Country and with the people,” which made him an effective liaison between the army and the area’s covert loyalist population.1 It also made him the capable cartographer and draftsman who, under the engineer John Montresor, produced an astonishing portrait of the revolutionary city. As the prominent earthworks and fortresses demonstrate, this was a city at war, indeed under occupation, when Nicole drafted the map. The civilian population was subject to the whims of a military authority that did not always hold the city’s health and well-being as a significant priority. Yet even today, the chart’s vivid colors and painterly elegance seem too opulent for its Spartan purpose.
On closer examination of the chart, not only Philadelphia’s physical attributes but also its social character and political culture come into focus. Nicole’s survey reminds us of how small Philadelphia was, the pink smear of the city engulfed by the vast green fields and broad blue river that surround it. It is easy to see farms of that rich hinterland and the commerce of the waterfront as opposites, but from the beginning, Philadelphia’s agricultural base and its commercial channel worked in concert to shape the city. Vestiges of William Penn’s original gridiron plan endure in the square lots and the broad streets that he hoped would make the city an airy country town free of the fires and diseases that plagued urban life in Europe. But in most respects, the Philadelphia captured in Nicole’s survey was one that departed dramatically from its founder’s vision. The city blocks, intended to provide space for freestanding houses on salutary lawns, were instead carved up by landlords into ever-smaller dwellings for laborers and artisans. Crisscrossing those warrens were dozens of filthy alleyways. And cutting through the (p.2)
(p.3) middle of town was Dock Creek, the polluted waterway that Philadelphia’s butchers, tanners, chandlers, and soap-boilers used as a receptacle for their witches’ brew of industrial by-products, over the frequent protests of sickened neighbors.
Unlike Thomas Holme’s better-known 1682 plan of the city, depicting an orderly grid spanning from the Delaware River all the way to the Schuylkill River, Nicole’s 1777 survey reveals a messy “city crowded next to the shore,” running more than a mile and half along the Delaware.2 Despite Penn’s disdain for commercial life, Philadelphia’s long, snaking riverfront, studded with wharves, proved that it was a trading city, attended by all the benefits and hazards that came with commerce. Early Pennsylvanians avidly pursued the prosperity that came with economic development, but they also wondered if it was worth the inescapable pollution of the commercial district or the always looming threat that one of those ships would disgorge an exotic disease along with its declared cargo.
If the map suggests all of the ways that Philadelphia courted disease and ruin, it also illustrates some of the measures the city adopted to protect itself and promote the common welfare. City life exposed residents to injury and illness, but a speck just outside the urban core, marked “Hospital,” testifies to the power of a civic philosophy that built institutions to treat the wounds and diseases of those who could not support themselves. The ships at dock may have carried contagion, but the lazaretto stood downriver on Province Island to inspect ships for signs of infection, to detain vessels that contained suspect goods or persons, and to house and treat the sickly during their convalescence. In so doing, Philadelphians were, in their own fashion, protecting the common health and defining their community.
A year before Nicole produced his survey, Philadelphia’s artisan radicals celebrated the state’s new constitution, probably the most radically democratic government established in that crowded season of state making. Ten years after the draftsman’s work, delegates gathered in Philadelphia to remake a nation suffering from what Alexander Hamilton called the “disease of democracy.” And between these two very different Philadelphia constitutions, Pierre Nicole, though unintentionally, gave us an ideal map for exploring the epidemic constitutions that equally shaped the city’s past, present, and future.3
Health and American Constitutions
In the American colonies and the broader Anglo-Atlantic world, “constitution” encompassed many distinct, but related meanings. An individual’s or animal’s constitution referred to the balance of humors in its body. The great English physician Thomas Sydenham (1624–1689) used the term “epidemic constitution” to describe the mixture of atmospheres that determined what (p.4) diseases could be expected in a particular territory. In matters of state, the constitution—whether codified in a single document as in the United States or accumulated in precedent and practice as in Britain—was the framework under which government structured the lives of individuals and the control of territories. This ambiguously overlapping language suggests how thoroughly ideas about health infused concurrent political developments. The relationship between medicine and politics went deeper than metaphor: it rested on the idea that humans, their environment, and their society operated on analogous principles that were therefore subject to the same kinds of defects and remedies, an understanding that provided a powerful vocabulary for articulating shared goals.
In Philadelphia, the most significant of those collaborations was the establishment of the city’s public health infrastructure. Generations of Philadelphians participated in a positive program to promote collective wellness that was connected to broader political goals of polity, security, and economy. In this book I explore how such a program developed, how Philadelphians thought they could achieve it, how their epidemiological aims interacted with competing political imperatives, and how all of those processes changed over time.
It can be tempting to condescend to the past, and modern observers routinely insist that premodern medicine was so primitive or so misguided that it does not merit the name of public health. It is certainly easy enough to flatter ourselves by dismissing the efforts of those who labored without germ theory, antibiotics, or gene therapy. But historians have good reason to understand these efforts as public health because the medical thinkers and political leaders who pursued them understood themselves to be practicing public health. They examined local features to identify the healthiest locations to build, and they tried to make those places healthier through extensive environmental engineering. They screened incoming traffic for possible infections. They recognized that crowding strained sanitary resources and exposed individuals to noxious nuisances, which they attempted both to prevent from appearing and to ameliorate when they did appear. They established institutions to provide care for the populace when those preventatives failed and tried to instill healthy habits that would fortify individuals against injury and illness. In short, they recognized that disease and debility were shared problems, and in recognizing that the problem was collective, they embraced a public responsibility to preserve and promote the common welfare, which they tried to fulfill to the best of their abilities.
I explore this intersection of medical knowledge and political culture through an era that saw both medicine and politics riven by controversy and turmoil. Reconstructing what the scholar John Pickstone called the “political ecology” of medical development not only illuminates the relationship of health and the state but also enriches our understanding of the other upheavals of the eighteenth century: the growth of an Atlantic economy (p.5) and the changes it wrought, the development of the British empire and the conflicts within it that culminated in the American Revolution, the articulation of the rights and duties of citizenship, the transformation of labor, the creation of a transatlantic intellectual culture, the imposition of racial and sexual hierarchies, and the revision of the human relationship with the natural world. Lurking behind each of those transformations is a common theme: the formation of shared identities through the processes of inclusion, exclusion, and regulation.4
Philadelphians used the rhetoric and technology of social medicine to assert a collective identity and to demarcate their place in a larger world. Health was not just a subject of politics; it was a distinctive political register. Decisions made under the banner of medicine articulated social values and reified social categories. Arguments about what kinds of spaces were healthy directly shaped the physical form of early Philadelphia and periodically resurfaced as attitudes toward urban life shifted during the eighteenth century. Quarantines imposed on sickly ships screened what people and things would be admitted to the city and reflected how much power the port had to set the terms of its participation in the maritime economy. Debates over public relief forced Philadelphians to think hard about who was entitled to such charity and, in a sense, who actually counted as full members of the community. Regulations on hazardous and unhealthy practices reflected the expected responsibilities of those members. I trace some of these tangled roots of “constitutions,” and show how political efforts to promote health on a collective basis—the health not of a person, but of a city—shaped the political culture of that city and of the province and the nation around it.
Healing Cultures and Cultures of Healing
The framework of constitutional correspondence was not a codex of ironclad laws, but rather a set of versatile tools that reformers on both sides of the Atlantic used to remake their societies. Beginning with the Puritan revolutionaries who “came to regard a medical restoration as a corollary of their spiritual regeneration,” when medical thought and political power combined, the potential of social medicine expanded dramatically from a simple charge of relieving the poor to a more expansive notion of transforming the world.5
Medical policy was an especially potent vehicle for enacting social visions, in part, because the body is so central to ordering human understanding. The immediacy of corporeal experience makes it a point of first reference in metaphor and cognition, rendering the constituted body a powerful means of asserting a particular kind of shared identity. The Hobbesian image of the body politic is only the most familiar example of using physiognomy to define polity.6 Furthermore, both popular and elite wisdom taught that (p.6) the outward body could be read for clues to essential moral character. Such associations are at least as ancient as Adam and Eve forfeiting immortality through sin and durable enough to survive into the twenty-first-century conceptions of disease as divine or karmic retribution. What made the medical ideas explored here useful enough to retain and refine was not only that they informed notions of English identity but also that the system provided tools within itself to adjust that identity, or even to create a new Anglo-Colonial identity. The political rhetoric of health was strong medicine, and it could be adapted and reformulated to serve new needs.7
In a nontrivial sense, to be constituted is to be simultaneously plural and singular. Multiple elemental substances combine to form an individual person. Airs and waters commingled to generate the disease environment of a particular location. The accumulation of precedents, customs, and laws created the unwritten constitution that colonists relied on to guarantee their liberties. These two factors—the enduring association of embodied and abstract characteristics and the simultaneously plural and singular nature of those characteristics—made the rhetoric of political medicine a versatile tool for implementing policy and for articulating a shared identity through that idea. The discovery of social health made it possible to exploit the rich rhetoric of health and disease on a broad new level to define the characteristics not only of the individual body but also of the polity as a whole.
Ideas about people, politics, and space influenced the way colonists, rebels, and republicans conceived their polity over the course of a century. Philadelphians thought about wellness and disease because they were vital aspects of their lives. The rhetoric of health was apocalyptic because the danger of contagion was potentially cataclysmic. But creating the conditions of health required politics as well as ideas. And those politics emerged in the train of official policies, popular practices, and partisan disputes rooted in the premise that public health was a shared goal and a collective obligation. Illness ceased to be a private matter. And by making wellness public, public health helped make Philadelphians, Pennsylvanians, Britons, and Americans.
(1.) “The Montresor Journals,” in Collections of the New York Historical Society, ed. G. D. Scull (New York: 1881), 538–39.
(4.) Pickstone, Medicine and Industrial Society, 2; Cunningham and French, eds., Medical Enlightenment, 3. But on social and political contexts of medicine, see also, for example, Porter, “The Gift Relation,” 149–78; Porter, “Gout”; Porter, Greatest Benefit to Mankind; Porter and Porter, In Sickness and in Health; Bourdelais, Epidemics Laid Low; Wilson, “Politics of Medical Improvement,” 4–15; Webster, The Great Instauration, 497–98. Eugene Link has examined how political and social commitments shaped doctors, and how their medical ideas shaped those commitments. See Link, Social Ideas of American Physicians, 4–36.
(p.168) (6.) Christina Jarvis, “Metaphor,” in The Oxford Companion to the Body, ed. Colin Blakemore and Sheila Jennett (Oxford: Oxford University Press, 2001), 463–64; Mark Johnson, The Body in the Mind: The Bodily Basis of Meaning, Imagination, and Reason (Chicago: University of Chicago Press, 1987).
(7.) Randy Shilts, And the Band Played On: Politics, People, and the Aids Epidemic, 20th anniversary edition (New York: Macmillan, 2007), 310; Peter Lewis Allen, The Wages of Sin: Sex and Disease, Past and Present (Chicago: University of Chicago, 2000); John Fisher, “Cattle Plagues Past and Present: The Mystery of Mad Cow Disease,” Journal of Contemporary History 33, no. 2 (1998); Peter Washer, “Representations of Mad Cow Disease,” Social Science & Medicine 62, no. 2 (2006); Rebecca A. Weldon, “An ‘Urban Legend’ of Global Proportions: An Analysis of Nonfiction Accounts of the Ebola Virus,” Journal of Health Communication 6, no. 3 (2001); Webster, The Great Instauration, 246; Sander L. Gilman, “Moral Panic and Pandemics,” The Lancet 375, no. 9729 (2010). Mary Douglas rejected the idea that spiritual and physical taint were strictly homologous, but in the early modern context it is impossible to escape the densely interwoven nature of the two systems of corruption and contagion. See Mary Douglas, Purity and Danger: An Analysis of Concepts of Pollution and Taboo (New York: Praeger, 1966).