Sunday, October 26, 2014

Ebola Africa 2014 and Yellow Fever Philadelphia 1793



In the 18th century doctors based their diagnosis on a patient's symptoms. While treating several patients near Philadelphia's Arch Street wharf in August 1793, Dr. Benjamin Rush confronted some daunting symptoms: flushed face, high pulse, excitability bordering on delirium, as well as periods of prostration with cold clammy skin, nausea and stomach pains so severe that doctors induced vomiting and diarrhea if the fever didn't, in one case blood gushing from the nose just before death, and in all cases a yellowish tinge to the skin. Rush concluded that the city was facing an epidemic of yellow fever.

Rush spread the alarm, advised preventatives, primarily cleaning up filth along the city's docks, and urged those of his patients he thought predisposed through weakness to get the disease to leave the city. When somebody near his house on Walnut between 3rd and 4th streets got sick, he sent his teenage sons out of the city despite their general good health. He had noticed that many who got the fever badly were teenage boys.


The bacterial and viral agents causing diseases were unknown in the 18th century, nor was there any understanding of exactly how diseases spread. Today doctors know the viruses that cause yellow fever and Ebola fever and how those diseases spread. So at first glance there is nothing to be learned from the yellow fever epidemic of 1793 that can be applied to today's Ebola fever epidemic. None of preventatives and protocols that Rush used did anything to stop the spread of yellow fever nor would they be of much use in the fight against Ebola.

But Rush didn't know he was wrong. He was as confident he could control the epidemic as doctors faced with today's epidemic, provided that people followed his instructions.

His confidence is worth contemplating. We can't dismiss it because he fought a more tractable disease. Only its greater mortality makes Ebola fever more terrifying than yellow fever. The symptoms are similar. Both fevers can torment victims with hemorrhaging from any orifice of the body. In 1976, the symptoms of a mystery disease in Africa were so horrible, pathologists assumed the patient died of yellow fever. Instead of isolating that virus from her blood, they discovered the Ebola virus.

There is no cure for either disease, but in 1793 many doctors, especially Rush, credited their treatments when their patients survived the disease. They didn't have tests proving they cleared a body of the virus. They didn't know viruses existed. They thought patients were in the grips of an infected environment that they called "mephitic." Rush thought rotting coffee on the Arch Street wharf infected the air there sparking the epidemic. He compounded that mistake when he assumed that the breath and discharges of yellow fever victims infected the surrounding air increasing the contagion. The imperative was to clean up the noxious filth, everywhere, and wrest control of the body from the fever racking it, all the while staying well so he could treat more patients.

Rush only touched a patient to take his or her pulse to measure the force of the fever. Before doing that he instructed the patient or a nurse to turn down the bed covers and he waited for what he assumed were pockets of air charged with contagion to disperse. Of course he also had any windows in the room opened and vinegar was sprinkled throughout the room. Rush dipped his fingers in that mild acid before taking a patient's pulse.  In the city's newspapers there were many recipes for concocting the best vinegar based disinfectants.

By doing all that Rush did not lessen the chance of an infected mosquito biting him and perhaps invited an uninfected mosquito in through the open window. Rush performed those precautionary rituals with confidence though he had no proof other than his survival that they worked. He thought fear of the disease predisposed one to get the disease, as well as too much meat in the diet. During the epidemic, Rush stopped eating meat altogether. When he got the fever, he decided it was because he got overheated while climbing stairs to see a patient.

Then as now, rooms where victims died were feared as death traps, but few believed the contagion was confined there. The heat and humidity of late summer made it easy to sense contagion in the streets of the city. Bonfires were set and cannons fired to make the air less contagious. Exploded gunpowder was prized for its medicinal properties. Efforts were made to disinfect anything leaving city. In 1793 mail and newspapers sent out of the city were exposed to wood smoke.

The problem presented by any epidemic is that society feels compelled to treat its victims and allow those in infected areas to evacuate, and, at the same time, stop the spread of the disease. Most thought prudence dictated keeping away from anyone sick with the fever. For those far from where the epidemic rage that meant warding off anyone who had been in Philadelphia, even though it was then the capital of country.

President Washington was stopped but allowed to go through Baltimore because he did not plan to stay in the city on his way to Mount Vernon. (He didn't exactly flee since he left for a vacation on the day previously announced.) The Secretary of War was not so lucky. He had to wait out a 14 day quarantine before he could go through New York. All refugees from Philadelphia were taken to tents on an island in the harbor.

That travelers from Liberia and Sierra Leone routinely fly to Brussels, the administrative center of the European Union, and then on to Washington and New York would have shocked authorities in 1793.

Many fleeing Philadelphia found refuge with family and friends in rural areas and villages and towns in nearby Pennsylvania and New Jersey that didn't organize patrols to keep refugees away. There was not a general evacuation of the city. To be sure, the rich and powerful were among the first to leave and many of them were government officials. In that day the federal government had no resources that could help in the crisis. State government controlled the port but, after finding a dead body on the steps of the State House, most state officials left after ordering the port cleaned and then closed.

That left the mayor and enough men eager to volunteer to help manage the crisis. Several Quakers comforted victims with no regard for their own safety and died as a consequence. The Society of Friends held their yearly meeting as schedule. To postpone it would thwart the will of God. Members of the French community had lived in what would soon become Haiti where yellow fever was endemic. They assumed that if they didn't get it there, they would not get it in Philadelphia and walked unafraid on the streets of the city.

From his close reading of the Bible, Rush believed God would not leave humanity defenseless against any scourge and looking through the medical literature he found that gift from God. Rush persuaded the leaders of the city's African American churches to organize crews to collect and bury the dead and also nurse the sick. He assured them that a doctor's report on a 1742 epidemic in Charleston proved that they would not get the disease.

Black nurses found positions in the houses of the middle class and rich. But Rush was wrong. It soon became apparent that any immunity blacks had in 1742 arose from their having once lived in Africa. Many blacks in Philadelphia had been born in that city and some of them succumbed to the disease. The service of those nurses, both men and women, is a shining moment in American history. However, by singling themselves out by that service, all blacks in the city were avoided by many whites fearful of getting the disease.

In 2014 foreign governments, including the United States, and international charities have promised to build special treatment centers for Ebola victims. In Philadelphia, the mayor and his volunteers realized the city needed a place to take those poor victims who couldn't afford a nurse. They took over the Bush Hill estate a few miles outside of the city. The owner was in Europe. Donations from individuals and other cities, including New York and Baltimore, helped defray expenses for a fever hospital. Today international aid has been pledged to support the African countries struggling with the disease. One of the richest men in Philadelphia, the French born merchant Stephen Girard, took a personal interest in the hospital and personally visited patients. So far none of the world's billionaires are that committed to fighting Ebola.


Once patients were moved from the sources of contagion in the city to fresh country air, doctors thought that the chance of the fever spreading from the hospital in such an isolated location was minimal. The first fever hospital, an arena closer to the city, just several blocks from the infected area, was almost burnt down by angry neighbors. As it turned out no one working at the hospital got the fever, thanks to the lack of infected mosquitoes in the area.

Moving patients to a fever hospital was not universally accepted. Rush thought taking patients there by horse drawn carts was bad for the patient and that they could be cured at home if they used his remedies. Philadelphia doctors and laymen published treatments in newspapers and distributed handbills.

Rush urged purging and bleeding, putting his own stamp on treatment popular since the late Middle Ages. He and his apprentices mixed equal amounts of calomel, an inorganic mercury compound, with jalap, powdered extract from a Mexican plant, to make pills for caregivers to pick up and give to patients. Finding enough experienced bleeders able to take the considerable amounts of blood Rush thought should be removed from sick patients was more difficult.

After the epidemic Rush opined that "All the knowledge that is necessary to discover when blood letting is proper, might be taught to a boy or girl of twelve years old in a few hours." Today treatment centers are being overwhelmed by Ebola victims. Despairing of being able to get all victims of the disease to treatment centers, health officials in Sierra Leone began distributing instructions on treatment so that patients could be treated at home by family members.

Any controversy over the hospital was muted because it was unable to treat the mounting number of victims. The September death rate doubled in early October with over 100 a day dying of the disease. A survey was taken trying to discover the most sickly parts of the city. Just as many Ebola victims live in crowded alleys in Monrovia,  so many yellow fever victims lived in the crowded alleys intersecting the squares made by Philadelphia's main streets near the waterfront. However, in 1793 when screens were not put on windows, no class of people could avoid mosquito bites.

Fortunately, 1793 timely frosts in late October killed the mosquitoes spreading disease and the epidemic seemed to end as quickly as it started. President Washington did not hug any recovered yellow fever patients (he didn't do hugging,) but he did reenter the city a day before the official all clear was given.

There is no indication that a change in the weather will stop the Ebola epidemic.

In 1793 the end of the epidemic brought calls for reform. Some ideas like a municipal water system would take time but scrupulously cleaning streets, alleys and wharves was more easily done. But despite that, there was another yellow fever epidemic in the fall of 1797. Hosing the infected areas seemed to limit its spread. At the beginning of the summer of 1798 many thought the city never looked cleaner. Then in August 1798 yellow fever struck with what seemed like twice the virulence of the 1793 epidemic. Cities all along the east coast including New York and Boston also had yellow fever epidemics in 1798.


The immediate reaction to the 1798 yellow fever epidemic in Philadelphia was mass evacuation. The city made it official policy. The Society of Friends postponed their yearly meeting. To accommodate the poor the city and businessmen stressed by the economic damage to the city built special camps outside the city. One housed 2,000 people in wooden buildings erected along a grid pattern of streets. Camp organizers did not neglect the opportunity to reform the poor. Rules were posted and enforced by armed guards. People had to wash their "body clothes" and air out their bedding three times a week; food was withheld from those caught breaking those or other rules; repeat offenders were expelled; people in the camp had to get permission to leave; the whole place was surrounded by sentinels. There were schools, churches and doctors on the premises. Able bodied men were employed digging a canal.

That hardly limited the death toll which topped 3,000. First Lady Abigail Adams returned to find that four of her domestics had died. President Adams made the epidemics the first topic in his annual message and called for legislation to help states enforce their quarantines.

The epidemics ended with the frosts. Supported by all political parties, a citizens' committee continued disciplining of the poor. A crew of 150 volunteer inspectors inspected "several hundred" houses by the end of February sending beds, bedding and clothes of people who had had the fever to the City Hospital to be "fumigated and purified" or destroyed. We've yet to see what measures will be taken in West Africa to prevent a return of Ebola.

In 2014, underlying the confidence that the epidemic will end as all previous Ebola epidemics have is the high mortality rate of the disease. Viruses spread more readily when those infected live a longer time. With this epidemic providing a wake-up call, efforts will be made to improve medical care in West Africa and address the problem of crowded living conditions. This could be the last major Ebola epidemic, especially since vaccines are already being tested.

But what happened in America after 1793 suggests that the lessons learned from the Ebola epidemic of 2014 might give a false sense of confidence. Viruses don't respect the good intentions of society. There is a vaccine for yellow fever which has not prevented recurring epidemics in tropical countries.

No one blamed doctors for misjudging yellow fever. Many died trying to fight and understand it. Rush lost three apprentices that he especially used to attend patients getting new remedies. Rush wanted to make sure that the medicines he prescribed were properly given to the patient and patients were bled as instructed. Then he wanted to know how the patients reacted to the therapy. In scientific papers today, the medical researchers who write the papers include technicians instrumental in collecting data as co-authors. In one paper exploring how Ebola spreads, five of the co-authors died of the fever.

After 1798 many, including Rush, overreacted to the persistence and spread of yellow fever. In 1798, alarmed doctors warned that America was possibly condemned to another half century of sickly summers and falls due to "the epidemic constitution of the atmosphere." That concept was as old as Western medicine having been used by Hippocrates to explain epidemics. After studying all known accounts of epidemics, Noah Webster published a book showing how for 2000 years eruptions of volcanoes charged the atmosphere with deadly gases that caused epidemics. Such thinking resonated with many who suffered through the terror of the recent epidemics. The last notable epidemics in the northeast were in 1822.

Today we are not strangers to over blowing the threat of future epidemics. If the Ebola virus mutates, some suggest, it may spread from person to person as easily as the common cold, or perhaps, like yellow fever be easily spread by biting insects. We can take some comfort that despite the grip it had on the Eastern seaboard shortly after the ratification of the Constitution, any mutation of the yellow fever virus has kept it farther away. The last sizable yellow fever epidemic in the United States occurred in the Mississippi Valley almost 150 years ago.

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