Book Review

Yellow Fever and the South

N Engl J Med 1993; 328:1793-1794June 17, 1993

Article

Yellow Fever and the South
By Margaret Humphreys. 226 pp. New Brunswick, N.J., Rutgers University Press, 1992. $45. ISBN: 0-8135-1820-2

This portable, readable, and scholarly book gives evidence of impressive analytic erudition on the part of the author. Her general theme is the multiple factors, attitudes, and reactions that shape society's behavior when epidemics arrive; her particular focus is the U.S. South at the time of the yellow fever epidemics of the second half of the 19th century.

In this book we learn of absurd and protracted conflicts among vested interests and about stubborn ideologies, stupid prejudices, and misguided decisions during the struggle to prevent and eradicate a terrifying disease. Ignorance, greed, and panic formed a destructive mixture. The saga was both tragic and ridiculous. International, national, regional, and local groups fought for turf. Also active were conflicts between the North and the South, between the federal government and the states, and between both and the counties and the cities. The business and medical establishments alternated between collusion and collision. The boards of health, the press, the ports, the inland towns, and the maritime and railroad industries usually pulled in different directions, while the poor, above all the rural poor, suffered from a neglect that could not be called benign.

Epidemics of yellow fever had appeared in recorded history by 1495, called then by the Spaniards vomito negro (black vomit). Yellow fever became one of the worst scourges the world has ever seen, affecting entire cities, nations, and even cultures. In the United States, from the 17th century on, it spread wildly and intermittently to innumerable places. In 1878 alone, it invaded more than 100 cities and was most virulent in Louisiana, Mississippi, and Tennessee; the reported cases numbered 120,000, with 20,000 deaths. The cost of the epidemic nationwide was $100 million. The horror of the disease, and the helplessness and hopelessness it caused, had not been matched since the Black Plague decimated medieval Europe.

The book covers the period roughly from 1840 to 1905, when yellow fever devastated the South. Dr. Josiah Clark Nott, from Mobile, Alabama, took consolation in the fact that the disease attacked mostly “the unwashed democracy,” while the longevity of “the better class” permitted its members to buy life insurance at acceptable rates. “Vicious poverty” was blamed as the cause of the infection. In Norfolk, Virginia, an angry mob burned the slums of “the dirty Irish.” Large refugee camps were created outside the urban zones.

Some quotations speak for themselves. For example, “Anyone unfortunate enough to be traveling in the South during the fall of 1888 had little idea what documents or evidence of surety the next town on his or her itinerary might require, or indeed whether entrance might be refused altogether.” The editor of the Philadelphia Medical Journal used strong language in stating, in 1898, “Our southern states . . . have suffered so seriously from the inefficiency of certain local health-authorities and the insane and murderous activity of others.” The secretary of the Pennsylvania State Board of Health said matter-of-factly in 1899 that the “sanitary interests of the United States” demanded the annexation of Cuba. He believed that “the purchase price of the island would be much below the cost of just one yellow fever season.” Although blacks were known to be resistant to the disease, in 1905 they were nevertheless accused by C.M. Brady, a physician, of spreading the disease as healthy carriers. Their alleged role in spreading the epidemic was exacerbated by the fact that, in Dr. Brady's words, they “associate with the Italians on certain terms of social equality.”

For several decades the nation was at its wits' end in a battle against a mysterious, intermittent (it disappeared in wintertime), and frustrating pathologic entity. Measure after measure failed. We ought to remember that at that time medicine was still in the dark as far as the causes of infectious diseases were concerned. Basic notions and terms that we take for granted were practically nonexistent, whereas illusory concepts like miasmas, foul air, alkaline atmosphere, spontaneous generation, animalcula, and similar loose fantasies took hold of the public and professional imaginations. The Civil War also affected the situation. Antebellum notions changed slowly. In the meantime, an extraordinary pleiad of medical thinkers appeared on the world scene: Pasteur, Lister, Manson, Ross, Grassi, Laveran, Koch, Smith, Carter, and others. They opened new vistas and illuminated the road. The causes of malaria, filariasis, sleeping sickness, cattle fever, tuberculosis, yellow fever, and other conditions were glimpsed. Modes of transmission were understood. The role of bacteria became so prominent that “bacteriomania” swept the healing arts. Nevertheless, it took some decades really to comprehend the issues. The initial ignorance was so abysmal that the many errors were excusable.

A statement that appears early in the book should be rectified. The author states categorically: “In 1900 Walter Reed and James Carroll discovered the mosquito vector of yellow fever.” The case was quite different.

In 1881, before the Royal Academy of Medical Sciences of Havana, Cuba, Dr. Carlos Finlay read a classic medical paper, “The Mosquito Hypothetically Considered as the Agent of Transmission of Yellow Fever.” In it, for the first time, Finlay not only explained the brilliant reasoning behind his conclusion and the complicated mechanisms involved, but also accurately identified (among more than 700 species) the specific culprit mosquito. He furthermore described how the biting was done exclusively by the female, which requires warm blood to speed up ovulation after mating. His paper was translated into English by his former student Rudolph Matas and published in the New Orleans Medical and Surgical Journal in February 1882. Finlay himself, who was a medical graduate of Jefferson College in Philadelphia and spoke good English (among other languages), defended his theory for years in the United States, Cuba, and other nations.

In June 1900 the members of an American research team (Reed, Aristides Agramonte, Carroll, and Jesse Lazear) were cordially received in Havana by Finlay, who gave them the fruits of two decades of observations, notes, writings, and experiments, including the pertinent mosquito eggs and suggestions about hatching them. Soon events began to move at a rapid pace, marked by the death of Lazear, a believer in Finlay's theory who heroically volunteered to let an infected mosquito bite him. A martyr to science, he is the young unsung hero of this dramatic epic. (Clara Mass, a volunteer American nurse, later died, too).

The research team decided to prove the mosquito theory once and for all with a clever and decisive experiment (albeit one perhaps not possible today because of laws regulating human experimentation), and its confirmation was then announced to the world. Using the sanitary measures suggested by Finlay, William Gorgas, backed by Leonard Wood, directed a vigorous campaign that in a matter of months cleansed Havana and Cuba forever of yellow fever. The same methods were applied by Gorgas in Panama, making possible the completion of the Panama Canal. The last epidemic of yellow fever in the United States occurred in 1905.

Those facts should be highlighted without equivocation or pussyfooting in the books that frequently appear on the history of tropical medicine. There is more than enough glory in the conquest of yellow fever to bathe all the protagonists in its light. As we near the end of this century, ample time has elapsed to see events in their proper perspective and to tell the tale accurately, “with malice toward none, with charity for all.”

Is this book a practical one for busy practitioners? At first sight, it is not, but that judgment depends on one's concept of being a physician. “The physician who knows just medicine,” said the Spanish doctor Jose de Letamendi, “does not know even medicine.” We are much more than technicians, diagnosticians, or signers of prescriptions and orders, of course. Ideally, we ought to know our patients in the contexts of their own lives (family, community, work, and culture). We are recipients of family secrets, requested to counsel or to console, forced into acting as medical detectives, responsible for life-and-death decisions and even for advice that could influence the destiny of thousands.

This book illustrates how unexpected circumstances can demand that we take on new roles and accept dangerous risks. Learning what happened in the United States a century ago, when it was invaded by an unknown, terrifying, and easily transmissible illness, can prepare us for the present and the future. Nowadays, after all, the circumstances resemble those of that period. The world is again facing a terrible scourge. The definitive solution -- although everybody can and should help -- will not come from governments, or businesses, or unions, or the media, nor from athletes, actors, entertainers, activists, protesters, victims, or the public. It will come, as before, from medicine.

R.D. Rumbaut, M.D.
Baylor College of Medicine, Houston, TX 77030