The politics of disease, demonstrated by yellow fever around 1800

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The history of yellow fever is one such piece of medical history illustrating how much medicine is often taking the wrong path.

“The profession couldn’t be any smarter than it is right now!”

This is often the paradigm we live with.  After all, if we didn’t think this way, then why are we allowing these poorly educated professional to even touch our ailing body, mind, or state of being?

The most highly educated physicians in 1800 believed the following:

Yellow fever is natural to the ecology of the torrid zone of the earth, that part situated between approximately 40 degrees north and south of the equator including the equatorial line.  This is the zone where countries with tropical climates bore fevers of various forms.  In Africa there were numerous fevers of unidentified origins that struck Europe on a fairly normal basis.  But yellow fever was a fever from the other side of the earth, South America, and had its greatest impact of North American before making its way to Europe.

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This restriction of the disease to the tropics on just one half of the earth was a very geographic characteristic of that cause for death.  It implied that not only did latitude matter in terms of defining where fevers come from, be they tropical or not, but also longitude since this helped define the blockade that existed between Europe and the Americas.  In a medical climatologist, medical topographer’s mind, this meant that latitude, longitude, ocean size, and land form had a great impact on how effectively a disease could be transferred from one place to the next.   Applying this to the very old theory of miasma as a cause for disease for a moment, we can easily understand why someone might think that the broad ocean with its overlying gales and precipitation would be enough to prevent any form of miasma on board that ship from ever making it as far away as the other hemisphere, and that the climate and temperatures of lands situated too far to the north and south, were able to avoid this miasma due simply to their thermal patterns.  Yellow fever had this way of just striking the coastal towns and cities, so in a medical climatologist’s mind, topography did have something to do with its places of returning contagion on an almost annual basis.  The humidity, winds and air of the ocean’s edge, combined with certain areas rich in decaying ocean or marshlands detritus, would be enough to add a terrible edge to the miasma that could make anyone ill, and so certain Oceanside places, like marshes and bays became the heart of the miasma responsible for this disease in places where oceans seemed to have minimal effects.

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To demonstrate how cultural bias is responsible for this manner of thinking . . . making judgments, consider the following . . . Just like the initial blame for AIDs by New York was asked to be place on the people of Haiti and Jamaica in 1985 (see related autobiographical article published in Milbank Quarterly in 1986, by Daniel Fox, the individual who refused to point the finger at Jamaicans for outbreaks in Queens, this nearly cost the State of New York’s its reputation, so they essentially fired him).

When small pox came to the United States, it was brought here primarily by African Slave Trade, although it was well known that most Europeans bore this contagion as well.  But the Africans were used as examples for illustrating its behaviors.

The initiation of African slave trade eliminated the former barrier that existed for this disease to spread outside the Americas.  Yellow fever at some point in history made its way via the trade routes to parts of Africa, where the climate was perfect for its survival as a tropical disease, and where plenty of opportunity existed for the miasma formed at these ports to constantly renew and sometimes redefine its relationship to the human race.  Yellow fever allows us to better understand the commercial routes that then existed. Whenever epidemics of this disease erupted during the late summer closer to North American, we could use this information to determine the into the trade industry for the time.

Unfortunately for the Americans, this fatal form of the bilious fever known as yellow fever was a rarity at first in European history.  This enabled American doctors to develop a certain level expertise in this disease before the British did.  In doing so, they had their own unique theories for disease that developed based on observations about local topography and medical geography.  But the British also had these insights into medical geography and at times took the lead in some medical geography ideas in general pertaining to the geography of yellow fever, but when it demonstrated a possible impact on slave trade, some British doctors refuted the American geographic claims whenever they seemed to interfere with certain British commercial activities.  (The Island off of the Ivory Coast and the reference to yellow fever as Bulimia fever was a prime example of this.)

For this reason, the geography of disease patterns was influential upon the European theories for disease we well, a new theory for disease in medicine that provided physicians with the highly credible philosophy needed to once and for all wipe the physicians’ slates clean of the four humours concept.  During the late 1700s, the medical climatology and medical topography theories continued to develop and evolve.  By the 1790s, its definition was finalized to many, and with the battle over between England and the United States, more time could be spent replacing the older concepts with new theories and new technologies.  Yellow fever gave doctors a reason to further explore the natural sciences as an important part of any medical training.  It was due to this relationship that temperature and humidity became measurable and were regularly logged in the books.  But due to its persistence and prevalence in the Americas, Yellow Fever gave American doctors an edge over British physicians paying attention to climatology, temperature, humidity and topographical settings as well.

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The yellow fever, known for its effects upon the eyes, gave American physicians had a slight edge over the British when it came to the need and desire to focus more upon its geographic behaviors.  The intent of such studies was to better understand the relationship between people and their environment with regard to health.

Yellow fever was not excluded from American history however, and became the most important epidemic disease to strike the newly established United States soon after the Revolutionary War was over. This disease had already made its way to the colonies in North America before the War began. It struck the tropical and sub-tropical islands in North and Middle America fairly consistently during the mid- to late 1700s. With an origin in South America, its ability to traverse the Pacific in order to infect Africa was made quite evident during the peak years of the slave trade, in particular, the 1760s. Rhode Island was also apparently struck by this disease in the 1760s, during the later weeks of summer into early fall. Its identification as a unique fever however had yet to occur, and so it was linked to other diseases striking similar places well into the late fall and early winter, such as the typhus spread by flea-ridden rats or the typhoid, yet to be distinguished from typhus, spread by various sources infected by Rickettsia.

By the mid 1790s, the difference between United States epidemics and Western European epidemics became quite clear. Physicians learned in the Western European medical schools and teaching hospitals would return to the United States well trained in human anatomy and physiology, but poorly trained in American plant medicines and even less trained in American disease patterns. Yellow Fever was not recognized or taught much by the European doctors and surgeons, and so these highly skilled, well trained and read physicians from the Old World were little prepared for the recurring yellow fever epidemics that struck somewhere in North America, almost every year, from 1790 to 1800.

Although there were several claims published about the import of a fever much like the yellow fever before the 1790s, 1793 was the first year yellow fever is known to have made its way into this country in full and complete epidemic form.  This disease killed thousands of people and forced tens of thousands to flee from their homes and city of residence, Philadelphia.

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Example of a military wagon from ca. 1800, from Meadowcroft, western Pennsylvania.  Wagons varied in design.   The cross ventilation this wagon provided had its benefits,  but might also be associated with the development of disease.  Tighter weaves and cloth linings may have been used for soldiers uniforms, wool blankets, and other delicate supplies.  The rear panel doors wold have been somehow locked for security purposes.  From http://www.thelittlelist.net/grligonierwagon.jpg

Military Interpretations.  The very first reaction to this epidemic we see in the military writings from 1792 to 1794.  This first period of the epidemic had a medicine that was practiced under a belief quite similar to the contagion theory related to small pox and measles.  The inoculation was a proven success during this time, and it had an impact on the philosophy of yellow fever.  Many believed that some form of miasma could be formed in or infecting something as simple as stacks of uniform clothing and blankets, transported about by horse and wagon.  There were two miasms that were believed in around this time–the iatro-miasm that people produced and passed onto others taken ill, and koino-miasm, that smelly vapor or gas emitted from rotting debris and vermin lying dead in shipping ports, decaying butcher meat and ripe, smelly swamps and marshes.  Either of these on an article of fabric was enough to kill anyone who came in close contact with it, not necessary physical contact, just close enough to breath in that smell of infectiousness.

Very quickly, the observations made by the military enabled leaders to discard this theory.  But until the year was over, and the passage of yellow fever into this country complete, there were strict requirements that had to be met for preventing the disease, such as burning any materials in contact with people infected or believed to be passing on this condition from one place to the next.  And for wagoneers to abide by their responsibilities, duties and schedules, so their contacts could be managed and policed, in case anything new did erupt.

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The 1793 epidemic that came to Philadelphia gave some of the local physicians of great fame further means to continue establishing their identity and generating additional followers. Benjamin Rush accomplished this with his essay on the 1793 yellow fever epidemic of Philadelphia, which he referred to as a serious case of biliary fever. This essay only gave his competitors in the big city next door, New York, sufficient reason to claim he was not being very patriotic as a post-war veteran. In fact, a lot of Philadelphia was very un-American to some of the more dispersed socialites in New York residing in the rural sections of the mid to upper Hudson River Valley, westward across the Mohawk. The further you were from New York, the less you heard about those occasional New York urbanites expressing their support for the patriotic survivors of the formerly famous families of British lineage and British loyalism. The Mayor of New York himself by the end of that decade, Alexander Colden, was the son of a borderline loyalist Cadwallader Colden, whose respect for New York’s wants and needs, and lack of sufficient British power and leadership in the eyes of the Parliament, only made his disliked by both sides. Were it not for the family’s money, and New York’s need for this source of revenue, it is unlikely Alexander and his siblings would have made it as far as they did, due to their overall lack of behavior as patriots.

New York’s elite in New York City, in spite of their occasional British descent, had their British-trained MDs who could tell that British medical philosophy was not going to suffice for treating New York diseases. The fact that Benjamin Rush argued against some of the claims made by the Scottish-trained physician in New York City, Samuel Mitchell, gave Mitchell the opportunity to raise the political wall and agenda for the New York medical school, which at times was in great conflict with the teachings and agenda for the Philadelphia medical school presided by Benjamin Rush.

Yellow Fever according to Benjamin Rush was of local origin and due to many things, the most amusing of which was spoiled, rotting coffee beans. Samuel Mitchell’s reasoning for this disease went along similar lines at first, but then he took the concept of the disease-causing agent miasma just a little bit further than Rush, inventing a term and ideology that Rush could not so effectively argue against. Mitchell defined several of his own terms to refer to his unique  philosophy of disease cause, and used these terms in many ways to explain the invisible causes for epidemics striking the region, be they yellow fever in signs and symptoms, geography, or not.

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John Haygarth’s essay on the definition of miasma for the time appeared in a letter to Percival on American Pestilence, 1800.  From Medical Repository of Original Essays and Intelligence Relative to …, Volume 5, 1801.

But Mitchell went still another step further in his philosophy about medicine and disease. he defined the field of medical geography for American physicians. Rush perhaps believed in the medical geography concept, although the popular term for this time was in fact medical climatology and medical topography. But it was Mitchell who used the term “Medical Geography” in a very early article published in the school’s journal that he was chief editor of, The Medical Repository. With Mitchell as the New York region’s medical geography expert, complete with expertise as well in mineralogy and paleontology, with that Patriotic edge, and Rush as Philadelphia’s expert epidemiologist and more traditional medical writer and theorist, with that British edge underlying his history, in spite of his famous signature, we see the stage now set for politics of medicine to come to a head between 1800 and 1830, by which time both Mitchell and Rush were both deceased.

Both Rush and Mitchell demonstrate this human behavior common to much of medical history. There are times when physicians make these miraculous discoveries which with time prove themselves to be true forever, impacting medicine to this day. Then there are those times when the same kinds of physicians make their miraculous discoveries, and draw their unbelievable conclusions, only no longer be recognized for these discoveries due to their extinction induced by learning more accurate truths.

The first medical geography map produced in the United States pertained to a yellow fever epidemic that struck lower New York City at its most active ports.  This map was the product of Valentine Seaman, and was preceded by just a few other maps developing in the German-, Bohemian- speaking parts of Europe in the 1790s.

We can watch the mapping of disease progress and yet see the classic rendering of the first ocean-shoreline renderings of this disease in later disease maps.  There was a considerable amount of controversy during this time about the limitations of yellow fever to maritime settings.  Similar occurances of fevers with similar symptoms did take place along major seaports inland, such as the St. Lawrence River into the Great Lakes and Finger Lakes regions of upper New York.  Yet few of the individual residing so far inland felt comfortable calling these yellow fever; their related climate,  topography and overall geography were too different.  Thus the geographic naming of disease became popular, the term Lake Fever was born, along with a few other similar yellow-fever-like diseases.

Medical geography has examples of these physicians as well. In the mid 1860s, as former homeopath John C. Peters developed his skills in understanding and believing in medical topography and disease mapping, another leader for the time, Haviland, began mapping cancer. Of course, the cause for cancer was not at all known, but some ideas for its causes existed.

Mid-1800s.  Haviland believed that the cause for cancer had something to do with the underlying geology of a region. This is the first example published of how a very credible theory can result in statistical results that suggest the original thesis for the study to be true, only to result in a obvious example of inferential type I error–saying something is the case when it is not (type 2 error is saying there is not a relationship when there is). Now, this claim of the type 1 error of Haviland’s work is not completely true, there are in fact some forms of cancer and cancer like diseases that occur due to local geological features. The various lung diseases may occasionally be presented and diagnosed as some form of tumor or cancer. The impact of radon or radium might also impact the body of people residing above it. Natural gases emitted from certain soil types are also potential carcinogens at times. The pure elements that make up certain stone formations, such as Mercury, Aluminum, Beryllium, the halogens, and even concentrated Sulfates, may on occasion be in such a form that a claim for geological cause can be justified. But Haviland’s theory in this case is very much in error, for the most part.

Another interesting maverick of British upbringing, practice and service during this period of time is Robert Lawson. To many he was the expert in terrestrial magnetism and the influence of the natural energy sources on pathogenesis. This is a precursor to the currently popular foreign born theory for viruses, the idea that comets, meteors, asteroids, and cosmic dust carry with them these very small objects, that when in contact with humans become pathogens. Lawson’s philosophy of the cosmic force and its impact on the earth’s climate and the earth’s energy fields formed the basis for his very short-lived pre-bacterial theory for disease with an extraterrestrial focus. His mapping of this phenomenon influenced the writings or other medical geographers, cartographers, and climatologists like Ferrel in the 1880s.

The late nineteenth century, just prior to the birth of the bacterial theory, has two other parts to it worth mentioning. The first is the development of the philosophy which defined small substances akin to atoms as the cause for disease. They were larger than miasmic particles, probably living and usually able to be vaccinated against, and had some relationship to the surrounding environment, either ecologically or in terms of how they are formed or generated. This theory was required for the subsequent bacterial theory to develop, and overlaps somewhat with the older animalcule theory for disease, around perhaps since Fracastorius (although his little organisms felt to be responsible for were really blood cells) in some way, shape or form, and the development of the bacterial theory around 1881/2.

Two hybrids of disease theory were generated during this era.  Ferrel’s map depicts one, the notion that scurvy could be both that mythical miasma floating above the ocean’s water surface, and yet be very limited in its placement, as if unfloatable once it is over landmasses.   Ferrel would later go on to participate in some fairly controversial activities related to racism and eugenics, probably a result of his medical geography research and unique association with several political social groups.

We also see culture and politics play a role in disease mapping and medicine with the arguments about African disease in general, yellow fever and the slave trade. Since the early 1800s, the fact that an island of Liberia was formed, a place where freed Africans could reside within their natural climate setting so as to avoid unnecessary illness, was claimed by some British pro-slavery writers to be the cause for certain epidemics.

With the rise of yellow fever in the United States between 1793 and 1797, we find Americans as concerned with its cause as much as they, in theory, were minimally concerned about the spread of other infectious diseases to Native American communities by way of infected blankets. For this reason, the blankets were considered to be the main cause for yellow fever in 1795-8 and had to be burned if people directly or indirectly associated with the wagons bearing these blankets became infected and died. Early attempts to stop the spread of the disease resulted in the smoking of these blankets in a closed space, followed by re-aeration and cleansing of the air, but later developed into the simple incineration of these sources for contagion, a substance that infected that due to their mere presence in the local air space