Last of the summer series

This is the last of my summer series. I know some of you have already seen the first frost, but summer here in Temple, Texas seems to just keep going, with 55 days of 100°F or more temperatures.

One hundred and thirty-six years ago this month (1873), a disease was ravaging my hometown of Calvert, Texas, striking approximately 1,900 of the just more than 2,000 population, killing approximately 300 (and no, I was not there and do not remember it). The numbers are approximate because of poor recordkeeping of the sick and dying, especially of the black residents. The following case is based on a real person victimized by that epidemic, gleaned from old records and publications that documented this tragic event. See if you can guess what this mysterious disease was.

Case

On Oct. 9, 1873, one of the eight town physicians in Calvert, Texas (figure 1, yes it is smaller now than in 1873) was called to the home of one of his colleagues to see his 5-year-old son, who had been sick with fever, malaise, headache, nausea and vomiting for the last several days. Shortly after the onset, he seemed to briefly get better for a day or so, but now he had become much sicker with a toxic appearance and the emesis taking on a black appearance along with his skin and eyes becoming jaundiced.

His past medical history was that of a previously healthy male with no known underlying conditions. However, it is noted that there are currently several similar cases in town, including one of the other physicians. This illness has been occurring in this community since mid-September, with a death rate of about 50%.

Examination revealed a very ill child with a fever of 102°F, jaundice, lethargy, some areas of ecchymosis of the skin and the black (coffee ground) vomit. The physician bled the child the prescribed amount and administered calomel (a mercury compound), but the child lapsed into a coma and died within hours (figure 2), as did the stricken physician mentioned above the very next day (figure 3).

What’s Your Diagnosis?

1. Reye syndrome
2. Malaria
3. Yellow fever
4. Meningococcemia

Case Discussion

Reye Syndrome, a severe hepatic encephalopathy, had not yet been described in 1873. It was first described by Reye and colleagues in the Lancet in 1963.

Meningococcemia can certainly result in outbreaks of a febrile disease with coagulopathy and fatalities, but nothing like this.

Malaria, a disease caused by a mosquito-borne intraerythrocytic parasite, on the other hand, may result in very similar clinical manifestations as yellow fever, but is not associated with this degree of fatality. Also, frequent, large outbreaks of malaria were not occurring throughout the southern United States.

The epidemic described above was one of the many outbreaks of yellow fever (C) that ravaged cities in the South, particularly New Orleans, in 1873.

Outbreaks of yellow fever in these communities were dependent on a large mosquito population and, of course, the introduction of the virus into the community. In Calvert, Texas, the spring of 1873 was marked by flooding, followed by a hot and humid summer with intermittent rains. This produced conditions just right for an unusually large mosquito population. The introduction of the virus remains somewhat the subject of legend, but it was thought at the time, as recorded in J. W. Baker’s book, A History of Robertson County, 5th edition, 1999, that a traveler from Louisiana arrived by train, having already gotten sick, got off in Calvert to be treated by one of the local physicians, Dr. John Coleman.

On day two, with the appearance of “black vomit,” the patient soon died and the physician had no doubt of the diagnosis. Even though this unfortunate traveler no doubt had yellow fever, that is not proof that he actually brought it to this community. Periodic cases were known to occur in river-bottom farming communities such as this.

Calvert is very near the Brazos River (figure 4), which makes for good cotton-growing land, but may also help promote the local mosquito population. We will never know. The exact date that the traveler from Louisiana arrived is not documented, and knowing that there is an extrinsic incubation period of two weeks within the mosquito, if cases among the local population occurred before that time had passed, then the traveler’s case was coincidental.

Briefly, yellow fever is a hemorrhagic fever caused by the yellow fever virus, which is a member of the Flaviviridae family, and is spread by the Aedes and Haemogogus mosquitoes, making this an arbovirus (arthropod-born virus). It was first described in Mexico in 1648, and outbreaks began being seen in Charleston and Philadelphia by 1699, and for the next two centuries, yellow fever would alter the history of the world with regular epidemics in cities as far north as New York and all across the South.

After an incubation period of three to seven days after the bite of the mosquito, patients will become symptomatic. It typically will occur in three stages; the first being a non-specific febrile illness with flu-like symptoms of headache, myalgias, fever and chills. This is when the patient is viremic and can infect the female mosquito as she takes a blood meal, which after the two-week extrinsic incubation period can turn around and infect another person. The second is the stage of apparent recovery that lasts one to four days. Most patients will have no further symptoms. About 15% of those infected will go on to the third stage, which has been referred to as the period of intoxication and is heralded by the return of fever, bleeding, jaundice, acute renal failure, hypotension and paradoxical bradycardia (in spite of fever).

The mortality of patients at this stage ranges from 20% to 50%, depending on currently available medical care. Those who were affluent enough to obtain medical care in 1873 were probably at greater risk of mortality as a complication of some of the therapies of those times, such as bloodletting, which was still in use in many areas of the world, including rural America in the late 19th century. However, before we start throwing stones at these physicians for such archaic, harmful therapies, we should reflect on the courage these brave practitioners displayed by merely not running in the opposite direction at the thought of even being in the same community as a large number of dying patients from a condition of unknown etiology and known to be highly fatal and possibly contagious.

On the contrary, there is an abundance of evidence that most physicians continued to practice, even in the face of their own colleagues dying around them. Five of the eight physicians in Calvert contracted the disease and died within those few months. Imagine the terror they must have felt at times, especially when they also saw their own family members die.

Some physicians were so dedicated to the healing of the sick that they would travel out of their way to deliver care. Such was the case of Dr. Edward Pye, a physician from the neighboring town of Hearne who traveled to Calvert to help the remaining physicians. Dr. Pye had a long history of altruism and did not hesitate when the need was known. However, his luck also ran out on Nov. 7 and he died of yellow fever. His wife, who left her three younger children with her oldest daughter, had come to Calvert along with her 18-year-old son, Edward, to nurse her husband. After he died, Mrs. Pye continued to nurse the sick until she contracted yellow fever and also died within two weeks (figure 5), as did her son.

The Calvert, Texas cemetery (figure 6), dedicated in 1870, would soon be the scene of frequent, sad family gatherings, as so well described by a nameless writer from Calvert in the November 1873 issue of the Texas Farm and Home Magazine:

“Our community is sorely stricken ... We go up and down our streets and miss many whose genial smile and warm grasp of the hand used to greet us. Only those who have passed through such an ordeal can realize the many solemn scenes to be witnessed. One of these now comes to our mind. It was a night – a moonless night, when a few of us followed the corpse mournfully to its narrow house. We lowered it in silence, all was solemn and even the stars looked sad, while the dew on the trees seemed tears from heaven. Our prayers were said, and the clouds fell rattling on the box, while the light of the lamps and the white tombstones and the weeping stricken ones made it a dismal place, we felt relieved when we turned sadly away. A funeral at night is truly a very solemn and impressive occasion.”

U. S. Army Maj. Walter Reed and his Yellow Fever Commission unraveled the mystery of the disease at the turn of the century. Reed published his report in the Journal of Hygiene in 1902. Then, it was largely a matter of vector control, and the disease began to fade away from the developed world. This information came too late for the lost souls of Calvert, Texas, but our challenges are ongoing. Whether it’s the mysterious acquired immune deficiency syndrome of 1983, before the cause was known to be the HIV, or pandemic flu, terrorist’s use of smallpox or tularemia as a weapon, or Ebola virus, there will always be challenges that test our courage. Think of this as we move into a season of possible pandemic influenza. Your opportunity may yet lie ahead.

Columnist comments

I have often dedicated this space to our military colleagues. What better opportunity now to continue this tradition? While he may not have won the Nobel Prize for his work in leading the Reed Commission in solving the mystery of yellow fever, Reed and his courageous co-investigators no doubt helped save countless lives by unraveling the cause and the vector of this devastating and frightening disease. However, he was immortalized within the U.S. Army by having the “Flagship” medical center in Washington, D.C. named in his honor (figures 7 & 8). To anyone interested in medical and/or military history, among the most written of is the story of yellow fever and its eventual control. And, in my opinion, the recent (2005) and most stimulating account of this amazing story is the book Yellow Jack - How Yellow Fever Ravaged America and Walter Reed Discovered Its Deadly Secrets, by Col. John Pierce, Medical Corps, U.S. Army (Retired) and Jim Writer. Pierce wrote an excellent factual account of this story that reads like a novel (figure 9, along with my wife, Ellen, at the 2005 Uniformed Services Pediatric Seminar). Additionally, the book contains a detailed bibliography and thorough index suitable to use as a reference for research. And, at about $25, it’s a real bargain. Col. Pierce retired from active duty after 30 years in the Army Medical Corps. At the end of his career, he was serving as the Deputy Commander of Walter Reed Army Medical Center. Knowing him at that time, I recall his passion for this subject matter and desire to “get it right.” Therefore, if you want to learn all you need to know about yellow fever, I strongly recommend this book as a starting point. You will probably find that you need no additional information.