MALK1

Yellow Jack

by
Frederick D. Malkinson

Delivered to The Chicago Literary Club
October 4, 1999

Yellow fever, also known as yellow jack for the quarantine flag flown by ships at sea, became one of the most feared diseases throughout urban America during the eighteenth and nineteenth centuries. Inadvertently imported from Africa, yellow fever made its first New World appearance in the Yucatan and Havana in 1648. "In modern America, where the triumph over disease is often taken for granted and yellow fever has ceased to be a menace, it is difficult to appreciate the (terror) once engendered by (that disorder)." It is not the purpose of this paper to analyze the medical aspects of yellow fever. Rather, it is to recount some of the intriguing social and political consequences of this epidemic disease, the public response and reaction to it, and, finally, changing ideas about its etiology and prevention in the late nineteenth and early twentieth centuries. The major examples to be cited are the outbreak of yellow fever in Philadelphia in 1793 and the repeated epidemics of this disease in Haiti in the 1790's and early 1800's.

"The 1793 epidemic of yellow fever in Philadelphia was no mere round of sickness but a major public health emergency that paralyzed city functions, halted business and trade, and caused a breakdown in social institutions. The fever's devastating effects on what was then our nation's capital is apparent in the grim statistics left in its wake: (among the city's 45, 000 inhabitants, some 17,000 people were infected), more than 17, 000 people fled .. for safer environs (including most government officials), nearly 5,000 died, and hundreds of children were orphaned." "The panic was so great that many people thrust their parents into the streets as soon as they complained of a headache." At least six previous epidemics of yellow fever had devastated Philadelphia since its founding in 1682, with one third of the population lost in 1699.

Briefly, patients seriously ill with yellow fever run temperatures to 104 F, and suffer nausea, severe gastro-intestinal upset, headache and intense generalized pains. In many patients symptoms remit on the third or fourth day of illness. In others the disease progresses rapidly: jaundice, due to liver failure (which gives the disease its name) or kidney failure lead to coma and death three to five days later. In only a week to ten days, then, the patient is either dead or on the road to recovery. Overall mortality figures range widely from less than 10 percent up to 70 percent of infected individuals in different epidemics.

The first case of yellow fever in Philadelphia in 1793 was diagnosed in early August by Benjamin Rush, signer of the Declaration of Independence and the most renowned physician in the United States at that time. In November, 1793, Mathew Carey published his on-the-spot instant history of the epidemic entitled "A Short Account of the Malignant Fever, Lately Prevalent in Philadelphia". Carey, an author and publisher, was later founder of Lea and Febiger, destined to be the longest-lived publishing firm in the United States. Carey's account features "the collapse of community under the terrifying burden of the epidemic and the rebirth of community through the heroic efforts of a small band of public-spirited volunteers . " He described streets filled with refugees and their belongings fleeing the city, a devastated local economy, massive, almost instant unemployment, universal terror, and the breakdown of established governmental authority. Left on their own, most people became obsessed with fears of heavenly punishment and thoughts of personal survival and protective isolation. Carey described the impact of the disaster within the family when fear of contagiousness was rife: "Who, without horror, can reflect on a husband . deserting his wife in the last agony, a wife unfeelingly abandoning her husband on his death bed - parents forsaking their only children - children ungratefully flying from their parents, resigning them to chance, often without an inquiry after their health or safety .. less concern was felt from the loss of a parent, a husband, a wife, or an only child than, on other occasions would have been caused by the death of a ..favourite lap-dog.." Carey describes many instances in which people were left to die unattended when supportive care might well have saved their lives.

On September 10 Mayor Clarkson, one of the few government officials who stayed in the city, established the Committee on Malignant Fever, composed of volunteers to assume social and medical support responsibilities. Carey, a committee member, wrote that the Committee was "so highly favored by providence, that they have been the instrument of averting the progress of destruction, eminently relieving the distressed, and restoring confidence to the terrified inhabitants of Philadelphia". The Committee first supervised the rehabilitation of the city's Bush Hill Hospital: a systematic plan for hospital admissions was organized, rooms were cleaned, patients were grouped according to disease stages in the hope of preventing further spread, plentiful medical supplies and food were procured, and patient care was greatly intensified with the enhanced hiring of nurses and attendants. This Committee met daily - often into the late hours of the night - from mid-September through November, and essentially became the functional governmental body for the city. The members also formed an orphanage for the children, provided food, clothing, and some support for those left without resources, obtained carts and caskets for burials and hired gravediggers.

As Sally Griffith has written, Carey's description of community destruction and rebirth has influenced the ways in which Americans have responded thereafter to all forms of civic catastrophes over the last two centuries. In disastrous floods over the years, for just one example, volunteer citizen groups have restored order, fought flood waters and provided rescue services and general aid to the victims. As Griffith has written, "Beyond its immediate significance, in telling the story of how benevolent citizens came forward to save their community, Carey contributed to the development of a broader paradigm of citizen voluntarism, in which the people' themselves, not the (city or) state, band together in moments of public emergency and reknit the bonds of society."

When the first American newspaper was published in Boston in 1690, it promised to publish news of God's making once a month, but did propose to appear more often if "any Glut of Occurrences happen". Gradually the prime responsibility for making the world interesting to read about shifted from God to the newspaperman. Even so, in the late 18th century, Daniel Boorstin describes most newspapers as being, "little more than excuses for espousing a political position, for listing the arrival and departure of ships, for familiar essays and useful advice, or for commercial or legal announcements" However, during the epidemic crisis in Philadelphia, the daily "Federal Gazette" - the only one of eight newspapers still being published by mid-September - became an extremely important source of information about the fever, supplied in good part now from the newspaper's readers themselves. The role of the newspaper, then, at least among the literate, became crucial to the public response to the epidemic. In addition to the publication of "authentic information", the paper's articles also included "ordinary people passing along rumors, offering folk cures . speculating on the religious meaning of the disease, and sharing their fears and sorrows." Obsessed by information about the fever and authentication of facts versus rumors, Philadelphia's citizens found that the most accurate information was only available in the "Federal Gazette". Mayor Clarkson contributed regular communiqu s to the paper, ranging from public orders on sanitation to the death toll of the week. The public Committee also placed frequent communications in the newspaper on its activities and its supervision of hospital services. The physicians of the city, too, were regular contributors, attempting to serve the public and to establish the authority of a particular mode of treatment. So intense was the flow of contradictory therapeutic recommendations, however, that many readers sent in letters of protest, claiming that these various opinions contributed to, rather than assuaged, the general distress of the populace. Common, too, were letters of censure for doctors, ministers and politicians - Pennsylvania Governor Mifflin and the main body of the Federal Government, including treasury secretary Alexander Hamilton, vice-president Thomas Jefferson and even President George Washington - who abandoned their duties and hastily left the city.

The anxiety for information overwhelmed the fear of death, and the bonds of communication established and maintained by the "Gazette" may have been more valuable than all of the treatment measures the physicians prescribed. "With notes, letters, discussions, arguments, prayers and meditations in the newspaper, (readers) replenished the texts of public discourse. For these (individuals) newspaper readership was a form of active citizenship, a way to participate in the on-going conversation of their community."

At long last, in late October, the "Gazette" published the Committee's announcement of the official end of the epidemic.

From a medical viewpoint, good health in 1793 was associated in the minds of many Philadelphia physicians with a recent theory of illness based on the maintenance of tone, strength and elasticity of blood vessels. Adhering to this theory, Benjamin Rush believed that all disease was related to excessive stimulation of the vasculature. As a consequence he argued that the only reasonable treatment for yellow fever victims was to relieve that excitement by heroic bleeding and purging, and the administration of powerful emetics. Other physicians, however, prescribed much gentler, essentially supportive therapy. There were also sharply divided opinions about the source of yellow fever. Many physicians believed that an effluvium or miasma arose from local sources of decay and spread disease through the air. Rush diagnosed that source as rotting containers of tobacco on Philadelphia wharves, left there because of disease decimation among the dock workers. Others argued that yellow fever simply spread from person to person. It is clear now, of course, that neither the form of treatment used, nor the theory of disease spread, had any effect on the recovery of patients or the implementation of disease prevention.

Rush's name is synonymous for the 1793 epidemic largely because of his intrepid method of treatment which included copious bloodletting of up to several pints of blood. In addition, however, Rush was also known to link the organization of social and political systems with the health of the people comprising these systems and to address medical concerns in light of their impact on both the body and body politic. Later on , in an amusing letter written to John Adams in 1806, Rush disclosed a great antipathy towards the country's leaders in his proposal that, "the remedies for . yellow fever would do wonders with the heads of the men who now move our world . Bleeding would probably lessen the rage for altering the Constitution of Pennsylvania in the leaders of the party who are now contending for that measure .. The cold bath might cure the peevish irritability of some of the members of our congress, and blisters and mustard plasters arouse the apathy of others. In short, there is a great field open for new means of curing moral and political maladies."

The yellow fever epidemic forged interesting links between health and politics. In addition to the two main theories of treating the disease, different additional ideas arose about its origins. Poor sanitation and local climatic conditions were considered causative by some. Others blamed the epidemic on unhealthy conditions aboard ships docking in Philadelphia. Many ships carried refugee passengers fleeing warfare in some of the Caribbean islands where yellow fever had been endemic for almost 150 years. Many of the Jeffersonian Republican physicians believed in the theory of causative local factors and backed Rush's strenuous "cures", while doctors espousing the "importationist" theory (largely Hamiltonian Federalists) had adopted gentler treatment measures. A number of prominent local and national political figures also took their respective party position on the origin of the epidemic. In aligning themselves with national parties for increased moral support, physicians and their allies "became an integral chapter in the history of the (formation of) the first political party system" in the United States. Since it was well-known that yellow fever epidemics favored urban centers, the local disease origin theory now also stimulated further support for movement of the national capital to Washington, D.C., the rural site for which had recently been selected.

The political implications of the medical controversies led the importationist Federalists to demand quarantine of shipboard arrivals or a halt to immigration, and to call for sharply reduced trade with the Caribbean islands. However, Republican merchants saw the importationist theory as a plot to destroy lucrative West Indies trade. But the Federalist stance on importation soon became quite popular in the young United States, since the thought of a native American plague irritated a highly sensitive patriotic nerve. "By denying any local source of the pestilence, the Federalists won much chauvinistic and local booster support. .. In addition the Federalists managed to identify (and link) their opponents with Benjamin Rush's advocacy of a dangerous and controversial remedy.." Ultimately, no compromise was ever reached on the stands of the two political parties in regard to the epidemic's origins, but after 1793 Philadelphia undertook both quarantine and sanitary reform measures.

Although nothing was known about the true causative agent of yellow fever or the manner in which the disease was spread, as the epidemic subsided city leaders and concerned citizens began to ameliorate what they believed lay behind the epidemic, namely, a filthy urban environment and a dangerously polluted water supply. Rats, cats, dogs and pigs roamed the streets, which were littered with garbage and human and animal excrement. The subsequent undertaking of extensive public health measures, the first in an American city, was an exceedingly important historical response to the 1793 disease outbreak, receiving repeated emphasis as recurrent epidemics of yellow fever in Philadelphia in 1797, 1798, and 1799 further decimated the Philadelphia population.

In the fall of 1793, the Committee on Malignant Fever recommended that a health office be established and given wide responsibilities, and that a site for a permanent hospital be selected. In December, the returning city council directed the Committee "to examine the rooms and houses where people had died of the fever and . clean out those still containing the seeds of infection". In January, 1794, the council devised a long-term plan to clean the streets better by systematically watering during summer and fall with flush carts and scrapers. Bedding and clothing of former yellow fever patients were to be smoked and otherwise purified. Later, the Council issued guidelines for the paving of roads and the construction of wells for drinking water. Installation of proper drainage and elimination of many sources of standing water were inadvertently, but directly, related to controlling yellow fever, as only became scientifically evident a full century later. For all of these measures the city now sought help and advice not from physicians but from civil engineers, although Rush and others had emphasized environmental sources of disease which now led to sound general public healthy policy.

One major factor missing from earlier planning in 1793 and 1794 was the subject of a pure water supply. A few years later the connection between the ingestion of pure water and bathing to health in general received new strong emphasis in Philadelphia's city council. Their report stated that "wholesome water (was) most effectual to prevent or mitigate the return of the late contagious sickness". At this time the earliest water closet in America, installed in a Baltimore home, dated only from the mid-1760's. In the summer of 1799 Elizabeth Drinker of Philadelphia wrote that she "went into the shower bath. I bore it better than I expected, not having been wett all over at once, for 28 years past." Her costume for this wild adventure was a thin gown and "an oyl cloath cap" The Drinker's shower was the first ever installed in a home in this country and dated only from the year before, 1798. Arguments over engineering designs and costs for a centralized water system delayed construction of a safe, efficient and pure water supply for Philadelphia until the 1820's. Nonetheless "the terrible yellow fever outbreak of 1793 defined the last decade of the century: . it added force to (inhabitants') responses to the milder epidemics (of later years) .giving support to bold urban initiatives and winning acceptance from a city whose individual interests had earlier thwarted (plans for) similar projects."

The United States was hardly alone in its experiences with yellow fever epidemics. While the disease was ravaging Philadelphia in 1793, it was revisiting Haiti throughout the 1790's and early 1800's. At that time the Haitian population consisted of about 30,000 Caucasians and 500,000 African slaves. Year-round average temperatures of 80 F and plentiful rainfall led to luxuriant production of sugar, cotton, and other crops, making some of the Haitian plantation owners among the richest men in the world. A French possession, Haiti accounted for 20% of France's foreign trade. However, the excessively cruel treatment of slaves (brandings, beatings, arbitrary murders) had resulted in eight armed revolts between 1679 and 1791, all doomed to failure.

From 1791 on, armed bands of black guerillas constantly harassed and killed French plantation owners and burned many of the plantations. In 1791, Toussaint-Louverture, a freed slave and converted Catholic, who was to become the greatest figure in Haiti's history, organized an army of blacks and trained it in guerilla warfare tactics. A charismatic leader of men, Toussaint seized control of Haiti and Santo Domingo when the French National Convention freed the slaves in 1794. In the next few years he did much to restore the economy, preached reconciliation of blacks and whites and established lucrative trade with Britain and the United States. In 1801, to solidify his command of the island he drew up a constitution in the name of France but without French governmental input. This act angered Napoleon Bonaparte, now First Consul and the dominant ruler in Europe, who feared loss of the island to independent status. Consequently, Napoleon organized the largest invasion fleet in France's history, and dispatched eighty ships and 35,000 men to reestablish French control of Haiti. Under the command of General Charles LeClerc , Napoleon's brother-in-law, the first ships reached Haiti in February, 1802. Against vastly superior arms, Toussaint now cleverly instituted a three-part military program that included a scorched earth policy, guerilla warfare, and an eagerly anticipated yellow fever epidemic that would strike after the rainy season began in April. Despite initial capture of several coastal cities, within four months the French had lost 5,000 men to one of the deadliest yellow fever epidemics ever seen in Haiti. LeClerc desperately began the first of several requests for reinforcements, only one of which was ever answered with a fifteen hundred man force that was almost totally exterminated by yellow fever. LeClerc 's physicians now predicted that by fall another 5,000 to 10,000 men would perish in the epidemic.

Although Toussaint was captured and exiled to a mountain prison in France in June, by early fall of 1802 LeClerc had lost 20,000 of his 35,000 man force to yellow fever and 8,000 more were in hospitals. With epidemic losses still climbing LeClerc wrote to Napoleon in October that, " .my position has turned from good to critical .because of the yellow fever". It was now clear to the French in Haiti and Napoleon in France that the French troops were fighting for a lost cause. On November 2, LeClerc himself died of yellow fever and French hopes for ultimate victory were doomed. France's death toll, with some estimates ranging to two-thirds of their forces lost to yellow fever, now set in motion one of the most extraordinary events in American history.

In dispatching troops to Haiti, Napoleon had had far more grandiose plans than simply reestablishing French control there. A secret treaty in October, 1800, had traded New Orleans and the Louisiana territory to France for modern-day Tuscany to Spain. Napoleon had aimed to base LeClerc 's army in New Orleans after victory in Haiti, establish absolute control over Mississippi River trade, and then raise a 25-30,000 man black force which, with French reinforcements, could be used to capture several of the British and Spanish held Caribbean islands. Ultimately Napoleon planned possible attacks on Canada and the United States, neither of which had a significant standing army.

In the face of the steady erosion of French forces in Haiti and LeClerc 's defeatist communiqu s, Napoleon soon realized that the loss of Haiti was inevitable. He thereupon abandoned his plan to enlarge France's New World colonies and conceived a bold alternate campaign to invade England and then extend the French empire further by reconquering Egypt and invading the Middle East and India.

Although Napoleon never lacked for ambition, what he did need now was substantial funding for his newly laid military plans. When rumors reached President Jefferson in 1802 that a secret treaty had ceded Spanish rights in North America, including control of the Mississippi, to the far more powerful government of France, "he promptly concluded that this was the greatest challenge to American independence and national integrity since the American Revolution." Jefferson thereupon authorized an old French friend to offer six million dollars for the purchase of New Orleans and the Mississippi valley, a startling idea for which there was no constitutional basis. The offer was refused. James Monroe, former ambassador to France, then joined Robert Livingston, current ambassador to France, to continue negotiations with Talleyrand, Napoleon's foreign minister. In early 1803 a higher offer of $9,250,000 was also refused. But on April 11, realizing that war with Britain and Europe would leave New Orleans easy prey for the British navy, Napoleon declared, "Irresolution and deliberation are no longer in season. I renounce Louisiana." Talleyrand then asked Livingston, "What will you give for the whole of Louisiana?" After a further two weeks of negotiations, the treaty of purchase and cession was concluded on April 30, 1803, for $15,000,000: twelve million was paid for Louisiana, and the United States assumed French debt of three million dollars payable to United States citizens who had suffered naval depredations in 1797 and 1798. Ironically, one week before the signing of the treaty, Toussaint-Louverture who, against all odds had set the events in motion that had led up to this treaty, died of pneumonia in his French prison cell.

The Louisiana purchase was the greatest bargain in American history, eclipsing by far the purchase of Manhattan from the Indians. Although the United States possessed no constitutional power to increase its domain by treaty, the Senate nonetheless approved the purchase by a vote of 24 to 7. Formal possession of Louisiana - the boundaries of which were unknown but which were generally agreed to extend westward to the Rocky Mountains - took place on December 21, 1803.

The Louisiana purchase instantly doubled the land mass of the United States by the acquisition of 800,000 square miles. As Livingston remarked, " . this is the noblest work of our whole lives .From this day the United States take their place among the powers of first rank". The acquired territory included the future states of Louisiana, Arkansas, Missouri, Iowa, and Montana, almost all of Oklahoma and Kansas, most of Wyoming and Minnesota, and roughly half of Colorado. As John Keats has written, "For something under four cents an acre, the least of nations acquired an inland empire that contained virtually every sort of climate, topography, soil and ore. Every sort of crop and domestic animal could be produced on it; pools of petroleum and natural gas awaited discovery . to serve the uses of a future industrial society. The timber in Minnesota alone was worth more than the purchase price of the entire region . the Louisiana purchase . enabled the United States to so exploit these resources as to become a (major) world power .". Finally, in the words of Joseph Ellis, Jefferson's recent biographer, "If . one ever wished to construct a monument in New Orleans memorializing the Louisiana Purchase, Jefferson would have to be a central figure, but he would also have to be flanked by busts of Toussaint and his fellow insurrectionaries, plus . a tribute to the deadly mosquito".

Now, what about that "deadly mosquito"? At a time when nothing was known about the cause or prevention of yellow fever, Benjamin Rush had noted that "moschetoes" were very numerous in Philadelphia in the summer of 1793. In 1848, Dr. Josiah Nott first presented the idea of possible disease conveyance by "insects", possibly inferring either mosquitoes or microbes. No experimental or clinical data supporting this theory were presented, however. In 1881, Carlos Finlay, a Cuban physician, asserted that yellow fever was transmitted from person to person by mosquitoes. After studying the effects of elevation, temperature and other factors affecting the prevalence of hundreds of mosquito species, he announced - correctly - that the A des aegypti mosquito was the disease carrier. However, his numerous studies of human volunteers failed to demonstrate that these mosquitoes could transmit disease from yellow fever patients to individuals from non-endemic areas. (Such volunteers were chosen because it had finally been recognized that a previous attack of yellow fever conferred permanent immunity). Despite Finlay's experimental failures, Ronald Ross' discovery in 1897 that Anopheles mosquitoes were carriers of malaria stimulated new interest in the mosquito as a vector for yellow fever.

In early 1901, American soldiers, stationed in Cuba after the Spanish-American war, were dying in large numbers from yellow fever. The army sent a four-member commission, headed by Major Walter Reed, to investigate the disease there. Following up on Finlay's observations, the commission members heroically decided to serve as their own volunteers, since no laboratory animal was yet known to be susceptible to yellow fever infection. One member, Jesse Lazear, died after being bitten by an infected mosquito, and a second, James Carroll, similarly developed yellow fever but survived. After recruiting additional volunteers, the commission demonstrated that a yellow fever patient was infective only during the first three days of illness, and that for a second case to occur the subject had to be bitten by a mosquito who had fed on a patient 10-14 days earlier. Ignorance of these special time constraints had doomed Finlay's earlier studies to failure.

Since observations of the A des mosquito had revealed its habit of depositing eggs on stagnant water surfaces, William Gorgas, an army medical sanitation officer and a recovered yellow fever victim, was now appointed to rid Havana of yellow fever. Gorgas eliminated all collections of standing water used for drinking, bathing, cooking and other purposes, instigated strict regulations for the use of screening, put all yellow fever patients in quarantine and organized a cadre of sanitary officers and inspectors to enforce these regulations strictly. From March to August, 1901, there were only five deaths from yellow fever in Havana. Over the next several years, the disease had entirely disappeared in contrast to at least 500 deaths that had occurred from it during every year in the previous decade.

On the strength of his astounding success in Havana, Gorgas was asked to conquer the yellow fever problem in Panama, where, in 1904, the United States had undertaken construction of the canal. The 51 mile isthmus was a hopeless tangle of jungle vegetation, where, as one visitor wrote, "in the world there is not . any single spot (with) . so much foul disease." Yellow fever was the principal killer, though malaria, typhus and dysentery were also prevalent. During the earlier and failed French construction period (1881-1888) in one month alone (October, 1884) yellow fever had killed 654 workers. Gorgas later determined that one-third of France's white laborers had died of yellow fever with overall losses of 20,000 men. Panama's fearful disease reputation was such that John Wallace, the first American engineer assigned to the Panama Canal project, landed at the isthmus with his wife and two sturdily constructed caskets.

Gorgas, arriving at the Canal Zone in 1904, found all of the same standing water conditions he had encountered in Havana. Over a six month period he instigated essentially the same preventive measures he had employed earlier. From September, 1906, on, yellow fever became an extinct disease in a region where it had flourished for 250 years. Moreover, by the time the canal was finished and opened in August, 1914, Gorgas' work had reduced the death rate from all diseases to well below that of any city or state in the entire United States. David McCullough has written that, "The creation of the water passage across Panama was one of the supreme human achievements of all time . primarily the Canal is an expression of that old and noble desire to bridge the divide, to bring people together. It is a work of civilization".

Over the following years, Rockefeller Foundation scientists and other investigators concentrated on elucidating the causative microbe of yellow fever. Newer pathology studies revealed evidence of a virus infection and monkeys and mice were now found to be susceptible to virus infected tissue for further experimentation. Dr. Max Theiler demonstrated that the virus could be grown in chick embryo cultures, that repeated passages so reduced virulence that it no longer produced laboratory animal infection, but that this attenuated virus induced excellent immunity. Mass immunization against yellow fever in endemic areas was initiated in 1937 and, in 1951, Theiler was awarded the Nobel Prize in medicine and physiology for his discoveries.

Unfortunately, unlike smallpox, yellow fever was not destined for world-wide eradication. It was found that a mosquito-monkey-human cycle carried by several other mosquito species occurred in jungle environs. These mosquitoes live in tree holes high above ground and are essentially impossible to eradicate. Consequently, lack of uniform vaccination and inability to interrupt the virus' jungle life cycle have left yellow fever an endemic disease in many underdeveloped countries. In 1960-62 over 30,000 people died of the disease in Ethiopia, and in 1987, 120,000 cases, with 25,000 deaths, occurred in western Nigeria. In recent years the return of A des mosquitoes to parts of South America pose serious additional threats to possible revivals of major urban epidemics.

In this century, the accumulation of knowledge about the cause and spread of yellow fever now fully explains the Philadelphia story. Active trade between that city and several Caribbean islands, where the disease was endemic, undoubtedly introduced the A des mosquitoes, as well as the infected passengers upon whom they fed, from aboard ship. Water barrels shipboard and swamps and marshes in Philadelphia provided innumerable mosquito breeding sites. The insects limited flying range confined disease to its urban site. The mosquito's inability to survive temperatures below 72 F accounted for disease disappearance in late fall and its reappearance with hatched larvae in late spring or early summer.

The history of yellow fever provides a model for understanding how disease can stimulate research, innovation and reform that carry far-reaching implications for science and society. The effects of this devastating infection or its conquest on major historical events are amply illustrated by the Haitian and Panamanian epidemics. The Philadelphia outbreak demonstrates the effects of sudden overwhelming disease spread on an urban population: stimulation of a sense of community, heightened religious concerns among life and death struggles, financial problems from an economy that stops functioning, and convictions of physicians about the origin and proper treatment of the disease. Most important was the resultant struggle by city leaders to select and establish pioneering public health measures. Lastly, as Mathew Carey claimed, only the heroic, selfless actions of a small group of people created a new social compact, regenerated central institutions and saved the city.

To conclude, in the same vein over 200 years later, in 1998, Michael Oldstone summed up the impact of sudden overwhelming and devastating disease outbreaks on civilization: "In the final analysis, the history of viruses, plagues and people is the history of our world and the events that shaped it. It is also a history of individuals who worked toward the conquest of viruses and the diseases they cause . In the end, the splendor of human history is not in wars won, dynasties formed or financial empires built, but in the improvement of the human condition. The obliteration of diseases that impinge on our health is a regal yardstick of civilization's success, and those (scientists) who accomplish that task will be among the true navigators of a brave new world".
BIBLIOGRAPHY

1. Scott, H. Harold. "History of Tropical Medicine". Two volumes. Williams and Wilkins, Baltimore, 1939. 1165 pages.

2. Estes, J. Worth and Smith, Billy G. Eds. "A Melancholy Scene of Devastation. The Public Response to the 1793 Philadelphia Yellow Fever Epidemic." Science History Publications, U.S.A., Canton, Massachusetts, 1997. 211 page.

3. Gorgas, Marie D. and Hendrick, Burton J. "William Crawford Gorgas. His Life and Work." Garden City Publishing Co., Inc., Garden City, New York, 1924. 359 pages.

4. Fick, Caroly E. "The Making of Haiti. The Saint Domingue Revolution from Below." University of Tennessee Press, Knoxville, 1990. 355 pages.

5. Ros, Martin. "Night of Fire. The Black Napoleon and the Battle for Haiti." English translation, Sarpedon Publishers, Inc., New York, 1994. 224 pages.

6. Chidsey, Donald Barr. "Louisiana Purchase". Crown Publishers, Inc., New York. 231 pages.

7. Keates, John. "Eminent Domain. The Louisiana Purchase and the Making of America." Charterhouse, New York, 1973. 389 pages.

8. Peterson, Merrill D. "Thomas Jefferson and the New Nation. A biography." Oxford University Press, London, 1975 (paperback edition). 1072 pages.

9. Ellis, Joseph J. "American Sphinx, The Character of Thomas Jefferson." Alfred A. Knopf, New York, 1997, 365 pages.

10. Mc Cullough, David. "The Path Between the Seas. The Creation of the Panama Canal, 1870-1914." A Touchstone Book, Simon and Schuster, New York, 1977 (paperback edition). 698 pages.

11. Oldstone, Michael B.A. "Viruses, Plagues and History." Oxford University Press, New York, 1998. 211 pages.

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