Fever

The Microbe behind the Mask

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Welcome back!

After a bit of an interlude, the blog is back, ready to delve into the murky and fascinating world of epidemics, told through the words of poets and writers. Just when you think that the world of microbes has caused enough destruction to leave little to the imagination, here comes a particularly dark little story of a fictional disease, as told by the master of horror, Edgar Allan Poe…

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Oscar Halling’s portrait of Edgar Allan Poe, late 1860s. Image in public domain at Wikimedia Commons [link]

‘The Masque of the Red Death’ narrates the grisly events that occur during the fictional reign of Prince Prospero. The story plunges us straight into a vivid description of the Red Death, a longstanding epidemic with high fatality rates and a gruesome effect on its victims, causing profuse bleeding, pain, seizures – and a mercifully rapid death.

“Blood was its Avatar and its seal”. The death toll is staggering: half the population have already succumbed by the beginning of Poe’s story.

Prince Prospero, who appears indifferent to the plight of his subjects, decides to “bid defiance to the contagion”, and with ample provisions, shuts himself and a thousand friends away in one of his sumptuous abbeys, to dance and merry-make in security from the Red Death. This seclusion continues successfully for the next six months, whilst those without fare poorly.

The Masquerade

A motley collection of masked guests, as illustrated by Arthur Rackham in “Poe’s Tales of Mystery and Imagination (1935). Image in public domain at Wikimedia Commons [link]

A masquerade! Prince Prospero certainly knows how to entertain, and throws an extravagant masked ball for his guests. The rooms are decorated vividly, as we enter a realm of metaphors. With some bizarre interior design, Prospero makes his tapestries and Gothic windows colour-coordinate; six rooms in blue, purple, green, orange, white and violet; a seventh of deep scarlet windows and black velvet walls, illuminated with fire. Ominous and wild, the revellers shy away from entering this last room: but each hour, stand transfixed in horror by the disconcerting toll of a pendulum clock from deep within the seventh chamber.

At the twelfth hour, as the clock chimes heavily and the waltzing falters, a masked figure fades into notice; a masked figure of unparalleled distaste, costumed as the Red Death itself. Tall, gaunt, corpse-like, phantasmagorical, daubed with blood, “besprinkled with the scarlet horror”: a vision of nightmare indeed!

The Red Death

“The dagger dropped gleaming upon the sable carpet” by Harry Clarke (1919). Image in public domain at Wikimedia Commons [link]

The encounter, suffice to say, with all its foreboding, ends badly, and rapidly, for Prince Prospero and his courtiers, who believed themselves safe against the Red Death. “One by one dropped the revellers in the blood-bedewed halls of their revel, and died each in the despairing posture of his fall… And Darkness and Decay and the Red Death held illimitable dominion over all.”

Well! Edgar Allen Poe isn’t renowned for his happy endings, so this gruesome end is probably to be expected. Just as well this is only a fictional disease….or is it?

In the wake of the recent devastating Ebola pandemics of Sierra Leone, Liberia and Guinea-Bissau, the parallels of the Red Death with one of the known haemorrhagic fevers can’t help but spring to mind. These haemorrhagic fevers include Ebola and Marburg fever, and have similar symptoms of fever, muscle pain, headache, nausea, then diarrhoea, vomiting and in some cases significant bleeding (WHO 2014).

As I suspected, I’m not the first to notice this: in fact, a published article in the journal ‘Emerging Infectious Diseases’ by Vora & Ramanan in 2002 explored this very question! The article is well worth a read and is available here. The authors postulate the mode of transmission of the Red Death (person-to-person, and possible aerosol inhalation) and the potential for either a very long incubation period for the Red Death microbe, or a new exposure to the abbey by an unspecified route.

So could Poe have modelled the Red Death after a known disease, or did he imagine up all of the gruesome features of the whole epidemic? Well, Poe probably have reasonable knowledge of yellow fever, a different type of haemorrhagic fever, – but one which causes liver failure and jaundice, neither of which are evident with the Red Death. Poe was also well aware of tuberculosis, which can manifest with coughing up blood from the lungs: both his mother and wife died of the disease.  Since Ebola, Marbug virus and another counterpart, Crimean-Congo haemorrhagic virus, all emerged in the 1900s, after Poe’s death, the parallel with the Red Death must be purely coincidental.

Whatever Poe’s experience of contemporary diseases, however, his description of the Red Death is vivid, realistic, and perhaps a warning of how complacency and seclusion in the interests of self-preservation are no match for a virulent pestilence with no respect for social contexts and hierarchy! Perhaps then, we should interpret Poe’s tale as a graphic and timely warning – public health initiatives, take note!

References:

Vora, S.K. & Ramanan, S.V. (2002) Ebola-Poe: A Modern-Day Parallel of the Red Death? CDC Emerging Infectious Diseases 8(12):December 2002

World Health Organisation (2014) Ebola Virus Disease: background and summary. Published 3 April 2014, available at: http://www.who.int/csr/don/2014_04_ebola/en/

 

Pestilence in Philadelphia!

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Let’s go to Philadelphia. It’s 1793: a busy marketplace bustles, full of the scent of West Indian stews and other temptations. Children run riot around boisterous chickens and ducks. The charcoal man sounds his horn to sell his wares. This is the world of Mattie Cook, a fourteen year old who helps run her family’s coffeehouse. The summer is hot, the mosquitoes are buzzing, and a new peril is about to enter Mattie’s life. I present to you ‘Fever 1793’, by Laurie Halse Anderson.

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As we dive into Mattie’s world through the pages of her diary, we learn of the arrival of a dreaded new disease. Polly, the Cooks’ serving maid, falls ill suddenly and dies after a short fever. News soon begins to surface of more cases near the Philadelphia wharf, and the church bells begin their death toll. Soon, the bustling market becomes ghostly and abandoned as the Philadelphia inhabitants flee the city, barricade themselves up to wait for winter, or succumb to the grip of Yellow Fever.

The devastating effects of yellow fever are clearly described in Mattie’s diary, who contracts the disease herself along with family members and acquaintances. The symptoms of yellow fever are described fairly accurately: this tricky little flavivirus typically presents first with either an asymptomatic phase, or a ‘flu-like’ syndrome with fevers, chills, muscle and back aches, and nausea and vomiting. Although most people improve, a small proportion of about 15% will get better only to get worse again within hours, developing the toxic form of yellow fever. It is this serious form which is described vividly in ‘Fever 1793’, as liver failure causing the whites of the eyes to become yellow or jaundiced, and haemorrhage occurs causing vomiting of fresh or dark congealed blood. In fact, this is the story behind the Spanish name for the disease, vomito negro or ‘black vomit’.

At this time, bacteria and viruses were not known about, and so a variety of theories were expounded as to the cause of contagious diseases. Anderson hints at these through the conversations Mattie overhears in the coffeehouse. Mr Carris, a businessman, tells a captive audience that the “heap of rotting coffee beans on Ball’s wharf…it’s the source of a deadly miasma, a foul stench”; a government clerk interjects to suggest that the Santo Domingan refugees have come down with fever near the wharf. At the market, the German farmers Mr and Mrs Epler proclaim that the fever is a sign from God, to let sinners know they should have gone to church.

So what caused the yellow fever epidemic, and how did it spread so fast? Mr Carris’ miasma theory was a popular idea at the time. In fact until the mid 1800s, foul stenches from rotting matter were thought to be the root cause of epidemics: miasma translates as pollution from the ancient Greek. However, Anderson gives us readers clues as to the true reason for the spread of the disease, as Mattie swats away various irritating mosquitoes that have come out to swarm in the hot summer sun. These mosquitoes carry the yellow fever virus, inoculating it into humans and cause the spread of disease. The Aedes aegypti mosquito, pictured below, was and remains one of the main culprits for transmitting the yellow fever virus from human to human. During the summer months, these mosquitoes breed and multiply, but vanish with the winter frost, and as described in this book, so does the epidemic.

Aedes aegypti

Aedes aegypti mosquito biting human, author US Department of Agriculture. Image in public domain at: https://commons.wikimedia.org/wiki/File:Aedes_aegypti_biting_human.jpg

Along with misconceptions about the true nature of yellow fever in the 1700s, the treatment options were limited, and often misguided. For example, Mattie’s mother Lucille contracts yellow fever, and is advised that “the pestilence boils within her blood and must be drained”. Ten ounces of blood are bled from Lucille, which with the gift of hindsight is likely to have caused far more harm than good as she has already vomited up a large amount of blood. In fact, the French doctors who have travelled to Philadelphia via the West Indies, with significant experience of yellow fever, hold this view. Later, Mattie is persuaded to avoid bleeding three small children in her charge who contract the fever, thereby most likely saving their lives.

Yellow fever persists today, although not in the United States. Travellers to certain places are required to have a yellow fever vaccine prior to entering certain areas in Africa and South America, for example. There are still no specific treatments apart from supportive therapies: rest, fluids, life-saving interventions in people who haemorrhage. But whereas the death toll during the 1793 Philadelphia epidemic was close to a staggering 10% of the population – 5000 of 50,000 died – the death rates nowadays tend to be much lower, with a total of 5100 deaths worldwide as reported in the Lancet Global Burden of Disease report from 2015.

‘Fever 1793’ by Laurie Halse Anderson does justice to a world yet to discover germ theory, at a time of limited understanding of public health interventions and specific medical therapy. Aimed at young adults, this book is definitely worth a read whatever age you are, to truly get to grips with this period of history.

Got a question or comment? Feeling blue about yellow fever?  Thinking of travelling somewhere exotic and making sure you’ve got your background research done? Get in contact with Infectious Reads below!

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