Filariasis in the United. States TODD L. SAVITT
HE coming of the European to North and South America after 1492 resulted in biological and cultural changes on both sides of the Atlantic, changes which one writer has termed 'The Columbian Exchange.' In addition to such items as foods, animals, and plants, several infectious diseases were also transmitted, including smallpox and tuberculosis, which ravaged the native American population, and perhaps syphilis, which afflicted many Europeans.1 A similar exchange of disease agents occurred in Africa during the European age of exploration, as Caucasians and Negroes met and traded along the African coast. Various forms of fever (including yellow fever and malarial fevers) and parasitic infestations plagued whites, while blacks suffered from pneumonia, tuberculosis, measles, and other disorders not commonly found in the tropics. With the development of Negro slavery and the transportation of large numbers of blacks to North and South America, the 'African Exchange' soon became important in the New World. Several African tropical diseases appeared and lingered in the Americas as legacies of the slave trade. Among the many transmissible infections which Africans carried with them to the New World were malaria in its various forms, yellow fever, smallpox, yaws, leprosy, guinea worm, filariasis, ascariasis, tapeworm, hookworm, and trypanosomiasis. Some of these infections disappeared with the first generation of imported slaves; others took firm root and lingered through the nineteenth century, and on to the present. No part of the New World entirely escaped the new African infections. Even the 1. Alfred W . Crosby, Jr., The Columbian exchange; biological and cultural consequences 0/1492 (West-
port, Conn., 1972), pp. 35-63, 133-164. See also P. M. Ashbum, The ranks of death; a medical history of the conauest of America, ed. Frank D. Ashbum (New York, 1947). The origin of syphilis is still a matter of controversy among medical historians. Some argue for a European and others for an American origin. Crosby (above, pp. 133-164) discusses this controversy in some detail. This publication was supported in part by National Institutes of Health Grant LM 03477 &° m die National Library of Medicine.
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American South, though not tropical, had a warm enough climate through much of the year to support the growth and permanent residence of a number of disease agents brought from Africa. One African parasite which became endemic in a portion of the South was the filarial roundworm, Wuchereria bancrofti, causative organism of elephantiasis.2 Wuchereria banaofti has a life cycle which involves both an intermediate insect and a final human host. Adult worms live in the lymphatic vessels and lymph nodes of humans, causing an inflammatory response, growth of connective tissue in the vessels, and the eventual development of lymphatic obstruction and varicosities. The closing off of the lymphatic circulation produces the well-known scrotal, labial, or leg and foot swelling so characteristic of elephantiasis. Many other manifestations of chronic filarial infection may also occur. One such symptom is chyluria, the discharge of milky urine which is caused by the rupture of an obstructed lymphatic vessel into the urinary tract. The enlargement of the scrotum, labia, or lower leg, or chyluria, actually occurs only in the later stages of filarial infections. Periodic attacks of glandular pain, scrotal or labial swelling, and general malaise, over the course of many years, are the commonest early signs of filariasis.3 The long time lapse between initial filarial infection and the appearance of severe symptoms was deceptive to slave traders and prospective buyers. Infected slaves brought to the North American colonies might appear perfectly healthy upon departure from western Africa or the West Indies, and also upon sale to a planter. Only years later, perhaps after many puzzling episodes ofpain in the groin or glands, did elephantiasis or chyluria develop. Though carried to the New World, Wuchereria bancrofti might have disappeared like Trypanosoma gambiense, the parasite causing African sleeping sickness, had no suitable insect vector been available to transmit it from one human being to another. In the case of sleeping sickness, which many Africans did bring with them to the Americas, the absence of its carrier, the tse-tse fly, in the New World, prevented establishment of the disease here.4 The parasite of elephantiasis was more fortunate. Throughout the West Indies and the Americas lived a mosquito, Culex quinquefasciatus (also known as C.fatigans), which, when it drew blood from a person infected with Wuchereria bancrofti, was capable of supporting the growth of several 3. R. Hoeppli, Parasitic diseases in Africa and the Western Hemisphere; early documentation and transmission by the slave trade (Basel, Switzerland, 1969). 3. Charles WiicoteindP.E.C.Maiixm-Bihi, Mansm's tropical diseases, 17th ed. (Baltimore, 197a), pp. 193-217. 4. Hoeppli, Parasitic diseases (n. 3), pp. 31-41.
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microfilariae, the offspring of adult worms. Thus, when the microfilariae, produced by worms situated deep in the human lymphatic system, escaped into the bloodstream, they could then pass on to, and survive in, the body of the mosquito. At the insect's next blood meal, filarial larvae escaped through the mosquito's proboscis onto human skin. They penetrated through the bite wound and entered the lymphatic system where they developed to adulthood in about a year. If the adult filaria worm settled in the same lymphatic as another of the opposite sex, the two worms mated, new microfilariae were produced, and the life cycle was repeated.5 Filariasis has usually been associated in this country with Charleston, South Carolina. A major endemic focus of the disease—perhaps the only one in continental North America—existed there until the 1920s. Elephantiasis was reported throughout the South and even in several northern states in the eighteenth, nineteenth, and twentieth centuries. Sporadically cases also occurred outside of Charleston, but usually among persons who had lived in or visited known areas of endemic filaria infection. In the United States only Charleston seems to have harbored a large enough population of infected persons to sustain the filarial life cycle for many generations. Wuchereria bcmcrofii is endemic to both East and West Africa in precisely those areas tapped by slave traders from Europe and America.6 Manifestations of bancroftian filariasis began to appear among slaves taken to the West Indies soon after the beginning of the slave trade. The island of Barbados in particular early became an endemic focus of filarial infection. In Barbados elephantiasis was originally confined to the slave population, but, beginning in about 1704, infection spread to an increasing number of white and creole residents. So common was the disorder that it became known in the English-speaking New World as 'Barbados-leg.' Throughout the nineteenth century and into the twentieth, Barbados (and several other West Indian islands) remained endemic foci of filariasis.7 On the North American continent Charleston, because of certain special factors, became a major center of filarial infection. As a primary port of entry for slaves from the West Indies during colonial times, Charleston 5. Wilcoda and Manion-Bahr, Manstm's tropical diseases (n. 3), pp. 192-217; Harold W. Brown and David L. Belding, Bask clinical parasitclogy, 2nd ed. (New York, 1964), pp. 132-137. 6. Wilcocks and Mamon-Bahr, Manstm's tropical diseases (n. 3), p. 193; James M. Gordon, 'Elephantiaiij—its hiitory, symptomatology, aetiology and pathology, with a report of a case and successful treatment,' Sth. med. surg.J., 1850, N.S. 6, 65-80, p. 67. 7. Gordon (n. 6), pp. 66-67; J- Scott, 'Elephantiasis Arabum,' The cyclopaedia ofpractical medicine, 4 vob. (Philadelphia, 1845), 1, 770-771; Aldo Castellani and Albert J. Chalmers, Manual of tropical medicine (London, 1919), pp. 1597-1598.
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constantly received persons infected with the parasite. Slaves also passed through and spread Wuchereria bancrofii in other port towns of North America at this time, but it is uncertain whether filariasis ever became endemic anywhere but Charleston. Charleston and the surrounding Low Country possessed one of the highest densities of blacks of all the continental colonies. Slaves imported to South Carolina—many carrying microfilariae in their blood—usually remained in Charleston or the vicinity, and were not dispersed to widely scattered plantations as occurred in the other large slave-owning colony, Virginia.8 Also, the Culex quinquefasciatus mosquito occurred in South Carolina and not to any great extent in lands to the northward.9 Even when numbers of infected slaves were brought into New York, Philadelphia, or Boston, Wuchereria hancrofti could not have been transmitted to new human hosts without the proper intermediate insect. The presence of the Culex quinquefasciatus mosquito together with great concentrations of Wuchereria bancrofii carriers assured the Charleston area of a constant supply of infected humans and mosquitoes sufficient to maintain the filarial life cycle. A sizable reservoir of infected human hosts was necessary because (a) not all microfilariae ingested by a mosquito survived residence in the insect's body; (b) unlike the malarial parasite which multiplied within the mosquito's body, microfilariae simply grew in size, not number, in the intermediary host; and (c) once settled in a human lymphatic vessel, adult worms could not reproduce without a member of the opposite sex in that same location. It usually required multiple bites of mosquitoes carrying Wuchereria bancrofii to obtain infestations in humans sufficient for the production of microfilariae.10 With a constantly replenished supply of human carriers from the West Indies passing through or settling in Charleston during the colonial period, conditions were ideal for that town to become an endemic focus of Wuchereria bancrofii. A further reason for Charleston's unique position as haven for filarial worms was its close ties with the major West Indian focus of this disease— Barbados. South Carolina was settled and initially developed in large part by whites and slaves transplanted from that island. The two colonies retained economic and social relations throughout their early histories, and 8. Peter H. Wood, Blade majority; Negrots in colonial South Carolinafrom1670 through the Stono Rebellion (New York, 1974), pp. xiii-xiv, 152. 9. Marcus W. Lyon, Jr., 'Filariasis; report of two cases in the District of Columbia, and analysis of the cases reported for eastern North America,' J. Amer. mei. Ass., 1917, 6$, 118-119, P- H910. Edward Francis, Filariasis in southern United States (Washington, United States Public Health Service, Hygienic Laboratory Bulletin No. 117, June 1919), pp. 17-19; Brown and Belding, Bask dlnkal parasttology (n. 5), pp. 133-134.
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on into the nineteenth century. As a result, black and white Barbadian emigrants and merchants simply transferred Wuchereria bancroftifromone hospitable environment to another.11 There is not enough evidence to designate an exact time at which the filarial worm became able to sustain itself in the Charleston area without periodic reinforcements from the West Indies or Africa. The estabhshment of the infection at Charleston must have occurred some time before cessation of the slave trade in 1808. It was not until 1886, shortly after Wuchereria bancrofti was discovered and associated with elephantiasis and chyluria, that medical scientists first recognized the endemicity of that parasite in Charleston and the Low Country of South Carolina. Before 1886 Charleston residents had known that cases of elephantiasis and chyluria occurred regularly in their city, but had been unaware of Charleston's uniqueness in this respect. Among the early descriptions of elephantiasis in the American colonies is the following, excerpted from Bernard Romans's 1775 book, A Concise Natural History of East and West Florida. Romans had for twenty years lived in Georgia and the Floridas, and traveled through the Carolinas. Though he did not state precisely where he observed cases of elephantiasis, the context of his excellent and accurate description indicates that the probable locale was coastal South Carolina and Georgia: A loathsome disease appears some times among the Negroes after severe acute disorders, especially if the patient has been obliged to keep his bed long, likewise after a violent exercise has brought on a surfeit: this is called the Elephantiasis from the swelling of the feet and legs; it is most frequently seen to affect one leg only; in the first stages of this disorder the patient becomes wretched through excessive lassitudes which bring on an emaciation of the body, then the corrupted juices subside into the leg or legs and feet, these swell, the skin becoming distended, shines and shews the distended veins every where below the knee; now the skin by degrees loses its gloss and becomes unequal and something scaly; after this chaps make their appearance, the glands are stretched and the scales are daily enlarged, appearing as hard and callous as the hide of an Alligator, notwidistanding which the slightest prick of a pointed instrument will cause the 11. Wood, Black majority (n. 8), pp. 24, 45-46, describes the settlement and development of South Carolina by Barbadian]. For mention of the continuing intercourse between these two areas, see John Guiteras, "The Filaria sanguinis hominis in the United States—chyluria,' Med. News, Phila., 1886, 48, 399-403, p. 400. The interesting speculation of Dr. I. Snapper (Hoeppli, Parasitic diseases [n. a], pp. 122-124) that a boatload of Brazilian Jews seeking refuge from the inquisition carried W. bancrofti to Charleston in the 16501 cannot be correct since few, if any, Jews actually settled in Charleston at that time. Most emigrated to Holland, and a small number moved to the West Indies, to FnglanH, and to New Amsterdam. The one or two families which might have gone to Charleston could not have caused the development of endemic filariaiiv See Jacob R. Marcus, The colonial American Jew, 14921776, 3 vok. (Detroit, 1970), 1, 8i, 343-345.
Nelson
Nelson
Two months after the operation performed by Dr. Picton on 3 October 1837
Before the operation
A case of elephantiasis in a Louisiana slave, from J. M. W. Picton, 'A case of elephantiasis scroti, with successful operation,' New Orleans Medical and Surgical Journal, 184.J-46, 2, 316-321.
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blood to exude; this disease affects neither the appetite nor the digestive powers of die body, on dae contrary die patient in diis and chearfulness [sic] of spirits resembles die healdiiest of men, and die inconvenience of his heavy leg only prevents his ability for the more laborious part of his duty.12 Subsequent cases of elephantiasis appearing in the medical literature often originated from this same area. Those that did not may have been nonfilarial in etiology, or imported from outside the United States, or the result of small endemic foci in other slave port cities. Disorders other than filariasis can also cause gross swelling of the scrotum, labia, or lower extremities. Bacterial or accidental mechanical obstruction of lymphatics often results in such elephantoid symptoms.13 Actually, there is no way to know whether the cases reported before the days of routine blood examinations (1880s) were truly filariasis. Patients with elephantiasis and chyluria in and around Charleston most likely harbored the parasites, because we know from later microbiological studies that Wuchereria bancrofti was endemic there. But how does one explain the several cases which arose in Georgia and Louisiana? Though public health surveys in 1915 and 1918 failed to turn up endemic cases of filariasis in Savannah or New Orleans, probably Wuchereria bancrojii was brought into these towns during the eighteenth and nineteenth centuries but did not survive. Botii cities had had sizable slave populations and served as ports of entry for imported African and West Indian slaves. But there are no early records which suggest that either town ever harbored large numbers of individuals with elephantiasis or chyluria.14 The first case to appear in the nineteenth century southern15 medical literature is a good example of the problem. Nelson, a thirty-eight-year12. Bernard Romans, A concise natural history of east and west Florida . . . (1775; reprint ed., New Orleans, 1961), pp. 170-171. 13. On other causes of elephantiasis, see Rudolph Matas, T h e surgical treatment of elephantiasis and elephantoid states dependent upon chronic obstruction of the lymphatic and venous channels,' Amer.J. trap. Dis., 1913, 1, 60-85, pp. 60-67. 14. Francis, Filariasis (n. 10), pp. 13, 15-16; Ernest Carroll Faust, 'Parasitism in southeastern United States; history of human parasitic infections,' Publ. tilth. Rep., Wash., 1955, 70, 958-965, p. 963. There is no mention of elephantiasis in John Duffy, ed., The Rudolph Matas history of medicine in Louisiana, 2 volfc (Baton Rouge, 1958-63), and only one death attributed to elephantiasis in Savannah between 1854 and 1869 (W. Duncan, Tabulated mortuary record of the city of Savannah, from January 1, i8i4, to December 31, 1869 [Savannah, 1870]). 15. There were cases of elephantiasis reported in the North throughout the nineteenth and early twentieth centuries, though most were either imported or of nonfilarial origin. A few may have been true filariatii contracted from some unknown source. See, for example, David Hosack, Essays on various subjects of medical science, 3 vols. (New York, 1830), m, 441-445; Isaac Pairish, Tumour of the left labium, resembling elephantiasis, removed from a Negress,' hied. Exam., Phila., 1840, 3, 229; J. W. Webster, 'Elephantiasis,' New Eng.J. Med. Surg., 1820, 9, 213-220; Lyon (n. 9), p. 118.
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old slave belonging to Mr. J. F. Piseros of St. Charles Parish, Louisiana, •was brought to New Orleans in June 1837 for treatment of an enormously enlarged scrotum. No other historical information was presented in the report except that the enlargement had begun some ten years earlier. A lithograph of Nelson before and after the successful operation to remove his huge burden accompanied the article. The physician's language throughout the report indicated that it was one of the first cases of elephantiasis he or his colleagues in New Orleans had seen. There was no mention of other persons with the disorder living in St. Charles Parish, so it is difficult to draw any conclusions as to the origin of Nelson's disorder.16 Similarly, the three cases of elephantiasis which Dr. Joseph Jones observed among whites in New Orleans during the 1870s are doubtful, but possible, instances of Wuchereria hancrofii infection. Jones provided little background information at the time on which present-day readers might base a diagnosis, and failed to mention any other local cases in an extensive review of the subject some nine years later. More easily explicable are Jones's six reported cases of elephantiasis (four of the foot and leg, two of the scrotum) observed among slaves on coastal Georgia cotton, rice, and sugar plantations during the 1840s and 1850s. This area, part of the Charleston-influenced Low Country, had large areas of marsh where mosquitoes bred readily, and many slaves whose parents and grandparents had come from the West Indies and Africa. Spread of the filarial infection under these favorable conditions was likely.17 The occurrence of three other reported cases of elephantiasis in the inland Georgia towns of Atlanta, Columbus, and Lawrenceville is difficult to explain as Wuchereria bancrofti infection. None of the three towns was a likely focus forfilariasis,and none produced subsequent reported cases of elephantiasis. Neither was Charleston mentioned as a previous residence of any of the three patients whose case histories were given.18 The pre-1886 evidence for filariasis in Charleston is very convincing. 16. J. M. W . Picton, 'A case of elephantiasis scroti, with successful operation,' New Or/, med. surg. J., 1845-46, 2, 3i6-3ai. 17. Joseph Jones, 'Observations on the African yawl . . . and on leprosy . . . in insular and continental America,' New Orl. med. surg. J., 1878, N.S. 5, 673-693, p. 690; Joseph Jones, Medical and surgical memoirs: containing investigations on the geographical distribution, causes, nature, relations and treat-
ment of various diseases, 3 vols. (New Orleans, 1876-90), n, 1188-1189, 1287-1332. 18. V. H. Taliaferro, "Remarks upon elephantiasis,' Atlanta med. surg. J., 1856-57, 2, 647-651; 'Service of Dr. Jones—elephantiasis,' ibid., 1859, 4, 341-342; Juriah Harrisi, 'Report of a case of elephantiasis,' Savannah J. Med., 1866, N.s. 5, 12-15; S. W. Francis, 'Report of a case of Elephantiasis Arabum,' Med. surg. Reptr., Phila., 1866, 14, 284-286; D. W. Hammond, "Elephantiasis,' Trans, med. Ass. Co., 1877, 2$, 109-112.
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Mention of elephantiasis by physicians occurred with some regularity, thereby suggesting that the cases of elephantiasis were not an isolated phenomenon oftraumatic or bacterial origin. Between 1855 andi858, for example, one black Charleston resident each year succumbed to elephantiasis.19 Chyluria occurred frequently enough for Dr. Charles Witsell of Ashepoo, South Carolina, in the Low Country near Charleston, to describe its pathology and treatment in 1855. Witsell stated that Dr. Dickson of Charleston had also seen several cases of'chylo-serous urine.'20 Some South Carolina physicians mentioned or described individual cases of elephantiasis. In 1849 Dr. William F. Holmes reported, in an article on the treatment of pneumonia, that a slave, Peter, suffering from pneumonia, was also 'the subject of elephantiasis.'21 In 1855 a medical student, Clarence A. Fripp of Beaufort, South Carolina (on one of the Sea Islands along the coast, heavily populated with slaves), thought he had seen enough cases of elephantiasis there and at the medical school in Charleston to justify writing his M.D. thesis on the disease: 'Our attention,' he wrote, 'has been directed into this channel, from having seen several cases & being impressed with the idea that, through causes neither appreciable, nor within our controul [sic], this disease formerly so rare, is now becoming far more frequent.'22 Fripp noticed that elephantiasis occurred much more often among mulattoes and blacks than among whites—in fact, of the several cases he had seen, none were among whites.23 He gave a general description of the disease and then mentioned specifically a case he had observed of a Negro man whose scrotum 'was so hypertrophied, as to hang below the knees involving the prepucial folds of the penis in one colossal mass of immense height.'24 Two other antebellum cases of elephantiasis in the Charleston area appeared in the medical literature. Dr. F. Galvez listed the name of Dr. Middleton Michel of Charleston in a 'Statistical Table of the different 19. J. L. Dawson, 'Return of deaths in the city of Charleston,' Charleston med.J. Rev., 1855,10, 747; 1856, 11, 574; 1858, 13, 282; 1859, 14, 138.
20. Charla Witsell, 'Pathology and treatment of a discharge of chyloierous urine,' Charleston med. J. Rev., 1855, 10, 621-62$. ai. William Fletcher Holmej, T w o cases of pneumonia, illustrating the comparative efficacy of mercury and tartar emetic, in the treatment of that disease,' Charleston med.J. Rev., 1849, 4, 176-179. 22. Clarence A. Fripp, 'An essay on elephantiasis' (M.D. thesis, Medical College of die State of South Carolina, 1855), p. 3, at Waring Historical Library, Medical University of South Carolina, Charleston. Fripp's paper included discussions of both elephantiasis (Elephantiasis Arabum) and leprosy (Elephantiasis Graecorum). The reference to a paucity of cases in previous years and an increase in recent times was probably made in regard to leprosy. 23. Ibid., pp. 7-8. Leprosy, Fripp observed, occurred more often among whites than blacks in South Carolina. 24. Ibid., p. 13.
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Operations for Elephantiasis of the Scrotum, performed in different parts of the World.' Though the present writer could locate no report of the procedure Dr. Michel performed, Dr. Galvez stated that the patient had been cured.25 In February i860, Dr. T. L. Ogier of Charleston presented a case history of elephantiasis to the South Carolina Medical Association. The patient, a twenty-six-year-old slave, desperately wished relief from the discomfort of a greatly enlarged leg and foot. His master agreed. Ogier succeeded in reducing the swelling by ligating the femoral artery, though, as in all radical 'cures' of elephantiasis, the results may not have been permanent.26 Elephantiasis continued to plague Charlestonians at the rate of several cases annually in the years following the Civil War. Throughout the 1870s and early 1880s both whites and blacks fell ill or died with the disorder, and a few people reported 'chylous urine.' In 1870, though no deaths occurred, three whites and four Negroes were treated for elephantiasis at the city hospital or at home by city health officers. Three years later there were two deaths attributed to elephantiasis—one white and one black—as well as seven cases—six black and one white—treated by public health officials. In 1883, three deaths of persons with elephantiasis occurred.27 By 1885 the frequent occurrence of chyluria and elephantiasis among Charlestonians had aroused enough concern among local physicians to have the matter discussed at the annual meeting of the State Medical Society.28 Also in 1885 a physician interested in the newly discovered relationship of human filarial infestations to elephantiasis and chyluria came to Charleston. During the previous year Dr. John Guite"ras had treated four Cubans in Key West iozfilaria sanguinis hominis (microfilariae in the blood), and now wished to examine Charlestonians for the presence of these parasites. His reasons for undertaking such an investigation were compelling: I was told that this disease [chyluria] and elephantiasis were not rare in die city. I also found diat mosquitoes were very plentiful during the summer and fall; that cistern water was in general use, and that nofilterswere to be found for sale in the shops. These observations, togedier with die fact that Charleston has been for many years in constant intercourse with the West Indies, induced me to be on die lookout for filaria.29 as- F. Galvez, 'Caje of elephantiasis of scrotum,' Charleston mecLJ. Rev., 1859,14,119-124, p. 124. 26. T. L. Ogier, 'Ligature of the femoral artery for the cure of elephantiasis of the leg and foot,' Charleston med.J. Rev., i860, 1$, 191-195. 27. Charleston, City Council, Annual report, 1S70, pp. 36, 39,40; 1S73, PP- 45i 4 s . 5+« 5"; 1874, p. 44; itj6, p. 46; Charleston, City Council, Year book, 1SS2, p. 83; 1SS3, p. 83. 28. Guiteras (n. 11), p. 399. 29. Ibid.
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Guite"ras was assisted in his work by several physicians, two of whom, J. J. Edwards and W. D. Bratton, had been examining the blood of suspected filarial carriers since 1882 or 1883, but without success.30 Microfilariae were seen (1886) first in the blood of a mulatto woman, a native of Charleston, suffering from chyluria. Over the next four years twenty-two Charlestonians—fifteen blacks and seven whites—were found to harbor microfilariae in their blood. One was a hundred-year-old Negro woman who had been brought from Africa in a slave ship.31 Manifestations of filarial infection continued to appear among Charleston area residents throughout the 1890s and 1900s.32 Writers of textbooks and articles on tropical diseases now began to include Charleston in the list of areas where filariasis was to be found.33 Not until 1914 did a large-scale statistical study of 400 individuals reveal the extent of the problem at Charleston. Dr. Francis B. Johnson, clinical pathologist at the Medical College of South Carolina in Charleston, disclosed that he had discovered microfilariae in the blood of 19.25% of 400 routinely cultured hospital and clinic patients. Still more startling was the finding that only a quarter of those infected showed symptoms of filariasis —the remaining three-quarters were carriers.34 Another study, performed a year later in Charleston's 'Old Folks' Home,' revealed that thirteen of the residents there (35%) had microfilariae in their blood.35 Dr. Johnson also questioned about two-thirds of Charleston's physicians regarding the number of filariasis cases they had seen in their practices. The physicians reported having noted 494 cases, including 244 of chyluria, 213 of elephantiasis, 8 of the two combined, 4 of other symptoms, and 25 not stated.36 After 1886, American physicians throughout the South began searching for other concentrations of filarial infection. Cases were reported from
30. P. G. De Saussure, 'A clinical history of twenty-two cases of filaria sanguinii hominis, icen in Charleston, S.C., from 1886 to May, 1890,' Med. News, Phila., 1890, 56, 704-707, p. 704. 31. Ibid., pp. 704-707. 31. Charleston, City Council, Year book, 1891, p. 51; 1S93, p. 83; 1894, pp. 91-92; 1S96, pp. 86, 89; 1899, p. 72; 1903, pp. 83, 86; 1906, p. 170; 1912, p. 189. 33. Patrick Manton, Tropical diseases, a manual of the diseases of warm climates (London, 1898), p. 448; W. M. Mastin, T h e history of the filaria sanguinis hominis, its discovery in the United States, and especially the relationship of the parasite to chylocele of the tunica vaginalis testis,' Arm. Surg., 1888, 8, 331-362, pp. 339-341. 346-347; Lyon (n. 9), pp. 118-119. 34. F. B. Johnson, Tnlarial infection; an investigation of its prevalence in Charleston, S.C.,' Sth. mei.J., Nashville, 1915, 8, 630-634. 35. Francij, Filariasis (n. 10), p. 11. 36. Some of these cases were undoubtedly duplicates, i.e., the same cases reported by more than one physician. Johnson (a. 34), p. 634.
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many towns but none were more than isolated phenomena.37 Finally, in 1917, Dr. Edward Francis of the United States Public Health Service undertook afiJarialsurvey on nine southern towns with climatic conditions and mosquito species similar to Charleston's, in order to discover the true extent of the problem.38 Interestingly, only nine of 1470 individuals tested showed microfilariae in their blood, and these nine had 'histories either of having been born and raised in Charleston or of having been born in Cuba which is a well-known fllarial focus.'39 Charleston was the only endemic focus offilariasisin the United States at that time, though others may have existed in earlier periods. The upshot of Johnson's and Francis's reports was an intensive mosquito control campaign during the early 1920s to eradicatefilariasisfromCharleston. In 1924, it was necessary to conduct only thirty-six blood tests at the city hospital for filariasis; this number was reduced to four the following year,40 and to zero by 1930.41 When a group of Mexican scientists visited Charleston in the late 1920s to study the filarial problem, the City Health Officer was unable to show them a single case. In 1949, a leading parasitologist reported: 'In the United States the one previously known endemic area, that around Charleston, South Carolina, has become filaria-free.'42 One of the consequences of the 'African Exchange'—filariasis—now became only a memory in the United States. Department of Community Health and Family Medicine University of Florida
37. See, for instance, Martin (n. 33), pp. 339-341; Lyon (n. 9), pp. 118-119; R. M. Slaughter, 'Fflaria sanguinis hominis, the discovery and prevalence of t~Vn* Hin*av in the United States,' Trtms. med. Soc Va., 1891, pp. 330-245. 38. The citiej were Columbia, Beaufort, and Georgetown, South Carolina; Milledgeville and Savannah, Georgia; Jacksonville and Tampa, Honda; Mobile, Alabama; New Orleans, Louisiana. 39. Francis, Filariasis (n. 10), p. 16. 40. Leon Banov, As I recall; the story of the Charleston County Health Department ([Charleston], 1 97°). PP- 56-57; Charleston, City Council, Year bock, 1924, p. 204; ip*j, p. 198. 41. George Cheever Shattuck, Diseases of the tropics (New York, 1951), p. 508. 42. PrrM-tf Carroll Faust, Human helmlnthology, 3rd ed. (London, 1949), p. 499.
HE coming of the European to North and South America after 1492 resulted in biological and cultural changes on both sides of the Atlantic, changes which one writer has termed 'The Columbian Exchange.' In addition to such items as foods, animals, and plants, several infectious diseases were also transmitted, including smallpox and tuberculosis, which ravaged the native American population, and perhaps syphilis, which afflicted many Europeans.1 A similar exchange of disease agents occurred in Africa during the European age of exploration, as Caucasians and Negroes met and traded along the African coast. Various forms of fever (including yellow fever and malarial fevers) and parasitic infestations plagued whites, while blacks suffered from pneumonia, tuberculosis, measles, and other disorders not commonly found in the tropics. With the development of Negro slavery and the transportation of large numbers of blacks to North and South America, the 'African Exchange' soon became important in the New World. Several African tropical diseases appeared and lingered in the Americas as legacies of the slave trade. Among the many transmissible infections which Africans carried with them to the New World were malaria in its various forms, yellow fever, smallpox, yaws, leprosy, guinea worm, filariasis, ascariasis, tapeworm, hookworm, and trypanosomiasis. Some of these infections disappeared with the first generation of imported slaves; others took firm root and lingered through the nineteenth century, and on to the present. No part of the New World entirely escaped the new African infections. Even the 1. Alfred W . Crosby, Jr., The Columbian exchange; biological and cultural consequences 0/1492 (West-
port, Conn., 1972), pp. 35-63, 133-164. See also P. M. Ashbum, The ranks of death; a medical history of the conauest of America, ed. Frank D. Ashbum (New York, 1947). The origin of syphilis is still a matter of controversy among medical historians. Some argue for a European and others for an American origin. Crosby (above, pp. 133-164) discusses this controversy in some detail. This publication was supported in part by National Institutes of Health Grant LM 03477 &° m die National Library of Medicine.
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American South, though not tropical, had a warm enough climate through much of the year to support the growth and permanent residence of a number of disease agents brought from Africa. One African parasite which became endemic in a portion of the South was the filarial roundworm, Wuchereria bancrofti, causative organism of elephantiasis.2 Wuchereria banaofti has a life cycle which involves both an intermediate insect and a final human host. Adult worms live in the lymphatic vessels and lymph nodes of humans, causing an inflammatory response, growth of connective tissue in the vessels, and the eventual development of lymphatic obstruction and varicosities. The closing off of the lymphatic circulation produces the well-known scrotal, labial, or leg and foot swelling so characteristic of elephantiasis. Many other manifestations of chronic filarial infection may also occur. One such symptom is chyluria, the discharge of milky urine which is caused by the rupture of an obstructed lymphatic vessel into the urinary tract. The enlargement of the scrotum, labia, or lower leg, or chyluria, actually occurs only in the later stages of filarial infections. Periodic attacks of glandular pain, scrotal or labial swelling, and general malaise, over the course of many years, are the commonest early signs of filariasis.3 The long time lapse between initial filarial infection and the appearance of severe symptoms was deceptive to slave traders and prospective buyers. Infected slaves brought to the North American colonies might appear perfectly healthy upon departure from western Africa or the West Indies, and also upon sale to a planter. Only years later, perhaps after many puzzling episodes ofpain in the groin or glands, did elephantiasis or chyluria develop. Though carried to the New World, Wuchereria bancrofti might have disappeared like Trypanosoma gambiense, the parasite causing African sleeping sickness, had no suitable insect vector been available to transmit it from one human being to another. In the case of sleeping sickness, which many Africans did bring with them to the Americas, the absence of its carrier, the tse-tse fly, in the New World, prevented establishment of the disease here.4 The parasite of elephantiasis was more fortunate. Throughout the West Indies and the Americas lived a mosquito, Culex quinquefasciatus (also known as C.fatigans), which, when it drew blood from a person infected with Wuchereria bancrofti, was capable of supporting the growth of several 3. R. Hoeppli, Parasitic diseases in Africa and the Western Hemisphere; early documentation and transmission by the slave trade (Basel, Switzerland, 1969). 3. Charles WiicoteindP.E.C.Maiixm-Bihi, Mansm's tropical diseases, 17th ed. (Baltimore, 197a), pp. 193-217. 4. Hoeppli, Parasitic diseases (n. 3), pp. 31-41.
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microfilariae, the offspring of adult worms. Thus, when the microfilariae, produced by worms situated deep in the human lymphatic system, escaped into the bloodstream, they could then pass on to, and survive in, the body of the mosquito. At the insect's next blood meal, filarial larvae escaped through the mosquito's proboscis onto human skin. They penetrated through the bite wound and entered the lymphatic system where they developed to adulthood in about a year. If the adult filaria worm settled in the same lymphatic as another of the opposite sex, the two worms mated, new microfilariae were produced, and the life cycle was repeated.5 Filariasis has usually been associated in this country with Charleston, South Carolina. A major endemic focus of the disease—perhaps the only one in continental North America—existed there until the 1920s. Elephantiasis was reported throughout the South and even in several northern states in the eighteenth, nineteenth, and twentieth centuries. Sporadically cases also occurred outside of Charleston, but usually among persons who had lived in or visited known areas of endemic filaria infection. In the United States only Charleston seems to have harbored a large enough population of infected persons to sustain the filarial life cycle for many generations. Wuchereria bcmcrofii is endemic to both East and West Africa in precisely those areas tapped by slave traders from Europe and America.6 Manifestations of bancroftian filariasis began to appear among slaves taken to the West Indies soon after the beginning of the slave trade. The island of Barbados in particular early became an endemic focus of filarial infection. In Barbados elephantiasis was originally confined to the slave population, but, beginning in about 1704, infection spread to an increasing number of white and creole residents. So common was the disorder that it became known in the English-speaking New World as 'Barbados-leg.' Throughout the nineteenth century and into the twentieth, Barbados (and several other West Indian islands) remained endemic foci of filariasis.7 On the North American continent Charleston, because of certain special factors, became a major center of filarial infection. As a primary port of entry for slaves from the West Indies during colonial times, Charleston 5. Wilcoda and Manion-Bahr, Manstm's tropical diseases (n. 3), pp. 192-217; Harold W. Brown and David L. Belding, Bask clinical parasitclogy, 2nd ed. (New York, 1964), pp. 132-137. 6. Wilcocks and Mamon-Bahr, Manstm's tropical diseases (n. 3), p. 193; James M. Gordon, 'Elephantiaiij—its hiitory, symptomatology, aetiology and pathology, with a report of a case and successful treatment,' Sth. med. surg.J., 1850, N.S. 6, 65-80, p. 67. 7. Gordon (n. 6), pp. 66-67; J- Scott, 'Elephantiasis Arabum,' The cyclopaedia ofpractical medicine, 4 vob. (Philadelphia, 1845), 1, 770-771; Aldo Castellani and Albert J. Chalmers, Manual of tropical medicine (London, 1919), pp. 1597-1598.
Savitt : Filariasis in the United States
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constantly received persons infected with the parasite. Slaves also passed through and spread Wuchereria bancrofii in other port towns of North America at this time, but it is uncertain whether filariasis ever became endemic anywhere but Charleston. Charleston and the surrounding Low Country possessed one of the highest densities of blacks of all the continental colonies. Slaves imported to South Carolina—many carrying microfilariae in their blood—usually remained in Charleston or the vicinity, and were not dispersed to widely scattered plantations as occurred in the other large slave-owning colony, Virginia.8 Also, the Culex quinquefasciatus mosquito occurred in South Carolina and not to any great extent in lands to the northward.9 Even when numbers of infected slaves were brought into New York, Philadelphia, or Boston, Wuchereria hancrofti could not have been transmitted to new human hosts without the proper intermediate insect. The presence of the Culex quinquefasciatus mosquito together with great concentrations of Wuchereria bancrofii carriers assured the Charleston area of a constant supply of infected humans and mosquitoes sufficient to maintain the filarial life cycle. A sizable reservoir of infected human hosts was necessary because (a) not all microfilariae ingested by a mosquito survived residence in the insect's body; (b) unlike the malarial parasite which multiplied within the mosquito's body, microfilariae simply grew in size, not number, in the intermediary host; and (c) once settled in a human lymphatic vessel, adult worms could not reproduce without a member of the opposite sex in that same location. It usually required multiple bites of mosquitoes carrying Wuchereria bancrofii to obtain infestations in humans sufficient for the production of microfilariae.10 With a constantly replenished supply of human carriers from the West Indies passing through or settling in Charleston during the colonial period, conditions were ideal for that town to become an endemic focus of Wuchereria bancrofii. A further reason for Charleston's unique position as haven for filarial worms was its close ties with the major West Indian focus of this disease— Barbados. South Carolina was settled and initially developed in large part by whites and slaves transplanted from that island. The two colonies retained economic and social relations throughout their early histories, and 8. Peter H. Wood, Blade majority; Negrots in colonial South Carolinafrom1670 through the Stono Rebellion (New York, 1974), pp. xiii-xiv, 152. 9. Marcus W. Lyon, Jr., 'Filariasis; report of two cases in the District of Columbia, and analysis of the cases reported for eastern North America,' J. Amer. mei. Ass., 1917, 6$, 118-119, P- H910. Edward Francis, Filariasis in southern United States (Washington, United States Public Health Service, Hygienic Laboratory Bulletin No. 117, June 1919), pp. 17-19; Brown and Belding, Bask dlnkal parasttology (n. 5), pp. 133-134.
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: April 1977
on into the nineteenth century. As a result, black and white Barbadian emigrants and merchants simply transferred Wuchereria bancroftifromone hospitable environment to another.11 There is not enough evidence to designate an exact time at which the filarial worm became able to sustain itself in the Charleston area without periodic reinforcements from the West Indies or Africa. The estabhshment of the infection at Charleston must have occurred some time before cessation of the slave trade in 1808. It was not until 1886, shortly after Wuchereria bancrofti was discovered and associated with elephantiasis and chyluria, that medical scientists first recognized the endemicity of that parasite in Charleston and the Low Country of South Carolina. Before 1886 Charleston residents had known that cases of elephantiasis and chyluria occurred regularly in their city, but had been unaware of Charleston's uniqueness in this respect. Among the early descriptions of elephantiasis in the American colonies is the following, excerpted from Bernard Romans's 1775 book, A Concise Natural History of East and West Florida. Romans had for twenty years lived in Georgia and the Floridas, and traveled through the Carolinas. Though he did not state precisely where he observed cases of elephantiasis, the context of his excellent and accurate description indicates that the probable locale was coastal South Carolina and Georgia: A loathsome disease appears some times among the Negroes after severe acute disorders, especially if the patient has been obliged to keep his bed long, likewise after a violent exercise has brought on a surfeit: this is called the Elephantiasis from the swelling of the feet and legs; it is most frequently seen to affect one leg only; in the first stages of this disorder the patient becomes wretched through excessive lassitudes which bring on an emaciation of the body, then the corrupted juices subside into the leg or legs and feet, these swell, the skin becoming distended, shines and shews the distended veins every where below the knee; now the skin by degrees loses its gloss and becomes unequal and something scaly; after this chaps make their appearance, the glands are stretched and the scales are daily enlarged, appearing as hard and callous as the hide of an Alligator, notwidistanding which the slightest prick of a pointed instrument will cause the 11. Wood, Black majority (n. 8), pp. 24, 45-46, describes the settlement and development of South Carolina by Barbadian]. For mention of the continuing intercourse between these two areas, see John Guiteras, "The Filaria sanguinis hominis in the United States—chyluria,' Med. News, Phila., 1886, 48, 399-403, p. 400. The interesting speculation of Dr. I. Snapper (Hoeppli, Parasitic diseases [n. a], pp. 122-124) that a boatload of Brazilian Jews seeking refuge from the inquisition carried W. bancrofti to Charleston in the 16501 cannot be correct since few, if any, Jews actually settled in Charleston at that time. Most emigrated to Holland, and a small number moved to the West Indies, to FnglanH, and to New Amsterdam. The one or two families which might have gone to Charleston could not have caused the development of endemic filariaiiv See Jacob R. Marcus, The colonial American Jew, 14921776, 3 vok. (Detroit, 1970), 1, 8i, 343-345.
Nelson
Nelson
Two months after the operation performed by Dr. Picton on 3 October 1837
Before the operation
A case of elephantiasis in a Louisiana slave, from J. M. W. Picton, 'A case of elephantiasis scroti, with successful operation,' New Orleans Medical and Surgical Journal, 184.J-46, 2, 316-321.
Savitt : Filariasis in the United States
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blood to exude; this disease affects neither the appetite nor the digestive powers of die body, on dae contrary die patient in diis and chearfulness [sic] of spirits resembles die healdiiest of men, and die inconvenience of his heavy leg only prevents his ability for the more laborious part of his duty.12 Subsequent cases of elephantiasis appearing in the medical literature often originated from this same area. Those that did not may have been nonfilarial in etiology, or imported from outside the United States, or the result of small endemic foci in other slave port cities. Disorders other than filariasis can also cause gross swelling of the scrotum, labia, or lower extremities. Bacterial or accidental mechanical obstruction of lymphatics often results in such elephantoid symptoms.13 Actually, there is no way to know whether the cases reported before the days of routine blood examinations (1880s) were truly filariasis. Patients with elephantiasis and chyluria in and around Charleston most likely harbored the parasites, because we know from later microbiological studies that Wuchereria bancrofti was endemic there. But how does one explain the several cases which arose in Georgia and Louisiana? Though public health surveys in 1915 and 1918 failed to turn up endemic cases of filariasis in Savannah or New Orleans, probably Wuchereria bancrojii was brought into these towns during the eighteenth and nineteenth centuries but did not survive. Botii cities had had sizable slave populations and served as ports of entry for imported African and West Indian slaves. But there are no early records which suggest that either town ever harbored large numbers of individuals with elephantiasis or chyluria.14 The first case to appear in the nineteenth century southern15 medical literature is a good example of the problem. Nelson, a thirty-eight-year12. Bernard Romans, A concise natural history of east and west Florida . . . (1775; reprint ed., New Orleans, 1961), pp. 170-171. 13. On other causes of elephantiasis, see Rudolph Matas, T h e surgical treatment of elephantiasis and elephantoid states dependent upon chronic obstruction of the lymphatic and venous channels,' Amer.J. trap. Dis., 1913, 1, 60-85, pp. 60-67. 14. Francis, Filariasis (n. 10), pp. 13, 15-16; Ernest Carroll Faust, 'Parasitism in southeastern United States; history of human parasitic infections,' Publ. tilth. Rep., Wash., 1955, 70, 958-965, p. 963. There is no mention of elephantiasis in John Duffy, ed., The Rudolph Matas history of medicine in Louisiana, 2 volfc (Baton Rouge, 1958-63), and only one death attributed to elephantiasis in Savannah between 1854 and 1869 (W. Duncan, Tabulated mortuary record of the city of Savannah, from January 1, i8i4, to December 31, 1869 [Savannah, 1870]). 15. There were cases of elephantiasis reported in the North throughout the nineteenth and early twentieth centuries, though most were either imported or of nonfilarial origin. A few may have been true filariatii contracted from some unknown source. See, for example, David Hosack, Essays on various subjects of medical science, 3 vols. (New York, 1830), m, 441-445; Isaac Pairish, Tumour of the left labium, resembling elephantiasis, removed from a Negress,' hied. Exam., Phila., 1840, 3, 229; J. W. Webster, 'Elephantiasis,' New Eng.J. Med. Surg., 1820, 9, 213-220; Lyon (n. 9), p. 118.
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Journal of the History of Medicine : April
old slave belonging to Mr. J. F. Piseros of St. Charles Parish, Louisiana, •was brought to New Orleans in June 1837 for treatment of an enormously enlarged scrotum. No other historical information was presented in the report except that the enlargement had begun some ten years earlier. A lithograph of Nelson before and after the successful operation to remove his huge burden accompanied the article. The physician's language throughout the report indicated that it was one of the first cases of elephantiasis he or his colleagues in New Orleans had seen. There was no mention of other persons with the disorder living in St. Charles Parish, so it is difficult to draw any conclusions as to the origin of Nelson's disorder.16 Similarly, the three cases of elephantiasis which Dr. Joseph Jones observed among whites in New Orleans during the 1870s are doubtful, but possible, instances of Wuchereria hancrofii infection. Jones provided little background information at the time on which present-day readers might base a diagnosis, and failed to mention any other local cases in an extensive review of the subject some nine years later. More easily explicable are Jones's six reported cases of elephantiasis (four of the foot and leg, two of the scrotum) observed among slaves on coastal Georgia cotton, rice, and sugar plantations during the 1840s and 1850s. This area, part of the Charleston-influenced Low Country, had large areas of marsh where mosquitoes bred readily, and many slaves whose parents and grandparents had come from the West Indies and Africa. Spread of the filarial infection under these favorable conditions was likely.17 The occurrence of three other reported cases of elephantiasis in the inland Georgia towns of Atlanta, Columbus, and Lawrenceville is difficult to explain as Wuchereria bancrofti infection. None of the three towns was a likely focus forfilariasis,and none produced subsequent reported cases of elephantiasis. Neither was Charleston mentioned as a previous residence of any of the three patients whose case histories were given.18 The pre-1886 evidence for filariasis in Charleston is very convincing. 16. J. M. W . Picton, 'A case of elephantiasis scroti, with successful operation,' New Or/, med. surg. J., 1845-46, 2, 3i6-3ai. 17. Joseph Jones, 'Observations on the African yawl . . . and on leprosy . . . in insular and continental America,' New Orl. med. surg. J., 1878, N.S. 5, 673-693, p. 690; Joseph Jones, Medical and surgical memoirs: containing investigations on the geographical distribution, causes, nature, relations and treat-
ment of various diseases, 3 vols. (New Orleans, 1876-90), n, 1188-1189, 1287-1332. 18. V. H. Taliaferro, "Remarks upon elephantiasis,' Atlanta med. surg. J., 1856-57, 2, 647-651; 'Service of Dr. Jones—elephantiasis,' ibid., 1859, 4, 341-342; Juriah Harrisi, 'Report of a case of elephantiasis,' Savannah J. Med., 1866, N.s. 5, 12-15; S. W. Francis, 'Report of a case of Elephantiasis Arabum,' Med. surg. Reptr., Phila., 1866, 14, 284-286; D. W. Hammond, "Elephantiasis,' Trans, med. Ass. Co., 1877, 2$, 109-112.
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Mention of elephantiasis by physicians occurred with some regularity, thereby suggesting that the cases of elephantiasis were not an isolated phenomenon oftraumatic or bacterial origin. Between 1855 andi858, for example, one black Charleston resident each year succumbed to elephantiasis.19 Chyluria occurred frequently enough for Dr. Charles Witsell of Ashepoo, South Carolina, in the Low Country near Charleston, to describe its pathology and treatment in 1855. Witsell stated that Dr. Dickson of Charleston had also seen several cases of'chylo-serous urine.'20 Some South Carolina physicians mentioned or described individual cases of elephantiasis. In 1849 Dr. William F. Holmes reported, in an article on the treatment of pneumonia, that a slave, Peter, suffering from pneumonia, was also 'the subject of elephantiasis.'21 In 1855 a medical student, Clarence A. Fripp of Beaufort, South Carolina (on one of the Sea Islands along the coast, heavily populated with slaves), thought he had seen enough cases of elephantiasis there and at the medical school in Charleston to justify writing his M.D. thesis on the disease: 'Our attention,' he wrote, 'has been directed into this channel, from having seen several cases & being impressed with the idea that, through causes neither appreciable, nor within our controul [sic], this disease formerly so rare, is now becoming far more frequent.'22 Fripp noticed that elephantiasis occurred much more often among mulattoes and blacks than among whites—in fact, of the several cases he had seen, none were among whites.23 He gave a general description of the disease and then mentioned specifically a case he had observed of a Negro man whose scrotum 'was so hypertrophied, as to hang below the knees involving the prepucial folds of the penis in one colossal mass of immense height.'24 Two other antebellum cases of elephantiasis in the Charleston area appeared in the medical literature. Dr. F. Galvez listed the name of Dr. Middleton Michel of Charleston in a 'Statistical Table of the different 19. J. L. Dawson, 'Return of deaths in the city of Charleston,' Charleston med.J. Rev., 1855,10, 747; 1856, 11, 574; 1858, 13, 282; 1859, 14, 138.
20. Charla Witsell, 'Pathology and treatment of a discharge of chyloierous urine,' Charleston med. J. Rev., 1855, 10, 621-62$. ai. William Fletcher Holmej, T w o cases of pneumonia, illustrating the comparative efficacy of mercury and tartar emetic, in the treatment of that disease,' Charleston med.J. Rev., 1849, 4, 176-179. 22. Clarence A. Fripp, 'An essay on elephantiasis' (M.D. thesis, Medical College of die State of South Carolina, 1855), p. 3, at Waring Historical Library, Medical University of South Carolina, Charleston. Fripp's paper included discussions of both elephantiasis (Elephantiasis Arabum) and leprosy (Elephantiasis Graecorum). The reference to a paucity of cases in previous years and an increase in recent times was probably made in regard to leprosy. 23. Ibid., pp. 7-8. Leprosy, Fripp observed, occurred more often among whites than blacks in South Carolina. 24. Ibid., p. 13.
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Journal of the History of Medicine : April 1977
Operations for Elephantiasis of the Scrotum, performed in different parts of the World.' Though the present writer could locate no report of the procedure Dr. Michel performed, Dr. Galvez stated that the patient had been cured.25 In February i860, Dr. T. L. Ogier of Charleston presented a case history of elephantiasis to the South Carolina Medical Association. The patient, a twenty-six-year-old slave, desperately wished relief from the discomfort of a greatly enlarged leg and foot. His master agreed. Ogier succeeded in reducing the swelling by ligating the femoral artery, though, as in all radical 'cures' of elephantiasis, the results may not have been permanent.26 Elephantiasis continued to plague Charlestonians at the rate of several cases annually in the years following the Civil War. Throughout the 1870s and early 1880s both whites and blacks fell ill or died with the disorder, and a few people reported 'chylous urine.' In 1870, though no deaths occurred, three whites and four Negroes were treated for elephantiasis at the city hospital or at home by city health officers. Three years later there were two deaths attributed to elephantiasis—one white and one black—as well as seven cases—six black and one white—treated by public health officials. In 1883, three deaths of persons with elephantiasis occurred.27 By 1885 the frequent occurrence of chyluria and elephantiasis among Charlestonians had aroused enough concern among local physicians to have the matter discussed at the annual meeting of the State Medical Society.28 Also in 1885 a physician interested in the newly discovered relationship of human filarial infestations to elephantiasis and chyluria came to Charleston. During the previous year Dr. John Guite"ras had treated four Cubans in Key West iozfilaria sanguinis hominis (microfilariae in the blood), and now wished to examine Charlestonians for the presence of these parasites. His reasons for undertaking such an investigation were compelling: I was told that this disease [chyluria] and elephantiasis were not rare in die city. I also found diat mosquitoes were very plentiful during the summer and fall; that cistern water was in general use, and that nofilterswere to be found for sale in the shops. These observations, togedier with die fact that Charleston has been for many years in constant intercourse with the West Indies, induced me to be on die lookout for filaria.29 as- F. Galvez, 'Caje of elephantiasis of scrotum,' Charleston mecLJ. Rev., 1859,14,119-124, p. 124. 26. T. L. Ogier, 'Ligature of the femoral artery for the cure of elephantiasis of the leg and foot,' Charleston med.J. Rev., i860, 1$, 191-195. 27. Charleston, City Council, Annual report, 1S70, pp. 36, 39,40; 1S73, PP- 45i 4 s . 5+« 5"; 1874, p. 44; itj6, p. 46; Charleston, City Council, Year book, 1SS2, p. 83; 1SS3, p. 83. 28. Guiteras (n. 11), p. 399. 29. Ibid.
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Guite"ras was assisted in his work by several physicians, two of whom, J. J. Edwards and W. D. Bratton, had been examining the blood of suspected filarial carriers since 1882 or 1883, but without success.30 Microfilariae were seen (1886) first in the blood of a mulatto woman, a native of Charleston, suffering from chyluria. Over the next four years twenty-two Charlestonians—fifteen blacks and seven whites—were found to harbor microfilariae in their blood. One was a hundred-year-old Negro woman who had been brought from Africa in a slave ship.31 Manifestations of filarial infection continued to appear among Charleston area residents throughout the 1890s and 1900s.32 Writers of textbooks and articles on tropical diseases now began to include Charleston in the list of areas where filariasis was to be found.33 Not until 1914 did a large-scale statistical study of 400 individuals reveal the extent of the problem at Charleston. Dr. Francis B. Johnson, clinical pathologist at the Medical College of South Carolina in Charleston, disclosed that he had discovered microfilariae in the blood of 19.25% of 400 routinely cultured hospital and clinic patients. Still more startling was the finding that only a quarter of those infected showed symptoms of filariasis —the remaining three-quarters were carriers.34 Another study, performed a year later in Charleston's 'Old Folks' Home,' revealed that thirteen of the residents there (35%) had microfilariae in their blood.35 Dr. Johnson also questioned about two-thirds of Charleston's physicians regarding the number of filariasis cases they had seen in their practices. The physicians reported having noted 494 cases, including 244 of chyluria, 213 of elephantiasis, 8 of the two combined, 4 of other symptoms, and 25 not stated.36 After 1886, American physicians throughout the South began searching for other concentrations of filarial infection. Cases were reported from
30. P. G. De Saussure, 'A clinical history of twenty-two cases of filaria sanguinii hominis, icen in Charleston, S.C., from 1886 to May, 1890,' Med. News, Phila., 1890, 56, 704-707, p. 704. 31. Ibid., pp. 704-707. 31. Charleston, City Council, Year book, 1891, p. 51; 1S93, p. 83; 1894, pp. 91-92; 1S96, pp. 86, 89; 1899, p. 72; 1903, pp. 83, 86; 1906, p. 170; 1912, p. 189. 33. Patrick Manton, Tropical diseases, a manual of the diseases of warm climates (London, 1898), p. 448; W. M. Mastin, T h e history of the filaria sanguinis hominis, its discovery in the United States, and especially the relationship of the parasite to chylocele of the tunica vaginalis testis,' Arm. Surg., 1888, 8, 331-362, pp. 339-341. 346-347; Lyon (n. 9), pp. 118-119. 34. F. B. Johnson, Tnlarial infection; an investigation of its prevalence in Charleston, S.C.,' Sth. mei.J., Nashville, 1915, 8, 630-634. 35. Francij, Filariasis (n. 10), p. 11. 36. Some of these cases were undoubtedly duplicates, i.e., the same cases reported by more than one physician. Johnson (a. 34), p. 634.
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many towns but none were more than isolated phenomena.37 Finally, in 1917, Dr. Edward Francis of the United States Public Health Service undertook afiJarialsurvey on nine southern towns with climatic conditions and mosquito species similar to Charleston's, in order to discover the true extent of the problem.38 Interestingly, only nine of 1470 individuals tested showed microfilariae in their blood, and these nine had 'histories either of having been born and raised in Charleston or of having been born in Cuba which is a well-known fllarial focus.'39 Charleston was the only endemic focus offilariasisin the United States at that time, though others may have existed in earlier periods. The upshot of Johnson's and Francis's reports was an intensive mosquito control campaign during the early 1920s to eradicatefilariasisfromCharleston. In 1924, it was necessary to conduct only thirty-six blood tests at the city hospital for filariasis; this number was reduced to four the following year,40 and to zero by 1930.41 When a group of Mexican scientists visited Charleston in the late 1920s to study the filarial problem, the City Health Officer was unable to show them a single case. In 1949, a leading parasitologist reported: 'In the United States the one previously known endemic area, that around Charleston, South Carolina, has become filaria-free.'42 One of the consequences of the 'African Exchange'—filariasis—now became only a memory in the United States. Department of Community Health and Family Medicine University of Florida
37. See, for instance, Martin (n. 33), pp. 339-341; Lyon (n. 9), pp. 118-119; R. M. Slaughter, 'Fflaria sanguinis hominis, the discovery and prevalence of t~Vn* Hin*av in the United States,' Trtms. med. Soc Va., 1891, pp. 330-245. 38. The citiej were Columbia, Beaufort, and Georgetown, South Carolina; Milledgeville and Savannah, Georgia; Jacksonville and Tampa, Honda; Mobile, Alabama; New Orleans, Louisiana. 39. Francis, Filariasis (n. 10), p. 16. 40. Leon Banov, As I recall; the story of the Charleston County Health Department ([Charleston], 1 97°). PP- 56-57; Charleston, City Council, Year bock, 1924, p. 204; ip*j, p. 198. 41. George Cheever Shattuck, Diseases of the tropics (New York, 1951), p. 508. 42. PrrM-tf Carroll Faust, Human helmlnthology, 3rd ed. (London, 1949), p. 499.
