Transcript PLAGUES, PESTILENCE AND PUBLIC HEALTH

PLAGUES IN HISTORY OF MEDICINE AND
PUBLIC HEALTH
December 20, 2010
Plague of Athens kills a third of the population c. 425
Plague of Justinian kills 25% of population c. 542
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Public baths and
gymnasia were
conspicuous features of
social life in Ancient
Greece for men and
women. Here, women
are taking shower baths
and their clothes hang
on rails.
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The Greek physician, *Hippocrates (c. 450-370 BCE)
and his followers defined the concepts of `epidemic' and
`endemic' diseases in two works, Epidemics and On
Airs, Waters, Places.
On Airs, Waters, Places gave practical advice for
selecting healthy inhabitable locations. The quality of
climate, soil and water were thought to be crucially
important.
Endemic diseases were always present in communities
and probably included influenza, tuberculosis and
malaria. Epidemic diseases were those which only
occurred occasionally but often erupted violently and
without warning. During the *Peloponnesian War (431404 BCE), for example, an unidentified plague of terrible
magnitude killed a fair proportion of the Athenian army
and a third or more of the population of *Athens.
Tuberculosis - scrofula, the King's Evil
Europe's monarchs begin
touching for the 'King's Evil'
1254
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The word scrofula comes from the Latin
scrofa. By the Middle Ages, scrofula
described an illness characterised by
swellings, particularly in the neck. It was
thought to be cured by the touch of a king and
became known as the `*King's Evil'. The ritual
of royal touching seems to have begun with
the kings of France after the return of *Louis
IX (reigned 1226-1270) from the *Crusades in
1254. The Plantagenet monarchs of England
(1154-1399) followed this tradition about a
decade later and *Edward I (1272-1307) is
said to have touched nearly 4000 people in 3  Mary I (1516-1558)
touching the neck of
years. At his coronation in 1722, *Louis XV
(1715-1774) of France touched more than
a boy for scrofula.
2000 sufferers.
Robert the Bruce falls victim
to leprosy 1339
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n 1339, King Robert the Bruce fell
victim to leprosy, and after his grave
in Dunfermline was opened in 1818,
a plaster cast was made of his skull
which showed signs of the disease.
According to Sir James *Simpson
(1811-1870), Professor of Midwifery
at Edinburgh University, who
published an article about leprosy in
1841, Scotland was severely
affected and the disease lingered In
long after it had almost vanished
from England. It remained endemic
in the Shetland Islands until the end
of the 18th century and Simpson
described a patient from the
Shetlands who, in 1798, was an inpatient at the Edinburgh Infirmary.
this 13th century French
miniature by Vincent de
Beauvois, a leper carries a
rattle and begging bowl.
Behind him is a crippled man
supported by a crutch.
Leprosy - a 19th century epidemic
 Leprosy declined during the late Middle Ages for reasons
which are not clear but may be related to segregation of
lepers, depopulation by the Black Death (1348), and the
fact that tuberculosis began to increase. Leprosy and
tuberculosis are caused by closely related Mycobacteria
and individuals exposed to tuberculosis seem to be
highly resistant to infection with leprosy.
 By the 16th century, the number of lepers in leprosaria
was very low and they were used for isolating people
with other `anti-social' diseases such as syphilis.
Nevertheless, leprosy persisted in Iceland and Norway
until the beginning of the 20th century and in 1849, a
government-sponsored leprosy research centre was set
up in Bergen.
Black Death kills
a quarter
of Europe's
population
1348
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This map depicts the history and global distribution of the Black
Death. In Milan, the city council sealed in the occupants of
infected houses and left them to die. In Basel, Jews were
blamed for the plague and were burned alive in a wooden
building.
Florence destroyed its population of dogs and cats, and the
Florentine doctor, Lapo Mazzei (1350-1412) recommended
drinking, ‘a quarter of an hour before dinner, a full half-glass of
good red wine, neither too dry nor too sweet'.
Syphilis first described in Europe 1495
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Detail from a painting
entitled, ‘Decapitation of S
Valerianus and his brother' by
Amico Aspertini (1475-1552).
Behind the executioner is a
leper with bandaged legs who
carries a banner emblazoned
with a Scorpion. By this sign
of the Zodiac, he declares
himself a sufferer from
syphilis.
Syphilis - the spread through Europe
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Epidemic syphilis was first described in Europe after the Siege
of Naples (1495) when Charles VIII of France fought the
Spanish over the Kingdom of Naples. The French army was so
stricken by the `Italian disease' that Charles was forced to
retreat, and his soldiers spread the infection throughout Europe
as they returned to their homes in England, Germany, Hungary
and Poland. It then became known as the `French disease' or
morbus gallicus. By 1497, it had reached Scotland where it was
called Gore, Grandgore, Verole and Grandverole. Victims of an
outbreak in Edinburgh were isolated on the island of Inchkeith
but in other parts of Britain and Europe, syphilitics were
confined in leprosaria which had fallen into disuse with the
decline of leprosy from the late Middle Ages.
Old and New Worlds
exchange diseases
c. 1520
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The brigantine slaver
‘Windward' on a transatlantic
voyage from West Africa to
America. The lower deck
would have been packed to
capacity with hundreds of
men, women and children
forced to endure foul air,
meagre rations, inadequate
sanitation or washing facilities,
disease and chronic sea
sickness. On a bad crossing,
a slaver might lose half its
human ‘cargo'.
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The Caribbean islanders began to die in their
hundreds as Europe's pestilential diseases were
introduced, and by about 1520, most of them
had crossed the Atlantic. These included
measles, smallpox, typhus and influenza.
Native Americans had their own diseases such
as pinta, trypanosomiasis (Chagas' disease),
bartonellosis (Carrion's disease, Oroya fever),
and leishmaniasis, of which the last 3 were
vector-borne.
They also most probably had syphilis which was
taken to Europe on *Columbus' return voyage.
Syphilis devastated its new victims. In addition,
smallpox became so virulent during the 16th
century that it accounted for 10%-15% of all
deaths in some countries of western Europe.
Great Plague of London kills
20% of the population
1665
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This costume, worn by
physicians attending
plague victims was made
of morocco leather,
underneath which was a
skirt, breeches, and boots,
all of leather and fitting into
one another. The long
beak-like nose piece was
filled with aromatic
substances and the eyeholes were covered with
glass.
Yellow fever in Philadelphia
kills 10% of the population
1793
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In 1897, a teenage girl named
Lucille died of yellow fever in
Memphis, Tennessee. Her
illness was described by her
uncle: ‘Jaundice was marked,
the skin being a bright yellow
hue: tongue and lips dark,
cracked and blood oozing from
the mouth and nose ... the most
terrible and terrifying feature
was the ‘black vomit' which I
never before witnessed ... it
was as black as ink and would
be ejected with terrific force. ‘
Edward Jenner develops
smallpox vaccine
1796
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This painting was
almost certainly
inspired by Jenner's
vaccination of his
young son.
John Snow stops cholera
epidemic
1854
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In 1854, John Snow (1813-1858), a
London physician, investigated
cholera deaths in an area of the
capital now called Soho. Most deaths
occurred in people who drew water
from the public pump in Broad Street
(now Broadwick Street) and on 7
September, he had the handle
removed from the pump which
stopped the epidemic. Water was the
main medium through which the
poison of cholera was spread by the
oral-faecal route. In Munich, Max von
Pettenkofer (1818-1901) pioneered
the development of water analysis
and purification.
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‘... is hardly an exaggeration of
many dwelling places of the poor
in London.' There was a belief
during the mid-19th century that
cholera lurked in the povertystricken courts and alleys of
towns and cities.
Prince Albert
dies of typhoid
1861
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Albert, Prince Consort (1819-1861), died of typhoid fever on 14
December 1861. Queen Victoria (1819-1901) sits on the
Prince's left. In a group on the left stand the Prince's doctors.
Queen Victoria strongly disapproved of the painting and wanted
to buy it in order to have it destroyed. However, the owner
made it a prize in a raffle so that the Royal household would
have needed to buy all the tickets to be sure of getting their
hands on it. It survived and was bought by the pharmaceutical
manufacturer and collector, Sir Henry Wellcome (1853-1936), in
1924.
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30% of deaths in England
and Wales caused by eight
infectious diseases
c. 1865
Mass overcrowding in
inadequate housing, dramatic
accumulation of human,
animal and industrial waste
products, atmospheric
pollution, contaminated and
inadequate water supplies.
Epidemic diseases increased
so much that by the 1860s,
nearly 30% of deaths in
England and Wales each
year were caused by the 8
infectious diseases measles, scarlet fever,
diphtheria, whooping cough,
typhoid, typhus and
tuberculosis.
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The building of the railways in the
mid-19th century resulted in the
demolition of many homes and the
forced eviction of a number of the
city's poorest inhabitants. This
contributed to overcrowding. In
Whitechapel, a district of London's
East End, the number of inhabited
houses fell by over 30% between
1871-1901 while the population
rose by nearly 3%, resulting in a
growth in person-to-house density
Measles in Fiji 1875
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This important medicine man of Worgaia,
Central Australia, could provide little
protection or hope of cure to members of
his aboriginal community struck down by
measles or any other infection to which
they had previously been unexposed.
Nevertheless, both he and they
understood that sickness was caused by
a ‘foreign substance' which had been
introduced into the body by a magical
route. Anthropologists Sir Baldwin
Spencer (1860-1929) and FJ Gillen
(1856-1912) described how the
Australian medicine man would bend
over his patient and ‘suck vigorously at
the part of the body affected, spitting out
every now and then pieces of wood,
bone or stone, the presence of which is
believed to be causing the injury and
pain'.
Koch discovers TB bacillus 1882
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Despite discovery of the
tuberculosis bacillus, many
doctors continued to believe
that the disease developed
more readily in those with a
hereditary predisposition. In
1912, a council member of the
National Association for the
Prevention of Consumption and
Other Forms of Tuberculosis
(NAPT) wrote that the bacillus
attacked ‘failures' by targeting
‘the depressed, the alcoholic,
the lunatic of all degrees'.
Koch was awarded a Nobel Prize in 1905.
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In 1882, the German bacteriologist, Robert Koch (18431910), identified the bacillus which caused tuberculosis. This
was not an easy task since the bacillus did not stain easily
and took up to six weeks to grow in culture. He presented his
discovery to the Physiological Society of Berlin on 24 March.
In the audience was Paul Ehrlich (1854-1915) who had
worked on the affinity of dyes for specific body tissues in
general histology. After the lecture, Ehrlich obtained some
microscope slides coated with tuberculous sputum (probably
his own since he had consumption), stained them with one of
his aniline dyes, and left them overnight on the cold stove. In
the morning, the cleaning lady started the fire which speeded
up the staining so that when Ehrlich arrived, the slide was
teeming with bacilli. This technique for direct microscopy had
important implications for rapid diagnosis of other diseases.
Pasteur inoculates with
rabies vaccine
1885
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Jean-Baptist Jupille was a shepherd
boy from Pasteur's home district of the
Jura. He was bitten as he tried to
protect other children from a dog
supposed but not proven to be rabid.
Pasteur inoculated him over a 14-day
period with increasingly virulent (and
painful) injections of vaccine. Much
publicity was given to the bravery of the
first children who received Pasteur's
rabies vaccine and helped vindicate the
role of experimental biology. In 1915, a
10-year study revealed that of 6000
people bitten by rabid animals, only
0.6% of those vaccinated had died
compared with 16% of the rest.
Ross blame on
mosquito
malaria development 1897
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in 1897, British army surgeon, Ronald Ross
(1857-1932), described the breeding cycle of the
Anopheles mosquito which transmitted the
malarial parasite (Plasmodium species). When a
female mosquito bites a person with malaria
(male mosquitoes do not bite), the parasite is
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ingested and undergoes part of its life cycle in the
insect's gut. She injects it into another human
host when she takes her next meal. The parasite
travels to the liver, multiplies, enters red blood
cells, continues its life cycle and waits to be
ingested by another mosquito. Ross had looked
for an insect vector following the discovery by
Scottish physician, Patrick Manson (1844-1922),
that the filaria worm was the vector for
elephantiasis.
Female
Anopheles
mosquito on
human skin,
1988
TB still a major cause of
death
c. 1900
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The severe wasting caused by tuberculosis of the lungs engendered the
name `consumption'. Another term was phthisis. During the 18th and 19th
centuries, consumption was associated with poverty, overcrowding,
malnutrition, and certain occupations such as tailoring and coal mining. It
was the leading cause of death in European and American cities throughout
most of the 19th and early 20th centuries. In Britain, it caused 1 death in 8,
and 90% of the population in urban areas were infected with the bacilli.
Many of the affluent and famous also died of tuberculosis.
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These houses were considered to be ‘breeding
grounds' for tuberculosis and were demolished
later in the century. Bad housing became
synonymous with sickness, particularly
consumption. In New York, tenement housing of
the ‘dumb-bell' design, constructed between 18791901, supposedly allowed the ingress of air and
particularly light which killed the tuberculosis
bacilli.
Princess of Wales donates Finsen lamp to the London
Hospital 1900
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Tuberculosis - the Lamps of Hope
During the 1890s, Niels Ryberg Finsen
(1860-1904), a Danish physician,
investigated the bactericidal effects of
light which he found was more effective
at the ultra-violet end of the spectrum.
He constructed a powerful carbon arc
electric lamp with four tubes down which
light was passed.
Finsen's results at treating lupus were
so successful that in 1896, the Finsen
Institute was set up in Copenhagen and
by the turn of the century, 500 patients
had been treated.
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Patients
undergoing
treatment for
lupus vulgaris.
'Typhoid Mary' 1915
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he most famous typhoid carrier was Mary
Mallon, `Typhoid Mary', who was born in
Ireland in 1869 and emigrated to the United
States as a teenager. In August 1906, she was
hired as a cook by New York banker, Henry
Warren, during a summer vacation in Oyster
Bay. Within weeks, 6 of the 11 members of the
household developed typhoid. Typhoid was
not an uncommon disease in New York. In
1906, there were 3467 cases and 639 deaths.
Nevertheless, a sanitary engineer, George
Soper, was hired to investigate the incident
and the trail of infected families led him to
Mary Mallon who was then working at an
address in Park Avenue. The family's only
daughter was dying of typhoid and a laundress
had been taken to hospital. Soper confronted
Mary in the kitchen and asked for samples of
her blood, faeces and urine.
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Mary Mallon who allegedly
infected at least 53 people
with typhoid, 3 of whom died.
Dr Baker captured Mary and
took her to hospital where
her stools tested positive for
Salmonella typhi.
She was finally caught in
1915 when 20 cases of
typhoid erupted at New
York's Sloan Hospital for
Women where Mary was
employed as a cook. She
spent the rest of her life in
detention on North Brother
Island and died in 1938.
Spanish 'flu kills 30 million
people worldwide
1918
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With the words, ‘A-TICHOO!! Good evening, I'm
the new influenza!!' the
‘monster' hits an old man
over the head as he sits
in his armchair. For the
first time, however, the
greatest proportion of
influenza victims were the
young.
Poliomyelitis - the `Iron Lung'
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In 1908, Karl Landsteiner (1868-1943) and Erwin Popper, in Vienna,
discovered that polio was an infection although the causative
organism was too small to be seen through a microscope. During
the 1920s, Philip Drinker at the Harvard School of Public Health,
developed a respirator for victims of bulbar polio. This was a large
tank which isolated the body and drew air into the lungs by creating
a vacuum. It was, in fact, powered by a domestic vacuum cleaner.
The first patient to use the Drinker respirator was an 8-year-old girl
who went into the machine on 12 October 1928 but died a week
later. The respirator, popularly known as an `iron lung', was
exhibited in the Hall of Science at the Chicago World Fair in 19331934.
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Epidemics of polio gradually became more severe and widespread,
and the disease was feared. In 1916, only about 5% of cases
involved adults but by 1955, a quarter were over 20.
In the United States, in 1944, there were 19,000 cases but by 1948,
the numbers had risen to 28,000.
In that year, Los Angeles County Hospital had 280 iron lungs in
operation but as fast as they were emptied, United States army
planes flew them to a part of the country where a fresh epidemic had
broken out. Britain experienced an iron lung `crisis' in 1938 and the
Sunday Chronicle ran a publicity campaign to highlight the shortage
of respirators. Lord *Nuffield (1877-1963), the head of Morris
Motors, donated iron lungs to any hospital in the British Empire
which wanted one, and they were built at his automobile plant in
Oxford.
Nuffield builds 'iron lungs' 1938
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Lord Nuffield was a generous
patron of medical research,
contributing £2 million in 1936
towards a postgraduate school
for clinical research in Oxford.
When interviewed by the
Sunday Chronicle after his
offer to build ‘iron lungs', he
admitted that his first ambition
as a boy was to be a surgeon.
‘But I had not the money for it,
so I became a mechanic - the
next best thing'. This Drinker
respirator is an English model
made by Siebe Gorman & Co.
Smallpox eradicated 1979
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The district surgeon
vaccinates African girls in
front of the mission court
house. Vaccination
became one of the major
rituals of the implantation
of Western medicine into
colonial lands, particularly
through the work of
medical missionaries.
HIV virus described 1983
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In 1983, Luc Montagnier at the Pasteur Institute in Paris,
discovered a new human retrovirus which he named LAV
(lymphadenopathy-associated virus) although it later became
known as HIV-1 (human immunodeficiency virus). Both he and
the American researcher, Robert Gallo, suggested that the virus
had been spreading throughout the 1970s since HIV infection
preceded the development of AIDS by up to 10 years.
Immunological damage occurred because the virus destroyed
the white blood cells known as CD4 lymphocytes which were
responsible for defending the body against certain infections.
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In 1984, tests to detect antibodies to the virus were developed
and by 1988, the World Health Organisation estimated that 510 million people in 138 countries were HIV-positive.
36 million HIV positive 2000
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IDS may not be a new disease. The
HIV virus probably long possessed its
own niche in the African rain forests.
The opening up of isolated areas to
economic exploitation, population
migrations, travel and tourism may
have flushed it out into a defenceless
world. Some experts consider that it
may not be a coincidence that AIDS
appeared in Africa at the same time
that the World Health Organisation was
eradicating smallpox. ‘During the
1970s members of the WHO were
vaccinating young people in central
Africa with live smallpox vaccine, reusing needles 40 to 60 times. Live
vaccines directly provoke the immune
system, and can awaken sleeping
giants such as viruses'.