PLAGUES IN HISTORY OF MEDICINE AND PUBLIC HEALTH

1. PLAGUES IN HISTORY OF MEDICINE AND PUBLIC HEALTH December 20, 2010

2. Plague of Athens kills a third of the population c. 425Plague of Justinian kills 25% of population c. 542 • 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.

3. 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 (431-404 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.

4. Tuberculosis - scrofula, the King's Evil Europe's monarchs begintouching for the 'King's Evil'1254 • 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 years. At his coronation in 1722, *Louis XV (1715-1774) of France touched more than 2000 sufferers. • Mary I (1516-1558) touching the neck of a boy for scrofula.

5. Robert the Bruce falls victimto leprosy 1339 • 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 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 in-patient at the Edinburgh Infirmary. In 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.

6. 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.

7. Black Death kills a quarterof Europe's population1348 • 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'.

8. Syphilis first described in Europe 1495 •  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.

9. Syphilis - the spread through Europe • 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.

10. Old and New Worldsexchange diseasesc. 1520 •  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'.

11. 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.

12. Great Plague of London kills20% of the population1665 • 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 eye-holes were covered with glass.

13. Yellow fever in Philadelphiakills 10% of the population1793 • 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. ‘

14. Edward Jenner developssmallpox vaccine1796 •  This painting was almost certainly inspired by Jenner's vaccination of his young son.

15. John Snow stops choleraepidemic1854 • 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. • ‘... 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 poverty-stricken courts and alleys of towns and cities.

16. Prince Albert dies of typhoid 1861 • 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.

17. 30% of deaths in Englandand Wales caused by eightinfectious diseasesc. 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. • 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 from 9.14 to 13.77.

18. Measles in Fiji 1875 • 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'.

19. Koch discovers TB bacillus 1882 • 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'.

20. Koch was awarded a Nobel Prize in 1905. • In 1882, the German bacteriologist, Robert Koch (1843-1910), 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.

21. Pasteur inoculates withrabies vaccine1885 • 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.

22. Ross blame onmosquitomalaria development 1897 • 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 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

23. TB still a major cause ofdeathc. 1900 • 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. • 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 1879-1901, supposedly allowed the ingress of air and particularly light which killed the tuberculosis bacilli.

24. Princess of Wales donates Finsen lamp to the LondonHospital 1900 • Tuberculosis - the Lamps of HopeDuring 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. • Patients undergoing treatment for lupus vulgaris.

25. 'Typhoid Mary' 1915 • 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. • 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.

26. Spanish 'flu kills 30 millionpeople worldwide1918 • With the words, ‘A-TICH-OO!! 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.

27. Poliomyelitis - the `Iron Lung' • 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 1933-1934.

28. 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.

29. Nuffield builds 'iron lungs' 1938 • 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.

30. Smallpox eradicated 1979 • 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.

31. HIV virus described 1983 • 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. • In 1984, tests to detect antibodies to the virus were developed and by 1988, the World Health Organisation estimated that 5-10 million people in 138 countries were HIV-positive.

32. 36 million HIV positive 2000 • 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, re-using needles 40 to 60 times. Live vaccines directly provoke the immune system, and can awaken sleeping giants such as viruses'.