As we have already seen, each epidemic occurs in a specific time and place, engenders a human response that is both individual and societal, creates tension and drama, uncovers structural vulnerabilities, and often unleashes scapegoating and recrimination.
In short, epidemics are “social, political, philosophical, medical and above all ecological.” They are also narratives – with a beginning, middle and end, and a range of heroes and villains, both human and microbial.
Environment and context matter when considering the interface between disease causing microbes and humans. This session is intended to emphasize this point, and focuses mainly on human advances during the 19th century, especially in a young, struggling nation – the United States.
Several points bear highlighting:
1. Microbial pressures have been synonymous with fear, flight, and a breakdown of societal order.
2. Progress in science, engineering, and urban planning ushered in a new era.
3. Social reformers, philosophers and theologians advanced the connection between cleanliness and godliness.
4. Economists sold an additional benefit – increased human productivity.
The end of the 18th century, and much of the 19th century in this growing experiment in self-governance, was marked by confusion, suffering, inequality, and ignorance. And yet, it also laid the grounding for our future as a nation. As Professor Jim Secord of the University of Cambridge wrote recently, “When we think about the past, we think about history. When we think about the future, we think about science. Science builds upon the past, but also simultaneously denies it.”
What is equally obvious is that disease brings out the best and the worst in human leadership and our human natures. In many ways, the disease events throughout history have created the caring professions as well as structural responses in modern evolving city centers to make them safer and less disease prone. Leading these scientific advances are a wide range of personalities, some of whom we’ll discuss in this session. Equally, we will encounter populations systematically denied care and some suffering wide ranging acts of cruelty that disadvantage their human potential to this day.
The fleeing white plantation owners from the island of Saint Dominique, numbering in the thousands, had been left with few options in the late 1700’s. If they remained in Saint Dominque, they would be hunted down by rebels, and if they tried to return to France, they would be guillotined as part of the French Revolution. Philadelphia, a thriving port city at the timer, appeared the safest choice. The 2000 or so new immigrants carried with them hastily gathered belongings and one unwelcome guest, mosquitoes carrying the Yellow Fever causing flavivirus.
When Yellow Fever broke out in 1793 shortly after the arrival of a trading ship from Saint-Dominque in Philadelphia, the colonists had no immunity. Most houses were within 7 blocks of the port. They city fathers imposed a quarantine of 3 weeks on the city but were unable to enforce it. By September 20,000 had fled including George Washington who headed for Mount Vernon, and Alexander Hamilton and his wife who evacuated to New York. Between August 10, 1793 and November 9, 1793, 5000 citizens perished, roughly 10% of the population.
It is useful to remember the state of medicine at the time. It was sourced from 18th Century England. British physicians understanding of human physiology and pathophysiology was primitive. Operations were brutal and overseen by surgeon/butchers. And perhaps the most sophisticated and learned professionals of the day were the apothecary chemists.
Philadelphia “experts” were at a loss to explain the cause of the sudden outbreak of disease, and were even more confused how to treat it. The colonies had in total some 200 physicians of varying skills with actual degrees, the very beginnings of hospitals, and no formal system of training for either doctors or nurses. The city at the time harbored two branches of medicine – the Heroics and the Homeopaths.
Benjamin Rush led the Heroic branch of Medicine, believing the problem they now encountered involved a disturbance of the four humors – blood, phlegm, black bile and yellow bile. His solution was the rather liberal and barbaric use of cathartics and blood letting. For the most severe cases, Rush set up the first “fever hospital” in the new nation, the Pennsylvania Hospital, whose primary initial purpose was to house the insane.
Publicity seeking Benjamin Rush published a timely pamphlet with advice for the public on how best to address the crisis. He wrote, “I have found bleeding to be useful, not only in cases where the pulse was full and quick, but where it was slow and tense. I consider in tepidity in the use of the lancet, at present, to be necessary, as it is the user of mercury and jalap in this insidious and ferocious disease.”
His intellectual opponent was the father of Homeopathic Medicine, Samuel Hahnemann. His guiding principle was that “likes are cured by likes.” This translated into delivering primitive pharmaceuticals to suffering patients that would cause a milder version of the symptoms than those they were currently suffering. In the body’s response, he reasoned, would come a kinder and gentler cure than what Rush was proposing.
Samuel Hahnemann, later remembered as the namesake of Hahnemann Medical College, established in 1848, challenged Rush directly. He was aghast at the Heroic’s assaults on human life and limb. He wrote, “My sense of duty would not easily allow me to treat the unknown pathological state of my suffering brethren with these unknown medicines. The thought of becoming, in this way, a murderer or malefactor towards the life of my fellow human beings was most terrible to me.”
But neither doctor was especially successful in halting the 1793 catastrophe, let alone explaining its cause. Expounding on their theories, each became famous, and ignited a 150 year struggle between the two branches. But the identification of the cause of the epidemic was still a century away.
The Heroics descendants ultimately launched the American Medical Association in 1847, with the American Homeopathic Society arriving a few years earlier in 1844. The Homeopaths would in time launch 100 hospitals, 22 Medical Schools, and create 15,000 practitioners who cared for 15% of the U.S. population at their peek. It would take nearly a century more for the AMA to eliminate its competitor.
A third competitor, the American Osteopathic Association, fared better. Their brand of Medicine, anchored in hands-on manipulation, survived by finally drawing a truce from the AMA in 1964 which involved the AMA admitting that the D.O. (Doctor of Osteopathy) degree was equivalent to their M.D. designation.
But in the first half of the 19th century, marked by a practice of westward spreading Manifest Destiny, ignorance, and extreme cruelty, daily survival displaced any thoughts of human longevity. The sheer size of the geographic expansion was dramatic, as one after another European nations between 1810 and 1848 signed off on treaties and sales, usually at bargain basement prices. These occurred under the pressure of forced conquest, dislocation, disease, famine, death and suffering. This was especially true for Native American populations, which largely suffered the same fate as natives to the south had since 1492.
Brutality in the ever-expanding new country was codified without apology. The 1980 Indian Removal Act directed “The forced relocation of all Native peoples east of the Mississippi River to ‘Indian Territory’ – the future Oklahoma and Kansas.” A map of Georgia in 1831, documents what the native Americans (in part) were forced to forfeit. Here were 4,365,054 acres, controlled by the Cherokees, described as “with many rich gold mines & many delightful situations & though in some parts mountainous, some of the richest land belonging to the state.”
Yellow Fever was just one of many diseases that migrated northward after the Columbian Exchange. The one best documented by the native peoples because of the associated disfigurement was smallpox. As one Aztec wrote, “There spread over the people a great destruction of men. [Pustules] were spread everywhere, on one’s face, on one’s head, on ones breast. There was indeed perishing, many indeed died of it…and many just died of hunger. There was death from hunger. There was no one to take care of another. There was no one to attend to another.”
In North America, European domestic animals once again were effective microbe transporters. Cattle and horses arrived in Virginia in 1620 and in Massachusetts in 1629. By the early 1630’s, smallpox had resulted in the mass extermination of Algonquin’s in Massachusetts. As early as 1580, there is documentation of Native Americans adjacent to the Virginia colony at Roanoke “beginning to die quickly…the disease so strange that they neither knew what it was, nor how to cure it.” As with South America, loss of adult caregivers extended the killing rate. As reported from the Plymouth colony, colonists and Native Americans “fell down so generally of this disease as they were in the end not able to help one another, no not to make a fire nor fetch a little water to drink, nor any to bury the dead.”
Natives in the ever expanding America were less fortunate. As European settlers and their domesticated animals encountered native tribes, violent dilocation and companion disease were widespread. In 1728, it was the Cherokee’s. In 1759, the Catawbas. In 1800, 2/3 of the Omahas perished. In 1838, the entire Mandan tribe and half of the peoples of the High Plains disappeared.
The imperial assault on Native Americans followed a similar pattern as with their neighbors to the south. The difference was the length of the engagement, which lasted several centuries, and arguably persists to this day, as evidenced by marked health disparities in Native Americans. The well documented Trail of Tears with forced relocation of Cherokees in 1838 from Georgia carried with it a 25% mortality not only from epidemic dysentery but also a range of communicable diseases like whooping cough caused by the respiratory bacteria, Bordetella pertussis, transmitted by coughing or sneezing.
The fate of our native American populations, attributed to the “virgin-soil epidemic” hypothesis, as it was laid out by historian Jared Diamond in his epic book, “Guns, Germs, and Steel” is too simple a narrative for some academicians. Critics admit that disease in native American populations was rampant for certain, and that they appeared especially susceptible to a wide range of infections, but that this notion of what some label as “genetic inferiority” glosses over the full, contextual story.
As University of Oregon historian, Jeffrey Ostler, challenges, “Although the virgin-soil-epidemic hypothesis may have been well intentioned, its focus on the brief, if horrific, moment of initial contact consigns disease safely to the distant past and provides colonizers with an alibi. Indigenous communities are fighting more than a virus.” Ostler tracked the fate of the Sauks and Mesquakies from Western Illinois to Oklahoma. It resulted in a staggering 85% mortality rate as a result of migration, dislocation, starvation, exposure, and yes disease in extremely susceptible and compromised men, women, and children.
The Trail of Tears in 1838, the forced relation of Cherokees, some 800 miles due west from Georgia, over eight months, with a mortality rate of 25%, is known to most and memorialized in paintings. But it is not atypical of the fate of other tribes at the time. A partial list of other tribes includes Creeks, Seminoles, Chickasaws, Choctaws, Senecas, Wyandots, Potawatomis, Sauks and Mesquakies, Ojibwes, Ottawas, Miamis, Kickapoos, Poncas, Modocs, Kalapuyas, and Takelmas.
As Ostler sees it, the impact has been lasting. “Native Americans are contending with the ongoing legacy of centuries of violence and dispossession… Countering the invisibility of Native peoples, of course, means greater awareness of how COVID-19 is affecting them and enhanced efforts to provide resources to help them combat the current outbreak…” One need only view the mortality rates from COVID-19 between 2020 and 2022, for documentation. Native Americans mortality rates were the highest measured at 552 per 100,000. This compares with 269/100,000 in Whites, 442/100,000 in Blacks, 466/100,000 in Hispanics, and 197/100,000 in Asians in America.
As long-term genocide was codified and practiced through slavery of Blacks and forced native relocation in this still young nation, science and technology was beginning to take hold. Immigration to the United States was steadily gaining steam, especially in the second half of the 19th century. Travel from Britain and the entire northern and western regions of Europe outpaced all other. In the last three decades of the century, nearly 8 million Europeans from this region relocated to the United States. In the scientific realm, physicians were not always in the lead. Arguably it was the pharmacists or apothecaries that were most aggressive. They achieved free-standing status with the Pharmacy Act of 1852. While Parliament rejected the request to grant pharmacists the exclusive right to sell medicines and poisons, they did endorse a registry of pharmacists that required prior selection by the national Pharmaceutical Society for individual entry into the profession.
To say that these scientific small business people were entrepreneurial somewhat understates their aggressiveness. For example, the Birkenshaw Pharmacy in Yorkshire in 1850, advertised 534 proprietary secret formulas including 316 medicinals, 69 cosmetic, 68 veterinarian, and 81 “domestic.” Their energy and product lines quickly crossed the Atlantic and back again, sowing the seeds for the future American pharmaceutical industry. The first wave of wholesalers were a mixed brood including a fair share of bogus offerings like Wm. Radams microbe killers, and Dr. Williams Pink Pills for just about everything. But they also included Colonel Eli Lilly who settled in Indiana and Charles Pfizer who set out his shingle in Brooklyn, NY.
The 1850’s in England also witnessed the rise of Florence Nightingale, whose participation and publication of activities in the Crimean War launched nursing as a profession and established her worldwide fame. Her lasting contribution, beyond Nursing, was a multi-decade campaign on behalf of structural changes and behavioral modifications that would promote societal sanitation.
Order had always been part of Florence Nightingale’s life. Her father was William Edward Shore, a Country Squire, who at age 21 inherited his rich uncle’s huge fortune as well as his name. On his death, the younger (now) Nightingale, seamlessly managed the profits of the family’s lead smelting business, as well as, not one, but two named estates – the 1300 acre Lea Hurst in Derbyshire, and the even more impressive 80 bedroom estate at Embry Park in Hampshire.
He and his wife had two daughters, each named after the Italian cities where they were born while vacationing. Parthenope carried the early Greek name for Naples, and Florence arrived one year later 300 miles north. The family was well connected with members of Parliament, none closer than Baron Sidney Herbert. It was he who the family turned to for reassurance and guidance when Florence declared at age 16 that her life’s work would be nursing the sick and ill in the service of the Lord.
This was quite a surprise to her father who had taken special care to see that she was classically trained in Greek, Latin, French, German, Philosophy, Mathematics and Religion. But in Florence’s words, she “craved for some regular occupation, for something worth doing instead of frittering away time on useless trifles.” To do so, she was willing to decline suitors and her mother and older sister’s life of comfort and philanthropy. Parthenope was unimpressed, making it clear that “She is ambitious—very, and would like…to regenerate the world.” In comparing the two sisters, a biographer put it this way, “Both sisters were trapped in a gilded cage growing up, but only Florence broke out of it.”
Sidney Herbert was willing to support the strong willed woman, 10 years his younger, carrying her along on fact-finding trips to Egypt and beyond. None of it shook her commitment. Her intent was clear when she noted in her diary, “On February 7, 1837, God spoke to me and called me to his service.” The calling was specific – nursing the ill in institutional settings. As luck would have it, her goal aligned well with the voluntary efforts of Sidney’s wife, the Lady Elizabeth Mary Herbert, and she became the first woman Superintendent of a small 20-bed hospital.
Queen Victoria assumed the throne of England following her Uncle’s death just 4 months after Florence’s religious awakening. The two were born exactly 1 year and 12 days apart. Both the young Queen and her husband, Albert, were military enthusiasts, and saw themselves as active participants in the nation’s armed conflicts. In September, 1854, they had a front row seat in a simmering conflict between the Ottoman Empire and Russia that became the Crimean War. Britain and France had thought they had brokered a deal between the two primary combatants when the truce fell apart
Russian Emperor, Nicholas I, had ordered the invasion of what is now current day Romania in July of 1853. By January, 1854, the British and French fleets had entered the Black Sea, and the war was on. Britain’s Prime Minister, Lord Palmerston, suggested the effort was preventive. As he said in words that ring true today, “The main and real object of the war is to curb the aggressive ambition of Russia.”
Military historians would later document: “The Crimean War is largely forgotten now, but its impact was momentous. It killed 900,000 combatants; introduced artillery and modern war correspondents to conflict zones; strengthened the British Empire; weakened Russia; and cast Crimea as a pawn among the great powers.”
At the time, Queen Victoria leaned heavily on her new Secretary of War, Sidney Herbert, and Florence Nightingale saw a once in a lifetime opportunity for clinical experience and seized it. She and the 38 nurses in her charge arrived at Barrack Hospital at Scutari, outside modern day Istanbul, ill prepared for the disaster that awaited them. Cholera, dysentery and frostbite – rather than battle wounds – were rampant in the cold, damp, and filthy halls. During that first winter, 42% of her patients perished, leaving over 4000 dead, the vast majority absent any battle wounds. Florence later described her work setting as “slaughter houses.” Their enemy wasn’t bullets or bayonets, but disease -typhus, cholera and typhoid fever. Over 16,000 British soldiers died, 13,000 from disease.
Nightingale’s initial assessment was that warmer clothing and food would stem the tide. Going over the heads of medical leadership, she did what she could, and leaked details of what she was observing to Herbert and journalists who, for the first time, were stationed within the war zone. In the process, she became a celebrity in her own right, and as Spring of 1955 approached, a Sanitary Commission was sent to the war zone and Victoria and Albert themselves, with two of their children, visited the area.
Famed artist Jerry Barrett made hasty sketches of what would become The Mission of Mercy: Florence Nightingale, which hangs to this day in the National Gallery in London. During this same period, the first lines of Henry Wadsworth Longfellow’s poem, Santa Filomena, would take shape, including “Lo! In that house of misery, A lady with a lamp I see, Pass through the glimmering of gloom, And flit from room to room.” And the legend of Nightingale, the actual “Lady of the Lamp”, appeared on the front page of the Illustrated London News complete with etched images.
It read: “She is a ministering angel without any exaggeration in these hospitals, and as her slender form glides gently along each corridor, every poor fellow’s face softens with gratitude at the sight of her.”
What became clear to Florence and others was that infection and lack of sanitation were the culprits, and corrective actions on the facilities themselves, along with sanitary practices that Nightingale led, caused the subsequent mortality rates to drop to 2%.
By the time the war drew to a halt in February, 1856, 900,000 men had died. Florence Nightingale remained for four more months, arriving home without fanfare on July 15, 1856. Her older sister recalled how she arrived, “…“like a bird, so quietly no one found her out.” Yet, in truth thanks to the first ever war correspondents, she was now the 2nd most famous woman in Britain, after Queen Victoria. While she was away, the Herberts raised money from rich friends. The Nightingale Fund now had 44,000 pounds in reserve. These would help fund a hospital training school and her famous book, “Notes on Nursing” in future years.
Though her re-entry was quiet and reserved, she had plenty to say, and committed most of it to writing. Working closely with Britain’s top statistician, William Farr, she documented in dramatic form, the deadly toll in Crimea and tied it to disease and lack of sanitation in “Notes Affecting the Health, Efficiency, and Hospital Administration of the British Army”, which she self-published and aggressively distributed. Illustrated with spin wheel designs divided into 12 sectors, each one representing a month, she graphically tied improved sanitation to plummeting death rates. Understanding their long-term value, she carefully approved the paper, ink, and process that have allowed these images to remain vibrant a century and a half later. As she said later with some cynicism, they were “designed ‘to affect thro’ the Eyes what we may fail to convey to the brains of the public through their word-proof ears.”
In that first year of her return, she was described as “a one woman pressure group and think tank…using statistics to understand how the world worked was to understand the mind of God.”
Meanwhile, the Herbert’s continued fund raising on her behalf was more than enough to support establishing a hospital and nursing training school that would bear her name. It opened on the Thames at St. Thomas Hospital, in the shadow of the Houses of Parliament. In modern times, the work of the Herbert’s and Nightingale is viewed by some as foundational. As one biographer claimed: “…the pioneering National Health Service was born on the floor of the Scutari Barrack Hospital.”
Nightingale was a crusader for this new profession intended “to promote the honest employment, the decent maintenance and provision, to protect and restrain, to elevate in purifying…a number…of poor and virtuous women,” As for content, by 1860, her “Notes for Nursing” was published, selling 15,000 copies in first two months. It purposefully championed sanitation (“the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet”) and promoted cleanliness as a path to godliness. It targeted “everywoman” while launching professional nursing. At the time two-thirds of the nurses in Britain were employed in private homes. Half were 19 years of age or younger.
She was not the originator of the Sanitary Movement in Dirty Old London. That honor goes to one Edwin Chadwick, a barrister who in 1848, who published his “Report on the Sanitary Condition of the Laboring Population of Great Britain.” As historians and commentators have noted, there was a good case to be made for cleanliness. Here are a few of those remarks:
“The social conditions that Chadwick laid bare mapped perfectly onto the geography of epidemic disease…filth caused poverty, and not the reverse.”
“Filthy living conditions and ill health demoralized workers, leading them to seek solace and escape at the alehouse. There they spent their wages, neglected their families, abandoned church, and descended into lives of recklessness, improvidence, and vice.”
“The results were poverty and social tensions…Cleanliness, therefore, exercised a civilizing, even Christianizing, function.”
As the saying goes, where there is a will, there is a way. But the Sanitary Movement required population wide participation, structural change, new technology, and effect story telling. When George Jennings patented the first toilet, as a replacement for soil pots, hand transported each mornings and emptied in an outhouse if you were lucky, or in the streets if not, its’ future was anything but assured. But, by good luck, the Great Exhibition (the premier display of futuristic visionaries) was scheduled for London in 1851. The Crystal Place exhibition was the show stopper, attracting a wide range of imagineers, but none more enthusiastic that Thomas Crapper. Jennings was already green-lighted for public urinals at the event, but it was Crapper (whose name there after would be tied to the toilet and its special passenger) who carried the narrative.
By then, Sir William Harvey’s description of the human circulatory system in 1628, complete with pump, outlet channels, and return venous channels, was well understood by most. Seizing on the analogy, Crapper, along with city engineers of the day, imagined an underground highway of pipes, to and from every building and home, whose branches, connected to sinks and toilets at the end of each branch, would carry clean safe water one way, and human refuse the other. This combined with Nightingale’s emphasis on fastidious housekeeping, and cleanliness in hospitals, enforced by nurses with religious zeal, would change the world. And it did. But those same changes would take decades to reach crowded immigrant entry points in locations like New York City.
On both sides of the pond, women and children remained especially vulnerable. Florence Nightingale took up the cause of sex workers in Britain in 1964. The Parliament had passed laws, in an attempt to conquer a massive breakout of venereal disease among the military, allowing the involuntary examination of suspect women and imprisonment for mandatory treatment in specific areas near military compounds. Not surprisingly, this spread from one location nearly country wide over a two decade period, and from 3 month confinement to 1 year, with horrid under-staffing and prison like deprivation. With the aid of Nightingale, the laws were finally repealed in 1886.
American women and children fared even worse. In the rapidly expanding and lawless nation, women had no vote, no safety, no security, no rights, no justice, and (more often than not) no health for themselves or their children.
In the mid-1800’s, our nation had more pressing concerns. The original sin of slavery predictably led to the Civil War. It ultimately claimed 620,000 lives. Little known is that 2/3 of those deaths were not the result of war time injuries but rather were staggering losses from epidemic diseases in the field including malaria, cholera, typhus, smallpox, typhoid, yellow fever and more. To keep men on the battle field, 10 million doses of opioids were dispensed during the war, leaving over a half million veterans to struggle and die from opioid addiction in the years that followed.
Progress was uneven scientifically. During this period Colonel Eli Lilly and Charles Pfizer appeared on the scene, and launched their business. Also the expansion of rail lines westward was nothing short of amazing. But Yellow Fever continued to rage in certain locales, and its cause was a mystery that would elude scientists until late in the 18th century, but eventually would be solved as “an outcome of global interaction, conflict, and exchange.” In the meantime, outbreaks of the viral disease had continued to haunt American cities. 730 died in New York City in 1795. 5000 perished in Boston, New York and Philadelphia in 1798. Baltimore suffered 1,200 casualties in 1800. More than 8000 died in New Orleans in 1853. 2000 were lost in Norfolk in 1855, and 20,000 died in the Mississippi Valley in 1878.
Finally in 1898, when an outbreak left hundreds dead in Cuba, the U.S. Army established the Yellow Fever Board led by Walter Reed. This was a full 12 years after Cuban scientist, Carlos Finlay, presented a paper, “The Mosquito Hypothetically considered as the Transmitting Agent of Yellow Fever” to the Havana Academy of Science, and was widely ridiculed. It took two decades, and the work of Walter Reed’s team, to confirm Finlay’s observations, and 25 years before the offending microbe, a virus, was confirmed. As for a cure, the vaccine to prevent Yellow Fever was finally created in 1930 by Harvard virologist, Max Theiler, and earned him a Nobel Prize.
But as modern day Yale historian Frank Snowden reminds us “We must avoid the pitfall of believing the driver of scientific knowledge is ever a single genius working alone.” Those words especially apply to the evolution of the Germ Theory and the emergence and synergy of three brilliant scientists – Louis Pasteur, Robert Koch and Joseph Lister.
As historians have noted, “The life saving ‘Germ Theory’ was the work product of complimentary insights and serial incremental progress.” Let’s begin with Louis Pasteur (1822-1895). He was a chemist with a sharp eye and an active mind. He was also an entrepreneur who had been hired to solve a problem that local wine makers had with early spoilage of their harvested beverage. The tools he employed were primitive by today’s standards, most notable a simple observational microscope. With it, he was able to identify microbes that he theorized were accelerating putrefaction of the grapes and spoiling the wine. Through a series of observational, trial and error experiments, he established that heating the liquid killed the microbes and halted the product’s degradation.
Pasteur took his experiments one step further, tying the observed microbes to diseases, and developing a commercial process of serial attenuation of the disease which allowed the defanged microbes to be safely inoculated into humans and trigger future protective immune reactions.
Robert Koch (1843-1910) was a physician who was 20 years younger than Pasteur but worked as a contemporary. While studying Anthrax at the University of Gottingen, he visualized the large causative bacteria, isolated it, and then reintroduced it into a lab animal who developed the disease. Going the extra yard, he observed that the bacteria produced spores, found the same spores in the animals grazing fields, and proved that eating grass laden with spores resulted in Anthrax in the animals.
Using the same investigative zeal, he subsequently uncovered the source of tuberculosis. But his most lasting contribution to science was not a single disease causing microbe, but rather a scientific 4-step approach to proving causality.
- The microorganism must be found in abundance in all organisms suffering from the disease, but should not be found in healthy organisms.
- The cultured microorganism should cause disease when introduced into a healthy organism.
- The microorganism must be isolated from a diseased organism and grown in pure culture.
- The microorganism must be re-isolated from the inoculated, diseased experimental host and identified as being identical to the original specific causative agent.
The third member of the “Famous Trio” was Joseph Lister (1827-1912). Lister was a professor of surgery at Edinburgh, Scotland. Thanks to the development of ether and nitrous oxide in the 1840’s, pain management intra-operatively was by then under partial control. Improvements in operatives tools and techniques also decreased the likelihood of bleeding to death. But post-operative infection remained a persistent and deadly threat.
Lister recognized, while viewing the work of Pasteur and Koch, that the likely cause was intra-operative contamination by microbes. Taking a multi-faceted approach, he employed hand washing, sterilization of tools, and spraying the skin of patients prior to incision with carbolic acid. Gowns, gloves and masks soon followed, and with each step, infection rates declined dramatically.
While surgical theaters were cleaning up their acts, the same could not be said for major American urban environments. New York City was suffering under the influx of immigrants arriving from all shores. In 1800, the city housed only 30,000 residents. A century later, it teemed with 4 million, and a seriously flawed sanitary infrastructure.
One historian described it this way, “As New York City ascended from a small seaport to an international city in the 1899’s, it underwent severe growing pains. Filth, disease, and disorder ravaged the city to a degree that would horrify even the most jaded modern urban developer.”
One of the prime offenders was the noble work horse. By 1900, on the eve of wholesale arrival of motor cars, there were roughly 200,000 horses in New York City, carrying and transporting humans, and products of every size and shape, day and night along the warn down cobble stone narrow roads and alley ways.
It was a hard life for the horse, who’s lifespan on average was only 2 1/2 years. They were literally “worked to death.” In the 1800’s, 15,000 dead horses were carted away in a single year. Often, they were left to rot in the street because they were too heavy to transport. If they weren’t dying, the horses were producing manure – a startling 5 million pounds dumped on city streets each day.
As for human waste, sewer construction didn’t begin in New York until 1849, this in response to a major cholera outbreak. Clean water had arrived seven years earlier with the arrival Croton Aqueduct carrying water south from Westchester County. This was augmented with rooftop water tanks beginning in 1880. By 1902, most of the city had sewage service including the majority of the tenement houses. The Tenement Act of 1901 had required that each unit have at least one “water closet.”
As for the horses, the arrival of automobiles almost eliminated the “horse problem” overnight. Not so for cows, or more specifically the disease laden “swill milk” cows. Suppliers north of the city struggled to keep up with demand in the late 1800’s. To lower production costs, they fed their cows the cast off “swill” of local alcohol distilleries. This led to infections and a range of diseases in the bargain basement beverage sold primarily to at-risk parents and consumed by children.
Swill milk was the chief culprit in soaring infant mortality in New York City between 1880 and 2000. Annually there were some 150,000 cases of diphtheria, resulting in 15,000 deaths a year. A Swiss scientist, Edwin Krebs, identified the causative bacteria, Corynebacterium diphtheriae, in 1883. A decade later, a German scientist, Emil von Behring, dubbed the “Saviour of Children” developed an anti-toxin to diphtheria and was awarded the Nobel Prize in 1901for the achievement.
As Paul DeKruif wrote in his 1926 book, The Microbe Hunters, “The wards of the hospitals for sick children were melancholy with a forlorn wailing; there were gurgling coughs foretelling suffocation; on the sad rows of narrow beds were white pillows framing small faces blue with the strangling grip of an unknown hand.”
One such victim was the only child of two physicians, Abraham and Mary Putnam Jacobi whose 7 year old son, Ernst, was claimed by the disease in 1883. Working with philathroper, Nathan Straus, the Jacobi’s established pasteurized milk centers in the city which coincided with a 70% decline in infant mortality from diphtheria, tuberculosis and a range of other infectious diseases. By 1902, the horses hero status was reclaimed as it became the source of diphtheria and tetanus anti-toxins. The bacteria were injected into the horses, and after a number of passes, serum collected from the horse was laden with protective anti-toxins, relatively safe for human use. In 1901 alone, New York City purchased and delivered 25,000 does of ant-toxin funded by the Red Cross and the Metropolitan Life Insurance Company.
Distribution of life saving anti-toxins remained a challenge in less populated areas of the nation. For example, an outbreak in Nome, Alaska, in 1925, occurred after the source city, Anchorage, 674 miles away, was frozen in, making transport impossible. The mayors of Nome and Anchorage organized 20 dog teams to tag-team and deliver the life saving doses in record time. The feat is now commemorated each year, by retracing the long and arduous route, in the Iditarod Dog Race. The dog that led the final leg of the original 1925 mission, “Balto”, is remembered still with a commemorative statue in New York City’s Central Park.
But the battles with epidemics at the turn of the century were not always this harmonious. Next week we will consider the case of a Methodist Pastor, Henning Jacobson, and his son. They lived in Boston, Massachusetts, where, in 1905, an outbreak of Smallpox, caused the governor of the state to mandate that all citizens be inoculated with the Smallpox vaccine or pay a fine. Jacobson refused, stating that he had had a bad reaction to previous inoculations. The case went all the way to the Supreme Court – twice. We’ll pick up that story line and delve more into Smallpox next week.