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Disease: The Deadliest Horseman of the Apocalypse (and Daily Life)

  • Epidemics have destroyed populations and significantly altered economic, social, intellectual and political aspects of life.
  • Behold, a pale horse and its rider’s name was Death, and Hades followed him; and they were given power over a fourth of the earth, to kill with sword and with famine and with pestilence. (Revelations 6:8)

The Plague of Athens (c. 430 BC)

  • Panic and breakdown of social order typify human reactions to epidemic illness. The Greek historian Thucydides, in his History of the Peloponnesian War tells how a lethal contagious disease afflicted the Athenians while Spartans laid siege to their city. The symptoms included fever, painful skin rash, and great thirst. No treatment was effective. Physicians, who were quickly exposed to many cases, died first; even birds and animals were killed. Opinion on the origin of the disease was divided. One rumor held that it came from Africa, but some thought that it was new, stemming from starvation and the strife of war. Still others said that the Spartans had poisoned Athen’s wells. Religious people were convinced that it was divine punishment for the people’s sins. However, oracles and priests were no better than doctors at relieving the suffering.
  • Modern historians and doctors have been intrigued by the plague of Athens. They have tried to discover the precise retrospective diagnosis—contenders include smallpox, typhus and even anthrax. Recent articles have argued that it was toxic shock syndrome, legionnaires’ disease, AIDS and Ebola fever. However, the danger is applying a modern diagnosis to the plague.
  • The importance of this event was that the disease resulted in the decay of social structures, rampant crime, and the abandonment of codes of behavior.

Medieval Engraving: “The Plague Kills Both Man and Beast”

The Black Death: Transforming the West

  • The most famous epidemic in Western history was the 14th century bubonic plague of Europe. Known at the time as the “Great Dying”, it was given its gothic name, the Black Death, in 1832 by the German physician-historian J.F.C. Hecker. Earlier outbreaks of plague had occurred, including one during the reign of the Byzantine Emperor Justinian in the 6th century A.D.
  • According to witnesses, the European plague traveled from Asia in ships and began with the arrival of Genoese vessels at the Sicilian port of Messina in October 1347. From there the disease marched north, fanning across Europe to reach Moscow by 1351. The symptoms were fever, swollen and oozing nodes (buboes), dehydration, and death.
  • During the Black Death, people abandoned their urban homes to wander the countryside, and sick family members were left to die. Corpses were shunned, and officials forced criminals to heap bodies into mass graves.
  • In the 14th century, many hypotheses for the cause of plague were expounded, including: atmospheric changes that resulted from a rare conjunction of planets in the constellation Aquarius in March 1345. Others saw it as divine punishment for the corruption of priests. Others blamed minorities (Jews), strangers and travelers. Many doctors fled, and those who stayed wore strange protective clothing (gowns, gloves and beaks). Some cities implemented quarantine measures to stop the plague, and others placed infected people and their families under house arrest.
  • One quarter to one third of Europe died. Pesthouses were built. Governments became more interested in public health. The lack of peasant labor resulted in the end of the old feudal order.

Plague Riding Through Europe Harvesting the Dead

The Plague in Early Modern Europe (London 1665)

  • The 1664-5 outbreak of plague in London killed between 75,000 and 100,000 people, at least 20% of the city’s population. It was thought that the disease was introduced to England by Dutch merchants who brought it to London in bales of cotton. It had been in Leiden and Amsterdam over the previous decade.
  • Those attacked by the plague became suddenly delerious, rolling around as if intoxicated, and then perspiring profusely. The poor of London, in their crowded, ill-kept, wooden houses, were especially threatened by contagion. In December 1663, and then again in March 1664, bright comets appeared in the skies, and many believed that they were signs from God of imminent punishment. During the winter of 1664-5 there were reports of several deaths from plague, but because the winter was cold, the disease was checked from spreading too rapidly. By the spring and summer months, as the temperature rose, so too did the number of cases of plague.
  • In London it supposedly started in the slums of St. Giles-in-the-Fields—an outer parish of the city. The disease then spread to Westerminster and the southern parishes by early July. King Charles II and his court (along with most physicians, and other wealthy professionals) fled London and moved to Oxford. Most shops and businesses closed for the summer of 1665 as the death toll grew to almost 1000 per week. By August 2000 were dying each week, and by September it was over 7000. Whole families were killed.
  • To cope with the dead huge plague pits were dug. The authorities ordered fires to be burning 24-7 in the city’s streets to ‘purify’ the air. Tobacco smoking was recommended as protection, and even children were forced to smoke! By the late fall the worse had past, but the plague only finally ended with the Great Fire in London of 2-5 September 1666.

“Gathering the Dead”, the Plague in London, 1665

The Plague Race in Hong Kong

  • Part of the Third Plague Pandemic, the 1894 outbreak in Hong Kong spurred international research leading to the discovery of the plague bacillus and to the eventual understanding of its mode of dissemination.
  • It originated in Yunnan Province in southern China, and spread to neighboring Guangzhou and the city of Canton in March 1894, where it killed 60,000 people in the port city in a few weeks. From here it made the short journey to the British outpost of Hong Kong where it spread among the residents of the city’s crowded slums of Taipingshan.
  • Terrified that the disease would spread throughout Asia along ocean trading routes, research teams were dispatched to Hong Kong. The Swiss-born bacteriologist, Alexander Yersin (of the Pasteur Institute in Indo-China), and the Japanese scientist Kitasato Shibasaburo (trained by Robert Koch) independently discovered the plague bacillus—Kitasato originally received credit, but the contagion, is now called Yersinia pestis.
  • Afterwards, other researchers established the role of the flea in transmitting the disease from rodents (who are its natural reservoir) to humans.

Kitasato Shibasaburo [Above]; and Alexander Yersin in Bamboo Laboratory [Below]

Smallpox and Medicine from the East: Efforts for Change by Lady Montagu

  • The acute viral form of the disease was transmitted through droplet infection, and variola major had a mortality rate of 25-30%, while the less potent variola minor usually did not result in death. Smallpox was one of the most feared diseases of the period, not only because of the severity of the symptoms, but also because of the long-term side effects of scarring, blindness and infertility. By the 18th century, smallpox accounted for 10-15% of the total mortality figures for Europe, and more than 80% of its victims were children.
  • There was no cure for smallpox, but preventive measures were known. The most common form in the 18th century was variolation (probably from Asia), in which fluid was taken from the pustules of an infected person, and then transferred into a cut made on the arm of another in the hope of producing a mild (immunizing) case of the disease. However, even a skilled practitioner often had a fatality rate of 1-5%. This technique was championed by Lady Mary Wortley Montagu, the wife of the English Ambassador in Constantinople, who after witnessing Turkish women having smallpox parties, convinced the upper classes to use this method by having her 5 year-old daughter inoculated in 1721. This was followed by experiments on condemned criminals. Lady Montagu had powerful allies, such as the physician James Jurin who noted that 1 in 14 inhabitants of London died from smallpox between the 1680s and 1720s. By the 1760s, scratches on the arm had replaced deep cuts (which had often led to infections), and some smallpox hospitals, where patients could be isolated after variolation had been established.

Lady Mary Wortley Montagu (1792-1876)

A Smallpox Vaccination Gone Bad in the Eighteenth Century

Smallpox and Cowpox: The Work of Edward Jenner

  • In the 1790s, the British country doctor and variolator, Edward Jenner, observed that people in his region of Gloucestershire (primarily dairy-maids) who had been exposed to cowpox showed no symptoms of smallpox after variolation. He developed a new process whereby people were vaccinated by matter taken from cow pox pustules (as this disease was benign in humans) and published his experimental findings in 1798. This work received great attention and was quickly published in America (1802), and throughout Europe in 1803. By 1799, a total of 5,000 people had been vaccinated in England, a figure that exploded to more than 100,000 by 1801. In Europe, Napoleon ordered his entire Army vaccinated, and between 1808 and 1811 almost 2 million people were inoculated in France. In 1802, the British government awarded Jenner £10,000 and established the Royal Jennarian Society to promote vaccination. Health promotion was becoming recognized as a responsibility by governments throughout Europe—an important shift in attitude.

Portrait of Edward Jenner (1749-1823)

Cowpox Inoculations in Britain in the Eighteenth Century

Cholera: Reform, Science, Trade, and Empire

  • The British reformer Edwin Chadwick applied statistics to population health and uncovered powerful correlations between poverty, class and disease. This resulted in tension among middle-class reformers: some blamed the poor for their misery and opposed public intervention; while others saw disease as a product of the miserable conditions and demanded public (government) action. The former ‘laissez-faire’ approach, however, was more popular (and far cheaper), among bureaucrats who balanced the budgets and even with physicians who focused on treating disease rather than prevention.
  • The early 1830s witnessed a massive epidemic of cholera throughout Europe (six more pandemics would strike by the end of the century). Global mortality is impossible to determine, but tens of millions died. British military action and colonial trade likely triggered the spread out of its usual endemic focus in India.
  • Characterized by massive diarrhea leading to dehydration and death (sometimes within hours), cholera is spread by the Vibrio cholerae, which was identified by Robert Koch in 1884. The hardy vibrio can live in cool water, contamination cycles are maintained when sewage comes into contact with drinking water during floods, earthquakes, war, and in the case of India, times of pilgrimages.
  • Despite Koch’s findings, the British government fought the contagion argument fearing that it could affect it lucrative trade with India.

The British East India Company’s Sphere of Control, Late 18th Century [Above]; and British India by the Early 20th Century [Below]

Cholera in Western Cities

  • Cholera swept through Europe in the early 1830s, and in 1832 arrived in Canada and the United States on immigrant ships. Sick newcomers were confined to sheds without fresh water or sewage facilities. Healthy immigrants were herded into the same buildings to be ‘quarantined’ side-by-side with those who were already sick. Management of the sheds was a charity, funded by rich and middle-class citizens, who were motivated by sympathy and a desire to keep the sickness at bay.
  • Six thousand people died in Canada’s first encounter with cholera. The figures endorsed the view that the dirty poor were the most susceptible. Later waves of cholera were handled in the same way.
  • Cholera at Quebec in 1832
  • The dreadful cholera was depopulating Quebec and Montreal when our ship cast anchor off Grosse Ile on the 30th August 1832, and we were boarded a few minutes later by health officers….At Quebec the almost ceaseless tolling of bells proclaimed a mournful tale of woe and death. Scarcely a person visited the vessel who was not in black, or who spoke not in tone of subdued grief. They advised us not to go on shore if we valued our lives, as strangers most commonly fell the first victims to this malady.
  • -- Susanna Moodie, Roughing It in the Bush (1852)
  • Cholera’s link to drinking water was established in 1854 by the English doctor John Snow who traced its victims to the Broad Street pump as the source of contagion. Eventually, this knowledge led to improved urban sanitation and public health.

Cholera’s Trek Through Europe in the mid 1800s [Above]; and Cholera in Europe, 1831 [Below]

The White Plague: Tuberculosis in the West

  • In the late 19th century, tuberculosis was the single most important cause of adult death. Many changes had taken place in the medical conceptualization of this disease. Formerly characterized by its symptoms of wasting, fever, and cough, by the late 1800s, after the work by Robert Koch, it bacterial origins were recognized. Despite Koch’s discovery, however, notions of heredity persisted, for the disease seemed to run in some families while others were resistant. Tuberculosis pervaded all social classes, and it shaped cultural notions of beauty and art.
  • Various public health measures, with more or less prejudicial baggage, were enacted to keep the germs of the tubercular sick, or the potentially sick, away from the healthy. Sufferers were isolated or quarantined in sanatoria. An effective vaccine using the Bacillus Calmette-Guerin (BCG) was developed in France in the 1920s. BCG became a central component in Canada’s tuberculosis-prevention program between the late 1940s and 1960s, as school-children, healthcare workers, prisoners and first nations’ peoples were inoculated. BCG, however, was never adopted in the US.
  • Surgical therapies for tuberculosis were invented to create a poorly oxygenated environment that was hostile to the organism. In 1927, the Canadian surgeon insisted on an artificial pneumothorax for himself, against the advice of his physicians at the Trudeau Sanatorium in New York State.

Veranda in a Children’s Ward in a Tuberculosis Sanatorium, c. 1920s

  • The first anti-tuberculosis drug was streptomycin, which was discovered by Selman Waksman (awarded the 1952 Nobel Prize).
  • Tuberculosis mortality declined steadily throughout 19th and 20th centuries. However, its decline started well before the advent of drugs, and the rate of decline was not dramatically altered when drugs appeared on the market.
  • Why? The germ may have become less virulent or human resistance to it may have grown with a rise in wealth, hygiene and nutrition.

  • The recent rise in tuberculosis rates are correlated with a parallel rise in poverty and homelessness in North America.

Coughing Up a Lung: Tuberculosis in Canada and the United States

The Father of the Sanatoria and the ‘Cure’: Edward Trudeau

Year Death-rate (per million)
1840 3900
1860 2500
1880 2000
1900 1400
1920 1000
1940 500
1960 50

The Great Influenza Pandemic, 1918-1919

US Army Hospital with Influenza Patients, Western Front, Autumn 1918 [Above]; and Child Sick with Influenza, in Philadelphia during Winter 1918-1919 [Below]

  • Along with polio, influenza was one of two great pandemics to sweep across North America (and the world) in the 20th century. In 1918, as World War One was drawing to a close, influenza killed 50,000 Canadians, many of them young occupants of military barracks and boarding schools. In contrast, in 4 years of fighting, the war had claimed 60,000 lives! Worldwide between 40 and 100 million died.
  • Also known as the Spanish Flu (Spain, as a neutral country was not censoring its press), the disease caused fever, pneumonia, and rapid death.
  • Influenza has since returned in pandemic waves, although not with such virulence. It has been given labels indicative of the various viral strains: Asiatic (1890), swine (1931), Asian (1957), and Hong Kong (1968).
  • A vaccine was developed in 1943, but it was only moderately effective because the influenza virus is extremely unstable and quickly mutates. The virus also spreads easily in air.
  • In 1976 rumors of an emerging strain of virulent swine flu (and the memories of 1918-19) resulted in the US President Gerald Ford recommending the inoculation of 50 million citizens. The result was another epidemic of Guillain-Barré syndrome amongst those vaccinated.

Eliminating the Vector to Fight the Disease: Anti-Mosquito Work

  • Even AIDS statistics pale when compared to malaria and its toll of 2 to 3 million death, mostly of children, from the half a billion cases each year. With its periodic fever, malaria has been known since antiquity as ‘swamp fever’, ‘ague’, and ‘paludism’ (from the Latin for marsh). The name ‘malaria’ came to English from the Italian for ‘bad air’ in the 18th century. Malaria was endemic to parts of Europe, where it annually killed thousands of people. During the 19th century, it ravaged British troops in India, and from this contact arrived in Canada.
  • The ancient Incan remedy was cinchona (Jesuit bark) was brought to Europe in the 17th century. Its active ingredient (quinine) was isolated in 1820. In 1880, at the height of British imperialism, the parasite was identified by C.L.A. Laveran, and 17 years later Ronald Ross proved the role (vector) of the anopheles mosquito. Ross and Laveran each received the Nobel Prize in 1902 and 1907.
  • In 1955 the WHO launched an eradication program against the mosquito, based on draining swamps and spraying insecticides (including the 1948 Nobel Prize-winning poison DDT). Unlike smallpox, however, malaria parasitizes other animals, and the use of insecticides and destruction of wetlands also harmed the environment and human health. By 1980 the WHO aimed to control and not the eradication of malaria. Meanwhile, malarial resistance to the quinine derivative chloroquine arose and is spreading. This disease is still endemic in much of the developing world (90 countries) and affects more than 40% of the world’s population.

Aedes aegypti – The Yellow Fever Mosquito [Above] and Mosquitoes’ Greatest Enemies (Ronald Ross, Walter Reed, and Alphonse Laveran) [Below]