Population and Disease

The PestilenceCholeraJohn SnowT.R.Malthus – An Essay on the Principle of PopulationWilliam Cobbett – Rural Rides

(contains several readings…)

“Imago mortis” of Hans Holbein (or Michael Wogelmut? 1493?) – death is often depicted with music and dancing ‘The Dance of Death’

http://travelguide.all-about-switzerland.info/lucerne-spreuerbridge-dance-death.htmlShows paintings of the Dance of Death from about 1620 placed under a covered bridge in the Swiss town of Nadelwehr… http://www.lamortdanslart.com/danse/Allemagne/Lubeck/dd_lubeck.htmCopies of a 1463 Dance of Death in Lubeck, Germany – original destroyed in WW II.

‘Death Plays with Medicine’ Hartman Schegel 1493. Note the glasses on the physician and the worm in death’s eyes.

“City of Death’ – the great Dutch painter Brueghal imagines Messina, Sicily at the time of the first infections in the 1340s.

A 19th C depiction of the Pestilence in Italy in 1346-8

Depiction of the plague from the Teggenberg Bible of 1411. The physician is hanging scented herbs to disperse the bad air that he believes to be the cause of the infection. Looks like he’s too late for these victims.

Norway, or Brown, or Sewer Rat –powerful swimmers and climbers who are at home in and around water.

This engraving of a flea was one of many detailed drawings done by the brilliant experimentalist Robert Hooke, published in Micrographia in 1665. Hooke did not invent the microscope, but he was by far the keenest observer and recorder of what he saw, and his improvements to the microscope made it a practical instrument for scientists to use in the centuries to follow.

Hooke’s illustration of his microscope. Clearly this is the direct ancestor of the modern microscope, with all the main features that we recognize from today’s microscopes.

“A Court for King Cholera” - Punch London

Public notice of cases reported in a district in Wales, 1849.

Note the % of mortality.

(Nashville, TN burial commission)

Dr John Snow

Dr John Snow 1813 – 1858

John Snow was trained as a physician in London. He became one of the first anesthesiologists in the world. According to the story, he was trying to make a living as a newly graduated general practitioner but finding few patients, when one day he ran into a friend from medical school on the front steps of the hospital. “Good Morning, ” said the man, “but don’t detain me. I am giving ether here, there and everywhere and am getting quite into an ether practice!” Snow, who considered this fellow to be an ignoramus, went the next day to the Head of the hospital and asked to be trained in anesthesia. “Please do!” said the Head, “Take over that Section – there’s now one there but so-and-so and he’s a fool!” Snow began practice with dental patients but soon was working with surgeons. He put everything in order, arranged the standards for how to administer the painkilling drugs, and incidentally, how to avoid blowing up the operating room with flammable ether and open kerosene lamps! By 1850 he had made the whole process orderly, trained new assistants, designed new safe equipment for handling the dangerous substances, and had everything under control. He continued his work with anesthesiology, including being the personal physician who in 1853 administered anesthesia to Queen Victoria during the births of her eighth child. (ps The first public demonstration of ether was at Massachusetts General Hospital, done by William T.G. Morton. In 1847, the New York Journal of Medicine published "pain is essential to the surgical procedure, its removal is harmful to the patient".1 The American Dental Association wrote, in response to the "alarming" dissemination of ether anesthesia outside of Boston, that "pain is evidence of God's love of humanity, to alleviate it is to do the work of the devil".2  Oliver Wendell Holmes wrote "disease itself, the offspring of sin and penalty of a poisoned nature, was for them [17th and 18th century persons] a theological

entity rather than a disturbed physiological process".3) 

Having set the anesthesiology department of the hospital in order, Snow was able to devote some of his attention to a medical question that had interested him for some time, namely, the terrifying epidemic disease, “Asiatic cholera.” Terrible epidemics of cholera spread westward from the Mediterranean in the 1800s, and had struck Britain hard in 1839, and in 1844/45. This was an extremely virulent and terrifying disease. Healthy victims often fell ill, went through agony, and then died within a few hours, so dehydrated and deformed that the were unrecognizable to their families who had seen the victim healthy only a few hours before. As with the ‘Black Death’ the disease seemed to come from nowhere and strike indiscriminately. The science of medicine was in its infancy in the early 1800s, but physicians did know enough not to blame demons or the Wrath of God for the disease. There was no really knowledge of microbes as causing disease, but they had worked out that cholera was somehow connected with sewage. They believed that the disease was connected with what were called ‘miasmas’ or toxic fumes from sewage and decaying matter. In Europe by this time most cities had built or were in the process of building modern sewers, so everyone expected that this would eliminate cholera.

The rates of cholera did decrease after sewers were built, but cases persisted, and repeatedly there were outbreaks in various cities, including in areas, and among people who had no contact with foul air or odors. Cholera remained a mystery.

(see Snow on Cholera by Snow, Richardson and Frost, 1965 and On Cholera John Snow, 1855 and 1.  Ashhurst, J. Surgery before the days of anesthesia. In:  Warren JC, White JC, Richardson WL, Beach HH,  Shattuck FC, Bigelow WS, editors. Massachusetts General Hospital: The semi-centennial of anesthesia. Oct 16, 1846-Oct 16, 1896, H.O. Houghton & Co, 1897, p27.; 2.  Glucklich A.  Anesthesia and the end of good pain.  In:  Sacred pain:  hurting the body for the sake of the soul.  Oxford:  Oxford University Press; 2001, p278.; 3. Green, SA, Holmes, OW.  Medicine in Boston.  In: Memorial History of Boston 1630-1880.  Boston:  Ticknor and Co., 1886 p526-70)

The Medical Community was well aware that this disease posed a giant threat to the public health. In particular, as the Crimean War developed in 1854, the servicemen were exposed to cholera at the Front. The following excerpt is from a letter dated Aug 23, 1854, written by a British Medical Officer serving in the Black Sea Fleet, published in the Medical Times and Gazette of Sept 30, 1854:

“A week after the return of the Fleet to Baljik, on the 7th of August, about 4000 French troops encamped on the heights abreast our anchorage…. The cholera had broken out among them and attacking 400 on the first night had destroyed 60. The total loss had been something incredible. It was said that out of 11,000 men, not less than 5,000 had perished in a few days. This dreadful calamity was attributed to drinking water from wells that had been poisoned by throwing in putrid carcases.

Putting aside the question of intentional poisoning, which always presents itself as the most ready was of accounting for such destruction, perhaps some support to the theory, that water is the medium by which cholera poison is conveyed, may be found in this circumstance and in another of which I was witness. These soldiers, wearied by marching from a focus of cholera infections were seen, many of them, washing their persons and clothing in the stream from which all the French ships of war and the majority of the English fleet obtained their water. This was going on on the 7th and 8th and on the nights of the 9th and 10th the disease burst out with great violence among the crews of several ships. … The two admiral’s ships, the Montebello and Ville de Paris were terribly affected. On the previous day they had been in as healthy a state as usual, and in the night the cholera attacked, in the former, 200 men of whom 40 lay dead in the morning… the Brittania, which left port in a favorable conditions, was attacked… in 20 hours upwards of 50 of her crew had expired… by… the Evening of the 16th, 80 had died and 200 more remained in greater or less danger. “

John Snow wrote in On the Mode of Communication of Cholera in 1855:

“The most terrible outbreak of cholera which ever occurred in this kingdom is probably that which took place in Broad St, Golden Square and the adjoining streets a few weeks ago. Within 250 yards of the spot where Cambridge St joins Broad St there were upwards of 500 fatal attacks of cholera in ten days. The mortality in this limited area probably equals any that was ever cause din this country, even by the palgue, and it was much more siudden as the greater number of cases terminated in a few hours. The mortality would undoubtedly have been much greater had it not been for the flight of the population… in less than six days from the commencement of the outbreak, the most afflicted streets were deserted by more than three-quarters of their inhabitants.”

Before John Snow’s investigation there had been numerous inquiries into the causes of cholera. After he published his results, the question was regarded as settled by most authorities. Snow’s adherents introduced protocols for the prevention of cholera which were effective and saved many thousands, perhaps even millions of lives. They still did not know about bacteria and the exact details of how cholera causes infection, but they knew enough to take action. Snow’s technology was not a microscope or a medicine. It was a concept – the concept of how to arrange evidence and prove a scientific case.

Dr Snow was alerted to the start of the cholera epidemic in the center of London and began monitoring the cases. He found 89 deaths during the first week ending 2nd September, six during the first four days, four on Thursday, and 79 on Friday and Saturday. He then found that nearly all the deaths, only excepting ten, had occurred within a short distance of the Broad St public water pump, and when he investigated he found that five of these ten had usually gotten their water from Broad Street. Three more were children whose schools were in Broad St. Snow attempted to interview the families of every single person who had died. He reported that 61 of the victims had used Broad St water, but six cases said they did not use that water, and six others no survivors could be found.

Snow concluded in his book, “There had been no particular outbreak or increase of cholera in this part of London, except among the persons who were in the habit of drinking the water of the (Broad St) pump-well… I had an interview with the Board of Guardians of St James parish and represented the above circumstances to them. In consequence of what I said, the handle of the pump was removed on the following day. “

1.Snow established that by far the large majority of the victims were definitely known to have used Broad St water. 2.He investigated further and found that Broad St water was commonly used to mix with alcoholic drinks in surrounding areas, and in sherbets and other ice or water based foods. So, there were many routes by which the other victims might have ingested Broad St water. In particular he found a local coffee shop where the owner said as early as Sept 6 that she knew of nine of her customers who were dead of cholera.3.Snow methodically tried to identify why some local people were NOT affected. He checked the welfare facility or ‘workhouse’ just around the corner in Poland St. It was physically surrounded by homes in which 1/5th of the residents had been cholera deaths, but among 535 inmates, many in poor health and elderly, only five had died of cholera – all had been sick when admitted. The workhouse had its own well. Also, a large Brewery was located almost next to the pump. None of the 70 workmen died. When Snow interviewed the owner, Mr Huggins, he was told that the men were allowed a ration of beer and that Huggins was quite certain that they did not drink water at all and never obtained water from the pump in the street. In contrast, a factory nearby on Broad St employed 200 people and provided tubs of water from the street pump. They lost 18 dead.4. Snow began methodically trying to track down cholera victims in other parts of the city. He found a whole family that had died or fallen ill in Gravesend, some miles away. They had just moved from London where they drank Broad St water. An Army officer who had dined with friends in Broad St died in a few hours. Seven workmen from a nearby dental factory had died after being provided with Broad St water. A man came to visit his dying brother in Broad St, ate a quick meal including a brandy and water, and returned home to die in Brighton, many miles away, two days later. A woman who lived in a different part of London had received a large bottle of Broad St water, her son visited her and died in 18 hours, the woman died the next day, and her niece who visited her died of cholera in Islington. There were many other instances of people who visited or passed through the Broad St area and later died in distant locations.

What ‘technology’ did John Snow use:

1.Look for the facts.

2.Collect and correlate the facts.

3.Explain and report the facts

4.Take action.

What is the key element?

Snow made a wonderful graphical display that creates a clear association between the well and the disease. Note that it is the comparison not the description that makes this powerful: Broad St compared to Brewer St or Oxford St.

And note that is it contradictions to the thesis that prove it in the end. Instead of ignoring or minimizing the cases that do not fit his hypothesis, Snow aggressively tracks down as many cases as possible – If his hypothesis about the Broad St pump is correct, then WHY did some local people not get sick? And, why did some people in other areas fall victim to the disease? By directly confronting the apparent evidence against his hypothesis, he eliminates it and convincingly confirms the guilt of the Broad St pump.

Natural disasters, poverty and wars cause conditions that promote the spread of diseases. This neighborhood in Baghdad, Iraq has lost water, power and sanitary services due to the war.

Stricken soldiers at Camp Fullerton, Kansas during the 1919 ‘Spanish’ Influenza pandemic

Rev. Thomas Robert Malthus 1766 - 1834

  I think I may fairly make two postulata.

    First, That food is necessary to the existence of man.

    Secondly, That the passion between the sexes is necessary and will remain nearly in its present state.

    These two laws, ever since we have had any knowledge of mankind, appear to have been fixed laws of our nature, and, as we have not hitherto seen any alteration in them, we have no right to conclude that they will ever cease to be what they now are, without an immediate act of power in that Being who first arranged the system of the universe, and for the advantage of his creatures, still executes, according to fixed laws, all its various operations.

    I do not know that any writer has supposed that on this earth man will ultimately be able to live without food. But Mr Godwin has conjectured that the passion between the sexes may in time be extinguished. As, however, he calls this part of his work a deviation into the land of conjecture, I will not dwell longer upon it at present than to say that the best arguments for the perfectibility of man are drawn from a contemplation of the great progress that he has already made from the savage state and the difficulty of saying where he is to stop. But towards the extinction of the passion between the sexes, no progress whatever has hitherto been made. It appears to exist in as much force at present as it did two thousand or four thousand years ago. There are individual exceptions now as there always have been. But, as these exceptions do not appear to increase in number, it would surely be a very unphilosophical mode of arguing to infer, merely from the existence of an exception, that the exception would, in time, become the rule, and the rule the exception.

    Assuming then my postulata as granted, I say, that the power of population is indefinitely greater than the power in the earth to produce subsistence for man.

    Population, when unchecked, increases in a geometrical ratio. Subsistence increases only in an arithmetical ratio. A slight acquaintance with numbers will shew the immensity of the first power in comparison of the second.

    By that law of our nature which makes food necessary to the life of man, the effects of these two unequal powers must be kept equal.

    This implies a strong and constantly operating check on population from the difficulty of subsistence. This difficulty must fall somewhere and must necessarily be severely felt by a large portion of mankind.

(T.R. Malthus states his thesis at the beginning of “An Essay on the Principle of Population” 1802)

Malthus continued…

Through the animal and vegetable kingdoms, nature has scattered the seeds of life abroad with the most profuse and liberal hand. She has been comparatively sparing in the room and the nourishment necessary to rear them. The germs of existence contained in this spot of earth, with ample food, and ample room to expand in, would fill millions of worlds in the course of a few thousand years. Necessity, that imperious all pervading law of nature, restrains them within the prescribed bounds. The race of plants and the race of animals shrink under this great restrictive law. And the race of man cannot, by any efforts of reason, escape from it. Among plants and animals its effects are waste of seed, sickness, and premature death. Among mankind, misery and vice. The former, misery, is an absolutely necessary consequence of it. Vice is a highly probable consequence, and we therefore see it abundantly prevail, but it ought not, perhaps, to be called an absolutely necessary consequence. The ordeal of virtue is to resist all temptation to evil.     This natural inequality of the two powers of population and of production in the earth, and that great law of our nature which must constantly keep their effects equal, form the great difficulty that to me appears insurmountable in the way to the perfectibility of society. All other arguments are of slight and subordinate consideration in comparison of this. I see no way by which man can escape from the weight of this law which pervades all animated nature. No fancied equality, no agrarian regulations in their utmost extent, could remove the pressure of it even for a single century. And it appears, therefore, to be decisive against the possible existence of a society, all the members of which should live in ease, happiness, and comparative leisure; and feel no anxiety about providing the means of subsistence for themselves and families.

    Consequently, if the premises are just, the argument is conclusive against the perfectibility of the mass of mankind. I have thus sketched the general outline of the argument, but I will examine it more particularly, and I think it will be found that experience, the true source and foundation of all knowledge, invariably confirms its truth.

William Cobbett 1778 - 1835

…one of the best known political commentators in Britain, continually advocating for the rights of small landowners and working people against the big landowners and merchants. He believed that government policies which forced rural people off the land and into the urban industrial workforce was the cause of great suffering. Cobbett hated Malthus, whose views on population opposed aid to the poor. For some years he argued against the idea that population was increasing, pointing out the rapid loss of people from rural districts which had been heavily populated in the earlier centuries:

In Rural Rides 1830 he describes the changes in the area near Warminster in the South of England:

… I leave in 21 parishes only 4,170 souls, men, women and children…39 families to a parish…. Here are 21 churches built… several of these churches, any one of which would conveniently hold the whole of these people… all of these built long before the reign of Richard II (1377-1400) … Some of them stand within a quarter mile of each other.

Cobbett calculates that these huge but now nearly deserted parish churches mean that the population of the country parishes must have been at least triple during the earlier period what they are at his time.

US Constitution

Article I, Section 2.The House of Representatives shall be composed of Members chosen every second Year by the People of the several States, and the Electors in each State shall have the Qualifications requisite for Electors of the most numerous Branch of the State Legislature.No Person shall be a Representative who shall not have attained to the Age of twenty five Years, and been seven Years a Citizen of the United States, and who shall not, when elected, be an Inhabitant of that State in which he shall be chosen.Representatives and direct Taxes shall be apportioned among the several States which may be included within this Union, according to their respective Numbers, which shall be determined by adding to the whole Number of free Persons, including those bound to Service for a Term of Years, and excluding Indians not taxed, three fifths of all other Persons. The actual Enumeration shall be made within three Years after the first Meeting of the Congress of the United States, and within every subsequent Term of ten Years, in such Manner as they shall by Law direct. The Number of Representatives shall not exceed one for every thirty Thousand, but each State shall have at Least one Representative; and until such enumeration shall be made, the State of New Hampshire shall be entitled to chuse three, Massachusetts eight, Rhode-Island and Providence Plantations one, Connecticut five, New-York six, New Jersey four, Pennsylvania eight, Delaware one, Maryland six, Virginia ten, North Carolina five, South Carolina five, and Georgia three.

(Constitution of the United States – this provision makes it a priority for the government to carry out a census of the whole population every ten years. They did the first census in 1790 – the numbers were: 1790: 3.9 million, 1800: 5.3 million, 1810: 7.2 million, 1820: 9.6 million – an increase of 250% in 30 years)

This New York Times photo by Vanessa Vick shows children playing in the filthy water of the Bengo River in Angola. In 2006 a cholera epidemic in the slums of Luanda sickened 43,000 and killed up to 2,000. The city of Luanda has a population estimated at 4.5 to 5 million. Most of the inhabitants are in slums and probably fewer than half of those have ANY sanitary facilities of any kind. During 2005-6 the government of Angola received about $17 billion in oil revenues.