Toronto, Canada (Fall 2013)
The Plague at Ashdod, 1630
Great medicine is driven by great passion, by a sense of outrage at the indignity that a disease visits on its victims. Across history the search for a solution to epidemic diseases has been rooted not in a desire for acclaim, prestige, or a prize, but first and foremost in the researcher’s emotional reaction to a disease and its effects.
It is easy to forget the importance of emotion when research is restrained, as it is today, by regulations and the protocols of granting agencies, and by the prevailing dogma that dispassion is the necessary stance of both medical researchers and practitioners. Young researchers are taught to be dispassionate in their approach to disease studies, ignoring the very human realities of the disease under study. What is lost in this approach is the driving force that over the years has led to so many great discoveries. It is from the medical researcher’s emotional reaction to an epidemic or pandemic assault that great medical advances always have been born.
A few examples will serve to emphasize passion as a necessary ingredient in the way researchers of the past have confronted the diseases of their day.
At the end of the 18th century yellow fever constituted a real threat to the emerging United States. “Why should cities be erected,” asked America’s Noah Webster, “if they are only to be the tombs of men?” What was assumed to be a tropical disease had traveled to temperate climes, decimating the developing mercantile cities. In the summer of 1793, for example, Philadelphia, PA, lost ten percent of its population in one vicious outbreak. Similar mortality rates during progressive outbreaks were reported in cities like Boston and New York.1 Trade between the newly United States and Great Britain was threatened by the decimating effect of yellow fever on local populations.
The dominant disease theory of the day was miasmatic, one that argued that endemic and epidemic conditions were born in the foul airs of the burgeoning city where public sanitation was virtually non-existent. Human and animal wastes were thrown into the streets to await rains that might eventually wash foul smelling refuse into the gutters and then into the rivers or the sea. If disease was in fact miasmatic, then the only way to combat yellow fever was through public health projects, a cleaning of the city and its disease-producing airs.
To argue for sanitation as a public health necessity in the face of epidemic outbreaks, Valentine Seaman attempted to prove that “no yellow fever can spread, but by the influence of putrid effluvia.”2 To do this he first located on a crude copperplate map a sample of the early cases of yellow fever occurring in a 1796 New York City outbreak. In another map he carefully marked the sites of “furry miasmata,” of odorous human and animal wastes that he believed were the source of the disease. To locate these sites he walked the streets of the study area, sniffing the most malodorous piles of refuse where, he reported, mosquitoes swarmed in unprecedented profusion. Seaman thus exposed himself to contagion and, not coincidentally, to repeated mosquito bites.
The result of his efforts suggested a correspondence between disease intensity and its proximity to odoriferous refuse piles. This placed the responsibility for yellow fever in the hands of city officials and helped propel the sanitarian movement of the 19th century.
Why did Seaman undertake such unpleasant, personally hazardous research when there was no possible profit in his work, no reward but a better understanding of disease? He was already a well-known and respected surgeon, a physician with a busy schedule. He was also something of a medical scholar, with good publications to his name. In addition, he served a member of the New York Health Committee, the forerunner of what would later be called the New York Board of Health.
The only answer is that he was offended by yellow fever and its outbreaks. Its attacks on Seaman’s patients were a personal affront. He was compelled to find its cause and seek a barrier to its return irrespective of the cost, dangers, or unpleasantness that search entailed, a surmise based upon a reading between the lines of his writings.3 We have, however, firmer evidence of the effects of passion on medical researchers in other epidemics, such as the work of John Snow in the search for the cause of cholera and its means of diffusion.
Cholera was a nineteenth century pandemic disease that spread from Peshwar, India, where it was first reported in 1817, to the Middle East, Russia, Europe, Great Britain, and then to the United States. In 1849, as the second of three pandemics began, John Snow wrote a monograph publicly arguing against then current medical wisdom that cholera was a waterborne rather than an airborne disease, born not in the foul airs of the city but in its sewage-contaminated rivers and wells.4
In 1854 Snow sought to prove his theory in two famous studies that in the 20th century became the sine qua non of epidemiological research.5 In the first he mapped a ferocious localized outbreak in St. James, Westminster, to demonstrate a correspondence between mortality and proximity to a local well (the “Broad Street pump”), providing water to registration district residents. In the second, he attempted a “natural experiment” that had it been successful would have proven a correspondence between cholera mortality and water quality at the more general scale of South London’s registration districts.6
Snow was successful only in convincing his contemporaries that water was one possible avenue for cholera’s diffusion, one potential locus of its generation. Why he was less than wholly successful in his argument is less interesting,7 than the question why he invested the last decade of his life in a tireless search for the source of cholera and its medium of diffusion. By 1849 Snow was a famous physician who had written the first comprehensive textbook on anesthesiology,8 patenting an inhaler to permit safer delivery of anesthetic drugs. Snow was much in demand as a specialist in the field he helped create. In 1853 he administered chloroform to Queen Victoria during the birth of Prince Leopold, a signal honor and the first use of anesthesia to members of Britain’s royal family.
Snow could have rested on his laurels, focusing on his burgeoning practice. And yet, in the 1850s he was driven relentlessly to prove his theory of cholera, traveling to various outbreak sites to gather data that would feed his next paper (or book) on cholera. His dogged insistence made him something of an irritating bore in the eyes of his medical contemporaries.9
The source of Snow’s passion is detailed in his writings. In 1831 Snow was training in the coal towns of Newcastle as an apothecary, a kind of senior apprentice charged with the care of patients under the general guidance of an experienced practitioner.10 Snow’s patient base was decimated as local communities lost as much as ten percent of their population. Snow was traumatized. Cholera became the enemy and with its return in 1849 he could do nothing but all he possibly could to combat it.
In his book and his papers he repeatedly described the unsanitary condition of the mines and the towns in which the miners lived. These, and especially the lack of clean water, he believed, permitted cholera to take effect and spread:
“There are no privies in the coal pits … as the workmen stay down the pit about eight hours at a time, they take food down with them, which they eat, of course, with unwashed hands, and as soon as one pitman gets cholera, there must be great liability of others working in the gloomy subterranean passages to get their hands contaminated, and to acquire the malady; and the crowded state in which they often live affords every opportunity for it to spread to other members of their families.11
Snow never forgot his impotence in the face of the miners’ deaths from cholera. They confirmed him as a sanitarian and their memories drove him, in the 1850s, to dedicate himself to arguing a cholera that could be tamed. It is little exaggeration to say Snow sacrificed everything to this goal: his practice was diminished, his reputation suffered, and his single-minded insistence made him, to his contemporaries, something of a crank.
The list goes on…
The history of medicine is filled with stories like Snow’s. There was, for example, Ignac Semmelweis whose belief that hand-washing and general sanitation might diminish if not extinguish “child bed fever” was not simply condemned but ridiculed by his 20th century contemporaries.12 And, too, there was the irascible father of modern pathology, Rudolf Virchow, demoted and put on probation for his Report on the Typhus Outbreak of Upper Silesia.” Sent to describe the outbreak and recommend a quick fix against future outbreaks, Virchow argued instead that only a comprehensive program of education, freedom, and prosperity could prevent future disastrous epidemics.13 That was not the kind of argument that won favor at the Prussian court.
Not all exemplars of passion in medicine are denied in their lifetimes or castigated for their conclusions. Famously, Oliver Sacks refused in the 1950s to accept then current assumptions about near comatose, apparently unaware post-encephalitis patients in his care. Experimenting with the introduction of L-Dopa he redefined the nature of their condition, producing a treatment if not a cure. In doing so, he also produced a cautionary tale warning against assuming patients were just bodies whose value diminished in apparent disability.14
In the history of research into HIV in the 1980s think of Abraham Verghese, a young specialist in infectious disease in Johnson City, Tennessee. Faced with a growing population of HIV patients he both struggled to treat his patients and to understand the condition afflicting them. A careful review of his patients’ personal histories described the migration of persons away from small towns that found their sexual preferences socially inimical and then their return, eventually, as either disease carriers or patients.15 His research provided the exemplar for the more broadly constituted work of other researchers like the equally concerned, equally passionate Peter Gould.16
In most medical schools students are nowadays trained to a adopt a distanced approach, in which diseases are to be categorized but not despised, while patients are to be treated with empathy but not sympathy. They are told that one does not, should not, become too involved.17 But the examples of Seaman, Snow, Virchow, Sacks, and Verghese illustrate that good medical research has always been intensely personal, the product of passionate commitment. And for medicine and medical science the result of this passion has been a series of profound advances, the conquest of diseases, and better outcomes for those afflicted by it.
- Tom Koch, Disease Maps: Epidemics on the Ground (Boston, MA: MIT Press, 2912), 80.
- Valentine Seaman 1798, 324–25 “Inquiry into the cause of the prevalence of yellow fever in New York,” Medical Repository 1:3 (1798): 324-5.
- Valentine Seaman, An account of the epidemic yellow fever, as it appeared in the city of New-York in the year 1795: containing, besides its history, &c., the most probable means of preventing its return, and of avoiding it, in case it should again become epidemic (NY: Hopkins, Webb & Co.), 1796.
- John Snow, “On the pathology and mode of transmission of cholera,” Medical Times and Gazette (Nov. 2, 1849): 745–52.
- Wade Hampton Frost, Ed. Snow on Cholera: A reprint of two papers by John Snow, M.D. … (New York: Commonwealth Fund), 1936.
- John Snow, “Cholera and the water supply of the south districts of London in 1854. Journal of Public Health 2 (1856): 239–247.
- Tom Koch and Kenneth K. Denike, “Crediting his critic’s concerns: Remaking John Snow’s map of Broad Street cholera, 1854,” Social Science & Medicine 69 (2009): 1246–51.
- John Snow, On the Inhalation of the Vapour of Ether in Surgical Operations: Containing a Description of the Various Stages of Etherization, and a Statement of the Result… (London: Churchill), 1847.
- Edmund Alexander Parkes, Review: Mode of communication of cholera by John Snow. British and Foreign Medico-Chiurgical Review 15 (1855): 449–56.
- Peter Vinten-Johansen, Howard Brody, Nigel Paneth, Stephen Rachman, Michael Rip, Cholera, Chloroform, and the Science of Medicine: A Life of John Snow ( NY: Oxford University Press 2009), 39-56.
- Snow, 1849, 747.
- Sherwin B. Nuland, The Doctors’ Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis (NY: W.W. Norton & Co.), 2004.
- Theodore M. Brown and Elizabeth Fee, “Rudolf Carl Virchow Medical Scientist, Social Reformer, Role Model,” Am. J. Public Health. 96: 12 (2006): 2104–2105.
- Oliver Sacks, Awakenings, Second Edition (London: Pandor), 1984.
- Abraham Verghese, My own Country: A Doctor’s Story (NY: Vintage), 1994.
- Peter Gould, The Slow Plague: A Geography of the AIDS Pandemic (Cambridge: Blackwell Publishers), 1993.
- Tom Koch and Sarah Jones, “The ethical professional as endangered person: blog notes on doctor-patient relationships,” Journal of Medical Ethics 36: 6 (2010): 371-374.
TOM KOCH, PhD, is a medical geographer and historian whose focus is the study of epidemic and endemic diseases and the environmental factors that promote or inhibit their spread. He is a professor of medical geography at the University of British Columbia, Vancouver, Canada and a consultant for Alton Medical Centre, Toronto, Canada in bioethics and gerontology. He is the author of more than 15 books and over 150 journal articles. His website is www.kochworks.com.
Highlighted in Frontispiece Fall 2013 – Volume 5, Issue 4