THE EYES HAVE IT: THE EARLY DAYS 

OF OPHTHALMOLOGY

 

         For many years, mankind endured diseases of the eyes with little remedy. Infections, especially from gonorrhea and syphilis, cataracts, injuries, and the ravages of untreated glaucoma were prevalent. Physicians had few remedies. Their inexperience was evident when a wave of “Egyptian ophthalmia” swept through Europe and England in the opening days of the 19^th century, introduced by Napoleon’s troops from a campaign in Egypt. The disease, now known as trachoma, and characterized by swollen, purulent eyes, eyelashes that scraped the cornea, corneal scarring, and blindness, resisted effective treatment. No department of ophthalmology existed at the time in Europe.

The first university chair of ophthalmology in the world was held by Georg Josef Beer, in Vienna. Beer had studied under the

Joseph Beer (Wikipedia)

Maltese anatomist and surgeon, Joseph Barth, who lectured on diseases of the eye. After graduating in 1786, Beer opened a private practice in his small apartment in Vienna focused on eye disease, treating the poor, mainly at his own expense. Twenty-six years later (1812), with no help from Barth, having earned a reputation on his own, he was appointed professor of ophthalmology at the University of Vienna.

Beer produced a two-volume practical text on eye disease. The text, though modern for its time, still cited contaminated air as the cause of purulence and recommended bleeding and leeches as treatments. But the new specialty was established. One of Beer’s pupils, Johan Nepomuk Fischer, founded a

Ferdinand Arlt (Wikipedia)

department of ophthalmology in Prague. His assistant, Ferdinand Arlt, the son a blacksmith, had trained in pathology with Carl von Rokitansky, the brilliant pathologist at Vienna’s Allgemeine Krankenhaus. He brought modern pathology and histology to the specialty and after succeeding Fischer in Prague assumed the prestigious ophthalmology chair in Vienna in 1856.

Two discoveries in midcentury dramatically enhanced the profession: the introduction of anesthesia in 1848 and the invention of the ophthalmoscope by Herman Helmholtz in 1851, both huge advances. For the first time doctors could operate without exquisite pain and could peer inside the eye. 

 The breakthroughs are reflected in Arlt’s three-volume text that grounded ophthalmology on a more scientific basis. First appearing in 1850, the work went through five editions in seven years and included ophthalmoscopic discoveries. Arlt also was the first to elucidate the cause of myopia: elongation of the longitudinal axis of the eye. He improved on methods of removing pterygia and developed new surgical procedures for complications of trachoma. 

One of Arlt’s students, Albrecht von Graefe, was awarded the

Albrecht von Graefe (Wellcome Library)

first chair of ophthalmology in Berlin. He founded the first journal devoted to ophthalmology, Archiv für Ophthalmologie. Graefe was a kindly man and after his death, three of his colleagues, including Arlt, renamed the journal Albrecht von Graefe’s Archiv für Ophthalmologie in his honor. 

Early Helmholtz ophthalmoscope owned by 
Albrecht von Graefe (National Museum of Health
and Medicine)

As an early user of the ophthalmoscope, Graefe was the first to describe changes in glaucoma from increased intraocular pressure, to describe swelling of the optic disc due to increased intracranial pressure, and record changes in the vessels, such as embolism of the central retinal artery. Tragically, Graefe developed tuberculosis and died in 1870 at the age of 42.

Von Graefe was well-known in Berlin. This image of him treating a young woman is from
a popular illustrated magazine, Die Gartenlaube, 1857 (Internet Archive)

Franz Cornelius Donders, his friend and professor in Utrecht, invented a tonometer to measure intraocular pressure and elucidated the mechanism of accommodation. His investigations of visual acuity

Snellen eye chart (Wikipedia)

and astigmatism led to the proper prescription of corrective lenses. His close associate was Herman Snellen, creator of the Snellen eye charts in use today.

In England, most of the early victims of the trachoma epidemic were military men. In one regiment, 636 out of 700 men were afflicted. John Cunningham Saunders, a young surgeon, on the advice of his superior, Astley Cooper, opened a practice for eye

John Cunningham Saunders 
(Wikipedia)

diseases. Saunders quickly recognized the extent of eye disease and especially the social consequences of blindness and, with state assistance, founded the London Dispensary for Eye Disease in 1805, which grew into the Royal London Ophthalmic Hospital of today. 

The European influence extended to America. In 1817 the Baltimore physician George Frick traveled to Vienna to study under Beer and returned to open a practice in eye disease. He published the first American text on ophthalmology, A Treatise on Diseases of the Eye, based largely on Beer’s tome and in use for

George Frick (From Hubble, A A,
The Development of Ophthalmology 
in America, Internet Archive)

some years. He taught at the University of Maryland and is considered by many to be the “father of American ophthalmology.”  In 1816 Edward Reynolds,  just ending a preceptorship under the Boston surgeon, John Collins Warren, and two recent graduates of the College of Physicians and Surgeons in New York, Edward Delafield and John Kearney Rodgers, journeyed to England. All three (and the poet, Keats) studied under John Cunningham Saunders. There they learned new surgical techniques, including the treatment of cataract by lens extraction (rather than by “couching,” an earlier process that dislodged the opaque lens, leaving it in the eye). 

On their return, the Americans founded two enduring institutions. Reynolds, with a second physician, established the Boston Eye Infirmary for the poor, later known as the Massachusetts Eye and Ear Infirmary, which exists to this day. Delafield and Rogers founded the New York Eye Infirmary, also providing free eye care to the city’s poor. It was the second permanent such institution in America, now affiliated with Mount Sinai Medical School. Both infirmaries were based on Saunders’ institute in London. The AMA recognized the specialty of ophthalmology with the founding of the American Ophthalmic Association in 1864.

 From Hubble, A A, The Development of Ophthalmology 
in America (Internet Archive)

         Knowledge of bacteriology in the late 19^th century allowed prevention and control of eye infections, the next major step toward modern eye care. Advancing technology continues to improve eye care and reduce blindness.

 

SOURCES:

Lesky, E, The Vienna Medical School of the 19^th Century. 1976, Johns Hopkins Univ Press.

 

Adler, F H, “Sketches from the Life of Albrecht von Graefe.” Ann Med Hist, 1928; 10(3): 284-90.

 

Rohrbach, J M, “Albrecht von Graefe in the Present, the Past, and the Future.” Graefe’s Archive for Clinical and Experimental Ophthalmology. 2020; 258: 1141-47.

 

Laios, K, et al, “Carl Ferdidand von Arlt, Ritter von Bergschmitt (1812-1887): A Pioneer in Ophthalmology.” Acta Medica Academica 2019; 48 (3): 331-36.

 

Ivanisevic´, M, “Prof. Dr. Carl Ferdinand Ritter von Arlt (1812-1887): His Life and Work During his Ophthalmological Career in Prague.” Čes. a slov. Oftal., 79, 2023, No. 1, p. 36–40. (available in English at: https://cs-ophthalmology.cz/en/journal/articles/268

Pearce, J M S, “The Ophthalmoscope: Helmholtz’s Augenspiegel.” European Neurology 2009; 61: 244-49.

Lyle, T K, “Some of the Great Historical Figures Associated with Moorfields.” Brit J Ophthalmology1961; 45: 251-58.

SchmidtiWyklicky, G and Gröger, H, “Georg Joseph Beer (1763–1821). Leben und Werk des Begründers der ältesten Universitäts-Augenklinik.” Spektrum Augenheilkunde 2012; 26: 266-72.

Duke-Elder, S, “Moorfields and British Ophthalmology.” Proc Royal Soc Med 1964; 58 (7): 541-45.

Tower, P, “George Frick: Factors Influencing Early Nineteenth Century Ophthalmology.” AMA Arch Ophthalmology 1958; 60: 989-94.

Kara, G B, “A Historical Review of the department of Ophthalmology at the New York Eye and Ear Infirmary.” N.Y. State J Medicine 1973; 73 (23): 1-10.

Snyder, C, Massachusetts Eye and Ear Infirmary: Studies in its History. 1984; Mass. Eye and Ear Infirmary.

 

 

 

 

 

 RICHARD MEAD AND PLAGUE

 

         In May 1719, several crewmembers on trading vessels arriving at Marseilles from the Middle East fell ill and died. The Chief Surgeon of Health found no evidence of contagion, only that the men suffered a "malignant fever."  By July, however, plague was recognized, the city was overwhelmed with the dead and dying, the well-to-do were fleeing, doctors and clergy were fleeing, even food producers such as bakers and butchers left town. The city was desperate and short of food. Beggars and galley slaves were enlisted to dig mass graves and bury the dead and smokey fires lit up the streets. Hospitals were overwhelmed and makeshift facilities sprang up. All to no avail. The final tally of the dead is estimated at between 40,000 and 60,000, with more in the surrounding Provence area. 

Translation of de Croissante's
work (Internet Archive)

       

         The following year, the “Counsellor and Orator” of Marseilles, Pichatty de Croissainte, published a journal of the plague, detailing the tragic events. Across the Channel, an English translation of de Croissainte’s journal appeared almost immediately. England’s last experience with plague had been the great London epidemic in 1665, a devastating event still in public memory. Daniel Defoe’s Journal of the Plague of London of 1722 is thought to be based on de Croissante’s work. The British Secretary of State asked London’s most prominent physician, Dr. Richard Mead, to advise on measures to prevent plague from visiting British shores. 

Richard Mead (Wikipedia)

         Richard Mead was born in Stepney, near London, in 1673. Following a nonconformist primary school education, he studied at Utrecht, Leyden (botany and medicine), and Padua (philosophy and medicine). He opened a practice in London in 1696, rising quickly in prominence. He gave anatomy lectures to the Company of Surgeons, was appointed physician to St. Thomas’ Hospital, received a medical degree from Oxford, a fellowship in the College of Physicians, and was elected to the Royal Society. He encouraged the wealthy Thomas Guy to fund a hospital for “incurables,” now the famous Guy’s Hospital. John Radcliffe, the leading physician in London (after whom the illustrious Radcliffe Infirmary is named), and physician to William III, took a liking to

John Radcliffe (Wikipedia)

Mead. When Radcliffe died in 1714, Mead moved into his house and inherited his fashionable gold-headed cane. The cane passed to a few later distinguished physicians and currently resides at the College of Physicians. Gold-Headed Cane awards for excellence in medicine are now granted by several medical societies and schools.

         

John Radcliffe's Cane on cover of The Gold-
Headed Cane by William Macmichael
 (Internet Archive)

Mead was an interesting choice to advise on plague. He had no direct experience with plague but carefully studied its history. He was one of the best educated men of his time, a friend of scientific figures like Halley (of comet fame) and Newton, of leading physicians, and a schoolmate and correspondent of Herman Boerhaave, the famous clinician in Leyden. He had published a work on poisons and a work concerning celestial influences on health based on the new Newtonian mechanics, a book that influenced Franz Mesmer in his formulation of the magnetic fluid theory of disease. 

         Mead condensed his thoughts in a brief work entitled A Short Discourse Concerning Pestilential Contagion, and the Methods to Be Used to Prevent It. On page two Mead writes, “Contagion is propagated by three causes, the air; diseased persons; and goods transported from infected places.” Mead recognized that plague moved from place to place, ruling out a generally

Mead's work on plague and contagion
(Internet Archive)

contaminated atmosphere, a common “non-contagionist” target, as a source of epidemics. When Mead spoke of air, he was referring to local air, into which the sick released poisonous atoms, a phenomenon to explain how people not in direct contact with the sick still developed plague. These “contagious atoms” (his words) caused disease nearby but were dispersed by wind to become ineffective more distantly, something he compared to London’s smokey air. The ideas are similar to those voiced by Girolamo Fracastoro in 1546, though Mead does not mention him. Neither man could have known about rats and fleas as carriers and transmitters of plague but Mead’s concept of contagion in the local atmosphere is a reasonable substitute. Thomas Sydenham, incorrectly, held that epidemics resulted from an interaction of atmospheric factors and emanations from the earth, a concept stemming from Hippocrates.

In short, Mead concluded that a quarantine would be effective. A quarantine was duly invoked, and England remained free of the pestilence. Considering that rats sneaking ashore could have foiled the quarantine measures, luck was probably a factor, though the basic idea has proven to be sound. Mead’s book on plague went through nine editions and appeared in several languages. Though some recommendations changed, the basic ideas remained the same.

         Mead was also involved in the first experiment with variolation (inoculation with live smallpox material to produce immunity), introduced by Lady Mary Montagu from Turkey. Six prisoners condemned to death received inoculation into the skin. All survived and were set free. Mead and other physicians involved in the trials recommended variolation, even in the face of a 2-3% mortality from the procedure.

         In the 1740s, Mead helped establish a foundling hospital. He, in concert with the artist William Hogarth, encouraged artists to show their creations in the hospital’s halls as a way to raise funds. 

Foundling Hospital (Wellcome Library and Wikipedia)

Gainsborough, Joshua Reynolds, and Hogarth exhibited works. It was the first public art gallery in London and influenced the formation of the Royal Academy of Art. 

Foundling Hospital Chapel, where Handel regularly performed his Messiah.
(Wikipedia)

         Mead wrote other works, managed a large practice, dispensed medical consultations to apothecaries in coffee houses (common at the time), collected books and works of art, and was a generous humanitarian. He was considered by C.E.A. Winslow, former professor of public health at Yale University School of Medicine, and others, one of the pioneers of preventive medicine.

         

SOURCES:

 

Meade, R H, In the Sunshine of Life: a Biography of Dr. Richard Mead, 1673-1754. 1974; Dorrance & Co., Philadelphia.

 

Winslow, C E A, “A Physician of Two Centuries Ago: Richard Mead and his Contributions to Epidemiology.” Bull History of Medicine 1935; 3: 509-44.

 

Roos, A M, “Luminaries in Medicine: Richard Med, James Gibbs, and Solar and Lunar Effects on the Human Body in Early Modern England.” Bull History of Medicine 2000; 74(3): 433-457.

 

Williamson, R, “The Plague of Marseilles and the Experiments of Professor Anton Deidier on its Transmission.” Medical History 1958; 2: 237-52.

 

Hattie, W H, “Richard Mead: A father of Preventive Medicine.” Canad Medical Assoc Journal 1928; 19(1): 101-5.

 

Zuckerman, A, “Plague and Contagionism in Eighteenth-Century England: The Role of Richard Mead.” 2004; Bull Hist Med 78(2): 273-308.

         

Anon, “The Great Plague of Marseilles.” BMJ  1900; May 12, p1172.

 

Mead, R, A Short Discourse Concerning Pestilential Contagion, and the Methods to be Used to Prevent It. London, 1720.

A full index of past essays is available at: 

https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 AZTEC CONTRIBUTIONS TO EUROPEAN 

PHARMACEUTICALS

 

         When Hernando Cortés and his troops entered the Aztec capital city of Tenochtitlan in 1519 they were stunned. Huge temples and palaces surpassed many of their own. Sweepers kept the streets cleaner than in Spain, and aqueducts carried in fresh water from the nearby mountains. A knowledge of mathematics, astronomy, two separate calendars, and pictorial writing revealed unexpected sophistication. Colorful markets tempted the troops, including one specializing in herbs and medicines, as noted in a letter by Cortés: “There is a street set apart for the sale of herbs, where can be found every sort of root and medical herb which grows in the country. There are houses like apothecary shops, where prepared medicines are sold, as well as liquids, ointments, and plasters.”

         Cortés found that the Aztecs enjoyed a well-organized medical system. Physicians, known as ticitl, took care of most ills using a combination of herbals and contact with various gods. Surgeons and midwives also practiced their specialties.  Extensive botanical gardens in and near the capital supplied the wide variety of herbals used as medicines. Aztec experts classified and named the plants and doctors prescribed them internally and externally. The Spaniards appreciated the skills of Aztec practitioners sufficiently for Columbus to suggest to Charles V that he need not send additional physicians to Mexico.

A ticitl (robed figure on mat and above) making a diagnosis
(from Codex Magliabechiano, folio 78r, Wikimedia Commons)

         A number of these herbal remedies entered the medical practices in Europe. One of the first was tobacco. “Tabaco,” originally the indigenous name for a y-shaped pipe to enable powder of any plant to be sniffed into each nostril (used mainly for hallucinogenics), became the name for the leaf. Columbus had noticed Caribbean natives applying leaves for wounds and illnesses

Nicolás Monardes (Wikipedia)

and others observed it being chewed, smoked, or mixed with other plants as poultices. When it arrived at the docks of Seville, the prominent Seville physician, Nicolás Monardes, praised its 
marvelous properties in an influential book (first edition in 1565) on medicines from “our West Indies.” The plant grew well in European soil.

         In 1560 the French ambassador to Portugal, Jean Nicot, found that it cured a number of ailments, including skin lesions, and popularized it. The French called it Nicotaine (Nicotiana in Latin, now the genus designation), and it appeared in numerous materia medica. Classified as “hot and dry” in

Jean Nicot (Wikipedia)

terms of Galen, it neutralized cold humors causing various ailments and was used topically and rectally. Nicolas Culpepper praised it in England. Eventually, smoking the leaves largely replaced its use as a medicine.

         Monardes also described sarsaparilla, also considered by European medical writers a hot and dry medicine and sudorific. It enjoyed brief popularity as an antisyphilitic but subsequently was used mainly for rheumatism and fevers. It became popular in patent medicines in the nineteenth century (though sassafras was often the main ingredient), was taken for a variety of ailments, and often mixed with alcohol or opium.

Patent medicine ad for sarsaparilla (Wellcome Library)

         The cathartic jalap, used liberally by practitioners like Benjamin Rush, was derived from Ipomoea purga, a Mexican plant. Monardes called it “Rhubarb of the Indies” after the cathartic rhubarb, though there is no botanical relation of the two plants. It was used for fevers, coughs, and chronic diseases as well as a cathartic.

         The medicine that achieved the most popularity was an extract of the wood of the Guaicum tree (Guaicum officinale), found in many of the Caribbean islands and usually referred to as lignum sanctum (holy wood) or, in Spain, guaiacum. Spaniards had noticed its use by locals for what apparently was syphilis and it soon arrived in Europe for the same purpose. Mercury had been the standard anti-syphilitic,

Ulrich von Hutten (Wikipedia)

used in doses that caused numerous side effects. Ulrich von Hutten, a notable German humanist and supporter of Martin Luther, wrote the first major work on lignum sanctum in 1519. He described his own case of syphilis, how to prepare the wood (a hot water extract), and outlined a treatment that included preparation with a cathartic and a special diet. Perhaps more well-known today is the work of Fracastoro, whose work on syphilis praised lignum sanctum and gave the disease its modern name. The enthusiastic recommendations of Hutten and Fracastoro stimulated a high demand for the wood. But the Fugger family of Augsburg had secured from Charles V a monopoly on guaicum in exchange for a loan. Prices went too high for patients of modest means until 1525, when the monopoly expired. Monardes also considered it helpful against scurvy, rheumatism, and “almost all chronical distempers.” Guaiacum lasted until the early 1800s though mercury persisted for syphilis until the advent of arsenicals.

Right: cutting, measuring, boiling guaiacum.
Left: administrating guaiacum. (Wikipedia)

 

The Spanish domains yielded other new medicines, some from non-Aztec areas. Extracts of bark of the chinchona tree in Bolivia and Peru were effective against malarial fevers, and eventually yielded the active ingredient quinine. Ipecacuanha root, from Central America, served as an emetic and sweating agent. It was especially popular in an English preparation called “Dover’s Powder,” a combination of ipecacuanha, opium, and potassium salts, used as a sweating agent to ward off colds and other fevers in early stages. Cocaine, from coca leaves chewed by Peruvian natives to allay hunger or for pleasure, came later as an ingredient in tonics, as a local anesthetic, and as an addicting drug. Peruvian balsam served as an aid to wound healing. Bezoars from Peruvian llamas were valued as healing agents, superior to bezoars from elsewhere. Hallucinogens, mainly from mushrooms, did not prove popular as European medicines, though used in Mexico for magical and religious purposes. 

         By the middle eighteenth century Spain alone was importing about 155 tons of New World medicinal plants annually, supplemented by copious imports from other countries. Many of these products are with us today.

 

SOURCES:

 

Gänger, S, “World Trade in Medicinal Plants from Spanish America, 1717-1815.” Medical History2015; 59 (1): 44-62.

 

Guerra, F, “Aztec Medicine.” Medical History 1966; 10: 315-338.

 

Estes, J W, “The European Reception of the First Drugs from the New World.” Pharmacy in History1995; 37 (1): 3-23.

 

Munger, R S, “Guaicum, the Holy Wood from the New World.” J Hist of Medicine 1949; 4: 196-229.

 

Hope, J, Lectures on the Materia Medica: Containing the Natural History of Drugs, their Virtues, and Doses. v 2. (from manuscript of Dr. Charles Alston)

 

Monardes, Nicolas, Joyfull newes out of the new-found worlde. Wherein are declared, the rare and singuler vertues of divers herbs, trees, plantes, oyles and stones, with their applications, as well to the use of phisicke, as of chirurgery ..., trans by John Frampton, 1596 (online in Wellcome Library).

 

A full index of past essays is available at: 

https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

         

 

 

         

 MEDICAL NOTES FROM THE 

NEW WORLD

         

 

         The tragic events following the arrival of Spanish colonizers in the Western Hemisphere are well known. The ravages of disease, including smallpox and measles, and abrupt social disruptions killed off large numbers of native inhabitants The new colonizers, though, had medical problems of their own.

         The first voyage of Columbus, in 1492, from a medical point of view, was fairly uneventful. Illness was not a problem and the foods the crew encountered, including beans, cassava (yucca), peppers,

Christopher Columbus, by Sebastian del
Piombo, 1519 (Wikipedia)

potatoes, mangoes, pineapples, papayas, guava, passion fruit, and other vegetarian fare provided sufficient nourishment. Two ship surgeons, or fisicos, Maestro Alonzo, on Columbus’ caravel Santa Maria, and Maestro Juan on the Pinta, sailed with the expedition. Alonzo returned to Spain with Columbus while Juan remained with fifteen men to maintain a small fort on Hispaniola (now Haiti).  Troubles began on the second voyage. 

The second expedition, comprising 17 vessels, left Spain in September 1493. Aboard were about 1500 male colonizers, various animals including pigs, cattle, horses, dogs, cats, chickens (none of which were native to the Caribbean), and a variety of crop seeds. Many of the men came from noble families, seeking adventure or riches after having been idled following the final conquest of the Muslims in 1492. Illness broke out during the voyage, affecting both passengers and animals and continued to plague the colonists after arrival. The exact diagnosis is unknown, but symptoms included fever and extreme lassitude. Scholars have suggested diagnoses of swine flu, dysentery (some had diarrhea), typhus (believed prevalent during the final assault on Grenada), or a mixture of diseases.      

           Columbus himself suffered from the epidemic, called modorra, and was prostrated for weeks with weakness and inability to work. A physician in court service (médico de cámera), Diego Alvarez Chanca, attended him. Details of his life are sketchy. He probably received his medical education at the University of Salamanca, where the medical theory he learned would have been Galenic and his major text Avicenna’s Canon of Medicine. The more investigative approach to medicine, exemplified by Vesalius, was yet to come. Chanca, an adventurous man, actually volunteered to go with Columbus.

Map of second voyage (Wikipedia) Click to enlarge.

         Chanca, in a letter back to Spain, gave some idea of local problems, but he provided no further insight into the diagnosis of the epidemic disease. Disease entities as we know them had not entered the medical vocabulary. He worked hard and Columbus praised him for his efforts to aid the sick. 

Famine accompanied the epidemic. The initial crops of the Spanish colonists grew poorly, provoking the Spanish to steal from the Hispaniola native Taíno. Attempts to enslave natives or otherwise maltreat them led to hostilities that reduced the food supplies of both groups. Hunger and starvation, lowering resistance to disease, drastically drove down the population of Spaniards and natives alike. When Columbus returned to Spain in early 1494, over half of the original 1500 colonists and untold numbers of Taíno had perished. Reports of illness with superficial ulcers appeared, perhaps the first recognition of syphilis, considered a “new world disease.” The surgeon of the previous trip, Maestro Juan, and the fifteen men left with him had all perished, probably killed by local natives. 

Columbus searched for spices as well as gold. He and Dr. Chanca identified plants they thought were varieties of aloe, pepper, and cinnamon. They were incorrect, though some plants proved useful as medicines. The spice they labeled “cloves” was allspice, so named because its odor suggested a mixture of clove, cinnamon, and nutmeg. And they found tobacco.

By the 1500s, colonizers and adventurers were arriving in larger numbers, both on the islands and the mainland. Various febrile diseases, probably including malaria, were now common, though no diagnoses familiar to us appear. Smallpox arrived in the Caribbean in 1518. The native population, never exposed to it and already in severe decline, suffered severely while the Spanish population, maintained only through new immigration, had fewer losses. In 1520, smallpox reached Mexico, imported by an expedition sent

Hernán Cortés, 1525 portrait
(Wikipedia)

from Cuba to arrest Hernán Cortés for disobeying orders. Cortés had attacked Tenochtitlán (now Mexico City) but had been forced by Aztec forces to withdraw. He was licking his wounds when smallpox intervened and devastated the victorious Aztecs, reducing their numbers and killing their leader. Cortés took the depopulated city back, another example of disease affecting history. Smallpox went on to devastate Central and South America, ravaging whole populations. 

Smallpox in early America, from Florentine Codex 
(Wikipedia)

The first documented epidemic of measles broke out in 1532, though reports suggestive of its appearance surfaced as early as 1529. Measles, highly infectious, swept through the colonies rapidly, causing many more deaths. In all the outbreaks of disease mentioned, the combination of Spanish disruption in the daily life of native Americans, slavery, work conditions, and the falloff in the ability to farm and prepare food, produced widespread famine and lowered resistance to disease, all contributing to the terrible mortality.

More epidemics plagued the Spanish possessions, though their nature is often obscure. Two deadly epidemics, in 1545 and 1576, of a new disorder, known in Nahuatl as cocoliztli, killed up to 80% and 50% of the native population respectively. Symptoms included nosebleeds, hemorrhagic phenomena, diarrhea, and fever. Recent studies suggest they might have been due to a virus related to today’s arenavirus or hantavirus (“four corners virus”) species, carried in rodents. Both outbreaks followed periods of severe drought.

Much is unknown about the early medical problems of the Spanish New World and will probably remain so. But it is clear that epidemics and death flourish in times of food shortage and/or severe social disruption, even today.

 

SOURCES:

 

Cook, N D, Born to Die: Disease and New World Conquest. 1998, Cambridge Univ Press.

 

Gonzalez, J P H, “En Torno a Una Biografía del Primer Médico de América Diego Álvarez Chanca (circa 1450 – post 1515).” 2012; Anuario de Estudios Atlánticos 58: 29-49.

De Ybarra, A M F, “ A Forgotten Worthy, Dr. Diego Álvarez Chanca, of Seville, Spain.” 1906; JAMA 47 (13): 1013 17.

Acuna-Soto, R et al, “Megadrought and Megadeath in 16^th Century Mexico.” 2002; Rev Biomed 13: 289-92. (also in Emerging Infectious Diseases 8 (4), 2002, available at: https://wwwnc.cdc.gov/eid/article/8/4/01-0175_article)

Griffinhagen, G B, “The Materia Medica of Christopher Columbus.” 1992; Pharmacy in History34(3): 131-45.

A full index of past essays is available at: 

https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

         

 CHOLERA BEFORE ROBERT KOCH

         Cholera outbreaks today are confined to areas of famine, war, or other sites of public health disarray. Though an old disease in India, it is a relatively new disease from a global viewpoint. The first recorded pandemic, that of 1817, marched from India eastward through Asia and westward to Persia and the Caucasus, but spared Europe.

         In the next pandemic, beginning in 1829, cholera reached Russia, swept down through Europe, and traveled across the Atlantic to the United States, Canada, and South America, killing hundreds of thousands during its march. Western medical skills were powerless. Arguments raged over whether it was contagious or came from

French drawing, cholera (Wikipedia)

miasmas and/or foul air, and how to treat it. Quarantines of various types were debated and instituted irregularly. Galenic ideas, especially those involving corrupted humors to explain symptoms, still prevailed in medical thought. Accordingly, for treatment medical opinion favored measures to rid the body of corrupting material. 

The losses of fluid in cholera are dramatic. Liters can be passed in liquid stools in a few hours, exacerbated by vomiting. Records describe patients as cadaveric, with dry, cold, grayish skin, near-absent pulse, and inaudible heart sounds.  Blood from a vein or artery, if it came at all, resembled tar. Claude Bernard even suggested that survivors passed through a form of suspended animation similar to hibernation. It is obvious today that replacement of fluid is essential, but that was not so in the 1830s. Bleeding and purging were highly recommended treatments. Since blood was hard to extract, doctors often resorted to an artery to obtain small amounts of tarry material. Emetics, purgatives like calomel, cupping, and blistering were also part of regimens that did more harm than good.

Investigators in Moscow in 1830 were among the first to discover the high hematocrit and low water content of blood in cholera patients. Scattered reports of injecting water or saline solutions intravenously appeared, but results were disappointing. Inadequate amounts of fluid, injection of air bubbles, and bacterial contaminants all contributed to poor results, delaying intravenous fluid therapy until the twentieth century. Attempts to suppress bowel movements with opiates also met with little success.

A third pandemic lasted from 1845 to 1856. By then, contaminated water was under suspicion. John Snow’s surmise of a “cholera poison” in the water from a certain London water company and from a particular well resulted in removing the handle from the

John Snow (Wikipedia)

Broad Street pump in 1854. But the epidemic was already subsiding and the medical world paid relatively little attention. The “discovery” of the causative agent by an Italian microscopist also brought little reaction.

Filippo Pacini, son of a cobbler, received his medical education in Pisa. As a student, using a rudimentary microscope, he was the first to describe the tiny “Pacini” tactile dermal corpuscles, work later confirmed. His proficiency with the microscope catapulted him to the professorship of anatomy at the University of Florence. During the same pandemic that struck Snow’s London, Pacini studied cases in Florence using his microscope. He

Filippo Pacini (Wellcome Library)

noted disruptions of the intestinal mucosa and myriads of comma-shaped bacteria in the intestinal fluid. He published his findings in 1854 in an Italian journal, suggesting that the organisms caused the disease. He sent copies of his findings to the French Académie des Sciences, to Virchow, Henle, and Max von Pettenkofer in Germany. Reports also went to authorities in England, and to the Medical Society of London, where Snow was a member. Snow and Pacini never met, and it is not clear if Snow knew of Pacini’s work. Snow died in 1858 and a brief obituary in Lancet did not mention his work on cholera epidemiology.

Cholera struck Florence again in 1865. This time Pacini’s writings attracted the attention of William Farr, the British Registrar-General, who described Pacini’s findings in a report of 1868, including his insight that excess fluid loss was the cause of vascular collapse. Pacini recommended fluid replacement and developed complicated mathematical models to measure the fluid balance. Pacini’s writings, however, did not appreciably affect general medical opinion. It was too early. Lister’s first article on bacteria in wound infections appeared in 1867, was received skeptically, and Robert Koch first proved the bacterial cause of a disease (anthrax) only in 1874.

Max von Pettenkofer, the great German pioneer in public health

Max von Pettenkofer (Wikipedia)

science, explored cholera extensively. Having studied Snow’s work, he investigated water provisions in Munich and concluded that Munich’s water supply was not the problem. He went on to develop a cholera theory that required three factors to cause disease: the presence of live organisms (not yet discovered), proper soil conditions where the organisms can develop, and a susceptible host.

Finally, in 1884, Robert Koch “discovered” again the offending

Robert Koch's Egyptian team. Koch is 3rd from right. (Wikipedia)

organism during a trip to Egypt. He does not seem to have known about Pacini’s work. As the leading bacteriologist of the time, Koch was able to culture the vibrio and study its properties, techniques unavailable to Pacini. Though Pettenkofer accepted Koch’s findings, he was so assured of his soil development theory that he swallowed a pure culture of cholera vibrio, sustaining only mild diarrhea. A couple of his students who tried it, though, suffered from severe cholera. 

In India, David D. Cunningham, an army doctor in charge of cholera research, was a follower of Pettenkofer and continued to

David Cunningham (Wikipedia)

resist Koch’s thesis of direct transmission for years. But accumulating evidence overcame the last doubters and solidified the modern view of cholera transmission, pathology, and treatment. Today the disease is primarily a feature of a breakdown in water supplies and hygiene.

 

SOURCES:

 

Isaacs, J D, “D D Cunningham and the Aetiology of Cholera in British India, 1869-1897.” Medical History 1998; 42: 279-305.

 

Carboni, G P, “The Enigma of Pacini’s Vibrio cholerae Discovery.” J Medical Microbiology 2021; 70 (11): 1-7.

 

Pettenkofer, M, “Nine Propositions Bearing on the Aetiology and Prophylaxis of Cholera, Deduced from the Official Reports of the Cholera Epidemic in East India and North America.” Indian Medical Gazette 1877; April 2, May 1, July 2, and  August 1.

 

Howard-Jones, N, “Cholera Therapy in the Nineteenth Century.” J History of Medicine 1972; 27: 373-95.

 

Pollitzer, R, Cholera 1959; WHO, Geneva.

 

Evans, A S, “Pettenkofer Revisited: The Life and Contributions of Max Pettenkofer (1818-1901).Yale J Biol Med 1973; 46: 161-76.

 

Vinten-Johansen, P, et al, Cholera, Chloroform, and the Science of Medicine: A Life of john Snow. 2003; Oxford Univ Press. 

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