The Millennium in Infectious Diseases: Focus on the Last Century 1900-2000

Vincent A. Fulginiti, MD

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In This Article

Nineteen Hundred

The year is 1900. . . . What societal factors influenced health, particularly of susceptibility and occurrence of infectious diseases? Which infectious diseases were prevalent? What ideas about causation and treatment were in vogue? Who were the leaders in thought and action in relation to infectious diseases?

Dietary principles were primitive and misleading. For example, despite earlier reports of benefits of such elements as vegetables, fruits, and meats, some experts often recommended that they be excluded from the diet. Sanitation was deplorable in many sectors of society and inadequate in most. Public health concepts were not developed in sophisticated fashion, and poverty remained a major residual of the industrial revolution in the previous century.[1,6,20]

In the years immediately preceding 1900, Pasteur, Behring, Metchnikoff, Koch, and others began what became the modern era in understanding infectious diseases.[1,6,9] Prior to this period, various "theories" of contagion were based on mythology and "inspired belief" without any observable foundation. In New York City there was no running water, no sewage system, extensive poverty, and a lack of knowledge of any hygienic principles. As a result, infectious diseases were rampant: diarrhea claimed the lives of three fourths of the children under age 5 by one account; neonatal tetanus preoccupied physicians of the day; diphtheria, scarlet fever, respiratory diseases and tuberculosis were all too common, and; noninfectious diseases occurred based on the lack of nutritional knowledge - these diseases then contributed to susceptibility to infection.[3,4,6,7,8,12,14,20,22,24,27,31]

Spread of knowledge was limited. The American Pediatric Society was one professional group that attempted to disseminate to other physicians what was known by experts.[3,7] At its meeting in Deer Park, Maryland, in June 1899, 28 papers were read to 24 attendees. Case demonstrations, small sections, presentation of fresh autopsy specimens, and lanternslide demonstrations complemented reading from the textbooks of the day. Among the subjects covered were the operative treatment of tuberculous peritonitis and the diagnosis and treatment of typhoid in children. In the latter case, some decried the current methods of treatment, such as cold-tubbing (immersion of children with typhoid fever into cold bath water in an attempt to overcome the fever and chills) and highly restricted diet.

At the same meeting a year later, Henry Koplik (who gave his name to the intraoral "spots" in early measles) spoke on "The Ambulatory and Hospital Management of the Gastrointestinal Derangements of Infancy in the Summer Months Among the Poor of Large Cities." He noted the dire outcome and the spread of diarrhea between hospitalized infants. He suggested a system of separate "huts" to prevent cross-infection. Others reported on nephritis complicating influenza, epidemic poliomyelitis, and blood counts in children with infections. Faber and McIntosh summarize the early 20th century state of affairs under the rubric, "Dark Ages of Pediatrics" with a few "streaks of dawn just beginning to lighten the sky." Dogmatism characterized many theories at the time, and many health professionals were not privy to new knowledge, even as others attempted to systematically study and understand basic biologic mechanisms in humans and in the subhuman world. Some breakthroughs did make it from the 19th into the 20th century: the contagious nature of infected milk; isolation of endotoxins in the gut; the discovery and application of diphtheria antitoxin; the introduction of lumbar puncture as a tool for precise diagnosis. The publication of Emmett Holt's classic, The Diseases of Infants and Children, complemented Osler's The Principles and Practice of Medicine and did for children what Osler did for adults. (Both Holt and Osler were founders of the American Pediatric Society and both served as President of the organization.)[3,7,12]

Some insight into medical thought of the era is provided in Steadman's treatise, Twentieth Century Practice of Medicine: Volume XIII, Infectious Diseases, published in 1895.[20] A discussion of some salient points from this text follows.

Ptomaines, toxins, and leucomaines were considered the principal pathogenic mechanisms for bacterial disease. The bacterial discoveries of Davaine & Pollender, Pasteur, and Koch converted the focus on a "contagium vivum" of a previous era to bacteria as the cause of many animal and human diseases. Mechanisms for the production of ill effects on humans were derived from faulty reasoning, eg, anthrax bacilli were thought to produce disease by competing for oxygen with the host; other bacteria were believed to destroy red blood cells as the sole mechanism for disease production. Other theories abounded: bacteria consumed sterols (proteids then); they interfered mechanically by blocking capillaries and, as proved to be true for some but not all bacteria, by production of toxins.

For cholera, diphtheria, tetanus, tuberculosis, glanders, and suppurative infections, the following quote gives some idea of the overall thought of the day, "An infection arises when a specific pathogenic microorganism, having gained admission to the body and having found conditions favorable, grows and multiplies, and in so doing elaborates a chemical poison which induces its characteristic effects." This chemical poison was characterized as "ptomaine." This description might well fit our understanding of some of these diseases even today, but other explanations of that era were speculative and erred because of lack of epidemiologic, microbiologic, and immunologic information. For example, Harold Ernst discusses the "racial influence" on disease by mistaking geographic occurrence in Africa to the black population's propensity for that disease occurring there. Other thoughts of the time were similarly misguided. For example, the pathogenesis of malaria was misunderstood because it was patterned after water-borne diseases such as typhoid and cholera. An elaborate theory was generated as follows; mosquitoes were infected and transferred the parasite to their offspring, who then ate the parents and thus released the agent into the water from whence it infected humans. Others postulated air or soil as the means of transmission, but no one, at the time, understood the true nature of transmission of disease by the bite of a vector.

However, despite the lack of specific knowledge in some areas and woefully inadequate therapy for serious infectious diseases, some improvement in morbidity and mortality did occur.[1,25] These reductions were undoubtedly related to other changes in the environment, such as some public health measures put in place to improve sanitation, pasteurization of milk, and other measures. One can see declines in tuberculosis, diphtheria, pertussis, and streptococcal disease prior to full understanding of pathogenesis and epidemiology and before specific therapies were discovered and applied. Kass attributes some of these improvements to the institution of "household service," by which he means the absorption of many of the poor classes of the times into households, rather than their subsisting in dreadful urban or rural settings that contributed to malnutrition, lack of adequate sanitation, generational poverty, and other malign influences.[25] By serving in households, better food was available, poverty decreased somewhat, and housing, crowding, and sanitation improved. This phenomenon was particularly evident in England, but also occurred in America to some extent.

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