Disease & History: Part I

Bonaparte Visiting the Plague Victims of Jaffa
(Bonaparte visitant les pestiférés de Jaffa)
Antoine-Jean Gros ~ 1804

I began my research for the Napoleon salon(s) by thinking about medicine and wondering on the state of medical practice around the turn of the 18th century. It soon came to my attention that the first vaccine (for smallpox) was created in 1796. This was the same year that Napoleon married Josephine, and the same year that the French forces in Italy - under Napoleon's command - began a campaign against Austria.

It bears mentioning that the practice of medicine in Napoleon's time was really more of a folk art than a formal science, and theories of contagion tended to develop from inaccurate and misinformed historic beliefs.

• The early civilizations typically subscribed to theurgical beliefs which held that epidemics, plagues, pestilences, et cetera were the result of divine judgment.
• The Greco-Roman scholars followed in the traditions set forth by Hippocrates (often referred to as the father of medicine), who held that diseases resulted from an imbalance of the four humors: blood (sanguine), yellow bile (choleric), black bile (melancholic), and mucous (phlegmatic).
• In the Middle Ages, classical medicine was maintained through the efforts of the Moslem scholars who translated the ancient texts. One such scholar was Rhazes, who made major contributions to the field of medicine, and used the so-called humoral theory as the basis for his innate seed theory - which claimed that diseases such as smallpox were the result of the blood's tendency to ferment and expel waste through the pores (thus, the disease originates in the body itself).
• Around the same time, several European practitioners subscribed to the belief that diseases were caused by changes in the atmosphere, which took on an "epidemic constitution". A trademark of an epidemic atmosphere was a foul smell, fog or haze, and humidity, so that diseases were associated with swamps or bogs and believed to come out of miasmas in the earth.
• In 1546, Girolamo Fracastoro (1478-1553) published a treatise on the "specific seeds" of measles and smallpox, citing three forms of contagions: person-to-person contact, intermediate agent (such as clothes or wooden objects), at a distance (through the air).
• Miasmatic theory remained the popular belief system well into Napoleon's time though, and was certainly accepted by Thomas Sydenham (1624-89) who disproved a number of Rhazes' methods - including the use of heat therapy to treat smallpox.
• The "animalculist theory" came as a result of Anton van Leevwenhoek's (1632-1723) invention of the microscope. The subsequent discovery of micro-organisms lead to a popular belief in so-called "venomous corpuscles" - living, animated atoms that attacked the body from within.
• In 1720, Benjamin Marten & Thomas Fuller contributed to the belief that contagions were spread by infection, that is "by receiving with the breath, or through the pores", and also introduced the concept of specific causality (pestilence doesn't breed smallpox, which doesn't breed hives).
• Angelo Gatti (1724-98) dispelled the innate seee theory by showing that "variolous matter" was introduced into organisms from without and then spread from body to body. And Hermann Boerhaave (1668-1738) was one of several 18th century doctors to suggest that smallpox survivors must have something inside to make them immune.

The exact origin of smallpox is uncertain, though there is strong evidence indicating that it "jumped" from animals to humans and was much less severe in its primitive form. Smallpox is believed to have originated in Egypt sometime around the 14th century BCE - evidenced in part by the well-preserved corpse of Ramses V which has distinctive pustules on the face, arms, shoulders, and legs. Smallpox flourished in the agricultural communities that developed around 10,000 BCE, driven by two factors: a tight, susceptible community, and sustained proximity to animals bearing novel viruses. The disease reached Athens in the spring of 430 BCE from Libya (through the Port of Pireus), and raged for 2-3 years before spreading to Persia. An outbreak among the Roman army in Mesopotamia under Avidius Cassius in 164-165 CE caused the Roman soldiers to retreat from Parthia (Persia), carrying the disease with them back to Rome. This marked the beginning of the "Plague of Antonius" - named after the reigning emperor Marcus Aurelius Antonius. The plague claimed an average of 2,000 Roman lives daily for the next 15 years, and eventually took the life of Marcus Aurelius in 180 CE. In total, the plague claimed somewhere between 4-7 million Roman lives. Wars, the establishment and collapse of empires, trade caravans, and major religious movements all helped contribute to the spread of the disease through Europe and Asia. Bishop Gregory of Tours wrote an eyewitness account of smallpox ravaging Southern France and Northern Italy in 580-81. Elizabeth I was diagnosed with smallpox in her 4th year as Queen (1562). After originally denying that she had the disease at all (likely because the pockmarks left behind would have been an insult to her vanity), Elizabeth's conditioned worsened and eventually she allowed herself to be treated. Upon her recovery, she rewarded her physician with 100 marks, a plot of land in Cornwall, and a set of gold spurs belonging to her grandfather Henry VII. Elizabeth would continue to reign over England for another 41 years.

The smallpox virus (variola major) multiplied by forcing the reproductive apparatus of normal human cells to replicate smallpox instead - which then leaked out and infected other cells. An individual infected with smallpox also shed millions of infective viruses into their immediate environment from the rash on their skin and open sores in their throat. Victims were the most contagious during the first few days, but remained contagious until the disease had run its course (roughly 3 weeks). Corpses and clothing contaminated with pus were effective carriers of the virus.

• The virus shows no signs of infection in the first week.
• The first symptoms manifested themselves around the 9th day: headache, fever, chills, nausea, backache + sometimes convulsions, delirium and terrifying dreams. This prodromal stage lasted about 3-4 days.
  
• At the end of the prodrome, the fever broke and victims tended to feel as if they were recovering, then the trademark rash began: Flat reddish spots began on the face and spread to the arms, chest, back, and then the legs (the rash was denser on the face and extremities than on the center of the body).
• Over several days, the flat spots became raised pimples, then blisters, then pustules which dried up and turned into crusts or scabs. Many died during the first few days of the rash. In addition, skin sometimes sloughed off in large pieces, and partial or complete blindness often resulted. The virus could also attack internal organs such as the heart, liver, and kidneys, which is how it killed (roughly 1 in 4 people died of smallpox).

Medicine continued to be considered something of a superstitious folk art until Louis Pasteur and his contemporaries Claude Bernard and Robert Koch developed a scientific method in medical practice toward middle of the 19th century. As such, cures for disease were widely varied and typically determined by an individual's unique circumstances (rather than a universal set of symptoms).

• The Theurgists recommended appeasing the angered deity and/or avoiding sinful behavior.
• The humoralists advocated bleeding or otherwise purging the body of excessive humors to restore balance.
• Rhazes' innate seed theory recommended heat therapy - thought to help expel foul humors through the pores, it was a remarkably inappropriate technique for treating a disease marked by hysteria inducing fevers.
• The miasmatic theory tended to advise cleaning up one's environs or moving altogether.
• Early contagionists tended to flee the infected environment as well, but also advocated the quarantine of infected individuals.
• Inoculation came out of Asia and became widely popular in Europe during the early 18th century.
• Edward Jenner (1749-1823) discovered a vaccine for smallpox after hearing of immunity among milkmaids who had contracted cowpox. Jenner's 1797 submission to the Royal Society was rejected, but an outbreak of cowpox the following year gave him an opportunity to conduct more research and publish the results himself.
  

In 1629, parishes in London began registering church burials by cause of death, which provided an accurate record of the importance of smallpox in history:

From 1647-1700 there was an average of 200 deaths per 100 thousand people per year.
From 1701-1800 there was an average of 300 deaths per 100 thousand people per year.
There were reports of inoculation in Europe in the early 1700s, but these were mostly ignored by doctors. It wasn't until a small handful of influential individuals (including Voltaire) took up the cause for inoculation that it gained some popularity in Europe. Inoculation is accomplished by inserting pus or powdered scabs from a previously infected person into the skin of a susceptible person. The inoculated patient then developed a much milder rash or illness, though they were still contagious. Vaccination, on the other hand, is the insertion of cowpox or a similar virus into the skin. Vaccinated individuals rarely developed so much as a rash and were not contagious unless they had smallpox at the time of vaccination. While inoculation made an individual immune for life, vaccination had to be performed every few years. The popularity of inoculation was erratic in France during the 18th century, and was even banned after being blamed for an outbreak of smallpox in Paris in 1762. The process was reestablished in France following the death of Louis XV (from smallpox) and subsequent inoculation of Louis XVI in June of 1774.

After Jenner performed the first human arm-to-arm vaccination (via humanized cowpox), the Duke of York sent Joseph Marshall and John Walker to work spreading the vaccine in Gibraltar, Minorca, and Malta - one sailor was vaccinated, which started the whole chain. After Malta was cleared, the vaccine traveled to Egypt and gave the English forces there a significant advantage against the plague-ravaged French army - to speed up his retreat, Napoleon ordered the poisoning of all disease stricken soldiers. The Duke of York then ordered the vaccination of the entire British army in 1802. During the brief peace in 1802-3, Marshall traveled through Paris, Genoa, Rome, and Turin spreading vaccination. When Marshall arrived in Paris, he joined Edward Jenner's nephew George at a dinner in Jenner's honor. Once Napoleon was emperor, he ordered 100,000 Francs to promote and encourage vaccination as well as the vaccination of the entire French army. A vaccination medal was also commissioned with a depiction of Napoleon on the front, and a small cow and lancet on the back. On several occasions Napoleon went so far as to release English prisoners at Jenner's request, and is famously quoted as saying in one such instance:

"Ah, Jenner, je ne puis refuser a Jenner"
[Ah, Jenner, I cannot refuse Jenner anything]

The global eradication of smallpox was certified by the World Health Assembly on 8 May 1980 - though there are still a number of viruses in containment around the world as a residual effect of germ warfare programs.