WEBVTT

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Prof: As you know,
one of the long-term themes in

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our course has been intellectual
history,

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and the impact of epidemic
diseases on that.

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And this morning,
in that light,

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I'm going to be looking at one
of the great medical debates--

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in particular,
a great medical debate of the

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nineteenth century--
which was the so-called debate

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between contagionism and
anticontagionism.

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Now, why would we be interested
in it?

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First of all,
if we're going to understand

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nineteenth-century medicine,
we have to realize that if you

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were to go back,
say, to reading The

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Lancet, one of the major
medical journals of the

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nineteenth century,
or say the Proceedings of

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the French Academy of
Medicine,

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you would see that they
were--one of the leading issues

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that was being hotly debated was
the rights and wrongs,

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the scientific evidence for and
against,

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the idea of contagionism,
and its opponents,

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the idea of anticontagionism.

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This was really a hot-button
topic in nineteenth century

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medicine.

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It consumed the middle decades
of the century.

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So, if we're going to--if part
of our course is to understand

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what was happening in the world
of medicine, well this debate

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was really crucial in it.

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Another part of our interest in
this debate is that it brings to

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a conclusion much of our
consideration of Asiatic

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cholera.

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We've talked about the impact
of cholera, and we need to

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recognize that its impact was
partly in the realm of ideas.

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Its legacy didn't include just
death, fear, social tension.

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It didn't just leave behind it
sewer lines and water pipes,

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in Britain, the broad
boulevards of Paris and Lyon,

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the rebuilt Lower City of
Naples;

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in addition it left behind it a
major debate on the causes of

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disease, and epidemic diseases
in particular.

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And this is the debate between
contagionism and

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anticontagionism.

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It's useful for us to turn to
this debate also because it

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helps us to prepare the ground
for one of the most important

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discoveries in the history of
science,

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and certainly medical science,
and that's the establishment of

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the germ theory of disease,
which is our topic for next

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week.

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So, what we'll want to do then
is we'll be moving towards the

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victory of contagionism.

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This is a debate then that
really mattered in medical

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history.

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Now, in discussing this issue,
there are a couple of pitfalls

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that I think we ought to avoid.

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They're distorting and make it
difficult for us really to

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understand history in general,
and history of science in

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particular.

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Let me point out two pitfalls.

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The first is a possibility of
what's been called the Whiggish

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view of history.

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In its application to science,
it sees history of science as a

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linear, upward march of truth,
moving steadily forward over

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ignorance and obscurantism;
that is, a history of constant

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progress.

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And it's reinforced if our
history of science deals and

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examines exclusively the ideas
that finally triumph,

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so that we study only a
constant progress,

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the march from one great idea
to the next.

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Another possible danger and
pitfall is what's called

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presentism,
which I might define as the

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rather smug view that science
all along has been striving,

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almost in Lamarckian manner,
to make the benighted people of

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the past finally emerge as smart
as we are,

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and we get to look back
condescendingly on the thinkers

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of past centuries,
giving them marks for how right

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or how wrong we now know that
they were.

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So, to avoid those pitfalls,
what I'd like to do is to

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approach this in a different
spirit.

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Next time I will take the more
traditional path of looking at

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the victorious germ theory of
disease,

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and at that point we'll pay our
respects to the famous trio of

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nineteenth-century science that
you all know of:

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Louis Pasteur,
Robert Koch, Joseph Lister.

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And in doing that,
we'll notice that what

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triumphed wasn't only
disembodied scientific truth--

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I'm not disputing,
let me stress this,

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I'm not going to be disputing
the truth of the germ theory of

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disease.

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But what I'll want to do is
something a little more subtle,

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which is to notice that what
triumphed wasn't just

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disembodied truth,
but also a worldview,

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and that when that worldview
won out,

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there were some losses as well,
that went with it.

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The germ theory of disease is
one of the greatest advances in

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the history of science.

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But we need to argue that
although true,

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it perhaps wasn't the entirely
of truth,

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and that its establishment as a
reigning orthodoxy,

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by the end of the nineteenth
century--

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because it does,
in fact, come to be held by the

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entirety of the international
medical community really after

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around the 1890s or so.

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And that brought with it one of
its consequences--

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an unintended one--was certain
negative impacts on

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understanding of disease that
we'll be talking about.

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And to understand and
appreciate this fact,

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I'm going to concentrate this
morning not on the victors--

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you know about them already,
to some extent,

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and we'll be turning to them
for the whole of next week--

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but I'd like to look instead at
someone you probably don't know,

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or maybe not know at all.

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In fact, just out of curiously,
before we talked about him in

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our course and reading,
how many of you had actually

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heard of Max van Pettenkofer?

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See, that's what I suspected,
actually no one had heard of

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Max van Pettenkofer.

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All the more reason we're going
to--the good news for you is

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we're going to be dealing with
him for the next forty minutes

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or so.

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He's the most sophisticated and
scientifically robust of those

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who were, as we might call,
wrong.

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He lived from 1818 to 1901,
and one of the great figures of

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nineteenth century medical
science,

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although his scientific defeat
was total and humiliating by the

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1890s.

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And, indeed,
that might form part of the

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background to the fact that he
was to commit suicide at the

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turn of the twentieth century,
when he shot himself.

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But I'm going to try to
understand that he was not just

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simply wrong,
but I'll argue that he was

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splendidly wrong;
that his mistaken ideas

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actually saved millions of
lives,

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and that their defeat had a
paradoxical consequence,

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not only of advancing medical
science,

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but in some ways impoverishing
it, in ways that are important

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and that we might want to
consider.

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Well, who was Max van
Pettenkofer?

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And since you hadn't met him
before, let me introduce you to

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him.

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And here he is, in splendor.

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And he was a German scientist
and physician.

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In particular--map of
Germany--Pettenkofer is

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associated with Bavaria,
here in the south of

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Germany--let's look at that a
little more closely--

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and he was associated
especially with the city of

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Munich.

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And I'm pointing this out to
you, not simply so that you'll

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know where he's from;
although that's nice to know.

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But this is extremely
significant in his theories,

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in that he tends to be the
defender of localism and the

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autonomy of Bavaria and Munich,
against the centralizing

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tendencies of Germany as a
whole.

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So, it has a political
significance that we'll be

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turning to.

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Now, what were his social
origins?

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Who was he?

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He came from a Catholic family
of very modest means but lots of

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children.

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And the family,
that is his nuclear family,

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didn't really have the means to
afford him with a higher

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education,
and he gained that because of

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an uncle.

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He had a wealthier uncle,
who was a prominent apothecary,

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but alas, had no sons,
and he wanted his nephew,

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Max, to carry on the family
business.

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So, Max van Pettenkofer started
out life by studying pharmacy

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and chemistry,
and this, in fact,

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was to have an impact on his
medical theories.

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But he soon discovered that he
hated the subjects he had

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originally enrolled in to study,
and he terminally disappointed

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his uncle when he enrolled as a
medical student.

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And he gained his medical
degree in 1843 from the

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University of Munich.

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Thereafter, he had a varied
career for a few years,

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casting about for what he
wanted to do in life.

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He worked for a while for a
mint, and he even had a failed

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attempt to become a stage actor.

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But in 1847,
he gained appointment to the

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medical faculty at Munich,
and became also a professor of

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organic chemistry.

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From then on,
he enjoyed a meteoric career as

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one of the rising stars of
science in Bavaria and Germany,

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and Europe in general.

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He became advisor to the
Bavarian Government,

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and a full Professor of
Medicine in 1853.

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Now, 1854 changed his life,
and it did so in relationship

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to an outbreak of Asiatic
cholera in Germany.

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And it's interesting that this
is the very same epidemic that

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Snow studied in London.

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But whereas Snow was a
contagionist,

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Pettenkofer reached the exact
opposite conclusion;

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indeed, thereafter he became a
lifelong opponent of Snow's

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ideas and what he referred to,
with scorn, as "the

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English water mania."

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The English,
he said, were obsessed with

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water.

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Well, what was the debate and
why was it so passionately held?

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Now, the debate was obviously
about the issue of whether

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diseases are contagious or not.

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But it didn't involve all
disease.

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No one doubted,
in the nineteenth century,

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that syphilis,
for example,

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was contagious.

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The debate was about a subset
of diseases,

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five in particular:
leprosy, typhus,

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and then what we might call
"the big three":

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plague,
yellow fever and cholera.

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In other words,
the debate centered on the

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diseases that were the most
feared diseases of the

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nineteenth century,
and so the debate was

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passionate because it concerned
diseases that were extremely

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important.

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And it wasn't just a matter of
academic disagreement.

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The decision on whether you
defined a disease as contagious

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or not had a practical
importance.

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It meant what are going to be
the public health strategies

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that you'd devise to combat it?

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And the European powers were
greatly divided as to whether

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they should defend themselves by
quarantine, the great

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contagionist measure,
or not.

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Well the two sides in the
debate then were contagionism

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and anticontagionism.

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Let's start with contagionism.

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This wasn't a new idea at all
in the nineteenth century.

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But it was unknown to the
Greeks.

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But it was part of biblical
tradition.

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And you've heard of its
popularization already by the

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Italian physician Fracastoro in
the sixteenth century.

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Contagionism had a widespread
importance in popular culture as

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well.

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The contagionist idea,
by the nineteenth century,

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was that there was some
infectious material.

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Some people thought it was a
poison--a chemical,

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in other words.

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Others, that it might be--it
was pure speculation--

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a living entity,
an animalcule--you'll see that

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word in John Snow,
for example,

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in one of his speculative
moments--

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that was transmitted in some
manner,

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perhaps person to person,
perhaps through the pores,

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perhaps by contact with a sick
person,

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perhaps by objects that had
been in contact with that

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person.

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And you've just been reading a
very powerful expression of the

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contagionist position,
and that's the work of John

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Snow.

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But an important thing to
remember was that down to the

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1890s,
contagionism--and this may

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surprise you--
was primarily the standpoint of

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popular culture,
rather than of the medical

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elite.

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Whereas anticontagionism
dominated the international

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medical profession.

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Most men of science regarded
contagionism as a view held by

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the ignorant and the
superstitious,

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and indeed the irony is that
contagionism reached a nadir,

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in respectability,
just before the work of Koch

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and Pasteur demonstrated its
ultimate vitality.

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To understand that,
take an example that by now you

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know extremely well,
and that is plague.

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To the layman,
the spread of plague seemed to

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justify the idea that by some
means,

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that people still didn't
understand,

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it spread from one person to
another.

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But to the learned physician,
the case for contagion still

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seemed weak.

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There wasn't a mechanism to
explain what it was,

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how it was transmitted.

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In many cases,
close inspection seemed to

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demonstrate that the disease
spread without the direct

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contact that the contagionist
view seemed to postulate.

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People caught the plague who
hadn't been in immediate contact

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with another plague victim.

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Conversely, where there was
such contact,

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often the plague didn't spread,
and people who cared for a

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plague victim sometimes didn't
fall ill.

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How could that be explained?

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Furthermore,
epidemics of plague began and

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ended in the most mysterious
manner, that no one could

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plausibly explain.

17:41.269 --> 17:45.919
And to strengthen their case,
the contagionists would need to

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discard their theory of
inanimate contagion,

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replacing it with something
that was living.

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Furthermore,
there was the need for the idea

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of transmission of over
distance, by water perhaps,

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food supplies,
or later, we'll see,

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insect vectors.

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But the debate was also fueled
by political conclusions,

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by politics,
because major conclusions

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followed from the position that
one adopted.

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Contagionists,
in their scientific

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conclusions, were people who
buttressed the power of the

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state.

18:26.450 --> 18:31.090
Because in the name of state
power, one could institute the

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most draconian measures:
cordons, lazarettos,

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quarantine.

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You could sequester and confine
individuals, you could limit

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civil liberty,
and you could radically control

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the movement of goods and of
trade.

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So, one of the results then of
contagionism--you can see here

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the idea.

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Here you have cholera,
yellow fever and plague trying

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to enter the citadel at the
gates.

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And here we have quarantine and
the draconian measures that

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follow from that.

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Cleanliness,
you know--by now,

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you're experts on the filth
theory of disease and the

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measures to be adopted against
it.

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The idea of contagionism
buttressed those ideas of a

19:29.344 --> 19:33.774
strong, powerful state
interventionism.

19:33.769 --> 19:37.979
Let's turn then to their
opponents, the

19:37.979 --> 19:43.189
anticontagionists,
the people who were skeptical

19:43.185 --> 19:47.835
with regard to the ideas of John
Snow.

19:47.838 --> 19:53.798
These were largely associated
with the political left.

19:53.799 --> 19:55.679
Why?

19:55.680 --> 20:01.650
Anticontagionism implied free
trade.

20:01.650 --> 20:07.150
It was associated with
liberalism, and with the defense

20:07.145 --> 20:13.655
of individual liberties against
arbitrary state bureaucracies.

20:13.660 --> 20:18.320
It implied opposition to
extreme, and sometimes violent,

20:18.316 --> 20:21.276
plague measures of public
health.

20:21.278 --> 20:26.188
So, it wasn't by coincidence
that it was a good idea to look

20:26.193 --> 20:29.783
at a map of Germany,
because the most important of

20:29.784 --> 20:32.114
the contagionists,
Robert Koch,

20:32.111 --> 20:38.161
was an icon and promoter of the
power of the centralized German

20:38.161 --> 20:39.041
state.

20:39.038 --> 20:42.678
He worked in Berlin,
and that wasn't by chance,

20:42.679 --> 20:46.159
and he defended the
centralizing and imperial

20:46.160 --> 20:48.850
interests of the German Reich.

20:48.848 --> 20:52.588
Whereas Pettenkofer was a
liberal,

20:52.588 --> 20:57.378
who championed the local
interests of Bavaria and Munich,

20:57.380 --> 21:01.780
and indeed his theories
coincided--both medically and

21:01.779 --> 21:06.409
politically,
they were sometimes referred to

21:06.410 --> 21:07.820
as localism.

21:07.818 --> 21:13.508
Another way of seeing the
stakes in this debate is to

21:13.508 --> 21:18.978
remember that Britain long
opposed the contagionist

21:18.978 --> 21:23.948
position,
in part for political and

21:23.951 --> 21:26.431
economic reasons.

21:26.430 --> 21:29.880
That is to say,
Britain was ranged in the

21:29.875 --> 21:34.955
international conferences
largely with anticontagionists;

21:34.960 --> 21:39.780
in part because its interests
prospered best through free

21:39.784 --> 21:42.554
trade,
and it felt threatened by

21:42.549 --> 21:47.409
medical arguments that implied
that the state should interfere

21:47.405 --> 21:51.795
with commerce,
impounding British ships and

21:51.801 --> 21:56.141
quarantining their crews for
forty days.

21:56.140 --> 22:00.490
The anticontagionists also had
the imprimatur,

22:00.491 --> 22:03.201
should we like,
of tradition,

22:03.201 --> 22:06.491
of the authority of tradition.

22:06.490 --> 22:11.280
Their views were sanctioned by
Hippocrates and Galen,

22:11.278 --> 22:15.418
and were buttressed by a whole
panoply of ideas that had grown

22:15.415 --> 22:19.855
up later but were,
if we like, compatible with the

22:19.859 --> 22:23.269
traditional practice of
medicine,

22:23.269 --> 22:26.839
with the idea of atmospheric
influences,

22:26.838 --> 22:30.228
of the epidemic constitution,
as it was called--

22:30.230 --> 22:33.540
a bit of jargon for you--of the
atmosphere.

22:33.538 --> 22:39.028
And it was compatible with the
filth and miasmic theory.

22:39.029 --> 22:43.799
Let's also remember that
anticontagionism inspired some

22:43.804 --> 22:48.494
robust health measures as well,
and it saved lives.

22:48.490 --> 22:52.300
Anticontagionism was the view
of people like Chadwick,

22:52.297 --> 22:54.877
whom you know now,
and his associate,

22:54.883 --> 22:56.323
Southwood Smith.

22:56.318 --> 23:00.298
It was the view of Haussmann
and the Second Empire,

23:00.300 --> 23:04.840
and it was the official
doctrine of risanamento;

23:04.838 --> 23:08.948
that is, the rebuilding of
Naples.

23:08.950 --> 23:12.130
Now, in the history of medicine
and public health,

23:12.130 --> 23:17.340
and epidemiology,
the cholera epidemic of 1854

23:17.335 --> 23:21.705
looms large,
giving rise to two foundational

23:21.707 --> 23:26.307
texts of epidemiology,
on opposite sides of the debate.

23:26.308 --> 23:28.738
On the one side we see John
Snow;

23:28.740 --> 23:32.190
and you've read his On the
Mode of Communication of

23:32.192 --> 23:35.872
Cholera,
the final version of which--it

23:35.868 --> 23:41.128
was first drafted in 1849,
but the draft that you have

23:41.134 --> 23:43.884
appeared after this event.

23:43.880 --> 23:47.220
And this was the classic
statement of the contagionist

23:47.215 --> 23:50.355
view,
to the extent that it could be

23:50.361 --> 23:55.471
supported without the definitive
evidence later provided by

23:55.467 --> 23:56.697
microscopy.

23:56.700 --> 24:00.780
So, Snow did everything that it
was possible to do,

24:00.775 --> 24:04.845
purely on the basis of
epidemiological evidence.

24:04.848 --> 24:09.978
There was going to need to be a
conceptual shift in order to

24:09.983 --> 24:14.863
clinch his view and demonstrate
it so that it was broadly

24:14.857 --> 24:15.987
accepted.

24:15.990 --> 24:20.010
On the other side,
we see a book that's been--it's

24:20.009 --> 24:24.849
not even on our own reading
list--a book that's been largely

24:24.851 --> 24:26.001
forgotten.

24:26.000 --> 24:31.550
This is Max van Pettenkofer's
work called Investigations

24:31.546 --> 24:36.806
and Observations on the Method
of Spread of Cholera,

24:36.806 --> 24:38.906
published in 1855.

24:38.910 --> 24:44.650
And this--I should say that
Pettenkofer was no less rigorous

24:44.651 --> 24:48.351
as an epidemiologist than John
Snow.

24:48.348 --> 24:51.858
And this was a major
foundational text in

24:51.855 --> 24:53.165
epidemiology.

24:53.170 --> 24:57.630
It was a study of the 1854
epidemic in Bavaria,

24:57.625 --> 25:03.435
reaching conclusions that were
diametrically opposed to those

25:03.436 --> 25:04.596
of Snow.

25:04.598 --> 25:10.828
From 1854, cholera became a
lifelong preoccupation of Max

25:10.826 --> 25:15.236
van Pettenkofer,
and he devoted himself to the

25:15.241 --> 25:18.341
epidemiological study of the
disease,

25:18.338 --> 25:24.498
staking his reputation on high
profile debates with Robert

25:24.502 --> 25:25.262
Koch.

25:25.259 --> 25:28.749
He was to write some two
hundred articles and books

25:28.750 --> 25:32.240
during his lifetime,
on a whole range of scientific

25:32.240 --> 25:33.010
topics.

25:33.009 --> 25:36.959
But the largest number,
about sixty,

25:36.961 --> 25:43.511
were devoted to cholera,
and its transmission and cause.

25:43.509 --> 25:48.899
So, Pettenkofer--and the reason
we're dealing with him now is he

25:48.897 --> 25:51.937
was the last major,
and the best,

25:51.938 --> 25:55.858
defender of the
anticontagionist doctrine,

25:55.859 --> 25:58.629
of miasmatism, in other words.

25:58.630 --> 26:02.650
And he defended it until his
death at the dawn of the

26:02.652 --> 26:04.202
twentieth century.

26:04.200 --> 26:08.370
He adopted the traditional
doctrine, dating back to

26:08.368 --> 26:12.698
antiquity, but provided it with
a new evidence-based,

26:12.704 --> 26:15.044
scientific underpinning.

26:15.038 --> 26:20.968
Well, why was Pettenkofer not
convinced by Snow when it came

26:20.971 --> 26:22.281
to cholera?

26:22.279 --> 26:25.149
Part of the reason you know.

26:25.150 --> 26:28.590
Contagionism,
Pettenkofer said--and in this

26:28.593 --> 26:33.763
he was right--it didn't produce
a really plausible mechanism for

26:33.758 --> 26:36.708
the transmission of the disease.

26:36.710 --> 26:41.280
It correlated cholera cases
with drinking water.

26:41.279 --> 26:45.439
But to Pettenkofer,
there seemed no means of

26:45.441 --> 26:50.281
explaining exactly what was
transmitted, or how.

26:50.279 --> 26:54.729
Also, as you know,
Pettenkofer had been trained as

26:54.729 --> 26:57.609
a chemist,
and he looked at the

26:57.613 --> 27:02.383
traditional idea that the
cholera poison was some sort of

27:02.381 --> 27:06.571
chemical substance,
and he argued that it was

27:06.566 --> 27:11.636
entirely improbable that a
disease could be spread then in

27:11.643 --> 27:13.873
the manner postulated.

27:13.868 --> 27:18.958
Looking at London and the River
Thames, how could a poison

27:18.957 --> 27:23.057
contaminating the Thames,
if it was a chemical,

27:23.061 --> 27:25.741
not be infinitely diluted?

27:25.740 --> 27:29.260
Furthermore,
he said there was a whole

27:29.259 --> 27:34.679
series of what we might call
cholera mysteries that Snow's

27:34.680 --> 27:38.390
position didn't help to
illuminate.

27:38.390 --> 27:44.960
Why did an epidemic start,
and why did it end?

27:44.960 --> 27:50.260
Why could doctors provide their
services in the midst of an

27:50.262 --> 27:55.752
epidemic of cholera and yet not
fall ill of it themselves?

27:55.750 --> 28:00.060
What caused the pronounced
seasonality of cholera?

28:00.058 --> 28:04.408
Why was its onset almost
invariably in the spring and the

28:04.410 --> 28:05.110
summer?

28:05.108 --> 28:10.708
And why did an outbreak always
seem to ebb with the onset of

28:10.713 --> 28:12.143
cold weather?

28:12.140 --> 28:14.630
And then lastly,
for the moment,

28:14.626 --> 28:18.716
there was what we might call
the problem of Lyon;

28:18.720 --> 28:22.480
that is, the great second city
of France.

28:22.480 --> 28:27.240
If cholera is contagious,
and if it follows the great

28:27.236 --> 28:31.166
routes of trade and population
movement,

28:31.170 --> 28:34.110
why is it that there are,
nonetheless,

28:34.108 --> 28:39.008
major centers that escaped
throughout the nineteenth

28:39.009 --> 28:39.969
century?

28:39.970 --> 28:44.750
Lyon was the second largest
city in France,

28:44.750 --> 28:49.540
located at the hub of a network
of trade and transportation,

28:49.538 --> 28:54.648
and it had all the--it was a
great textile center of

28:54.646 --> 28:58.756
manufacturing--
and it had all the urban

28:58.756 --> 29:03.366
problems of an industrial center
at its time.

29:03.368 --> 29:08.458
If ever, Pettenkofer would say,
there was a city that seemed

29:08.460 --> 29:12.430
primed to be devastated by
Asiatic cholera,

29:12.430 --> 29:16.700
it was Lyon,
and yet it escaped the

29:16.701 --> 29:22.481
visitations of this exotic
Asiatic outsider.

29:22.480 --> 29:25.250
Well, what was Pettenkofer's
theory?

29:25.250 --> 29:31.770
And it was his delight to
believe that he could provide an

29:31.773 --> 29:36.353
apparently clear,
epidemiologically-based

29:36.352 --> 29:42.192
explanation for all of those
cholera mysteries.

29:42.190 --> 29:47.010
Indeed, another aspect of his
theory--that Robert Koch

29:47.010 --> 29:50.650
discovered the Vibrio
cholerae.

29:50.650 --> 29:54.070
You've seen a picture of the
Vibrio.

29:54.069 --> 29:58.439
And he discovered it in 1883.

29:58.440 --> 30:03.880
Pettenkofer didn't reject the
idea of the Vibrio.

30:03.880 --> 30:09.410
Instead, he incorporated it
elegantly into his larger

30:09.414 --> 30:12.944
theory,
explaining that it played a

30:12.944 --> 30:18.394
role in the etiology of cholera,
but that its role and its

30:18.392 --> 30:23.362
mechanism were completely
different from the ones that

30:23.356 --> 30:24.946
Koch espoused.

30:24.950 --> 30:29.340
Pettenkofer's theory is often
referred to as the groundwater

30:29.339 --> 30:30.009
theory.

30:30.009 --> 30:32.199
We've seen it can be called
localism.

30:32.200 --> 30:36.990
It can be called the
groundwater theory.

30:36.990 --> 30:40.910
The simplest approach to his
method is a very simple

30:40.907 --> 30:44.437
mathematical equation,
that he was very fond of

30:44.442 --> 30:47.442
himself, for illustrative
purposes.

30:47.440 --> 30:53.860
It was perhaps the simplest of
all mathematical formulas:

30:53.863 --> 30:55.013
X Y = Z.

30:55.009 --> 30:59.249
What did that mean to Max van
Pettenkofer?

30:59.250 --> 31:03.240
Well, for him,
Z was a cholera outbreak,

31:03.240 --> 31:07.230
the result then of combining X
and Y.

31:07.230 --> 31:09.550
It's produced,
in other words,

31:09.554 --> 31:13.884
under certain specific
conditions of two other factors,

31:13.884 --> 31:16.614
the X factor and the Y factor.

31:16.608 --> 31:19.228
The X factor,
he said, was the presence of

31:19.232 --> 31:21.092
the Vibrio cholerae.

31:21.088 --> 31:26.578
You see, he accepts that the
Vibrio plays a role.

31:26.578 --> 31:30.438
But for Pettenkofer,
the Vibrio itself,

31:30.439 --> 31:33.869
on its own, would never make
you sick.

31:33.868 --> 31:39.218
You could swallow it quite
safely and remain entirely

31:39.220 --> 31:40.250
healthy.

31:40.250 --> 31:43.070
He regarded it as harmless on
its own,

31:43.068 --> 31:47.088
and as we'll see in a moment,
he carried out a famous

31:47.089 --> 31:50.719
auto-experiment in which he
tried to demonstrate

31:50.723 --> 31:53.743
conclusively the truth of his
view.

31:53.740 --> 31:56.920
In other words,
he made himself a cocktail of

31:56.915 --> 32:00.015
the Vibrio cholerae and
drank it,

32:00.019 --> 32:02.989
and, in fact,
he remained healthy,

32:02.994 --> 32:07.864
and therefore persuaded,
to the end of his life,

32:07.862 --> 32:12.942
that the Vibrio on its
own was harmless.

32:12.940 --> 32:17.650
He was to say that the
Vibrio causes disease in

32:17.645 --> 32:20.755
an entirely different,
but orthodox,

32:20.755 --> 32:22.615
miasmatic manner.

32:22.618 --> 32:28.168
The danger doesn't arise when
the Vibrio contaminates

32:28.172 --> 32:30.622
food and drinking water.

32:30.619 --> 32:32.189
The problem is different.

32:32.190 --> 32:36.180
It happens when the
Vibrio gets into the soil

32:36.180 --> 32:37.980
beneath a major city.

32:37.980 --> 32:42.720
And there, Pettenkofer used a
horticultural analogy,

32:42.721 --> 32:46.721
referring to germination or
fermentation.

32:46.720 --> 32:50.030
After the Vibrio gained
access to the soil,

32:50.029 --> 32:54.439
under certain conditions it
could germinate like a plant and

32:54.440 --> 32:57.580
give off its poison into the air
above,

32:57.578 --> 33:02.208
that the population inhaled,
and those who were susceptible

33:02.212 --> 33:07.692
fell ill in large numbers,
and it was then that you'd have

33:07.689 --> 33:10.339
the onset of an epidemic.

33:10.338 --> 33:13.458
In nineteenth-century medical
parlance,

33:13.460 --> 33:18.000
cholera was an example of a
whole category of diseases that

33:18.002 --> 33:24.632
were called zymotic diseases,
diseases caused by fermentation.

33:24.630 --> 33:29.020
So that we see the X factor
involves the Vibrio

33:29.023 --> 33:30.373
cholerae.

33:30.368 --> 33:36.318
Then the Y factor was simply
those local conditions--

33:36.318 --> 33:40.728
again localism--that were
necessary for fermentation to

33:40.727 --> 33:44.607
take place,
and for poison to be given off

33:44.605 --> 33:46.515
into the atmosphere.

33:46.519 --> 33:49.329
What makes up the Y factor?

33:49.328 --> 33:53.708
Again let's think of
horticulture and the growth of a

33:53.705 --> 33:54.375
plant.

33:54.380 --> 33:59.770
A plant doesn't need only soil
to develop, it also needs

33:59.765 --> 34:02.405
nutrients and fertilizer.

34:02.410 --> 34:07.300
And here was the critical role
of filth and excrement.

34:07.298 --> 34:12.468
They were, in Pettenkofer's
mind, the nutrients for this

34:12.467 --> 34:15.847
plant, the Vibrio
cholerae.

34:15.849 --> 34:21.519
Unsanitary urban conditions
literally fed the Vibrio.

34:21.518 --> 34:24.958
Sewage was dangerous,
not because it got into the

34:24.963 --> 34:27.743
water,
but because it seeped into the

34:27.742 --> 34:31.982
soil beneath the city,
nourishing the Vibrio

34:31.978 --> 34:34.958
and giving rise to fermentation.

34:34.960 --> 34:39.680
But there's more to it,
in Pettenkofer's epidemiology.

34:39.679 --> 34:43.429
Like a plant,
fermentation required a number

34:43.429 --> 34:45.609
of other preconditions.

34:45.610 --> 34:49.380
It needed water;
plants always need water.

34:49.380 --> 34:52.510
It needed a warm temperature.

34:52.510 --> 34:56.990
It needed air and porous soil
in which to grow.

34:56.989 --> 35:01.469
And it was at this point that
we see why Pettenkofer's theory

35:01.469 --> 35:04.829
is sometimes called the
groundwater theory.

35:04.829 --> 35:09.159
Groundwater was important to
his analysis because he

35:09.161 --> 35:14.171
considered variations in the
water table beneath the city to

35:14.172 --> 35:19.012
be a measure of the capacity of
a soil beneath the city to

35:19.014 --> 35:24.284
support fermentation and give
rise to cholera epidemics.

35:24.280 --> 35:27.970
Too high a water table would be
like flooding,

35:27.972 --> 35:30.602
and that would kill the plant.

35:30.599 --> 35:35.159
Too low a table would be like a
drought or a desert.

35:35.159 --> 35:40.249
So, for a cholera epidemic,
the ideal was an ebbing water

35:40.253 --> 35:44.443
table that left moist,
porous soil above it;

35:44.440 --> 35:48.950
a condition that was likely to
be characteristic of the early

35:48.952 --> 35:49.632
summer.

35:49.630 --> 35:53.970
And indeed, Pettenkofer now
thought he understood the

35:53.972 --> 35:56.062
seasonality of cholera.

35:56.059 --> 36:01.179
He could explain its
seasonality by reference to the

36:01.175 --> 36:05.485
water table of European and
other cities.

36:05.489 --> 36:09.999
Armed with this theory,
Pettenkofer proceeded to

36:10.003 --> 36:14.613
conduct exhaustive
epidemiological studies of the

36:14.614 --> 36:20.094
local conditions of localities
vulnerable to cholera.

36:20.090 --> 36:23.440
For Pettenkofer,
it seemed obvious why

36:23.438 --> 36:28.688
mountainous areas--the Alps,
for example--weren't afflicted

36:28.690 --> 36:30.230
with cholera.

36:30.230 --> 36:34.640
There, there was such a deep
layer of insulation between the

36:34.637 --> 36:39.047
groundwater and the population,
who were therefore protected

36:39.047 --> 36:41.137
from the cholera poison.

36:41.139 --> 36:46.619
Similarly, desert areas
provided no conditions for

36:46.621 --> 36:48.301
fermentation.

36:48.300 --> 36:54.480
Pettenkofer also thought that
he had solved the Lyon problem.

36:54.480 --> 36:59.860
By investigating and studying
Lyon, he realized that it was

36:59.862 --> 37:04.412
built on a thick layer of
impenetrable granite.

37:04.409 --> 37:08.299
It was built on stone,
and therefore provided no

37:08.304 --> 37:12.204
opportunity for fermentation and
germination.

37:12.199 --> 37:16.559
The best conditions were
provided by cities that were

37:16.563 --> 37:19.173
built at sea level,
on alluvial,

37:19.166 --> 37:20.506
porous soil.

37:20.510 --> 37:25.820
This could explain why Naples
was ravaged, Paris,

37:25.824 --> 37:27.934
London, Calcutta.

37:27.929 --> 37:31.629
And then he decided,
being an honest scientist,

37:31.630 --> 37:34.270
that he should also
investigate, in particular,

37:34.268 --> 37:37.598
the hard case,
the one that seemed to conflict

37:37.603 --> 37:41.413
with his theories,
and that was the Island of

37:41.405 --> 37:42.005
Malta.

37:42.010 --> 37:47.180
Malta was built on rock,
but it experienced disaster

37:47.184 --> 37:51.044
during recurring cholera
pandemics,

37:51.039 --> 37:53.549
and he thought,
to his own satisfaction,

37:53.550 --> 37:55.530
that he could solve the riddle.

37:55.530 --> 37:59.700
Malta, unlike Lyon,
was not built on impermeable

37:59.702 --> 38:00.592
granite.

38:00.590 --> 38:04.850
It had everything to do with
the specifics of the stone

38:04.849 --> 38:05.559
itself.

38:05.559 --> 38:10.089
Malta was built on porous,
soft limestone,

38:10.090 --> 38:14.410
and that provided infinite
air-filled cavities,

38:14.409 --> 38:17.619
that if watered and fertilized,
in warm conditions,

38:17.619 --> 38:21.899
would provide wonderful places
for germination.

38:21.900 --> 38:25.000
You can see Pettenkofer
visiting Malta,

38:24.998 --> 38:28.668
which he did,
and having his eureka moment.

38:28.670 --> 38:30.320
He did core samples.

38:30.320 --> 38:34.280
I'm trying to say that
Pettenkofer was a very

38:34.275 --> 38:38.315
conscientious research
scientist, and a strong

38:38.320 --> 38:40.030
epidemiologist.

38:40.030 --> 38:41.190
And he went further.

38:41.190 --> 38:45.750
He argued also that he could
explain not only which cities

38:45.750 --> 38:50.710
were most afflicted by cholera,
but also the very neighborhoods

38:50.710 --> 38:51.990
within them.

38:51.989 --> 38:55.309
Low-lying areas,
close to the water table,

38:55.307 --> 38:57.977
would be vulnerable to cholera.

38:57.980 --> 39:00.910
Neighborhoods built on hills
would be protected.

39:00.909 --> 39:03.459
Naples was a good example.

39:03.460 --> 39:07.140
The Lower City was ravaged,
the Upper City was not,

39:07.135 --> 39:09.925
and Pettenkofer thought he knew
why.

39:09.929 --> 39:11.729
Neapolitans,
as you know,

39:11.726 --> 39:15.846
in fact agreed with him,
and Pettenkofer's theories were

39:15.847 --> 39:17.567
much admired there.

39:17.570 --> 39:23.110
It seemed to explain Neapolitan
history, and it was his theories

39:23.110 --> 39:27.860
that were the very basis for the
rebuilding project.

39:27.860 --> 39:32.600
He saw his great achievement as
that of developing a single

39:32.599 --> 39:35.439
unified theory,
with no internal

39:35.440 --> 39:38.950
contradictions,
that could explain all the

39:38.954 --> 39:44.274
known facts of cholera,
and clarify those puzzling

39:44.273 --> 39:46.473
cholera mysteries.

39:46.469 --> 39:51.069
Now, an interesting point about
Pettenkofer's theories.

39:51.070 --> 39:54.780
They're now rejected by modern
science.

39:54.780 --> 39:59.600
But during the nineteenth
century, they provided a major

39:59.599 --> 40:03.629
impetus to undertake needed
sanitary reform.

40:03.630 --> 40:08.240
His ideas therefore can be
credited probably with saving

40:08.237 --> 40:13.097
hundreds of thousands of lives,
from a variety of diarrheal

40:13.097 --> 40:16.087
illnesses;
cholera, of course,

40:16.088 --> 40:19.438
but also typhoid,
gastroenteritis.

40:19.440 --> 40:24.190
So, this is a case of an idea
that we now know not to be

40:24.190 --> 40:29.700
robust scientifically,
that nevertheless produced very

40:29.697 --> 40:35.417
practical results that had a
major impact on combating

40:35.422 --> 40:37.692
epidemic diseases.

40:37.690 --> 40:42.350
Pettenkofer was responsible,
in fact, for bringing the

40:42.347 --> 40:44.717
sanitary idea to Bavaria.

40:44.719 --> 40:49.119
He wanted to install sewer
systems to take away waste and

40:49.121 --> 40:52.271
fecal matter,
but not for the reason that

40:52.266 --> 40:53.836
Snow would have.

40:53.840 --> 40:59.070
He wasn't worried that
Bavarians would drink infected

40:59.070 --> 41:02.490
water, or eat contaminated food.

41:02.489 --> 41:06.359
He was afraid that the fecal
matter would get beneath the

41:06.364 --> 41:09.414
city and would nourish the
Vibrio,

41:09.409 --> 41:13.789
and thereby give rise to
poisonous fumes that would

41:13.788 --> 41:15.538
poison the people.

41:15.539 --> 41:21.159
His idea was to make the soil
of Germany's cities infertile,

41:21.164 --> 41:26.224
and you could do that by
depriving the soil of organic

41:26.215 --> 41:28.595
matter and excrement.

41:28.599 --> 41:33.409
So, he wanted to supply Germany
with clean water.

41:33.409 --> 41:36.419
But not specifically clean
drinking water,

41:36.422 --> 41:40.612
but he wanted to prevent sewage
from gaining access to the

41:40.610 --> 41:43.990
groundwater and the soil beneath
the city.

41:43.989 --> 41:48.239
He also championed the idea of
sand filtration of water,

41:48.235 --> 41:50.085
to ensure clean water.

41:50.090 --> 41:55.730
He thought that Snow had been
seriously misled.

41:55.730 --> 41:57.630
There was a matter of
proportion here.

41:57.630 --> 42:02.030
Snow, he said,
was really concentrated on the

42:02.030 --> 42:05.630
few liters that a person
consumed.

42:05.630 --> 42:09.220
That water, he argued,
no matter how contaminated,

42:09.224 --> 42:11.284
would actually do no harm.

42:11.280 --> 42:15.620
The real issue was the massive
quantity of water,

42:15.619 --> 42:19.679
of domestic,
industrial or household waste,

42:19.679 --> 42:22.739
that carried fertilizer to the
city soil,

42:22.739 --> 42:25.969
and there dread disease.

42:25.969 --> 42:29.719
Now, Pettenkofer recognized
then that clean water and

42:29.717 --> 42:32.307
effective sewage,
and waste disposal,

42:32.311 --> 42:35.341
were essential public health
measures.

42:35.340 --> 42:40.010
So, he had--as his legacy,
Pettenkofer was the founder of

42:40.010 --> 42:42.930
the sanitary movement in
Germany.

42:42.929 --> 42:46.829
He was also a professor of
hygiene at the University of

42:46.829 --> 42:47.479
Munich.

42:47.480 --> 42:52.170
He founded a journal called
The Archive for Hygiene,

42:52.170 --> 42:55.270
in 1883;
and indeed it's still published

42:55.271 --> 42:59.631
as The International Journal
of Hygiene and Environmental

42:59.634 --> 43:00.674
Health.

43:00.670 --> 43:04.990
He was the founder of the Max
van Pettenkofer Institute in

43:04.994 --> 43:09.404
Munich, a world-famous research
institute, dedicated to the

43:09.396 --> 43:11.746
promotion of public health.

43:11.750 --> 43:16.640
He became its director,
and trained people.

43:16.639 --> 43:19.529
It became a center of research
and training,

43:19.534 --> 43:20.954
unique at its time.

43:20.949 --> 43:24.909
He was an important figure in
the founding of the Johns

43:24.914 --> 43:27.414
Hopkins School of Public Health.

43:27.409 --> 43:31.739
And along with his opponent,
John Snow, he was a founding

43:31.735 --> 43:34.665
father in the field of
epidemiology.

43:34.670 --> 43:38.200
His arguments,
though now largely discredited,

43:38.201 --> 43:41.421
were supported by prodigious
fieldwork.

43:41.420 --> 43:44.300
You can imagine him going
around Europe,

43:44.300 --> 43:48.050
taking core samples of soil and
rock,

43:48.050 --> 43:52.490
and correlating that with
measurements of the rise and

43:52.494 --> 43:56.774
fall of groundwater levels,
and correlating all of that

43:56.771 --> 44:00.501
information with rainfall,
temperature measurements,

44:00.500 --> 44:03.390
and the history of cholera
outbreaks.

44:03.389 --> 44:07.929
And Pettenkofer was tireless in
propagating his ideas as a

44:07.934 --> 44:09.854
lecturer, as a writer.

44:09.849 --> 44:13.929
He was an advisor to the
Bavarian government,

44:13.927 --> 44:19.577
and he became president of the
Bavarian Academy of Science.

44:19.579 --> 44:24.109
Another factor was that
Pettenkofer was quite interested

44:24.106 --> 44:28.876
in something else as well:
what made people susceptible?

44:28.880 --> 44:32.400
And he believed that poor
nutrition was an important

44:32.396 --> 44:33.566
factor in that.

44:33.570 --> 44:38.360
So, his public health policies
also involved attention to diet

44:38.362 --> 44:39.622
and nutrition.

44:39.619 --> 44:44.919
Of course, some of his
recommendations were misguided.

44:44.920 --> 44:49.430
But one measure he gave great
attention to was also the siting

44:49.434 --> 44:53.064
of infectious disease hospitals
and cemeteries.

44:53.059 --> 44:55.729
A cholera hospital,
or a cemetery,

44:55.726 --> 45:00.486
should be located on a hilltop,
far from the city center and

45:00.494 --> 45:02.034
downwind of it.

45:02.030 --> 45:06.460
That would prevent the cholera
germ from percolating down

45:06.463 --> 45:09.713
easily into the soil beneath the
city,

45:09.710 --> 45:13.890
and would ensure that any
poisonous miasma that arose

45:13.891 --> 45:17.191
would be dispersed from the
population.

45:17.190 --> 45:21.040
We can see that he helped the
way--condition--

45:21.039 --> 45:23.119
-the way Naples,
for example,

45:23.117 --> 45:26.127
was rebuilt,
and where the infectious

45:26.132 --> 45:29.622
diseases hospital in that city
was located;

45:29.619 --> 45:33.689
which was high above the city
and downwind from it.

45:33.690 --> 45:36.490
And as I said,
to prove his theory,

45:36.487 --> 45:39.857
he tried his dangerous
auto-experiment.

45:39.860 --> 45:45.110
His theory was losing ground by
1892,

45:45.110 --> 45:48.340
when there was a major epidemic
of cholera at Hamburg,

45:48.340 --> 45:53.650
in Germany, and Pettenkofer and
Robert Koch were greatly at

45:53.648 --> 45:54.288
odds.

45:54.289 --> 45:58.109
To prove his case,
Pettenkofer challenged Koch to

45:58.112 --> 46:02.732
provide him with a cholera
cocktail, that he volunteered to

46:02.733 --> 46:03.693
swallow.

46:03.690 --> 46:08.350
Koch's collaborator,
Gaffke, duly dispatched a vial

46:08.349 --> 46:13.759
filled with Vibrio.
There's some interesting ethical

46:13.755 --> 46:17.625
issues here,
as Gaffke sent Pettenkofer what

46:17.630 --> 46:20.660
he thought was a fatal dose of
cholera,

46:20.659 --> 46:26.649
and fully expected Pettenkofer
to die an agonizing death.

46:26.650 --> 46:30.200
There are then various accounts
of what happened next.

46:30.199 --> 46:34.969
One account has it that
Pettenkofer's lab assistants

46:34.972 --> 46:39.372
intercepted the package and
diluted the dose.

46:39.369 --> 46:44.209
It's also true that the cholera
cocktail was sent in February,

46:44.210 --> 46:48.290
and it may well be that the
cold temperature in transit

46:48.291 --> 46:52.981
attenuated the virulence of the
Vibrio. In any case,

46:52.980 --> 46:56.600
Pettenkofer was a man convinced
of his theory.

46:56.599 --> 47:01.589
He put his life on the line to
prove it, and he duly swallowed

47:01.588 --> 47:04.858
the vial that Koch's lab had
provided.

47:04.860 --> 47:09.290
He fell seriously ill of
diarrhea, but didn't develop the

47:09.289 --> 47:12.769
symptoms he recognized as
Asiatic cholera.

47:12.768 --> 47:16.388
He rapidly recovered,
and was convinced that he'd

47:16.391 --> 47:20.541
proved that the Vibrio
cholerae does not directly

47:20.543 --> 47:23.943
cause the disease,
not by being ingested.

47:23.940 --> 47:28.380
Well, there was an unhappy
sequel for Pettenkofer.

47:28.380 --> 47:31.200
Koch's microbiology,
by the 1890s,

47:31.197 --> 47:35.467
convinced the medical world of
the germ theory,

47:35.469 --> 47:38.009
and miasmatic doctrine of all
kinds,

47:38.010 --> 47:41.630
including Pettenkoffer's own,
were discredited.

47:41.630 --> 47:45.870
In 1894, he resigned his
university chair.

47:45.869 --> 47:50.959
In 1899, he resigned from his
other offices.

47:50.960 --> 47:54.850
In the 1890s also,
three of his five children

47:54.851 --> 47:56.711
died, and his wife.

47:56.710 --> 48:01.790
And on February 9^(th),
1901, Pettenkofer committed

48:01.793 --> 48:02.813
suicide.

48:02.809 --> 48:07.279
Well, there's a final aspect
I'd like to raise in my last

48:07.280 --> 48:10.440
minute,
and that is to say the defeat

48:10.438 --> 48:15.238
of anti-contagionism may have
had some negative legacies,

48:15.239 --> 48:18.269
that it took time to recognize.

48:18.268 --> 48:21.948
One of the strengths of
Pettenkofer's ideas was the

48:21.954 --> 48:26.604
stress they put on what we would
now call the environmental,

48:26.599 --> 48:31.469
social and economic
determinants of disease.

48:31.469 --> 48:36.149
For a time, the germ theory of
disease relegated those aspects

48:36.148 --> 48:40.518
of medicine to the background,
leading to a narrow-gauge

48:40.521 --> 48:44.371
stress on microbes,
and the attempt to find magic

48:44.373 --> 48:46.363
bullets to destroy them.

48:46.360 --> 48:50.330
So, Pettenkofer then was
ultimately wrong.

48:50.329 --> 48:54.289
But I would argue that his
ideas were magnificently wrong,

48:54.289 --> 48:57.919
and that they contained
important elements of truth,

48:57.920 --> 49:02.360
and important and vital
measures for public health and

49:02.362 --> 49:03.622
for medicine.

49:03.619 --> 49:08.489
Next time, we'll take the high
road and move on to the victors

49:08.492 --> 49:11.132
in this debate--
Pasteur, Koch,

49:11.130 --> 49:15.160
Lister--and the successful
proof of the truth of

49:15.159 --> 49:19.189
contagionism and the germ theory
of disease.

49:19.190 --> 49:22.170
But I thought you needed a
moment with Max von.

49:22.170 --> 49:28.000