Infectious Madness, the Well Curve and the Microbial Roots of Mental Disturbance

3cfce0fe054a12627f41292ec26e6b22Today’s guest post is written by Harriet Washington, a science writer, editor and ethicist. She is  the author of several books, including Medical Apartheid: The Dark History of Experimentation from Colonial Times to the Present. On Wednesday, March 15 at 6pm, Washington will discuss: “Infectious Madness, the Well Curve and the Microbial Roots of Mental Disturbance.” In this talk, based on her book Infectious Madness: The Surprising Science of How We “Catch” Mental Illness, Washington traces the history, culture and some disturbing contemporary manifestations of this ‘infection connection.” To read more about this lecture and to register, go HERE.

“Mind, independent of experience, is inconceivable.” —Franz Boas

Psychological trauma, stress, genetic anomalies and other experiences that limit the healthy functioning of the mind and brain are widely recognized as key factors in the development of schizophrenia, major depression, and bipolar disorder.  However, despite a plethora of examples and evidence of microbial disorders from rabies to paresis, infection has been slow to join the pantheon.  This aversion persists largely because the perceived causes of mental disorders have evolved not only with our scientific knowledge of medicine but also with our tenacious cultural beliefs and biases.  Instead, we have long clung to what  Robert Sapolsky calls a “primordial muck” of attribution that includes broken taboos, sin—one’s own or one’s forbears’— and even bad mothering.

Brueghel_dancingMania

Representation of the dancing mania by Flemish painter Pieter Brueghel the Younger.Source.

Flemish painter Pieter Brueghel the Younger (1564–1636) painted the above representation of the dancing mania known as choreomania or St. Anthony’s Fire, which has seized a pilgrimage of epileptics en route to the church at Molenbeek. Such compulsive dancing was originally ascribed to satanic influence such as bewitchment, and later to a collective hysterical disorder, but is now ascribed to ergotism— the  infection of rye and other grains by the fungus Claviceps purpurea.  When people ate the tainted bread, their symptoms included compulsive dancing. Some have ascribed the mass hysteria of the Salem witch trials to ergotism.  Streptoccocal infections have also produced cases called Sydenham’s chorea.

Not all traditional “causes” of mental illness are confined to the past.  As late as the 1980s, the alternating rage, coldness and oppressive affection of domineering “schizophrenogenic mothers” was taught in psychology classes as the root of schizophrenia, just as Tourette’s syndrome initially was laid to poor parenting.

For Infectious Madness: The Surprising Science of How We “Catch” Mental Illness, I interviewed scientists working on the effects of infections on mental health such as Susan Swedo, chief of the pediatrics and developmental neuroscience branch at the National Institute of Mental Health, who studies the role of Group A strep (GAS) infections in children in rapid-onset cases of obsessive compulsive disorder, anorexia, and Tourette syndrome. Other visionary researchers, such as E. Fuller Torrey, executive director of Maryland’s Stanley Medical Research Institute, and Robert Yolken, director of developmental neurovirology at Johns Hopkins University, have for decades investigated the role of microbes in mental illness and have traced the path of viruses such as influenza, herpes simplex and Toxoplasma  gondii, among other microbes, in schizophrenia and bipolar disorder.

There are a myriad of ways in which infections cause or encourage mental disease. In order to suit its own need to reproduce within the stomach of a cat, the unicellular parasite Toxoplasma gondii changes the behavior of rodents — and incidentally, use it to gain entry. This seems strange, but changing the behavior of a host to suit its own needs is a common stratagem of parasites. The Cordyceps fungus, for example, manipulates an ant in the Amazon into climbing a tree where the fungal spores can be more widely disseminated. The spore- bearing branches extend from the corpse of the ant pictured below.

Ant1

The Cordyceps fungus manipulates an ant in the Amazon into climbing a tree where the fungal spores can be more widely disseminated. The spore-bearing branches extend from the corpse of the ant.Photograph © Gregory Dimijian, MD.

Infection, redux

“Everything has been thought of before, but the problem is to think of it again.” —Goethe

There is a long, all but forgotten history of infectious theories of mental illness. In his 1812 psychiatry text Medical Inquiries and Observations upon the Diseases of the Mind, for example, Benjamin Rush, MD, included a first detailed taxonomy of mental disorders, each with its own physical cause. He cited disruptions of blood circulation and  sensory overload as the basis of mental illness, and he treated his patients with devices meant to improve circulation to the brain, including such Rube Goldberg designs as a centrifugal spinning board, or to decrease sensory perceptions, such as a restraining chair with a head enclosure.

Restraining Chair

Pictured here is the “tranquilizing chair” in which patients were confined. The chair was supposed to control the flow of blood toward the brain and, by lessening muscular action or reducing motor activity, reduce the force and frequency of the pulse.Photograph © 2008 Hoag Levins.

Paresis, an infectious mental disorder

In 1857, Drs. Johannes Friedrich Esmark and W. Jessen suggested a biological cause for paresis: syphilis. Many researchers started to view paresis as the tertiary stage of syphilis, which often attacked the brain indiscriminately, and they began referring to it as neurosyphilis. This theory held out hope that if syphilis was ever cured, paresis could be too.

Nineteenth-century asylum keepers, however, persisted in viewing paresis as wholly mental in character. The long-standing insistence on divorcing physical illnesses from mental ones had to do with religious philosophy and culture but also with the politics of the asylum, which remained a battleground between physicians and religious and philosophical healers.

Matters were complicated by the fact that most physicians, despite the evidence that paresis was the mental manifestation of a physical disease, continued to treat paretics with the same ineffectual therapeutics given other mentally ill patients. Traditional treatments such as “douches, cold packs, mercury, blistering of the scalp, venesection, leeching, sexual abstinence, and holes drilled into the skull [trephination]” continued—without positive results. Even when toxic mercury-based treatments for syphilis were replaced by Paul Ehrlich’s safer, more effective arsenic-based Salvarsan (also called arsphenamine and compound 606), it was not used against paresis.

But in June 1917, Professor Julius Wagner-Jauregg of the University of Vienna Hospital for Nervous and Mental Diseases undertook a radical approach. He had noticed that some paretic patients improved markedly after contracting an infectious illness that gave them fevers. He decided to fight fire with fire by turning one disease against another: he sought to suppress the symptoms of paresis by infecting its sufferers with malaria.

Before Wagner-Jauregg won the Nobel and Freud forged the future of psychiatry, a paradigm shift had already taken place that transformed science’s approach to the nature of disease. It is the very framework that supports the role of infection in mental illness—germ theory. Developed by Louis Pasteur and Robert Koch, germ theory posits that specific microbes such as bacteria, viruses, and prions (infectious proteins) cause illness.

For more on this fascinating topic, join Harriet Washington on Wednesday, March 15 at 6pm.  More information can be found here

Polio: A Fearful Disease Nears Its End

By Paul Theerman, Associate Director, Center for the History of Medicine and Public Health

Friday, October 24, is World Polio Day. Inaugurated a decade ago, the day is promoted by the World Health Organization, UNICEF, and Rotary International to mark the coordinated battle to eradicate polio worldwide. The date for World Polio Day honors Jonas Salk, whose 1950s polio vaccine effectively ended the epidemic in the United States. World Polio Day comes just before Salk’s birthday on October 28.

Jonas Salk. Courtesy of  the Steeltown Entertainment Project. Click to enlarge.

Jonas Salk. Courtesy of the University of Pittsburgh, via the Steeltown Entertainment Project. Click to enlarge.

Jonas Salk was born in 1914, and on the centenary of his birth, many celebrations mark his achievement. Here at the New York Academy of Medicine, we are screening a documentary about Jonas Salk on November 18, The Shot Felt ’Round the World, with commentary from his son Dr. Peter Salk, Time magazine writer Jeffrey Kluger, and historian of medicine Dr. Bert Hansen. Elsewhere in New York both City College of New York and NYU Langone Medical School are hosting celebratory symposia, and the Jonas Salk Legacy Foundation maintains a list of events and exhibitions in many different venues.

Though every analogy is partial, the American polio epidemics of the 20th century bear resemblance to the current outbreak of Ebola in West Africa. Both diseases were around and known before their largest epidemics. In 1916 polio broke out in the United States, with New York City having more than 9,000 cases, a quarter of which resulted in death. Another major New York City outbreak occurred in 1931. Even by then, little was known about the disease: it fell under a category now known as “emerging infectious diseases.”1

In their 1934 book, Poliomyelitis: A Handbook for Physicians and Medical Students, NYAM Fellow Dr. John F. Landon and his co-author, Lawrence W. Smith, called it a “still obscure disease” (p. vii) with a “particularly baffling” origin and means of transmission (p. 1). There were no effective treatments; the most one could do was to relieve symptoms, which included fever and strong pain, especially in the head and neck. Prevention was difficult if not impossible. Like Ebola, the disease’s spread, write Landon and Smith, could be curtailed chiefly by taking extreme care in physical contact and by quarantining active patients. The Handbook provided several practical appendices on nursing care and aseptic techniques, so caregivers could protect themselves and others from contagion. One appendix reproduced the New York City Health regulations on polio, which specified a three-week quarantine for all patients and a two-week quarantine for those in contact with them, with placarding of premises with quarantine signs.1

Two polio quarantine cards, courtesy of the National Library of Medicine.

Two polio quarantine cards, courtesy of the National Library of Medicine. Click to enlarge.

Chart from Poliomyelitis: A Handbook for Physicians and Medical Students. Click to enlarge.

Chart of the 1931 New York polio epidemic, compiled by the New York Department of Health. In Poliomyelitis: A handbook for physicians and medical students. Click to enlarge.

And like Ebola, the disease had terrible effects. The virus can enter the central nervous system, causing both temporary and at times permanent paralysis long after the disease runs its course. And even if the paralysis is temporary, post-polio syndrome can debilitate people years later. But in the early 20th century polio was often fatal, at rates that in 1931 averaged about 10% to 15% overall, but rose to over 20% for those under six months of age, and over 30% for those 15 to 19 years old (p. 158).1 By the time of the post–World War II epidemics, the death rate had dropped, but with increasing numbers of paralyzed survivors.

In 1952, polio struck the United States hard, with 58,000 affected, of which more than 3,000 died and more than 21,000 were left paralyzed to some degree or other.2 This was a huge number, even given the size of the country. Polio was four times as prevalent in the United States then as Ebola is in Liberia today. And while death rates from Ebola are higher, overall death and disability rates are comparable.

With this as a backdrop, the possibility of an effective polio vaccine was electrifying. In 1954, Jonas Salk’s promising new vaccine started widespread field testing, with over a million children taking part. On April 12, 1955, Dr. Thomas Francis Jr., director of the Poliomyelitis Vaccine Evaluation Center at the University of Michigan School of Public Health, pronounced the vaccine safe and effective. Large-scale immunization campaigns quickly started up.3–5 Polio was under control in the United States by the 1960s.

"The 1954 Poliomyelitis Vaccine Field Trial Areas." In Evaluation of the 1954 field trial of poliomyelitis vaccine: Final report. Click to enlarge.

“The 1954 Poliomyelitis Vaccine Field Trial Areas.” In Evaluation of the 1954 field trial of poliomyelitis vaccine: Final report. Click to enlarge.

The disease is one of the few for which eradication rather than control is considered feasible, a goal announced in 1988 by WHO, UNICEF, and Rotary. As of 2013, only three countries worldwide still had polio endemic in their populations—Pakistan, Nigeria, and Afghanistan—and the number of cases stood at fewer than 500, in less than a dozen countries in all.6 Yet polio is in the news again, as war has hindered vaccination programs, health workers have been put under attack, and cases have spread.7 At the eve of eradication, polio is proving difficult, even if it no longer inspires the wholesale fear that it did 60 years ago.

References

1. Landon JF, Smith LW. Poliomyelitis: A handbook for physicians and medical students, based on a study of the 1931 epidemic in New York City. New York: Macmillan; 1934. All in-text page numbers come from this handbook.

2. Salk Institute for Biological Studies. History: Polio today. Available at: http://poliotoday.org/?page_id=13. Accessed October 22, 2014.

3. Francis T. Evaluation of the 1954 field trial of poliomyelitis vaccine: Final report. Ann Arbor: University of Michigan; 1957.

4. March of Dimes. April 12 1955: Polio Announcement. 1955. Available at: https://www.youtube.com/watch?v=2LlDn_MQDkc. Accessed October 22, 2014. The March of Dimes was known earlier as the National Foundation for Infantile Paralysis, the group that underwrote much of the research and testing on polio.

5. Progress report to physicians on immunization against poliomyelitis, advance briefing. Indianapolis: Eli Lilly and Company; 1955. This report was part of the campaign and excitement around the Salk vaccine.

6. World Health Organization. Polio Case Counts. Accessed October 22, 2014.

7. For example: Gladstone R. Amid Iraq’s Political Chaos, a New Polio Vaccination Campaign Faces Challenges – NYTimes.com. New York Times. http://www.nytimes.com/2014/08/12/world/middleeast/amid-iraqs-chaos-a-new-polio-vaccination-campaign.html?_r=3. Published August 11, 2014. Accessed October 22, 2014.

“The Pest at the Gate”: Typhoid, Sanitation, and Fear in NYC

By Lisa O’Sullivan, Director, Center for the History of Medicine and Public Health

The relationship between medicine and public health could be a complex one at the turn of the last century. In particular, the question of how to deal with infectious disease epidemics demanded that medical professionals and city officials grapple with sanitation and cleanliness, city infrastructure, water supplies, and garbage and sewage. Epidemics also raised questions of individual autonomy and the proper role of government. In response to these issues, Boards of Health emerged in many American cities in the second half of the 19th century. The New York Metropolitan Board of Health was the first, founded in 1866 after a campaign by Dr. Stephen Smith and The New York Academy of Medicine.

Poultney Bigelow, The Pest at Our Gates, ([New York] : Merchants’ Association of New York, [1908])

Bigelow Poultney, The Pest at Our Gates, (New York: Merchants’ Association of New York, 1908)

Relations were often fraught between the different groups responsible for the city’s health. Many physicians resented the interference of city-nominated health officials (many of whom they considered corrupt and/or incompetent) into the medical domain; health officials blamed doctors for failing to report cases of infectious diseases; and families regarded hospitals with suspicion and did their best to keep their ill relatives out of them.

The diseases most feared by New Yorkers included cholera, typhus, and typhoid fever. Between 1898 and 1907, at least 635 New Yorkers died from typhoid, with cases of the disease in the thousands.1 Typhoid spreads through water supplies contaminated with infected fecal matter. It can be transmitted via contaminated food or water, and more rarely, through direct contact with someone infected with the disease. As such, sources of the illness in late 19th-century New York were many and largely invisible, as the investigative journalist and author Poultney Bigelow described in 1908 in “The Pest at Our Gates”: typhoid sources ranged from the “placid, perilous Potomac” to “the deadly house fly,” “the fish and oyster menace” and the “perils that lurk in ice.”2 Fear of typhoid pushed public health initiatives and legislation to ensure safe water and food, adequate plumbing, and proper sewage control.

The specters of cholera, yellow fever, and smallpox recoil in fear as their way through the Port of New York is blocked by a barrier on which is written "quarantine" and by an angel holding a sword and shield on which is written "cleanliness." Courtesy of the National Library of Medicine.

Cholera, yellow fever, and smallpox recoil in fear as a quarantine barrier and an angel holding bearing a shield of cleanliness blocks their way through the Port of New York. Image courtesy of the National Library of Medicine.

Fear of infectious disease often overlapped with fears about the changing face of the city and nation. As Alan M. Kraut explores in Silent Travelers: Germs, Genes and the Immigrant Menace, the relationship between immigration and public health in the United States has historically been informed by nativist debates about the identity of the nation and its ethnic makeup, fears about the potential limitations of scientific medicine, and the public health impact of immigration.3 As the gateway to America for hundreds of thousands of new immigrants, New York City became a focus for questions of quarantine and infectious disease. Epidemics, particularly of cholera, prompted many public health reforms in the city, especially increased scrutiny of immigrant arrivals at quarantine stations, including Ellis Island, where officials assessed arriving immigrants for their physical and mental health between 1892 and 1924.

In the case of typhoid, the specter of the foreigner as the reservoir of disease came to be personified by the Irish-born Mary Mallon, so-called “Typhoid Mary.” Mallon was a cook whose employment history in the kitchens of wealthy New Yorkers matched a spate of typhoid outbreaks in those same households in 1906. Mallon was a healthy carrier of typhoid, and was put under enforced quarantine by the Board of Health, which she vigorously resisted. On her release in 1909 she took multiple aliases and continued to work as a cook until 1915, when she was again detained and kept in isolation until her death in 1932. To some, Mallon was “the most dangerous woman in America”; to others, she was a symbol of the undermining of individual liberties by the government.4

In the case of typhoid fever, a combination of new vaccine technology and improved sanitation measures (particularly water chlorination) saw cases in the United States drop dramatically in the early 20th century. However, as is the case for many preventable infectious diseases, typhoid remains a problem in parts of the world with less developed public health infrastructure. On a global scale, medical and governmental responses to public health issues continue to exist in an uneasy tension with broader political and social concerns.

References

1. John Duffy,  A history of public health in New York City (New York: Russell Sage Foundation, 1968), p566

2. Poultney Bigelow, The Pest at Our Gates, (New York: Merchants’ Association of New York, 1908)

3. Alan M. Kraut, Silent Travelers: Germs, Genes and the Immigrant Menace (New York: Basic Books, 1994), pp 1-9

4. Judith Walzer Leavitt, Typhoid Mary: captive to the public’s health (Boston: Beacon Press, 1996); Alan M. Kraut, Silent Travelers: Germs, Genes and the Immigrant Menace (Baltimore: Johns Hopkins University Press, 1995), 97-104.