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CHAPTER 2 Historic Developments in Epidemiology CHAPTER 2 Historic Developments in Epidemiology OBJECTIVES After completing this chapter, you will be able to: List and describe the contributions made by several Describe important historic events in the field of key individuals to epidemiology. epidemiology. Recognize the development and use of certain study designs in the advancement of epidemiology. 17 9781284094497_CH02_PASS02.indd 17 02/11/15 6:40 PM he history of epidemiology has involved many key players who sought to under- Tstand and explain illness, injury, and death from an observational scientific perspective. These individuals also sought to provide informa- tion for the prevention and control of health- related states and events. They advanced the study of disease from a supernatural viewpoint to a viewpoint based on a scientific foundation; from no approach for assessment to systematic methods for summarizing and describing public health problems; from no clear understanding of the natural course of disease to a knowledge of the probable causes, modes of transmission, and health outcomes; and from no means for prevent- ing and controlling disease to effective approaches for solving public health problems. Initially, epidemiologic knowledge advanced slowly, with large segments in time where little or no advancement in the field occurred. The time from Hippocrates (460–377 BCE), who attempted to explain disease occurrence from a rational viewpoint, to John Graunt (1620–1674 CE), who described disease occurrence and death with the use of systematic methods and FIGURE 2-1 Hippocrates. who developed and calculated life tables and life United States National Library of Medicine, National Institutes of expectancy, and Thomas Sydenham (1624– Health, History of Medicine. Available at: http://wwwihm.nlm.nih.gov/ 1689), who approached the study of disease ihm/images/B/14/553.jpg. Accessed December 29, 2008. from an observational angle rather than a theo- retical one, was 2,000 years. Approximately 200 years later, William Farr (1807–1883) advanced Army physician working in the tropics, made John Graunt’s work to better describe epidemio- the connection in 1900. Hippocrates also intro- logic problems. In the 19th century, John Snow, duced terms like epidemic and endemic.1–4 Ignaz Semmelweis, Louis Pasteur, Robert Koch, Hippocrates gave advice to people wishing Florence Nightingale, and others also made to pursue the science of medicine and provided important contributions to the field of epidemi- insights on the effects of the seasons of the year ology. Since then, the science of epidemiology and hot and cold winds on health. He believed has rapidly progressed. Although it is impossible the properties of water should be examined and to identify all of the contributors to the field of advised that the source of water should be con- epidemiology here, several of these individuals sidered.1–4 He asked questions such as, “Is the and their contributions are considered. water from a marshy soft-ground source, or is the water from the rocky heights? Is the water Hippocrates, the First Epidemiologist brackish and harsh?” Hippocrates also made some noteworthy observations on the behavior Hippocrates was a physician who became of the populace. He believed the effective physi- known as the father of medicine and the first cian should be observant of people’s behavior, epidemiologist (FIGURE 2-1). His three books, Epi- such as eating, drinking, and other activities. demic I, Epidemic III, and On Airs, Waters, and Did they eat lunch, eat too much, or drink too Places, attempted to describe disease from a little? Were they industrious? rational perspective rather than from a super- For traveling physicians, Hippocrates sug- natural basis. He observed that different diseases gested they become familiar with local diseases occurred in different locations. He noted that and with the nature of those prevailing diseases. malaria and yellow fever most commonly He believed that as time passed the physician occurred in swampy areas. It was not known, should be able to tell what epidemic diseases might however, that the mosquito was responsible for attack and in what season and that this could be such diseases until Walter Reed, MD, a U.S. determined by the settings of the stars. Sources of 18 CHAPTER 2 Historic Developments in Epidemiology 9781284094497_CH02_PASS02.indd 18 02/11/15 6:40 PM water, smells, and how water sets or flows were with Robert Boyle, a colleague who sparked always considered in his study of disease states.1–4 Sydenham’s interest in diseases and epidemics. Hippocrates identified hot and cold diseases Sydenham went on to get his medical license, and, consequently, hot and cold treatments. Hot and he spoke out for strong empirical diseases were treated with cold treatments, and approaches to medicine and close observations cold diseases required hot treatments. The pro- of disease. Sydenham wrote the details of what cess of deciding whether a disease was hot or he observed about diseases without letting vari- cold was complex. An example is diarrhea, ous traditional theories of disease and medical which was considered a hot disease and was treatment influence his work and observations. believed to be cured with a cold treatment such From this close observation process, he was able as eating fruit.1–4 to identify and recognize different diseases. Hippocrates also ascribed to and incorpo- Sydenham published his observations in a book rated into his theory what is now considered the in 1676 titled Observationes Medicae.4 atomic theory—that is, the belief that every- One of the major works of Sydenham was thing is made of tiny particles. He theorized that the classification of fevers plaguing London in there were four types of atoms: earth atoms the 1660s and 1670s. Sydenham came up with (solid and cold), air atoms (dry), fire atoms three levels or classes of fevers: continued (hot), and water atoms (wet). Additionally, Hip- fevers, intermittent fevers, and smallpox. Some pocrates believed that the body was composed of Sydenham’s theories were embraced, of four humors: phlegm (earth and water whereas others were criticized, mostly because atoms), yellow bile (fire and air atoms), blood his ideas and observations went against the (fire and water atoms), and black bile (earth and usual Hippocratic approaches. He treated small- air atoms). Sickness was thought to be caused pox with bed rest and normal bed covers. The by an imbalance of these humors, and fever was treatment of the time, based on the Hippocratic thought to be caused by too much blood. The theory, was to use heat and extensive bed cov- treatment for fever was to reduce the amount erings. He was met with good results but erred of blood in the body through bloodletting or the in identifying the cause of the disease.4 application of bloodsuckers (leeches). Imbal- Sydenham was persecuted by his col- ances were ascribed to a change in the body’s leagues, who at one time threatened to take “constitution.” Climate, moisture, stars, mete- away his medical license for irregular practice orites, winds, vapors, and diet were thought to that did not follow the theories of the time; cause imbalances and contribute to disease. Diet however, he gained a good reputation with the was both a cause of and a cure for disease. Cures public, and some young open-minded physi- for illness and protection from disease came cians agreed with his empirical principles. from maintaining a balance and avoiding imbal- Sydenham described and distinguished different ance in the constitution. diseases, including some psychological mala- The essentials of epidemiology noted by dies. He also advanced useful treatments and Hippocrates included observations on how dis- remedies, including exercise, fresh air, and a eases affected populations and how disease healthy diet, which other physicians rejected at spread. He further addressed issues of diseases the time.4 in relation to time and seasons, place, environ- mental conditions, and disease control, espe- The Epidemiology of Scurvy cially as it related to water and the seasons. The broader contribution to epidemiology made by In the 1700s, it was observed that armies lost Hippocrates was that of epidemiologic observa- more men to disease than to the sword. James tion. His teachings about how to observe any Lind (1716–1794), a Scottish naval surgeon, and all contributing or causal factors of a disease focused on illnesses in these populations. He are still sound epidemiologic concepts.1–4 observed the effect of time, place, weather, and diet on the spread of disease. His 1754 book, A Disease Observations of Sydenham Treatise on Scurvy, identified the symptoms of scurvy and the fact that the disease became Thomas Sydenham (1624–1689), although a common in sailors after as little as a month at graduate of Oxford Medical School, did not at sea.3,4 first practice medicine but served in the military Lind noticed that while on long ocean voy- and as a college administrator. While at All ages, sailors would become sick from scurvy, a Souls College, Oxford, he became acquainted disease marked by spongy and bleeding gums, The Epidemiology of Scurvy 19 9781284094497_CH02_PASS02.indd 19 02/11/15 6:40 PM bleeding under the skin, and extreme weakness. citrus-eating sailors were asked to nurse the He saw that scurvy began to occur after 4 to 6 others who were still sick. Thus, Lind observed weeks at sea. Lind noted that even though the that oranges and lemons were the most effec- water was good and the provisions were not tive remedies for scurvy at sea.5 As a conse- tainted, the sailors still fell sick. Lind pointed out quence of Lind’s epidemiologic work, since that the months most common to scurvy were 1895, the British navy has required that limes April, May, and June.
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