a brief history of medicine 医学史简论 （ 7 ） a brief history of medicine...

医学史简论（ 7 ） A Brief History of A Brief History of MedicineMedicine浙江大学医学院 余 海

yuhai@zju.edu.cn

送瘟神送瘟神 Send away the Good of Send away the Good of

PlaguePlague

人类与传染病的斗争人类与传染病的斗争 Battles to Infectious

Diseases

History of Infectious Diseases

Infection 感染 the invasion of the body by any of

various infectious agents – including bacteria, viruses, fungi, protozoan and worms， and the reaction of the body to them or their toxins.

Definitions Infectious disease 感染病 (cause)

The disease caused by infection and/or capable being communicable by infection

Communicable disease 传染病 (transmission)

The disease capable of being transmitted from one person to another or from animals (intermediate host) to human.

Epidemic disease 流行病 (incidence) The occurrence of cases of disease in excess of what is usually expected for

a given period of time. (epidemic hysteria)

Endemic disease 地方病 (location) The disease that is constantly present in people living in a particular

location (endemic thyroid disease-goiter)

Human and Infectious Diseases

Epidemics 流行 Sudden outbreak of diseases in excess of

what is expected

Pandemics （全球）大流行 Sudden geographically widespread

outbreak of diseases

History of Infectious Disease

Prehistoric period ： Infectious disease rare Agriculture society ： Increased transmission Urban civilization ： Congestion of urban inhabitation, war

and travelling result to outbreak of infectious diseases

Routes of transmission

Three factors of transmission of infectious disease•Source of infection (Typhoid Mary)

•Susceptible population

•Transmission routes

Direct touch

Indirecttouch

Droplet spittle Indirect

utensils

Air-borne

insect

Speed of sneeze: 170km/h 47.2m/s

Victories over infectious diseases

Smallpox plague Influenza Diphtheria Measles Tetanus poliomyelitis schistosomiasis

天花 smallpox

天花病毒 poxviridae

othopoxvirus

pockmarked face， from maculopapular rash to raised fluid-filled blisters to pustules

天花 smallpox Egyptian Pharaoh Ramses V died

from smallpox in1157 B.C Frequent outbreak in the history 300 million people died from

smallpox in 20th century (100 million died from wars)

Ramses V 1157 BC

Victims of Smallpox

Louis XV 1777 Elizabeth I 1533-1603

Joseph I d1711 顺治 1638-1661 Marry II 1662-1694

天花 smallpox

Lady Montagu

Chinese invented inoculation of human smallpox (variolation) in 10th century, widely used in 14-16 century

Lady Montagu brought back from Turkey to Europe in 1721

variolationBlow the scab of smallpox skin lesion

天花 smallpox Inspired by the fact that

dairymaids infected with cowpox were immune to small-pox, Edward Jenner invented cowpox vaccine against human smallpox.

Edward Jenner

1749-1823

variolation vaccination (vaccinia vacca-cow)

天花 smallpox Jenner deliberately infected

James Phipps, an eight year old boy, with cowpox in May 14, 1796. He then exposed Phipps to smallpox–which Phipps failed to contract. After repeating the experiment on other children, including his own son, Jenner concluded that vaccination provided immunity to smallpox without the risks of variolation. Jenner’s findings were published in 1798.

天花 smallpox in 1840 Vaccination

Acts were passed, the British government banned variolation and provided vaccination, free of charge.

In 1805 vaccination was introduced to China via Portugal merchants in Macao

天花 smallpox 1840 British vaccination Acts 1940 Smallpox was eradicated in Europe and North America 1960 Last Chinese case occurred in a Yunnan-Burma border village 1967 WHO launched smallpox eradication movement

（ At that time 30 million

patients,2million death every

year ） 30 countries

1700 medical doctors

200,000 health worker

Mobilized in the movement

天花 smallpox

Last natural infected Somalia patient cured in Oct 26 1977

A fatal incidence occurred in Birmingham University in August 1978 a woman lab photographer Janet Parker became the last victim of smallpox, Prof Henry Bedson committed suicide.

May 8, 1980 WHO announced:

Global eradication of smallpox Ali Maali

天花 smallpox

Reasons for possible eradication of smallpox

There are no other virus reservoirs but man Only acute infection exists, the outcome of

disease: die or life-long immunity Virus is highly immunogenic, so vaccine

has been most effective

鼠疫 Plague

bacterium  Yersinia pestis

Prairie dog Flea Rat

Bubonic and Pneumonic Plague

伍连德和鼠疫 Chinese Plague Fighter Wu Lien-teh

Born in Penang, Malaya in a Chinsese family

Studied Medicine in England 1907 Vice-Director of the Imperial Army

medical College in Tientsin In the winter 1910 a endemics of plague

outbroke in Manchuria which claimed 60,000 victims, the endemic was controlled under his leadership.

chaired the International Plague Conference in Mukden (Shenyang) in April 1911

He was the first president of the China Medical Association (1916–1920) and directed the National Quarantine Service

1937 he moved back to Ipoh as a GPWu Lien-Teh 1879-1960

伍连德和鼠疫 Chinese Plague Fighter Wu Lien-teh

1935 he was nominated as the candidate of Nobel Prize of Physiology or Medicine for work on pneumonic plaque and especially the discovery of the role played by the Tarbagan in its transmission.

(Folke Henschen)

梁启超：“科学输入垂五十年，国中能以学者资格与世界相见者，伍星联（即伍连德）博士一人而已！”

Black death in 14th century1346-1353 plague outbreak in Europe（ black death 黑死病） ,claimed 2.5million, 1/3 of European population ( Threw bodies into city using trebuchet to spread plague-first biological warfare

by Tartar cavalrymen)

CaffaCrimea

Learn from plaque： contagion gown

Beak fill of spices

Quarantenaria （ 40 天）Quarantine （检疫）

Learn from plague: quarantine

Bacteriological weapon

During the Sino-Japanese War , plague was used as a bacteriological weapon by the Imperial Japanese Army. These weapons were provided by Shiro Ishii’ Units ( 石井 , 731 部队）  and used in experiments on humans before being used on the field.

Vivisection One of the survivorsBacterial bomb

血吸虫病 SchistosomiasisSchistosoma heamatobium (Bilharzia) Africa, Middle East

S. Japonicum China, Phillipines

S.mansoni Africa, Latin America

Paleopathology FindingsSchistosoma eggs discovered in a

well-preserved ancient lady’s body (in Changsha Mawangdui of Hunan Province, 165 BC) , and also found in another well-preserved man’s body (167 BC) in Jiangling of Hubei Province

血吸虫病 SchistosomiasisUsed be prevalent in 12 provinces, 400 counties, threatened 100 million people and 1 million domestic animals (buffalo)

Mass Movement of Schistosomiasis Prevention ( 血防 Xuefang)in 1950s

Treatment of patients and animals－ eradication of the sources

Clearance of snails-intermediate host

Water and feces control-cut the transmission routes

七律二首 送瘟神Send away the God of Plague 1958.07.01

绿水青山枉自多，华佗无奈小虫何！千村薜荔人遗矢，万户萧疏鬼唱歌。坐地日行八万里，巡天遥看一千河。牛郎欲问瘟神事，一样悲欢逐逝波。

春风杨柳万千条，六亿神州尽舜尧。红雨随心翻作浪，青山着意化为桥。天连五岭银锄落，地动三河铁臂摇。借问瘟君欲何往，纸船明烛照天烧。

The God of Plague (Shistosomiasis) is back

Infection disease control-Long way to go传染病控制 - 任重而道远

Eradicated: smallpox

Vaccine preventable: measles, poliomyelitis, diphtheria,

whooping cough, tetanus

Uncontrolled ： plague, cholera, tuberculosis, viral hepatitis

Re-emerging ： sex-transmitted disease, Dengue fever,

schistosomiasis

Newly emerging ： Legionnaires’ disease, Ebola fever, SARS,

bird flu, AIDS, Chikungunya Disease

流感 Influenza1918 flu pandemic (Spanish flu) spreading to nearly every part of the

world.

Caused by Influenza virus strain subtype H1N1.

From March 1918 to June 1920, estimated 20 to 100 million people were killed (mortality rate 2.5-5%)

The extreme virulence may be associated with overreaction of immune system-cytokine storm

Mittelmachte (Central Power 同盟国 )Entente Power ( 协约国）

Avian Influenza (Bird Flu) Bird flu is influenza caused by viruses adapted to birds,

which belong to Influenza virus A

Influenza virus with the diameter of 80 ～ 120nm

Hemagglutinin,H: H1～ H15,Neuraminidase, N: N1～ N9 ,Theoretically there could be 135 subtypes,

Treatment: Tamiflu (Oseltamivir phosphate) A neuraminidase inhibitor

Avian Influenza Virus

Ecology of Avian Influenza Virus

Bird migration

Viet N

am

Cambodia

Thailand

Indonesia

Felines (tiger, leopard) can be infected with bird flue (60 tigers and 1 leopard in Thai zoo died from bird flue in 2003)

Country 

2003-2009 2010 2011 2012 2013 2014 Total

case death case death case death case death case death case death case death

Azerbaijan 8 5 0 0 0 0 0 0 0 0 0 0 8 5Bangladesh 1 0 0 0 2 0 3 0 1 1 7 1Cambodia 9 7 1 1 8 8 3 3 26 14 9 4 56 37Canada 0 0 0 0 0 0 0 0 1 1 0 0 1 1

China 38 25 2 1 1 1 2 1 2 2 2 0 47 30

Djibouti 1 0 0 0 0 0 0 0 0 0 0 0 1 0

Egypt 90 27 29 13 39 15 11 5 4 3 3 0 176 63

Indonesia  162 134 9 7 12 10 9 9 3 3 2 2 197 165

Iraq 3 2 0 0 0 0 0 0 0 0 0 0 3 2

Laos 2 2 0 0 0 0 0 0 0 0 0 0 2 2

Myanmar 1 0 0 0 0 0 0 0 0 0 0 0 1 0

Nigeria 1 1 0 0 0 0 0 0 0 0 0 0 1 1

Pakistan 3 1 0 0 0 0 0 0 0 0 0 0 3 1

Thailand 25 17 0 0 0 0 0 0 0 0 0 0 25 17

Turkey 12 4 0 0 0 0 0 0 0 0 0 0 12 4

Viet Nam 112 57 7 2 0 0 4 2 2 1 2 2 127 64

Total 468 282 48 24 62 34 32 20 39 25 18 8 667 393

Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO 2003-2012

The overall case fatality rate 393/667=59.0%

禽流感和“猪流感”发病对比Comparison of bird flu with “swine flu”

Cytokine storm “细胞因子风暴”

死亡率 ～ 60% vs ～ 1%

Antigenic drift抗原漂移

Antigenic shift抗原转移

Potential risk 潜在危险 The mutation of virus may

cause the outbreak of pandemics of avian influenza (gene shift or draft, leading to transmitted from human to human)

Nature estimated： That may cause one third of world population infected , 30 million may need hospitalized, one quarter

of which would die.

AIDS- 世纪之疫

AIDSAIDS-the plague for the century-the plague for the century

Plague in 21th century-AIDS•1981 in US 5 cases reported and named as Acquired Immunodeficiency Syndrome (AIDS)

•1983 and 1984 Montagnier of Pasteur Institute and Gallo of NIH isolated the virus (lymphadenopathy-associated virus, LAV; human T-lymphotropic virus type III, HTLV-III)

•1986 naming as “Human Immunodeficiency Virus HIV”

•1987 President Mitterrand of France and President  Reagan of the USA met that the major issues were ironed out.

Epidemiologic Notes and ReportsPneumocystis Pneumonia --- Los AngelesIn the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died. All 5 patients had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and candidal mucosal infection. Case reports of these patients follow.Patient 1: A previously healthy 33-year-old man developed P. carinii pneumonia and oral mucosal candidiasis in March 1981 after a 2-month history of fever associated with elevated liver enzymes……

June 5, 1981 / 30(21);1-3

The Nobel Prize in Physiology or Medicine 2008

Harald zur Hausen Francoise Barre-Sinoussi Luc Montagnier

Germany Cancer Research Center , Heidelberg, b 1936

Regulation Retroviral Infections Unit, Virology Department, Institut Pasteur, b 1947

World Foundation for AIDS Research and Prevention, b 1932

"for his discovery of human papilloma viruses causing cervical cancer"

"for their discovery of human immunodeficiency virus"

AIDS virus

retrovirus

CCR 5

Replication of HIV

Clinical manifestation- cachexia

Clinical manifestation-Kaposi’s sarcoma

Pneumocystis carnii pneumonia ）

Clinical manifestation- Pneumocystis carnii pneumonia

Estimate Range

People living with HIV/AIDS in 2007 33.0 million 30.3-36.1 million

Adults living with HIV/AIDS in 2007 30.8 million 28.2-34.0 million

Women living with HIV/AIDS in 2007 15.5 million 14.2-16.9 million

Children living with HIV/AIDS in 2007 2.0 million 1.9-2.3 million

People newly infected with HIV in 2007 2.7 million 2.2-3.2 million

Children newly infected with HIV in 2007 0.37 million 0.33-0.41 million

AIDS deaths in 2007 2.0 million 1.8-2.3 million

Child AIDS deaths in 2007 0.27 million 0.25-0.29 million

More than 25 million people have died of AIDS since 1981.Africa has 11.6 million AIDS orphans.In developing and transitional countries, 9.7 million people are in immediate need of life-saving AIDS drugs; of these, only 2.99 million (31%) are receiving the drugs.

Global HIV/AIDS estimates, end of 2007UNAIDS 2008 Report of the global AIDS epidemic

Adult HIV Prevalence

Region

Adults & children 

living with HIV/AIDS

Adults & children 

newly infected

Adult prevalenc

e*

Deaths of adults & children

Sub-Saharan Africa

22.0 million

1.9 million 5.0% 1.5 million

North Africa & Middle East

380,000 40,000 0.3% 27,000

Asia 5 million 380,000 0.3% 380,000

Oceania 74,000 13,000 0.4% 1,000

Latin America

1.7 million 140,000 0.5% 63,000

Caribbean 230,000 20,000 1.1% 14,000

Eastern Europe & Central Asia

1.5 million 110,000 0.8% 58,000

North America, Western & Central Europe

2.0 million 81,000 0.4% 31,000

Global Total

33.0 million

2.7 million 0.8% 2.0 million

Regional statistics for HIV & AIDS, end of 2007* Proportion of adults aged 15-49 who were living with HIV/AIDS

Region

Adults & children 

living with HIV/AIDS

Adults & children 

newly infected

Adult prevalenc

e*

Deaths of adults & children

Sub-Saharan Africa

22.0 million

1.9 million 5.0% 1.5 million

North Africa & Middle East

380,000 40,000 0.3% 27,000

Asia 5 million 380,000 0.3% 380,000

Oceania 74,000 13,000 0.4% 1,000

Latin America

1.7 million 140,000 0.5% 63,000

Caribbean 230,000 20,000 1.1% 14,000

Eastern Europe & Central Asia

1.5 million 110,000 0.8% 58,000

North America, Western & Central Europe

2.0 million 81,000 0.4% 31,000

Global Total

33.0 million

2.7 million 0.8% 2.0 million

RegionAdults & children 

living with HIV/AIDSAdults & children 

newly infectedAdult prevalence*

Deaths of adults & children

Sub-Saharan Africa 22.0 million 1.9 million 5.0% 1.5 million

North Africa & Middle East

380,000 40,000 0.3% 27,000

Asia 5 million 380,000 0.3% 380,000

Oceania 74,000 13,000 0.4% 1,000

Latin America 1.7 million 140,000 0.5% 63,000

Caribbean 230,000 20,000 1.1% 14,000

Eastern Europe & Central Asia

1.5 million 110,000 0.8% 58,000

North America, Western & Central Europe

2.0 million 81,000 0.4% 31,000

Global Total 33.0 million 2.7 million 0.8% 2.0 million

Reported:

HIV infection 492,191

（ surviving 383,285 ） （Dec, 2012 ）

Estimated ：

HIV infection 780,000,

AIDS patients 154,000

AIDS death 160,000

中国爱滋病形势 AIDS in China

Ice burgerIce burger

IDUsbl ood trsexual l ybl ood prMTCTothers

61.6%

18.7%

9.4%

8.4%1.6%

0.3% 18.7%

AIDS transmission:China

Mode of Transmission ：Between US and China

11.6%Sexually transmitted (1985-2005) 75.2% (2011) half of which via MSM

爱滋病的来源？

Origin of Aids?

The origin of HIV HIV virus not detected in any blood samples before

1959 It may transformed from simian immunodeficiency

virus (SIV) of African primates (African Green Monkey, Chimpanzee)

发达国家艾滋病死亡率下降 （美国）

艾滋病传布途径 AIDS transmission

control transmission

控制性传播 控制输受血传播 控制医源性传播 控制吸毒传播 控制母婴传播

Prevention from iv drug use

Drug control

Detoxification

Provision of sterilized syringes

两害相较取其轻To choose the lesser of two evils

Prevention of sexual transmission

Abstinence

Be faithful

Condom

两害相较取其轻

To choose the lesser of two evils

No condomNo condom

No sexNo sex

World Aids Day: 1 December (since 1988）

World AIDS Day, 1 December 2013

“GETTING TO ZERO.“ 行动起来，向零艾滋迈进 全民参与，全力投入，全面预防 ZERO New HIV infections. ZERO Discrimination and ZERO AIDS-related deaths.

Essay writing

Medicine: its past, present and future You may choose any topics as long as follow the theme of

“history of medicine” Should be ORIGINAL Using your own words, not “copy” and

“paste” or “control-v””control-c” No less than 2000 words, including title, abstract, full text,

references, with your name and student number Word format, student number as file name Electronic version only Send to: yuhai@zju.edu.cn, before April 20, 2014

谢谢谢谢