John Snow and the 1854 Broad Street Cholera Outbreak

Many historians trace modern public health and epidemiology to the day in 1850s when Dr. John Snow, having discerned the link between cholera outbreaks in London and water sources used by the afflicted populace, removed the handle of the Broad Street water pump. Thus one cholera epidemic was stopped, but it would still be years before the etiology of cholera was discovered.

In the mid-19th century, the Soho district of London had a serious problem with filth due to the large influx of people and a lack of proper sanitary services. Many cellars (basements) had cesspools of nightsoil underneath their floorboards. Since the cesspools were overrunning, the London government decided to dump the waste into the River Thames. This action contaminated the water supply, leading to the cholera outbreak.


Outbreak
On 31 August 1854, after several other outbreaks had already occurred elsewhere in the city, a major outbreak of cholera struck Soho. Dr Snow later called it "the most terrible outbreak of cholera which ever occurred in the kingdom."

Over the next three days 127 people on or near Broad Street died. In the next week, three quarters of the residents had fled the area. By 10 September, 500 people had died and the mortality rate was 12.8 percent in some parts of the city. By the end of the outbreak 616 people died.

Snow was a skeptic of the then-dominant miasma theory that stated that diseases such as cholera or the Black Death were caused by pollution or a noxious form of "bad air". The germ theory was not widely accepted by this time, so Snow was unaware of the mechanism by which the disease was transmitted, but evidence led him to believe that it was not due to breathing foul air. He first publicized his theory in an essay On the Mode of Communication of Cholera in 1849. In 1855 a second edition was published, with a much more elaborate investigation of the effect of the water-supply in the Soho, London epidemic of 1854.

By talking to local residents (with the help of Reverend Henry Whitehead), he identified the source of the outbreak as the public water pump on Broad Street (now Broadwick Street). Although Snow's chemical and microscope examination of a sample of the Broad Street pump water was not able to conclusively prove its danger, his studies of the pattern of the disease were convincing enough to persuade the local council to disable the well pump by removing its handle. Although this action has been popularly reported as ending the outbreak, the epidemic may have already been in rapid decline, as explained by Snow himself:

Snow later used a spot map to illustrate how cases of cholera were centred around the pump. He also made a solid use of statistics to illustrate the connection between the quality of the source of water and cholera cases. He showed that the Southwark and Vauxhall Waterworks Company was taking water from sewage-polluted sections of the Thames and delivering the water to homes with an increased incidence of cholera. Snow's study was a major event in the history of public health, and can be regarded as the founding event of the science of epidemiology.

Malaria

This word comes from the mediaeval Italian mal (=bad) and aria (=air), describing the miasma from the swamps around Rome. This 'bad air' was believed to be the cause of the fever that often developed in those who spent time around the swamps.

The first Heart Transplant

He performed the world's first human heart transplant operation on 3 December 1967, in an operation assisted by his brother, Marius Barnard; the operation lasted nine hours and used a team of thirty people. The patient, Louis Washkansky, was a 54-year-old grocer, suffering from diabetes and incurable heart disease. Barnard later wrote, "For a dying man it is not a difficult decision because he knows he is at the end. If a lion chases you to the bank of a river filled with crocodiles, you will leap into the water, convinced you have a chance to swim to the other side." The donor heart came from a young woman, Denise Darvall, who had been killed in a December 2, 1967, road accident while crossing a street in Cape Town. After securing permission from Darvall's father to use her heart, Barnard performed the transplant. Twenty years later, Dr. Marius Barnard recounted, "Chris stood there for a few moments, watching, then stood back and said, 'It works.'"[3][who?] Washkansky survived the operation and lived for eighteen (18) days. However, he succumbed to pneumonia induced by the Immunosuppressive drugs he was taking. Though the first patient with the heart of another human being survived for only a little more than two weeks, Barnard had passed a milestone in a new field of life-extending surgery.

Barnard became an international superstar overnight and was celebrated around the world for his daring accomplishment. He was quite photogenic, and enjoyed the media attention following the operation. Barnard continued to perform heart transplants. A transplant operation was conducted on 2 January 1968, and the patient, Philip Blaiberg, survived for 19 months. Dorothy Fisher was given a new heart in 1969 and became the first black recipient. She lived for 12 years 6 months after the transplant.[4] Dirk van Zyl, who received a new heart in 1971, was the longest-lived recipient, surviving over 23 years.[5]

Barnard performed ten orthotopic transplants (1967 – 1973). He was also the first to perform a heterotopic heart transplant, an operation that he himself devised. Forty-nine consecutive heterotopic heart transplants were performed in Cape Town between 1975 and 1984.

When many surgeons — disillusioned by poor results — gave up cardiac transplantation, Barnard persisted until the advent of cyclosporin, which helped revive the operation throughout the world. He was also the first surgeon to attempt xenograft transplantation in a human patient, while attempting to save the life of a young girl unable to leave artificial life support after a second aortic valve replacement. He was later accused of wrongdoing by her parents.

After his first successful heart transplant Barnard became known as the "film star surgeon". He was loved by his patients throughout the world, hundreds of whom were treated free of charge, and hated by many others who were jealous of his instant success. He was accused by some colleagues in the profession of "stealing" the idea and the opportunity to perform the first heart transplant. Often considered a spoiled and arrogant personality, he was also regarded as kind and considerate by others. Due to his widely publicized love affairs, he became jokingly known as "doctor of hearts", referring to the heart as emotional symbol rather than in its usual medical context.

Barnard was an outspoken opponent of South Africa's laws of apartheid, and was not afraid to criticize his nation's government, although he had to temper his remarks to some extent in order to travel abroad. Rather than leaving his homeland, he used his fame in order to campaign for a change in the law. After Denise Darvall provided the means for the very first heart transplant, Barnard transplanted her kidney into a 10-year-old coloured boy. The donor for the second heart transplant was also coloured. Christiaan's brother, Dr. Marius Barnard, went into politics, and was elected to the legislature on an anti-apartheid platform. However, Barnard later claimed that the reason he never won the Nobel Prize in Physiology or Medicine was probably because he was a "white South African".

Intra Aortic Ballon Pump

This story may be apocryphal, but here it goes. In the late 1960s, the intra-aortic balloon pump (IABP) was being readied for its first use in a human.(The IABP device was pioneered at the Grace-Sinai Hospital in Detroit during the early 1960s by Dr. Adrian Kantrowitz) Its developers thought that private insurance companies would not stand for such a radical new therapy, and approached the military, asking them to keep an eye out for IABP candidates in military hospitals.
One day, the call came. A retired general was hospitalized in Walter Reed Army Medical Center. He had a history of multiple infarcts and was now end-stage. The IABP scientists were all ready to go, until they found out the general was Eisenhower. They declined the opportunity because they worried that if the IABP failed in him, it would permanently ruin the future prospects of the device.