The Socio-Cultural Factors Influencing the Level of Public Compliance with Infection Control Measures during the 1918 Influenza Pandemic in Italy: A Historical Approach.

During health emergencies, non-pharmaceutical interventions (NPIs) are adopted in various combinations until a vaccine can be produced and widely administered. Containment strategies, including the closure of schools, churches, and dance halls; banning of mass gatherings; mandatory mask wearing; isolation; and disinfection/hygiene measures, require reasonable compliance to be successfully implemented. But what are the most effective measures? To date, few systematic studies have been conducted on the effects of various interventions used in past epidemics/pandemics. Important contributions to our understanding of these questions can be obtained by investigating the historical data from the great influenza pandemic of 1918, an event widely considered one of the greatest natural disasters in human history. Taking on particular importance is the study of the possible role played by the behaviour of the population and the lack of public obedience to the non-pharmaceutical interventions in a Mediterranean country like Italy-one of the most affected countries in Europe-during that pandemic, with special attention paid to the weight of the socio-cultural factors which hindered the ultimate goal of containing the spread of the virus and preventing excess deaths in the country.

Brief history of the medical and non-medical use of amphetamine-like psychostimulants.

The alkaloid ephedrine derived from Ephedra vulgaris is at the origin of psychostimulant-drugs as amphetamine. These drugs have been principally utilized for medical treatments in the past, while their utilization has been largely reduced from the 1970s when the high risk of addiction and abuse has been recognized. The first reported treatments were as anti-asthmatics and to contrast narcolepsy until their recreational stimulant and anorexic effects were reported. Benzedrine and Pervitin use were of great importance during the Second World War due to their abundant utilization among military troops. Nowadays the use of selective amphetamine-like drugs is limited to ADHD treatment.

The association of adult height with the risk of cardiovascular disease and cancer in the population of Sardinia.

The relationship between body height and the risk of non‒communicable diseases such as cardiovascular disease and cancer has been the subject of much debate in the epidemiological literature. Concerns have recently arisen over spurious associations due to confounding factors like birth cohort, especially in the context of epidemiological transition. The population of Sardinia represents an interesting case study, as the average physical stature of inhabitants was the lowest recorded in Europe until a few decades ago. In this population we tested whether height is an independent risk factor for cardiovascular disease and cancer. We analysed the stature of 10,427 patients undergoing endoscopy for any reason, for whom a detailed clinical history of cardiovascular disease and/or malignancies had been documented. Poisson regression modelling was used to test the association between stature and disease risk. When patients were subdivided according to sex and height tertiles, the risk of cardiovascular disease proved significantly greater for subjects in the lowest tertile irrespective of sex (men: 1.87; 95%CI 1.41‒2.47; women: 1.23; 95%CI 0.92‒1.66) and smaller for those in the highest tertile (men: 0.51; 95%CI 0.35‒0.75; women: 0.41; 95%CI 0.27‒0.61). However, after adjusting the risk for birth cohort and established risk factors, it mostly resulted in non-significant values, although the overall trend persisted. Similar results were obtained for all-cancer risk (relative risk for men and women in the lowest tertile: 1.44; 95%CI 1.09-1.90 and 1.17; 95%CI 0.93-1.48, in the highest tertile: 0.51; 95%CI 0.36-0.72 and 0.62; 95%CI 0.47-0.81, respectively) as well as for some of the most common types of cancer. We concluded that the risk of developing cardiovascular disease and malignancies does not vary significantly with stature in the Sardinian population, after adjusting for birth cohort and more obvious risk factors.

Metals in bones of the middle-aged inhabitants of Sardinia island (Italy) to assess nutrition and environmental exposure.

Metals in bones of 72 subjects lived between the twelfth and eighteenth century AC and collected in four Sardinian (Italian insular region) burial sites (Alghero, Bisarcio, Geridu, and Sassari) were determined and used as biomarkers to evaluate diet and potential social-environmental differences. Concentrations of Ba, Ca, Cd, Cu, Hg, Pb, Sr, and Zn were quantified in different types of compact bone (femur, fibula, humerus, radius, tibia, ulna) by sector field inductively coupled plasma mass spectrometry previous acidic digestion and differences among the various burial sites, centuries, types of bone, gender, and age were explored by univariate and multivariate analyses. Results indicated differences between sites in terms of diet: Bisarcio (inland village) had increased ratios of Ba/Ca and Zn/Ca due to higher incidence of vegetables, cereals, and animal foods in the diet; Geridu (coastal village) showed increased Sr/Ca ratio indicating foods of plant and marine origin that were predominant; Alghero (coastal site) and Sassari (inland site) displayed prevalently a mixed diet reflecting a higher economy and food imports. In addition, these latter sites showed increased levels of Hg/Ca (fish, drugs, cosmetics) and Pb/Ca (coins, utensils, pipeline for water). In conclusion, the elemental Ba/Ca, Sr/Ca, and Zn/Ca ratios were indicative of provenance and diet, while Hg/Ca and Pb/Ca ratios were associated to various forms of environmental exposure.

Why were Sardinians the shortest Europeans? A journey through genes, infections, nutrition, and sex.

Since ancient times the Mediterranean island of Sardinia has been known for harboring a population with an average body height shorter than almost every other ethnic group in Europe. After over a century of investigations, the cause(s) at the origin of this uniqueness are not yet clear. The shorter stature of Sardinians appears to have been documented since prehistoric times, as revealed by the analysis of skeletal remains discovered in archaeological sites on the island. Recently, a number of genetic, hormonal, environmental, infective and nutritional factors have been put forward to explain this unique anthropometric feature, which persisted for a long time, even when environmental and living conditions improved around 1960. Although some of the putative factors are supported by sound empirical evidence, weaker support is available for others. The recent advent of whole genome analysis techniques shed new light on specific variants at the origin of this short stature. However, the marked geographical variability of stature across time and space within the island, and the well-known presence of pockets of short height in the population of the southern districts, are still puzzling findings that have attracted the interest of anthropologists and geneticists. The purpose of this review is to focus on the state-of-the-art research on stature, as well as the factors that made Sardinians the shortest among Europeans.

Posterior Arch Defect of the Atlas Associated to Absence of Costal Element of Foramen Transversarium from 16th-Century Sardinia (Italy).

STUDY DESIGN: A paleopathological case of posterior arch defect of the atlas associated to the absence of costal element of the foramen transversarium. OBJECTIVE: In living patients as well as in postmortem analysis it should be difficult to distinguish between a congenital and an acquired anomaly. Any anomaly in the anatomy of atlas should be taken into consideration by clinicians, surgeons, radiologists, and anatomists in order to avoid misinterpretations and clinical complications. SUMMARY OF BACKGROUND DATA: Posterior arch defect has a current occurrence of approximately 4%. Posterior arch schisis is attributed to the defective or absent development of the cartilaginous preformation of the arch rather than a disturbance of the ossification. The absence of costal element of the foramen transversarium has an incidence of ranging from 2% to 10% and is attributed to a developmental defect or to variations in the course of the vertebral artery. METHODS: The skeleton of a man aged 20-30 years, brought to light in the plague cemetery of 16th century Alghero (Sardinia), showed anomalies of the atlas, consisting in failure of the midline fusion of the 2 hemiarches with a small gap and an open anterior foramen trasversarium on the left side. A macroscopic, radiological, and stereomicroscopic study was carried out. RESULTS: The study allowed to rule out a traumatic origin of the defects and to diagnose an association of 2 congenital anomalies. CONCLUSION: Osteoarchaeological cases provides with a valuable opportunity to examine and describe variations in the anatomy of the atlas. LEVEL OF EVIDENCE: N/A.

A case of brachymetatarsia from medieval Sardinia (Italy).

Archaeological excavations carried out in the Medieval village of Geridu (Sardinia) uncovered several burials dating to the late 13th or the first half of 14th century. Among these individuals, the skeleton of an adult female showing a bilateral abnormal shortness of the fourth metatarsal bone was identified. Bilaterality and absence of other skeletal anomalies allow to rule out an acquired aetiology of the disease and to support a diagnosis of congenital brachymetatarsia. Such a rare deformity has a clinical incidence of 0.02% to 0.05%, with strong predominance of the female gender. To our knowledge, no other cases of brachymetatarsia have been reported in paleopathology so far.

Lessons from the history of quarantine, from plague to influenza A.

In the new millennium, the centuries-old strategy of quarantine is becoming a powerful component of the public health response to emerging and reemerging infectious diseases. During the 2003 pandemic of severe acute respiratory syndrome, the use of quarantine, border controls, contact tracing, and surveillance proved effective in containing the global threat in just over 3 months. For centuries, these practices have been the cornerstone of organized responses to infectious disease outbreaks. However, the use of quarantine and other measures for controlling epidemic diseases has always been controversial because such strategies raise political, ethical, and socioeconomic issues and require a careful balance between public interest and individual rights. In a globalized world that is becoming ever more vulnerable to communicable diseases, a historical perspective can help clarify the use and implications of a still-valid public health strategy.

[History of chlorosis]. / Storia di una malattia scomparsa, la clorosi, dal morbus virgineus all'anemia (XVI-XX secolo).

The once-prevalent disease known as chlorosis, that for centuries has been considered as typical of young unmarried women, is--in the history of Medicine--one of the few for which the abundant medical literature allow to assign the exact date of beginning in the sixteenth century--and its disappearance in early twentieth century. Origin and history of chlorosis--along four centuries--are an intriguing example of how sickness is not only related to the history of medical science, but it is also deeply rooted to the history of the imaginary, mentalities, culture and social trends. But that's not all. In general, through the history of chlorosis it is possible to focus some important issues: the transformation of puberty and adolescence in medical problems; the growing medicalization of the society that is reflected in the gradual inclusion into the scientific medical discourse of social and cultural issues (the status, the emancipation of women, etc...). Using a range of medical writings and treatises, supplemented with statistical data, this article focuses on the spread of the chlorosis--the incidence of which apparently increased at that time--and explores the interpretations of the disease in Nineteenth Century Italy. A "golden age" of medical debate and speculations about the disease, that even after the developments of haematology and its diagnostic identification as hypochromic anaemia, will continue for a long time to carry the weight of the nervous and emotional factors that had accompanied the chlorosis for centuries.

Program to eradicate malaria in Sardinia, 1946-1950.

During 1946-1950, the Rockefeller Foundation conducted a large-scale experiment in Sardinia to test the feasibility of indigenous vector species eradication. The interruption of malaria transmission did not require vector eradication, but with a goal of developing a new strategy to fight malaria, the choice was made to wage a rapid attack with a powerful new chemical. Costing millions of dollars, 267 metric tons of DDT were spread over the island. Although malaria was eliminated, the main objective, complete eradication of the vector, was not achieved. Despite its being considered almost eradicated in the mid-1940s, malaria 60 years later is still a major public health problem throughout the world, and its eradication is back on the global health agenda.

The rise and fall of syphilis in Renaissance Europe.

The rapid changes that syphilis underwent after the first major outbreak that occurred in Naples in the mid-1490s are believed to constitute the first well-documented example of a human disease. The new plague was of exceptional virulence, highly contagious and causing severe ulceration at the site of infection. According to medical and other historical sources, the 'genius epidemics' changed some years after this onset, and a slower-progressing form of syphilis seems to have replaced the initial severe form, as do many virulent epidemic infectious diseases that appear in devastating forms in a previously uninfected population. But what exactly were the features of the disease at the moment of its appearance in Europe at the end of the fifteenth century? How many years did it take for the early, virulent form to be replaced and become endemic? What was the pace of these changes through the decades following the onset of the epidemic? In this essay, I review these issues through an analysis of a large number of chronologically-ordered primary historical sources.

[Camillo Golgi and the contribution of the Italian scientists to the development of the malariology in the last quarter of the nineteenth century]. / Camillo Golgi e il contributo degli scienziati Italiani allo sviluppo della malariologia nell'ultimo quarto dell'ottocento.

Between 1885 and 1892--a period in which great advances have been made in techniques and practice of the young science of microbiology--Camillo Golgi provided a notable contribution to malariology. Continuing studies and researches of Roman malariologists Ettore Marchiafava (1847-1935) and Angelo Celli (1857-1914), on the malarial parasites--described by the French military physician Alphonse Laveran--he studied the reproduction cycles of the Plasmodium in human blood (Golgi cycles) and elucidated the temporal coincidence between the recurrent chills and fever with the rupture and release of merozoites into the blood stream (Golgi law). He also demonstrated that the so-called tertian and quartan intermittent fevers are due to the presence in the blood of two different protozoan organisms Plasmodium malariae and Plasmodium vivax (Alphonse Laveran believed that there was only one species, Oscillaria malariae). These observations made it possible to diagnose and treat the disease. He established that quinine, to varying degrees, was effective against the parasites at different stages of their development--those in the early stages were most affected. Moreover, excluding the etiological specificity of the famous Bacillus malariae, isolated by Klebs and Tommasi Crudeli before Laveran's discovery in the ground and water of the Pontin Marshes south of Rome, his studies determined the definitive disappearance from the scene of this bacterium; and opened a new phase of the research to which the Italian malariologists will give an important contribution, although the contrasts and scientific rivalries. This article follows the developments of the malariological research in Italy, plagued by the disease, on the contrary of other developed European countries (France and Great Britain) and examines the factors that influenced Italian scholars.

The origins of the health defence system against contagious illness: the strategies of isolation and quarantine in Mediterranean cities from the XIV-XIX centuries.

From the onset of the Black Death in 1347-48, Italian cities which faced the Mediterranean, an epidemic sea, constructed a complex and articulated health defence system which was an example to all other western countries. The cornerstones of this health defence system lay in quarantine, sanitary cordons, lazarets, disinfection, and in the social regulation of the population at risk. Medicine played no part. Its impotence in dealing with epidemic diseases left health defence to the initiative of the civil authorities who rigorously fought the repeated incursions of plague, which from the end of Middle Ages severely tried and tested social organisation, economic life and public order, all of which were threatened by reactions of fear and aggression. From the fifteenth century onwards the public authorities instituted health magistracies which perfected policing and hygiene strategies based on isolation, separation and social control. This progressively extended to individuals in the community through 'health certificates'. This paper follows the evolution and crises of the conceptual, cultural adn institutional response to epidemics through the centuries up to the appearance of the plague of cholera and its disappearance.

[The rearrangement of the medical faculty and the teaching of the medicine in the era of the reforms. The plan of the medical studies in the "restored" university of Cagliari and Sassari (1764-1766)]. / Il riassetto delle facoltà mediche e l'insegnamento della medicina nell'età delle riforme. Il piano degli studi medici nelle università "restaurate" di Cagliari e di Sassari (1764-1766).

In the same decade during which Vienna government was proceeding to the rearrangement of the Medical Faculty of the University of Pavia, Savoy government started the reform of Cagliari and Sassari Universities. The programme of medical studies to be introduced in the "restored" Universities aroused an important debate which involved the government of Turin, the local authorities and the Magistrature. The main points concerned the teachings to be started, the programmes and the texts to be adopted, the methods and contents of teaching. The range of ideas aiming to conform island medical Faculties to the progress of science, gave life to the critique of a teaching model, still ruled by the Galenic authority and by metaphysical etiological explanations, which ignored the physiological and pathological reality revealed by the anatomical study methodically on performed corpses. The new programme of studies admitted the teaching of surgery, which had completely disappeared in the university ruled by Jesuites, and increased the value of anatomy teaching, that will be chosen as a subject for the speech made during the solemn opening of the medical Faculty of Sassari in 1765. The need for an empirical testing which had to follow theorical studies in wards, where teachers had to give lessons at patients' bedside, was considered of such importance that it was codified in the Regulations of the reformed University. It was the very first step towards the welding between medical-surgical studies and nosocomial practice which was about to revolutionize the teaching framework of medical studies.

Scientific triumphalism and learning from facts: bacteriology and the "Spanish flu" challenge of 1918.

The devastating influenza pandemic known as 'Spanish flu', which killed at least 20 million people all over the world in 1918, was responsible for the first bitter blow inflicted on triumphant bacteriology, fortified by the series of resounding successes achieved in identifying the pathogenic agents of terrible diseases such as anthrax, cholera, tuberculosis, plague, and syphilis. Over-confidence and the idea, born of the Pasteur revolution, that every infectious disease was caused by a bacterium, had led the scientific community to accept the theory put forward by the German bacteriologist, Richard Pfeiffer, who, in 1892, believed he had identified the pathogenic influenza agent in a bacterium, Haemophilus influenzae. But, while the most appalling epidemic ever to sweep through the world since the 'Black Death' of the 1300s was still raging, the scientific community had to admit that influenza originated not from a microbe, but from a virus. This article aims to reconstruct the enlightening and little-known cultured/scientific events and issues of the dramatic crisis that bacteriology experienced in the autumn of 1918, with the consequent simultaneous collapse of both the 'Pfeiffer doctrine' on the microbial origin of influenza and the illusion of a world free of infectious diseases. This was an illusion destined to surface again at the end of the century and collapse with the advent of AIDS.