Ah, the Staph of Life! Ether Frolics & Gas Gangrene…

Gangrene and Glory Book Cover

I have found very few good books on Civil War medicine. One of the better ones is “Gangrene and Glory” by Frank Freemon (1998). With an MD and a doctorate in American History, Freemon fills in many of the blanks. In the last post I mentioned that battlefield amputations were often done with only a shot of whiskey for anesthesia. While whiskey was ubiquitous and available, both armies supposedly had access to ether and/or chloroform.

“Ether frolics” were popular entertainments during the 1830s. Traveling lecturers dispensed diethyl ether to any audience member who wanted to test its mind-altering effects, which were similar to those of nitrous oxide.

William Edward Clarke (1819-1898) participated in these events. When he became a medical student, he administered ether to a Miss Hobbie to assist in a dental extraction, thereby establishing himself as the first to use an inhaled anesthetic for a surgical procedure.

In 1842 Crawford Long (1815-1878) used ether before removing a neck tumor from a James Venable. Later he used ether for limb amputations. A hospital in Atlanta is named after him and is now a part of Emory University.

In 1846 William T. G. Morton (1819-1868), a New England dentist, used ether as a general anesthetic at Massachusetts General Hospital.

In 1847 Scottish obstetrician James Young Simpson (1811-1870) used chloroform for general anesthesia. Chloroform became very popular thereafter at least partly because it was non-flammable, but its popularity waned after its toxicity to heart and liver was discovered.

During the Civil War (now there’s an oxymoron!) those dripping ether or chloroform had little, if any, training. But they did have one advantage I supposeif the patient died on the table they always had the excuse that it was because of their battle injuries and not their incompetent anesthetist. Under those primitive conditions it is a miracle that any patient survived. Yet thousands did.

With luck, the patient developed “laudable pus” instead of gas gangrene. Infection was expected, and if it was just staph the patient was considered well on the road to recovery (of course, in those days they didn’t know staph from staff). So that was the staph of life? How times have changed!

Civil War Medicine: Surgeons With Saws & A Stiff Shot of Whiskey

Civil War Polaroid Transfer_s

On April 29, I had a right half-knee arthroplasty. The procedure was done with epidural anesthesia and some additional propofol. I requested a minimal dose of the latter so that I could be more or less awake during the procedure — which happened — and I remember hearing the electric saw doing its thing and also apparently a mallet and chisel. The procedure went smoothly and with dozens of people taking care of me in the hospital, and several more from home health care, I am making a good recovery ahead of schedule.

What a contrast from Civil War medicine! If you have ever been to a Civil War battlefield, you may have seen what passed for a hospital then. At the Battle of Bull Run I believe it was a little one-room schoolhouse that was pressed into service by the Union army. The “service” consisted mainly of a surgeon with a saw who knew how to separate limbs from injured soldiers. Anesthesia was a stiff shot of whiskey and some helpers to hold the screaming patient immobile.

How the patient was sewed up didn’t attract much attention in the few books on the subject, but the suturing and dressing had to have been pretty primitive. If the patient was lucky, he was transferred to an “ambulance” for a very bumpy trip back to Washington or wherever and a “respectable” hospital. Pictures show some of these hospitals to have been large tents with hundreds of bunks lined up cheek by jowl.

How anyone could have survived this level of care boggles the bean, but thousands did from all accounts. The alternative to surgery they learned early, was likely to be gas gangrene with certain death. Why this nasty bacterial infection? Those noxious Clostridium spore formers lived largely in the guts of horses. And horses — the engines of the Civil War — were ubiquitous. They contaminated the soil and the soil contaminated soldiers.

I once did an autopsy on a case of gas gangrene. The man had been kicked on the shin by a horse with an injury that just barely broke the skin. When crepitation was first detected around the knee, a hindquarter amputation was performed immediately. The patient still showed up in the morgue a couple of days later. Makes one a believer in the power of Clostridium.

So, how did those survivors survive? They must have been some tough dudes!

There’s an interesting audio quiz and history lesson on the Public Radio International website about first responders and the Civil War. Have a listen here.

Win the war on food-borne bugs in 20 seconds

Call Homeland Security—there’s an invasion on restaurants and kitchens everywhere. We’re talking about bugs. Bacteria, viruses, fungi, parasites…the ones you savor during mealtime then pay a big price for later. These microorganisms would just love to ruin your day with a good case of accelerated peristalsis, forward or reverse (you know it as vomit, upchuck, puke and the Aztec two-step, Montezuma’s revenge, or the Greek’s own diarrhea). Don’t let them win. Declare war on these bugs.

The culprits have many names, so we’ll just refer to them collectively as food-borne illnesses. The Centers for Disease Control and Prevention (CDC) estimates that each year roughly one in six Americans (or 48 million people) get sick, 128,000 are hospitalized, and 3,000 die of food-borne illnesses each year. While outbreaks of this and that get a lot of attention and spur concerns over food processing and food imports, the reality is that as much as 70 percent of food poisoning cases originate in the kitchen.

That’s right—people, not products, are the main cause of food-borne illnesses—and they can be avoided by following some basic principles of food safety. That’s where we come in. The CDC says the first line of defense to protect against food-borne illness is to wash your hands the correct way: 20 seconds with soap and running water. And be sure to scrub the backs of your hands, between your fingers, and under your nails. Most people don’t wash their hands right but winning this war means that changes.

We’re a longtime partner with the Handwashing for Life® to advocate and teach correct hand washing techniques. You can buy a DVD that demonstrates the why, when and how of good handwashing practice to motivate your employees and more. Of course you can use our products to check that you’ve washed correctly, too. Ready to fight the invasion of food-borne bugs? Reach for the soap and water and leave the anti-diarrheal medication on the shelf.

The fickle finger of fate at the Treaty of Versailles

The Big Four
The Big Four at the Treaty of Versailles, photo courtesy of Wikipedia

This is the second post of a two-part article on The Great Influenza’s impact on World War II:

The war ended with an armistice on the eleventh hour of the eleventh day of the eleventh month in 1918 (who said generals don’t have a sense of humor?) In spring of 1919 the allies gathered to hammer out a peace agreement with “The Big Four” (or Council of Four) in attendance: David Lloyd George of Britain, Georges Clemenceau (“The Tiger”) of France, Vittorio Orlando of Italy, and Woodrow Wilson of the US. Wilson was for treating Germany kindly and allowing it to recover its place among the community of nations.

But not Clemenceau. Now aged 77, “The Tiger” wanted to destroy and humiliate Germany so that it could never again be a threat to France. Wilson fought back and was so disgusted with Clemenceau that on occasion he threatened to leave the peace talks altogether.

But then the fickle finger of fate in the form of flu touched Wilson. He recovered sufficiently to continue with the peace conference, but he was but a mere shadow of his former self. He quickly acquiesced to Clemenceau. Germany was forced to accept the humiliating Versailles Treaty with its demands for huge reparations.

Germany sank into a severe depression. When Hitler showed how it would be possible to rebuild Germany’s economy and military, the German public enthusiastically looked upon him as their savior. And when Germany overran France in 1940, Hitler rubbed France’s nose in it by forcing the French to sign the surrender document in the same railway car in which Germany had been forced to sign the 1918 armistice agreement. But what was the explanation for the mental collapse of Woodrow Wilson? One of the sequelae of influenza is mental illness or deterioration (and in some cases even schizophrenia). This combined with pre-existing cerebral arteriosclerosis did the trick. Wilson’s will to fight Clemenceau disappeared. His brain was incapacitated. Wilson had a severe stroke only four months later and he never recovered.

Once again the 1935 wisdom of Hans Zinnser (American physician, bacteriologist, and prolific author) that the history of humanity is more often determined by microbes than by men is shown to be on the mark.

The rise of Hitler & World War II: The impact of The Great Influenza

The Great Influenza by John M. Barry

The story of the 1918-1919 flu pandemic is fascinating on its own terms and is superbly recounted by John M. Barry in his book, “The Great Influenza.” But did you know that this flu was the direct cause of the rise of Adolph Hitler and World War II? Here’s the story.

The virus itself was probably circulating before 1918, most notably in Etaples, France in 1916. Be that as it may, the pandemic itself was enhanced by the congregation of vast numbers of immunologically naive young men in camps such as Fort Riley, Kansas, its site of first appearance in the U.S., and then spread by them as they were deployed to Europe. Somewhere in its migration from birds to pigs to humans, the influenza virus (H1N1) most likely mutated to its ultimate virulent form. Regardless, there were three waves of infection: In the spring of 1918, the fall of 1918 and again in the spring of 1919.

Why this flu pandemic preferentially targeted young people is still debated. One suggestion is that prior epidemics of flu were immunologically similar enough that older citizens still had some residual resistance. The other obvious suggestion is that forcing large numbers of immunologically naive young men into close proximity in military camps was an ideal scenario for rapid spread. If it started in France or in Kansas, why was it known as “The Spanish Influenza”? Seems the Spanish press was uncensored at the time since Spain was not a participant in the World War. Therefore most of the news was printed in Spanish newspapers and it became “The Spanish Flu.”

Mystery of the Misery

bug-eyes-narrow

Why is it that dogs can drink out of mud puddles with impunity but tots cannot? Or maybe we could but just don’t know it. I’m not about to suggest that we perform that experiment, but it does intrigue me that within the past several years there has been a lot of talk about the “hygiene hypothesis.” Since it doesn’t promote the wisdom of “hygiene,” maybe it should be called “antihygiene” or “lowgiene.” We have all observed with fear our little rug-rats wrapping their gums around all kinds of debris they have picked up off the non-hygienically approved floor. Do they survive in spite of—or because of—this activity?

The hygiene hypothesis claims that we are getting all kinds of diseases, such as asthma and Type I diabetes, because we are not training our immune systems adequately. How? By avoiding exposure to all the germs that used to visit us in early childhood before we began bathing in soap and alcohol twenty times a day.

World population was 2 billion when I was born and is now 7 billion. Would the 1918 flu pandemic have gotten off the ground in the absence of crowded military camps containing thousands of potential hosts waiting for the virus to arrive? Probably not.

Pandemics seem to be one of Mother Nature’s favorite strategies for population control. Earth could support several times its current people load if we went to a vegan diet, but does a world population of 20 billion humans sound like fun?

On our present course it seems certain that global warming will produce widespread effects that will not, in general, be desirable. But are we also setting ourselves up for a global pandemic that will prune the population to where it might have been in the first place if we had listened to those who have been warning us for some decades? Or will medical science give us enough vaccines and new antibiotics to shield us from whatever bugs come along?

Given our penchant for not doing anything until it is too late, I suspect that our experiment will continue but with Mother Nature at the controls—population controls. Keep your fingers crossed and your seat belt fastened. It may be a bumpy ride.

Gordon Short, MD
March 2014

Who was Shiro Ishii?

If you are a WWII history buff, you probably recognize the name of Josef Mengele, the ethically challenged Nazi physician who was known as “The Angel of Death.” Dr Shiro Ishii was his Japanese analog.

Dr Ishii, who later became a Lt General, was in charge of Unit 731 of the Imperial Japanese Army located in a suburb of Harbin, Manchuria. This was the most famous biological warfare death camp but not the only one. Others included even Nanking. Human subjects were inoculated and thousands died. The list of organisms included such delights as anthrax, meningococcus, influenza, smallpox, tetanus, typhoid, typhus, tuberculosis, plague and many others.

For effective Biological Warfare one has to know how to weaponize and disseminate the organisms. Aerosols? Bombs? Water supply? It was a difficult challenge. The heat of exploding bombs would kill organisms and those that survived that challenge would die off in the atmosphere from drying and UV exposure. This was also true of aerosols. Would there be person-to-person spread and could an epidemic be controlled? Many questions.

After the war, Ishii was captured. But instead of being executed for killing thousands of Chinese citizens and POWs, he was offered amnesty in return for turning over the records of his experiments to the Americans. Although medical ethics did not allow American researchers to perform experiments on living human beings, ethics did allow American authorities to exonerate the person who did the experiments.

General Ishii thus lived until October 9, 1959 dying at the age of 67. (“The Angel of Death” lived until February 7, 1979 also dying at the age of 67 in Sao Paulo, Brazil although assiduously hunted by the Israeli Mossad.)

Makes me wonder, what is ethics anyway?

Gordon Short, MD
24 Mar 2014

“The Cobra Event”

“Kate Moran was an only child” may not compete with “Call me Ishmael” or “It was the best of times, it was the worst of times” as an opening salvo, but it will do. In this novel, Richard Preston wanders from the arena of fact into fantasy. But when one deals with viral hemorrhagic fevers, the distance is very small. The “Cobra” virus in the story is a genetically engineered combination of a rhinovirus and smallpox that attacks the brain and liquefies it and is meant to be an agent of bioterrorism..

It’s reported that President Bill Clinton read the book and was so unnerved by it that he called his science advisers together for advice. That led to Donald Ainslie Henderson forming the Johns Hopkins University Center for Civilian Biodefense Studies. D.A., as he was always known, was the person mainly responsible for organizing the highly successful campaign to eradicate smallpox and was also one of my mentors in the Epidemic Intelligence Service course I took at CDC in 1957. At that time he was one of Alexander Langmuir’s bright young acolytes. Since the conclusion of the smallpox crusade around 1980, he has been a leading light in promoting bioterrorism defense.

Richard Preston, who is known for his meticulous reporting, has popularized the bioterrorism threat in a way that will get the public’s attention with books such as “The Hot Zone” and “The Cobra Event.” Especially when turned into a movie such as “Outbreak.”

If you have always longed for curly (or curlier) hair, you might check them out.

Gordon Short, MD
27 Mar 2014

EBOLA

Few diseases conjure up as much dread as Ebola hemorrhagic fever. If you’re tired of watching sitcoms and romantic comedies, take a look at “Outbreak,” a 1995 film with a stellar cast. It explores the ethical dilemma of a government that faces the decision whether to annihilate a small town where there is an outbreak of a new airborne mutant of Ebola with a mortality of close to 100% in order to prevent escape into the general population with millions of deaths or just try to contain the virus and hope for the best. The science is a bit speculative but the basic premise is more or less believable. The action, including some of the helicopter flying, is almost unbelievable.

Ebola has been the subject of a number of good books including “Ebola” by William Close MD, father of the actress Glenn Close, who was personal physician to Zaire’s infamous President Mobutu. He was a first-hand witness to the original human outbreak originating in the Belgian Catholic Yambuku Mission Hospital. Of 318 cases, 280 died (88%). The use of unsterilized needles and syringes was blamed for the rapid spread but person-to-person spread also occurred in those with close contact with patients alive or deceased.

Ebola and the related filovirus, Marburg, live in monkeys of various species and only rarely jump into humans. Fortunately. Since mortality is still on the order of 50% or more. Genetically engineering these viruses to produce a bioweapon is a distinct possibility. As we saw with the anthrax attack, there are enough adequately trained scientists lying around to do this if one of them should lose his/her grip on basic humanity. This might be especially true of Russian scientists who worked on the very extensive biological warfare program that went on in the Soviet Union up through the tenures of Gorbachev and Yeltsin and who lost their employment after the national collapse.

If you’re sick of counting sheep at night, you might try counting all the ways some madman might come up with to do us all in. Bugs, nukes, poisons, etc. Or you could think of all the ways chocolate has been made irresistible. As for me . . . .

Gordon Short, MD
28 Mar 2014

“1491”

Did you ever wonder what the population of North and South America was before Columbus made his big “discovery”? As Charles C. Mann shows in his book “1491,” there is a wide diversion of opinions. The “Low Counters” estimate about 10 million while the “High Counters” guess it is more like 100 million. Why the high level of uncertainty? Seems native Americans – Aztecs, Mayans, Incas, Iroquois, Cherokees et alia – saw no need for taking censuses. Only when the Spanish arrived did the idea of taking body counts of the living become accepted.

And while the Spaniards certainly knew how to count, what they were counting were those who remained after smallpox, measles, influenza and other pandemics had decimated the various populations they were estimating. The idea that the western hemisphere was an empty continent waiting to be occupied by needy Europeans has been laid to rest along with the millions of native Americans who were killed off in short order by European diseases, particularly smallpox. In 1542 Bartolome de Las Casas, Spanish historian, Dominican friar, and American explorer, said that the Americas were so thick with people “that it looked as if God has placed all of or the greater part of the entire human race in these countries.” (Mann)

Zinnser, in his delightful book, “Rats, Lice and History,” comments on the relative unimportance of generals as compared with microbes. The outcome of more campaigns was determined by epidemic pathogens than by the brilliance of generals. How else could a piddly number of conquistadors and colonists have “opened” up the Americas for settlement and exploitation?

Although the science is disputed, it is not unreasonable to believe that the native Americans attempted to upstage the European invaders – both human and microbial – and their “Small Pox” by exporting back to Europe the “Great Pox.” (Syphilis, in case you didn’t know) Poetic justice? You decide.

Gordon Short, MD
7 Apr 2104